Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

Subtalar fusion decreased talonavicular motion more so than calcaneocuboid motion in this cadaver study. Isolated talonavicular fusion is the most influential of the hindfoot joints, locking hindfoot motion.

Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.

C oughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.

The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. The dorsalis pedis and the artery of the sinus tarsi supply the talar head.

Total braking time following open reduction and internal fixation of right ankle fractures was tested at 6, 9, and 12 weeks postoperatively. These patients were managed with a functional brace, non-weight bearing, and early range of motion in the postoperative period. Braking time was significantly slower than normal at 6 weeks, but had returned to near normal by 9 weeks postoperatively.

In cadaver specimens, the anterolateral capsular reflection of the ankle joint extended proximally the highest with an average of
9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.

Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge-shaped structural bone graft.

Biopsies of the edge of fracture blisters following ankle fracture show that blood-filled blisters represent a deeper injury than clear fluid-filled blisters. The dermis of clear blisters still showed some epithelial cells remaining, while the dermis of blood blisters showed no epithelial cells. Therefore, blood-filled blisters are more difficult to heal.

This clinical study following triple arthrodesis patients for 10 years showed a 27% loss of ankle plantarflexion but no loss of dorsiflexion.

The Moberg procedure involves a dorsal closing wedge osteotomy of the proximal phalanx. This sets the hallux higher off the floor, allowing for easier toe-off with less dorsal impingement during gait.

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.

First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.

The optimal position for ankle arthrodesis is neutral flexion, 5° valgus, and 5° external rotation. Historically, surgeons thought that women should be fused in some amount of equinus to better allow them to wear heeled shoes. However, this can increase the development of neighboring joint arthritis and also create a knee recurvatum deformity when ambulating barefoot. C urrently it is recommended that all patients are fused in neutral dorsi-/plantarflexion.

This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talo- navicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.

The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.

The optimal position for hallux interphalangeal joint arthrodesis is 5° to 10° of plantarflexion, neutral varus-valgus, and neutral rotation. The plantarflexion helps the toe pad to contact the ground during gait.

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.

Stauffer and colleagues quantified ankle joint reactive force to be approximately 5 times body weight. This is a significant concern for prosthetic ankle arthroplasty because the implant surface area is relatively small over which these forces must be spread out.

In a large series of patients with hallux rigidus, risk factors were evaluated. The only factor that had a positive correlation with having hallux rigidus was the radiographic shape of the 1st metatarsal head. Metatarsus primus elevatus, first ray hypermobility, or long first metatarsal head were not significantly associated with hallux rigidus.

The three terminal branches of Baxterâs nerve are the nerve to the medial calcaneal periosteum, the nerve to the flexor digitorum brevis, and the nerve to the abductor digiti minimi. The lateral dorsal cutaneous nerve is a branch of the sural nerve.

In a study performed by Alvarez and colleagues, 47 patients with stage I or II posterior tibial tendon dysfunction were treated nonoperatively with either a hinged ankle-foot orthosis or foot orthosis and a supervised physical therapy program. After 10 therapy visits, 83% of patients had successful subjective and functional outcomes. Eighty-nine percent of patients were satisfied with the outcome of nonoperative treatment. This included significant improvement in visual analog scale scores and increased strength, concentrically and eccentrically. In this study, 11% of patients failed conservative treatment and required surgery.

A meta-analysis of 12 studies showed that healing rates increased from 48% to 76%, and amputation rates decreased from 45% to 19% with the use of hyperbaric oxygen (HBO) and local wound care. In randomized controlled trials, wound area decreased significantly and days to healing decreased significantly in patients treated with HBO. The juxta-wound pO2 was also significantly increased in the HBO-treatment group.

Twenty patients were prospectively monitored with laser Doppler measurements of metatarsal head blood flow during chevron bunionectomy with lateral release. The greatest loss of blood flow occurred with the medial capsulotomy (45% decrease). The lateral release combined with the adductor tenotomy decreased the blood flow to the metatarsal head by 13%, and the metatarsal osteotomy decreased blood flow by an additional 13%. Total decrease in blood flow to the head was 71%. No patients developed avascular necrosis.

In the study by Gibson and Thomson, 38 fusions and 39 arthroplasties were prospectively compared at 2-year follow-up. There was an 82% improvement in the arthrodesis group and only a 45% improvement in the arthroplasty group. Fusion also had lower complication rates and lower cost. There was not a significant increase in first metatarsophalangeal joint dorsiflexion between preoperative and postoperative levels following total joint replacement.

In a prospective cohort study following 105 Lapidus bunionectomies for 3.7 years, the nonunion rate was found to be 6.7%. The American Orthopaedic Foot & Ankle Society scores improved significantly, and loss of correction over 3.7 years was less than 1° for intermetatarsal and hallux valgus angles.

