Adult-Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched

Mid-term Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis with Bulk Femoral Head Allograft

Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis with bulk femoral head allograft has previously been reported as a way to fill large osseous hindfoot deficits in order to restore limb length, but few studies have been performed evaluating outcomes and prognostic factors. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors. Methods: A retrospective review of patients undergoing TTC arthrodesis with bulk femoral head allograft performed at an academic institution by a single fellowship-trained foot and ankle surgeon between 2004 and 2015 was conducted. Patient charts and operative reports were reviewed for patient and procedural variables, respectively. Radiographic union was assessed at the ankle and subtalar joints by another fellowship-trained foot and ankle surgeon not involved in any patient’s surgical care. Radiographic stability, defined as proper maintenance of hardware and graft positioning in the hindfoot, was also assessed. A procedure was “failed” if there was a need for revision surgery. Patients with a successful arthrodesis were contacted to score the Foot and Ankle Ability Measure-Active Daily Living (FAAM-ADL) questionnaire, visual analog scale (VAS) for pain, and Short Form-12 (SF-12) mental (MCS) and physical (PCS) components. 22 patients were identified, with average radiograph and functional follow-up times of 39.7 and 57.1 months, respectively. Results: Complete radiographic union of involved joints was achieved in 13 patients (59.1%) and in 72.7% (32/44) of all joints. Eighteen patients (81.8%) were assessed to be radiographically stable at final follow-up. Three patients (13.6%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 19 patients (86.4%) did not require additional surgery as of final follow-up. At an average of 57.1 months postoperatively, patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P<.001). The mean VAS for pain significantly improved from 76.8 to 32.9 (P<.001). The mean postoperative SF-12-MCS and SF- 12-PCS scores were 53.9 and 40.6. Additionally, 73.3% (11/15) reported being satisfied with their surgical outcomes. Male sex (P=.03) and a lateral operative approach (P=.03) both resulted in significantly worse outcomes. Conclusion: The utilization of a femoral head allograft with TTC arthrodesis in patients with large hindfoot defects is an acceptable method that can offer improved functional and sustained radiographic outcomes and patient satisfaction. Male sex and a lateral approach may be associated with an inferior prognosis

Ankle Stress Radiographs Predict Lateral Ankle Instability Better Than MRI

Category: Ankle Introduction/Purpose: Chronic ankle instability is a common entity that may be mechanical or functional in nature. Patients with mechanical instability are thought to have limited rehabilitation potential from non-operative treatment alone. Reliable identification of patients with mechanical instability may be beneficial in their treatment approach. A standardized diagnostic algorithm has not been well established using various modalities including physical examination, stress radiography, and MRI. This study aims to determine the utility of stress radiography and MRI in diagnosing mechanical ankle instability as compared to the gold standard of intra-operative stability. Methods: A retrospective chart review was performed on all patients that had stress radiographs between January 2008 through August 2013. All charts were reviewed for operative reports, progress notes, radiographs, MRI images, and reports. Stress radiographs were performed on those patients presenting with complaints of ankle instability using the Telos Stress Device (Hungen, Germany) and radiographic measurements of talar tilt and anterior drawer distance were performed by a senior resident. One hundred and four patients were identified, and 1 was excluded due to inadequate stress radiographs. The average age was 40 years, and there were 54 males and 49 females. Twenty-nine (28%) patients presented after an automobile accident or work-related injury. Thirty-eight patients (37%) were taken to the operating room, and 20 patients (53%) were found to be unstable requiring lateral ligament repair. An MRI was available for review in 30 (79%) of the patients that were taken to the operating room. Results: Talar tilt measurement of 6 degrees or greater on stress radiographs significantly predicted ligament incompetence (p = 0.0016) using intra-operative stability as the gold standard. Sensitivity of the stress radiograph was found to be 90% with respect to identifying ligament incompetence; specificity was 61%. MRI reports were reviewed and the lateral ligaments were described as intact, thickened, attenuated, or torn. There was no correlation between radiologist description of the anterior talofibular ligament (ATFL) and intra-operative stability (p = 0.31). Of the 29 patients presenting after an automobile accident or work- related injury, 18 (62%) were taken to the operating room; 10 were found to be stable and 8 were unstable requiring lateral ligament repair. Table 1 includes talar tilt measurements and intra-operative findings. Conclusion: The dynamic nature of stress radiographs may be better suited to diagnosing mechanical instability than a static MRI. This study demonstrates that stress radiographs can successfully predict mechanical instability diagnosed intra-operatively. There was no correlation between MRI findings and intra-operative stability. Though physical examination remains an important part of the work-up of a patient complaining of ankle instability, stress radiography may be a more objective tool to utilize in this population of patients

Determination of minimum clinically important difference (MCID) in visual analog scale for pain scores after hallux valgus correction

Category: Bunion Introduction/Purpose: Surgical outcome studies rely on patient reported outcome measurements to assess the effectiveness of treatment. The concept of minimal clinically important difference (MCID) proposes a necessary threshold to achieve clinically significant treatment results, and refers to the smallest change in outcome measure important from the patient’s perspective. In the context of visual analog scale (VAS) questionnaires, MCID refers to a clinically significant change in pain score. Determination of MCID in patient-oriented outcome questionnaires is necessary to further evaluate the effectiveness of hallux valgus surgery. Further, MCID analysis of hallux valgus surgical outcomes could provide improved insight into post-operative patient satisfaction. The purpose of this study was to determine the MCID in pre- to post-operative VAS pain score in patients undergoing surgical treatment of hallux valgus. Methods: Adult patients undergoing surgical treatment of hallux valgus were retrospectively included. Pre- and post-operative VAS pain scores (0-10) and surveys inquiring about satisfaction with pain level after surgery were collected at a minimum of 1-year post-surgery. Patients were categorized as responders or non-responders based upon a completed 6-point pain satisfaction scale. Patients reporting satisfaction scores 0-3 were categorized as non-responders, and 4-6 as responders. Four MCID calculation methods were used that have been described in previous literature: the standard deviation (SD) approach, the average change approach, the minimally detectable change (MDC) approach, and the change difference approach. The total percentage of patients meeting the calculated VAS threshold score for each MCID method was determined. The likelihood of meeting the VAS threshold for each MCID method based on responder status, hallux valgus severity, and correction status of concomitant hammertoe deformity was also determined using bivariate analysis. Results: 170 patients were included with post-operative follow-up averaging 23.6 months. VAS MCID threshold scores were 1.77points (SD approach), 5.21points (average change approach), 1.98points (MDC approach), and 4.27points (change difference approach). The patient percentage meeting the VAS threshold score for each MCID approach was 73.5%, 40.6%, 73.5%, and 48.8%, respectively. Moderate deformity procedures (Ludloff) demonstrated greater likelihood than mild deformity procedures (Chevron, Modified McBride, Aikin, Silver) of meeting the average change, MDC, and change difference approach thresholds (p=0.036, 0.035, 0.034). Severe deformity procedures (Lapidus) demonstrated greater likelihood than mild deformity procedures of meeting the SD approach threshold (p=0.046). Hammertoe correction demonstrated greater likelihood than non-correction of meeting the average change approach threshold (p=0.038). Responders demonstrated greater likelihood than non-responders of meeting all MCID approach thresholds (p<0.001). Conclusion: This study demonstrated marked variability in determining VAS MCID for hallux valgus correction (range 1.77- 5.21 points). This study suggests an association between type of hallux valgus correction and likelihood of post-operative improvement, as there was greater chance of meeting MCID with correction of greater hallux valgus deformity or hammertoe deformity. MCID methods utilizing comparisons of responder status may not be appropriate for hallux valgus patients, as responders tended to improve with time and non-responders tended to decline. Additional investigation of the optimal MCID method for hallux valgus correction is necessary to narrow the range and determine surgical efficacy

Modified Anatomic Hamstring Graft Reconstruction for Revision and Severe Cases of Lateral Ligament Instability

Category: Ankle Introduction/Purpose: Treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined. Results after ankle stabilization techniques involving non-anatomic reconstruction have historically been suboptimal, and newer techniques have limited presence in the literature. The purpose of this study is to report clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in patients with severe ankle instability or failed previous ankle stabilization. A novel technique for ligament reconstruction is also presented that is hypothesized to restore functional and radiographic ankle stability. Methods: A retrospective chart review was performed on all patients that had undergone modified anatomic lateral ligament reconstruction by a single surgeon between 2011 and 2015 with at least 6 months follow-up. Indications for modified anatomic reconstruction included failure of previous ankle stabilization or severe laxity with greater than 20 degrees of talar tilt or anterior drawer greater than 15 mm on stress radiographs. Patients completed routine pre- and post-operative functional outcome scores including Foot and Ankle Outcome Score (FAOS), Short Form 12 Health Survey (SF-12), and Visual Analog Scale (VAS). Patients underwent pre- and post-operative stress radiographs using the Telos Stress Device (Hungen, Germany). Thirty-four patients (35 ankles) were included with average follow-up of 26.7 months. Average age was 34.2 years, and there were 29 female patients and 5 male patients. Hamstring autograft was utilized in 31 ankles and hamstring allograft in 4 ankles. Results: Indications for surgery included failure of previous ankle stabilization in 13 patients and severe ankle instability in 22 patients. All functional outcome scores improved; VAS increased from 5.3 to 1.0 points (p < 0.0001), SF-12 increased from 64 to 89 points (p < 0.0001), and FAOS scores increased in all categories (p < 0.05). Radiographic measurements of instability also improved; anterior drawer decreased by 3 mm (p = 0.0002) and talar tilt decreased by 11 degrees (p < 0.0001) (see Table 1). One patient (3%) returned to the operating room for removal of hardware after over 2 years. There were 4 patients (12%) with delayed wound healing, 2 patients (6%) with neurologic complications, and 2 patients (6%) with venous thromboembolic events. Conclusion: Patients demonstrated significant improvement in functional outcome scores as well as radiographic measures of ankle stability following modified anatomic lateral ligament reconstruction in a population with severe or recurrent instability. This is the largest series to date of ankle ligament reconstruction using autograft, and it is associated with high patient satisfaction, reduced pain, improved objective stability, and low morbidity. Further study is warranted to develop well-defined guidelines on the management of patients with severe or recurrent instability

Anterior Talofibular Ligament Abnormalities on Routine Magnetic Resonance Imaging of the Ankle

Category: Ankle, Sports, Trauma Introduction/Purpose: The anterior talofibular ligament (ATFL) is one of the most commonly injured structures of the lower extremity after an ankle sprain. Evidence of remote injury to this structure is frequently encountered on magnetic resonance imaging (MRI) of the ankle, with uncertain clinical significance. Previous studies in the orthopaedic literature have discussed the prevalence of abnormal MRI findings in asymptomatic patients, most notably with regards to the spine and shoulder. More recently, a study on the prevalence of peroneal tendon abnormalities on routine MRI of the ankle was published. However, to our knowledge, no such study exists for the ATFL. The purpose of this study is to determine the prevalence of abnormal findings of the ATFL on MRI in asymptomatic individuals. Methods: All foot and ankle MRIs performed at our institution over a 4-month period were considered for inclusion in our study. Studies were excluded if performed on patients with documented ankle inversion injuries, ankle sprains, lateral ankle trauma, tenderness over the ATFL, or ankle instability. A total of 320 MRIs were eligible for inclusion. The integrity of the ATFL was noted in addition to the primary pathology. Results: The median age of the patients included in this study was 51 years with 203 females (63%) and 117 males (37%). One hundred eighteen (37%) of the 320 MRIs demonstrated some ATFL pathology. The most commonly encountered ATFL pathologies were thickening (38%), chronic tear (35%), attenuation (25%) and acute tear (2%). Conclusion: The results of this study demonstrate that a sizeable percentage of asymptomatic individuals (37%) will have ATFL abnormalities on magnetic resonance imaging of the foot and ankle. This study can have important clinical implications for patients who present with concerning MRI findings that do not correlate clinically. Based on our results, orthopaedic surgeons or any other physician providing musculoskeletal care can provide counseling and reassurance to patients who present with ATFL pathology on MRI but an absence of clinical findings. Much like MRI of the shoulder or spine, abnormalities must be correlated with the clinical exam

Value of Supine Positioning in Repair of Achilles Tendon Ruptures

Category: Hindfoot Introduction/Purpose: The optimal method of Achilles tendon repair remains undefined. Few previous studies have quantified the financial expenses of Achilles tendon repairs in relation to functional outcomes in order to assess the overall value of the accepted repair techniques. The purpose of this study is to demonstrate the value of supine positioning during open repair (OS) of acute Achilles tendon ruptures through the quantification of operative times, costs, and outcomes in comparison to the commonly performed percutaneous prone (PP) repair technique. Methods: A retrospective review was conducted on 67 patients undergoing OS and 67 patients undergoing PP primary Achilles tendon repair with two surgeons at four surgical locations. Total operating room usage times and operating times were collected from surgical site records. Total operating room times were used to estimate the costs of room usage and anesthesia, while costs of repair equipment were collected from the respective manufacturers. Patients undergoing OS repair completed the Foot and Ankle Ability Measure (FAAM) questionnaire, with activities of daily living (ADL) and sports subscales, Short Form-12 (SF-12), with mental (MCS) and physical (PCS) health subcategories, and the visual analog scale (VAS) for pain preoperatively and at final follow-up. Results: Even with a significantly longer mean surgical time (P=.035), OS repairs had a shorter duration of total operating room time when compared to that of PP repairs (58.4 versus 69.7 minutes, P<.001). Estimated time-dependent costs were lower in OS repairs ($739 versus$861 per procedure, P<.001), while the estimated average total per procedure cost was also lower for OS repairs ($801 versus$1,910 per procedure, P<.001). For patients undergoing OS repair, FAAM-ADL (P<.001), FAAM-Sports (P<.001), SF-12-PCS (P<.001) all increased and VAS grades (P<0.001) decreased from time of initial encounter to final follow-up and were comparable to reported outcomes in the current literature. The complication rate in OS repairs (6.0%) was lower than PP repairs (11.9%), with revisions only occurring in the latter technique. Conclusion: Performing open Achilles tendon repair in the supine position offers substantial value, or “health outcomes achieved per dollar spent”, to providers due to decreased total operating room times and costs with satisfactory functional outcomes

Total Ankle Arthroplasty

Category: Ankle, Ankle Arthritis Introduction/Purpose: Reports of ankle range of motion and how it affects patient outcomes following total ankle arthroplasty (TAA) have been mixed. Furthermore, recent studies have relied on clinical exam to obtain postoperative range of motion and have lacked preoperative functional scores. The purpose of our study was to analyze how preoperative range of motion and functional scores change with time following TAA using postoperative functional scores and radiographs for range of motion calculations. Methods: A retrospective chart review was performed on 107 patients (109 ankles) that had undergone fixed-bearing implant TAA by a single surgeon between 2010 and 2015. Preoperative range of motion was gathered clinically in office by the senior author. Postoperative range of motion through the ankle joint was evaluated with dedicated weight-bearing maximum dorsiflexion and plantarflexion lateral radiographs at 3 and 6 months, 1 and 2 years. The range of motion was measured using the angle measurement tool on the picture archiving and communication system. Patients completed visual analogue scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire subcategorized into activities of daily (ADL) and sports subscale preoperatively and at postoperative intervals of 3 and 6 months, 1 and 2 years. The mean age was 65 years (range, 31-83 years). Mean BMI was 28.1 (range, 14.9-44.9). There were 53 males (50%). Results: The mean total arc of ankle motion preoperatively was 20.7 degrees and improved significantly to 28.3, 34.3, 33.3, and 33.3 degrees at 3 and 6 months, 1 and 2 years, respectively (P<0.001) (Figure 1). Mean VAS pain and mean FAAM ADL preoperative scores improved significantly at each postoperative time point as seen in Figure 1 (P<0.001). Increased ankle range of motion was correlated with lower VAS preoperatively (r=-0.38, P=0.007), and at 1 year (r=-0.36, P<0.001), and 2 years (r=-0.2, P=0.033) postoperatively. Increased ankle range of motion was significantly correlated with higher FAAM-ADL at 3 months (r=0.48, P=0.012), 1 year (r=0.24, P<0.034), and 2 years (r=0.37, P<0.001) postoperatively. Conclusion: Patients undergoing fixed-bearing TAA had continued and sustained improvement from preoperative total arc of motion, pain, and function at each postoperative visit, up to 2 years. Ankle range of motion was noted to peak at 6 months, while pain and FAAM-ADL continued to improve up to 2 years postoperatively. Patients with greater ankle range of motion correlated with less pain and improved function at 1 and 2 years postoperatively. Though pain and function may continue to improve even as far out as 2 years postoperatively, it is not likely that range of motion will continue to increase

Identifying Risk Factors for Failure of a Modified Broström’s Procedure

Category: Ankle Introduction/Purpose: The modified Broström’s procedure has been widely accepted as the operative treatment of choice for treating lateral ankle instability in patients that have failed nonoperative management. However, the predisposing risk factors for failure of operative treatment, which has important implications for patient selection, is unknown. The purpose of this study is to thus identify independent risk factors for failure of an index Broström’s procedure. Methods: A retrospective single institutional study of 123 modified Broström’s procedures, average age 40 years, was performed with a minimum of 2 year follow-up. An electronic query based on Current Procedural Terminology codes was initially performed followed by a manual review of the operative report. Patients with any concurrent osteotomy, arthrodesis, or arthroplasty procedures were excluded. Foot and Ankle Ability Measure (FAAM) and Short Form Survey 12 (SF-12) were obtained both preoperatively and postoperatively. Cormorbidities and relevant demographic information were manually obtained. Treatment success was defined as a postoperative FAAM Sport score increase by greater than 9 points, an established minimal clinical difference established in the literature. A linear regression controlling demographic factors and baseline scores was utilized to predict scores at last follow-up. Results: At last follow-up, 31.4% did not demonstrate a self reported clinical improvement in the FAAM Sport scores with 2% (3/123) of the entire cohort requiring reoperation. A higher preoperative physical SF-12 score was associated with a reduction in the postoperative physical SF-12 score (p=0.035) while higher body mass index (p=0.010) was associated lower mental component SF-12 scores at follow-up. Interestingly, higher age is associated with higher 2-year PCS score. Furthermore, the occurrence of a complication was associated with lower ADL (p<0.001), Sport (p=0.002), and total FAAM (p=0.002) scores and higher pain (p=0.017) at 2-years. Conclusion: A significant amount of patients did not demonstrate a clinical improvement in functional outcomes although the overall reoperation rate was low. Surgeons should be aware that approximately one third of patients may not have achieved their desired clinical outcome and that BMI and preoperative function is associated with worse outcomes

Effect of Post-Operative Toradol Administration on Bone Healing After Ankle Fracture Fixation

Category: Ankle, Trauma Introduction/Purpose: Ketorolac has been reported to delay bone healing when administered after spine surgery, and there is hesitancy to use non-steroidal anti-inflammatories (NSAIDs) in the fracture setting despite its reliable ability to relieve surgical pain. The effect of ketorolac administration after foot and ankle surgery has not been well-defined in the literature to date. The purpose of this study is to report clinical and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. A secondary purpose is to determine whether there are other patient factors that affect radiographic healing in this population. We hypothesize that the time to radiographic healing with ketorolac use after ORIF of ankle fractures is no different than a historical control. Methods: A retrospective chart review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients were prescribed 5 days of 10 mg ketorolac every 6 hours. Radiographs were evaluated independently by two blinded fellowship-trained foot and ankle surgeons to assess for radiographic healing of lateral malleolus, medial malleolus, and posterior malleolus fractures at 6, 12, and 16 weeks post-operatively. Two hundred and ninety-four patients were included with an average age of 50 years with 138 males (47%). Literature review was performed to determine an appropriate historical control of time to radiographic healing after ankle ORIF for comparison. Statistical analysis consisted of a linear mixed-effects regression which was performed to estimate the effect of time and covariates, taking into account repeated measurements on the same subject. Results: Radiographic healing was demonstrated by 16 weeks in 221 of 281 (79%) lateral malleolus fractures, 105 of 132 medial malleolus fractures (80%), and 53 of 57 (93%) posterior malleolus fractures (see Figure 1). Median healing times were 12, 11, and 6 weeks for lateral, medial, and posterior malleoli fractures respectively. There was no significant difference in time to radiographic healing of lateral malleolus when compared to a historical control of 16.7 weeks to union. Active tobacco use was an independent risk factor for delayed radiographic healing (p < 0.05). Diabetes mellitus and age greater than 50 years were independent factors associated with faster healing of the lateral malleolus fractures (p < 0.05). Rheumatoid arthritis, oral steroid use, and obesity had no effect on radiographic healing. Conclusion: Perioperative ketorolac use did not affect radiographic healing of ankle fractures after ORIF. As expected, active tobacco use was associated with slower radiographic healing. There is no evidence that ketorolac use further delayed union in smokers, but this may warrant further study. We unexpectedly identified diabetes mellitus and older age as factors associated with faster healing which also warrants further study. This is the first study to date examining the effect of ketorolac on radiographic time to union of ankle fractures. Further study may help determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures