Medial gastrocnemius flap for reconstruction of the extensor mechanism of the knee following high-energy trauma. A minimum 5 year follow-up

The purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage.This retrospective review consisted of a consecutive series of four patients (age 28-40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score.At the final follow up was 61.5 (57-66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training.For severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique

2017 Roger A. Mann Award Winner

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is a very common symptomatic problem affecting one in 40 patients over the age of 50 years. A variety of treatment options exist and, as is common in surgery, grading systems are used to assess severity of the condition and aid in the guidance of treatment. The most commonly used grading system for HR uses radiographic images, great toe range of motion and clinical symptoms. This study examines the relationship of radiographic and motion findings to observed intra-operative cartilage loss in patients with HR and explores hallux rigidus grade and cartilage loss as predictive variables for treatment outcomes. Methods: A prospective, randomized non-inferiority study examining outcomes of arthrodesis compared to hemiarthroplasty of the first metatarsal phalangeal joint (Cartiva®) was performed.2 All randomized and treated patients were included in this study. Patients underwent pre-operative clinical examination, including measures of joint motion, radiographic assessment and HR grade. Operatively, observations of cartilage loss on the metatarsal head and opposing proximal surfaces were recorded. All patients’ data, irrespective of treatment, were aggregated and Spearman Rank Correlation coefficients used to assess for strength of correlation of active peak dorsiflexion and cartilage loss to HR grade. Outcomes data were then separated by treatment group and two-sided Fisher’s Exact test assessed these variables’ impact on clinical success (p<0.05). Results: In 202 patients, 59 (29%), 110 (55%), and 33 (16%) were classified as Coughlin1 Grades 2, 3, and 4, respectively. There was no correlation between grade and active peak dorsiflexion (-0.02, p=0.78). While rank correlations between grade and cartilage loss on the proximal phalanx and metatarsal head statistically significantly differed from zero, the magnitudes of the correlations were small, 0.176 (p=0.01) and 0.224 (p=0.001), respectively (Table 1). Among Grade 4 patients, 36.4% had no metatarsal cartilage remaining; but this was also found in 8.5% of Grade 2 patients. Similarly, 52.5% of Grade 2 patients had ≥50% metatarsal cartilage remaining; but this was also found in 21.2% of Grade 4 patients. None of the observed factors were significantly associated with likelihood of achieving composite success. Conclusion: This study examines the relationship of motion and intra-operative cartilage loss findings with a commonly used clinical and radiographic grading system for hallux rigidus. This study population included only candidates with HR considered a candidate for arthrodesis based on review of clinical symptoms however the Grade assigned maybe Coughlin Grade 2, 3 or 4. Irrespective of the Grade, positive outcomes were demonstrated within both treatment groups. The weak correlations of preoperative motion and intra-operative cartilage loss to grade suggests that clinical symptoms should be a significant determinant guiding the treatment option rather than radiographic or range of motion factors

Five-year Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is the most common arthritic condition of the foot. A prospective, randomized, non-inferiority clinical trial of first metatarsophalangeal joint (MTPJ) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant, for moderate to severe hallux rigidus, demonstrated maintenance of MTPJ active dorsiflexion motion and excellent pain relief; additionally, the trial showed functional outcomes and safety equivalent to first MTPJ arthrodesis at 24 months (Baumhauer et al. 2016; FAI:37(5):457-469). Recognizing that many hemiarthroplasty and total toe implants have initially good results that deteriorate over time, the purpose of this study was to prospectively assess the safety and efficacy outcomes for the synthetic cartilage implant population and to determine if the excellent outcomes were maintained at >5 years. Methods: One hundred and fifty-two patients underwent implant hemiarthroplasty in the original trial; 14 underwent implant removal and conversion to fusion and 3 were lost to follow-up during the first 24 months, leaving 135 eligible for this study. One hundred patients were evaluated at 5+ years; 5 could not be reached for follow-up. Thirty are pending consent, follow-up, and/or data entry; their status will be available for inclusion at the conference presentation. Patients completed a pain visual analogue scale (VAS) and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, preoperatively and at 2, 6, 12, 26, 52, 104 and 260 weeks postoperatively. Minimal clinically important differences are: =30% difference for pain VAS, 9 points for FAAM Sports, and 8 points for FAAM ADL. Great toe active dorsiflexion, weight-bearing radiographs, secondary procedures, and safety parameters were evaluated. Results: Of 100 synthetic cartilage implant hemiarthroplasty patients available at mean 5.8 years follow-up (SD ±0.7; range: 4.4- 7.4), 5 underwent implant removal and conversion to fusion in years 2-5 (Figure 1), and 2 underwent subsequent surgical interventions during the pivotal trial and were censored, leaving 93 patients for evaluation. Pain and function outcomes observed at 5.8 years were similar to those at 2 years (Figure 1). VAS Pain and FAAM Sports Scores were maintained or improved at 5.8 years follow-up, but these differences were not clinically significant. Joint motion was maintained at 5.8 years. No evidence of avascular necrosis, device migration or fragmentation was observed upon independent radiographic review. Eighty-six percent of patients agreed their overall well-being had improved, and 92% would have the procedure again. Conclusion: Clinical and safety outcomes of patients having undergone synthetic cartilage implant hemiarthroplasty for the surgical treatment of hallux rigidus were previously demonstrated to be non-inferior to the gold standard treatment, MTPJ fusion, at 2 years. Prospectively determined outcomes for 100/135 of these implant hemiarthroplasty patients at 5.8 years are similar to those reported at 2 years. Longer-term results demonstrate that clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty are durable, and that the implant remains a viable treatment option to decrease pain, improve function and maintain motion for advanced hallux rigidus