In a cadaveric and in vivo study of the reflections of the ankle joint capsule, the distal tibia-fibula joint was found to communicate with the ankle joint capsule, thus representing a risk for ankle sepsis if it is penetrated by a transfixion wire. The anterolateral capsule displayed the most proximal reflection in all specimens.

Forty-one patients were prospectively randomized into traditional open reduction internal fixation (ORIF) versus primary arthrodesis. The American Orthopaedic Foot & Ankle Society scores at 2-year follow-up were significantly better in the fusion group versus the ORIF group. Of the patients in the ORIF group, 25% later developed arthritis and were converted to fusions.

A retrospective Level IV study followed 84 patients with diabetes who underwent open reduction internal fixation of unstable ankle fractures. After analyzing multiple patient factors including sex, fracture pattern, open or closed injury, nephropathy, hypertension, vasculopathy, peripheral neuropathy, and diabetic control (insulin-dependent compared with non-insulin- dependent), the only factors that predicted a higher rate of complications were vasculopathy and peripheral neuropathy. There was a 12% rate of postoperative infection and an overall 14% rate of complications.

A randomized controlled trial compared recalcitrant insertional Achilles tendinopathy treated with eccentric heel cord stretching versus low-energy shockwave therapy. At 4 months, 28% of the stretching group and 64% of the shockwave therapy group reported complete relief of symptoms or greatly improved symptoms. All outcome measures showed favorable results with shockwave therapy.

A prospective randomized study compared intraarticular lidocaine injection to conscious sedation for analgesia during reduction of ankle fracture-dislocations. There was no difference in the amount of analgesia provided by the two methods. Time for reduction and splinting was less in the local anesthetic group. Quality of reduction was similar in both groups.

4-5 intermetarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.

The description of the ulcer indicates that it is not grossly infected and that there is no underlying bony involvement. According to evidence based medicine, the only treatments that are likely to be effective in the healing of diabetic foot ulcerations are topical growth factors, total contact casting, and for severely infected ulcers hyperbaric oxygen.

In a magnetic resonance imaging topography study looking for the best corresponding shape of the articular surface between the non-weightbearing femoral condyle and the medial talar dome, plugs from the supero-lateral femoral condyle had the best fit with osteochondral lesions of the medial talus in the anterior, central, and posterior zones.

A survey of 428 osteochondral lesions of the talus was undertaken using a nine zone anatomical grid system to determine the most frequent location in which these lesions occur. Results showed that 62% of lesions occurred in the medial talar dome and
34% over the lateral talar dome. The most frequent location along the medial dome was the mid-body of the talus. Medial lesions were larger in surface area as well as deeper than lateral lesions.

A prospective gait study was performed measuring various gait parameters 1 week prior to and 1 year following first metatarsophalangeal joint arthrodesis. The three significant changes in gait were increased maximal ankle push off power, increased single limb support time on the affected limb, and decreased step width. Stride length, walking velocity, and cadence were not significantly different after fusion.

A clinical series of 122 bunions was evaluated for demographic, etiologic, and radiographic findings associated with moderate to severe hallux valgus deformity. The following findings were reported:
83% of patients had a positive family history of bunions
84% of patients had bilateral bunion deformities
71% of patients had curved or oval-shaped metatarsophalangeal joints
71% of patients had a longer 1st metatarsal compared to the 2nd metatarsal by an average of 2.4 mm
11% of bunions were associated with an Achilles tendon contracture

Noninsertional Achilles tendinosis is a noninflammatory degenerative condition that is common in middle-aged athletes. In a 3- year follow-up study examining the use of topical glyceryl trinitrate for Achilles tendinosis, patients were noted to have significantly less tendon tenderness and improved clinical scores compared to the placebo group. At 3 years, 88% of treated patients were asymptomatic. Novel nonoperative measures include sclerosing injections into the Achilles tendon with polidocanol and shock-wave therapy to the Achilles tendon.

A study using the National Medicare C laims History System was performed looking at outcomes following ankle fracture in 33,704 elderly patients, specifically looking at mortality, rehospitalization, and the need for additional surgery. Researchers found that conservatively managed patients had a higher mortality rate up to 2 years following injury compared to patients who underwent open reduction internal fixation. Operatively treated patients had a higher rate of rehospitalization following their injury. Less than
1% of patients required revision of internal fixation, arthroplasty, arthrodesis, or amputation.

C iprofloxacin was shown to cause a decrease in fibroblast proliferation, proteoglycan synthesis, and collagen synthesis. Matrix degrading proteolytic activity was increased.

The resting position of the hallux in normal patients is 20° of dorsiflexion relative to the first metatarsal shaft. In patients with hallux rigidus, the resting position is decreased to 10° of dorsiflexion relative to the metatarsal shaft. This relatively plantarflexed position was not improved to a more normal value following cheilectomy.

The initial description of the Gould modification of the Brostrom procedure recommended âsuturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculumâ.