Orthopedic entrepreneur, surgeon and scientist Phone: 614-895-8747 Address: Orthopedic Foot and Ankle Center 350 West Wilson Bridge Road Worthington Ohio 43085
Journal of Bone and Joint Surgery, American Volume, Jul 1, 2013
Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic... more Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic connective tissue progenitor cells. Alternative harvest sites in foot and ankle surgery include the distal aspect of the tibia and the calcaneus. To our knowledge, no previous studies have characterized the quality of bone marrow aspirate obtained from these alternative sites and compared the results with those of aspirate from the iliac crest. The goal of this study was to determine which anatomic location yields the highest number of osteoblastic progenitor cells. Methods: Forty patients were prospectively enrolled in the study, and separate bone marrow aspirate samples were harvested from the ipsilateral anterior iliac crest, distal tibial metaphysis, and calcaneal body. The aspirate was centrifuged to obtain a concentrate of nucleated cells, which were plated and grown in cell culture. Colonies that stained positive for alkaline phosphatase were counted to estimate the number of osteoblastic progenitor cells in the initial sample. The anatomic locations were compared. Clinical parameters (including sex, age, tobacco use, body mass index, and diabetes) were assessed as possible predictors of osteoblastic progenitor cell yield. Results: Osteoblastic progenitor cells were found at each anatomic location. Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < 0.0001). There was no significant difference in concentration between the tibia and the calcaneus (p = 0.063). Age, sex, tobacco use, and diabetes were not predictive of osteoblastic progenitor cell yield. Conclusions: Osteoblastic progenitor cells are available in the iliac crest, proximal aspect of the tibia, and calcaneus. However, the iliac crest provided the highest yield of osteoblastic progenitor cells. Clinical Relevance: The study demonstrated that osteogenic progenitor cells are available in bone marrow aspirate harvested from the tibia or calcaneus as well as the iliac crest. All three sites are easily accessed, with a low risk of adverse events. However, larger volumes of aspirate may be needed from the tibia or calcaneus to approach the yield of cells from the iliac crest.
Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of... more Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of implants has gained increased popularity in total ankle replacement surgery. With the integration of porous coating into the newer generation of implants, this theoretically increases the chances of osseous ingrowth and survivorship in total ankle replacements. Alternatively, literature in hip replacement surgery has shown increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects this may have on longevity or aseptic loosening secondary to a stress shielding effect. Methods: Our study identified 9 patients who underwent total ankle arthroplasty via a smooth-stemmed tibial prosthesis and matched these patients based on implant age with patients who received fully porous-coated tibial implants. We reviewed radiographs and compared postoperative rates of backside loosening and cystic formation secondary to stress shielding between the two groups. We also compared rates of heterotopic ossification between the two groups. A homoscedastic t-test was used to identify any statistical significance, which was defined as P &lt; 0.05. Results: While the smooth-stem group showed no rates of backside cystic formation or stress shielding, the follow-up matched porous-coated group showed a rate of 55% of cystic formation and potential loosening secondary to stress shielding observed on final radiographic follow up (P &lt; 0.01). There was no statistical difference between the two groups in their rates of heterotopic bone formation (P = 0.37). Conclusion: Despite having a relatively small sample size, this data shows that there is some consistency with the hip arthroplasty literature suggesting an increased risk for stress shielding in fully porous-coated stemmed tibial implants compared to smooth- stemmed tibial implants in total ankle arthroplasty.
Focal damage to articular cartilage and the supporting subchondral plate, commonly referred to as... more Focal damage to articular cartilage and the supporting subchondral plate, commonly referred to as an osteochondral defect (OCD), can be a cause of joint pain and subsequent decreased range of motion. There are few studies specifically describing these lesions in the first metatarsophalangeal (MTP) joint, where they are traditionally grouped into hallux rigidus. There exists an opportunity for early detection and intervention with the intent to prevent deterioration and improve patient outcomes. One contemporary treatment concept is to implant particulated juvenile cartilage allograft to restore articular cartilage. The aim of our study was to review the clinical results of patients that had undergone this procedure for first metatarsal head OCDs. Methods: After IRB approval, a retrospective review of a consecutive case series was studied utilizing the records of three foot and ankle surgeons. Inclusion criteria included all adult patients who were a minimum of one year post surgery and consented to participate. Patient demographics and preoperative visual analog scale (VAS) pain level were recorded from a standardized intake sheet. From the operative note, the OCD size and location was recorded, as well as any concomitant procedures. At a minimum follow up of one year, we obtained objective measurements of arthritis grade and subjective considerations of pain and function, including VAS pain level, Foot Function Index (FFI) questionnaire, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal scale, and an overall patient satisfaction score. Results: Nine patients met inclusion criteria, 4 males and 5 females. The average age was 41 years old (±11.77, range 21-65). The mean preoperative VAS pain score was 57.50 (±18.32, range 30-80). Four OCDs were located centrally on the first metatarsal head. The average OCD size intraoperatively was 30 mm2 (range 16-49). The average time since surgery was 3.26 years (±1.21, range 1.41-5.62). Average first MTP dorsiflexion was 41.78 degrees (±20.70, range 6-70). The average postoperative hallux rigidus classification was grade 2 (range 1-3). The mean VAS pain score improved to 5.22 (±8.44, range 0-20). The average AOFAS score was 88 (±15.91, range 52-100). The average FFI score was 8.04 (±12.60, range 0-30.6). All but one patient were satisfied or very satisfied with their results. At an average of 3.26 years postoperatively, patients had improved pain, did not show significant progression of their first MTP joint degeneration, and were satisfied with their results. Patients reported very little, if any, limitations in their activity level. We believe that articular damage of the first MTP should be viewed in the same way as OCD lesions in larger joints with emphasis on early detection and treatment to avoid the progression to arthritis. Particulated juvenile cartilage allograft is a valuable tool for surgeons to use in treating focal articular defects of the first metatarsal head.
Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral... more Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.
The purpose of this article is to report the complications associated with autogenous bone marrow... more The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation. 4 (Case Series; Therapeutic Study).
INTRODUCTION. The role of total ankle replacement (TAR) is expanding in the United States. As the... more INTRODUCTION. The role of total ankle replacement (TAR) is expanding in the United States. As the number of ankles implanted increases, undoubtedly the number of failures will increase. Several reports in the literature have dealt with salvage of the failed TAR through various methods. MeTHODS. A retrospective chart and radiographic review was performed on all patients who had conversion from a failed Agility TAR to an INBONE TAR at 2 centers and had been performed at least 12 months prior to the study. Exclusion criteria included any patient converted from a different type of TAR, primary TAR, patients followed less than 12 months, and surgical approach other than the standard anterior incision. RESULTS. Five patients met inclusion criteria. The average age was 65.6 ± 13.6 years (range = 45-79 years). Complicating comorbidities were found with 4 patients. The average follow-up was 17.2 ± 6.6 months (range = 7-25 months). The cause of failure of the original Agility TAR was coronal plane deformity in 3 patients, and 1 patient each failed from extensive heterotopic ossification or infection. All patients presented with pain. In 4 cases, there was component subsidence at the talus, tibia, or both. All patients had adjunctive procedures at the time of the revision, including malleolar screw placement in 4 patients and hindfoot arthrodesis in 2 patients. All patients had either 4 or 5 tibial stem components placed. During the follow-up period, 3 patients required additional surgery, including 2 patients classified as failures (1 transtibial amputation and 1 tibiotalocalcaneal arthrodesis). DISCUSSION. This salvage option is technically demanding. The authors caution against TAR revision by conversion in the place of previous infection and in ankle imbalance not amenable to reconstruction. In all cases the initial deformity was corrected. The early results, however, demonstrate high risk of early failure and positional changes.
Background: Access to the medial half of the talus can be challenging even with an osteotomy. Alt... more Background: Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy. Methods: A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications. Results: At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation. Conclusion: Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement. Level of Evidence: Level IV, retrospective case series.
The use of metals as implant materials has become common practice in the field of orthopaedics. A... more The use of metals as implant materials has become common practice in the field of orthopaedics. A wide variety of conditions are treated with metallic implants, and designers have used an assortment of materials to meet the unique mechanical demands of each application. The majority of implants used today, whether pins, plates, screws, or total joints, are made of cobalt-chrome alloy, stainless steel, or titanium. Common metallurgic wisdom cautions against bonding dissimilar metals in a biologically active environment. Surgeons have therefore shied away from combining dissimilar metal implants because of the fear of inciting corrosion that could potentially compromise the implants and lead to aseptic loosening, implant failure, or adverse biological reaction in host tissue. As surgical reconstruction and arthroplasty options expand with the advent of newer implants and expanded operative techniques, the orthopaedic surgeon will increasingly be faced with weighing the risks and benefits of combining implants made of dissimilar metals in a patient. Here, the authors examine the origins of the concern over using mixed metals, discuss mechanisms of corrosion as they relate to surgical implants, and review both in vitro and in vivo studies concerning the most common combinations of dissimilar metals in order to guide the surgeon in choosing implants.
Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treat... more Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. Methods: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. Results: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 ± 13.7 (range, 12 to 73) years. The average followup was 37.2 ± 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 ± 0.67 cm 2. There were 20 lesions larger than 1.5 cm 2 and 110 lesions smaller than 1.5 cm 2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm 2 and uncontained lesions were associated with a poor clinical outcome. Conclusions: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions
Category: Ankle Arthritis; Ankle; Hindfoot; Trauma Introduction/Purpose: The etiology of ankle ar... more Category: Ankle Arthritis; Ankle; Hindfoot; Trauma Introduction/Purpose: The etiology of ankle arthritis is multifactorial and secondary osseous changes to the tibiotalar joint can be variable. The relationship of bone density within the tibia and talus with respect to type of ankle arthritis is not well understood. Improved insight of osseous characteristics amongst ankle arthritis patients is helpful in determining optimal implant selection for total ankle arthroplasty. The purpose of this study is to retrospectively analyze pre-operative total ankle arthroplasty patients' films for osseous characteristics associated traumatic ankle arthritis compared to other forms of arthritis using computed tomography (CT) generated Hounsfield units (HU) to analyze bone mineral density and rate of cyst formation. Methods: A retrospective analysis was performed of 440 patients, under a single orthopedic practice, who underwent primary TAA between 2013-2019. Pre-operative HU of tibia and talus were analyzed amongst two groups (Non-traumatic OA, Post- traumatic OA) within one year prior to TAA. Results: Forty-nine qualified patients (23 NTA, 26 PTA) with mean follow-up in months of 19.98 (SD 15.22) were analyzed. Cystic changes at level of TAA cuts or retained bone: 5 tibia (10.2%), 7 talus (14.29%), 16 combined (32.65%). Overall tibial HU mean 270.23 (SD 91.28) and talus 463.26 (103.65). HU of the tibia amongst post-traumatic and non-traumatic patients was 257.21 (SD 93.9) and 284.94 (SD 87.9) (p=0.29137) and talus 434.53 (104.7) and 495.75 (94.33) (p=0.0365). Conclusion: Our results suggest with tibiotalar arthritis HU is a useful tool to predict bone quality. Clinical results amongst the NTA and PTA groups was comparable. Significantly lower HU values were recorded for the PTA groups. Rate of cystic formation within bone of distal tibia does not necessarily correlate with overall HU measured bone mineral density.
Clinical Orthopaedics and Related Research, Aug 1, 2011
Background Fresh osteochondral allograft transplantation can be used to replace talar osteochondr... more Background Fresh osteochondral allograft transplantation can be used to replace talar osteochondral defects (OCDs) with single bulk osteochondral graft. While limited studies report improvement of function, improvement in quality of life and radiographic durability is unknown. Questions/purpose We therefore determined if this technique improved function, increased quality of life, and provided durable graft stability radiographically and by MRI. Patients and Methods We prospectively followed 19 patients (19 OCDs). We excluded seven patients (four with insufficient followup, two who were lost to followup, and one with graft failure), leaving 12 patients with a minimum followup of 2 years (average, 3.3 years; range, 2.0-4.6 years). Functional and quality of life outcomes were quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the SF-12 Health Survey. Graft incorporation and stability were assessed through radiographs and MRI. Results Mean total AOFAS scores (61 ± 9 to 79 ± 6), pain subscores (17 ± 8 versus 26 ± 5), and function subscores (34 ± 3 versus 42 ± 4) improved from preoperatively to last followup. We observed no improvements of the physical and mental health components of the SF-12 Health Survey from preoperatively to last followup. At last followup, three of the 12 grafts had radiolucencies, four had edema, one failed to incorporate, and none had subsidence. One of the 19 patients in the overall series underwent graft revision. Conclusions Patients with talar OCDs can expect functional improvement after this technique. The majority will have stable grafts at least short term. Larger studies with longer followup are needed to determine if this procedure substantially improves quality of life, if graft radiolucencies and edema have any long-term implications, and whether the grafts are durable. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical mana... more Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years. Levels of Evidence: A retrospective case series
Coronal plane deformity is a common consideration in endstage ankle arthritis. Historically, it h... more Coronal plane deformity is a common consideration in endstage ankle arthritis. Historically, it has been suggested that coronal plane deformities exceeding 10 to 15 degrees would be better served with ankle arthrodesis due to increased failure rates. 15,25,26 More recent literature has shown comparable outcomes for deformities between 15 and 30 degrees. 10,13,17,20,21 All authors emphasize the importance of correction of the coronal plane deformity prior to placing the ankle arthroplasty. It has been shown that preoperative deformity that is not corrected at the time of total ankle arthroplasty may cause increased rates of wear and recurrence of deformity. 4,5,7,10,17,21 Interventions to achieve and maintain coronal plane correction include soft tissue releases, ligament reconstruction, and osseous procedures. Modern total ankle arthroplasty systems are 3-component designs with the polyethylene being either fixed or mobile. Coronal stability provided through articular geometry varies according to the implant design. Tibial component instability has been documented with incomplete coverage of the anterior and posterior cortices, resulting in 862744F AIXXX10.
The purpose of the present study was to assess the validity of the Thompson sign and determine wh... more The purpose of the present study was to assess the validity of the Thompson sign and determine whether the deep flexors of the foot can produce a falsely intact Achilles tendon.Ten unmatched above-the-knee lower extremity cadaveric specimens were studied. In group 1, the Achilles tendon was sectioned into 25% increments. The Thompson maneuver was performed after each sequential sectioning of the Achilles tendon, including after it had been completely sectioned. If the Thompson sign was still intact after complete release of the Achilles tendon, we proceeded to release the tendon, and tendon flexor hallucis longus, flexor digitorum longus, and posterior tibial tendons. The Thompson test was performed after the release of each tendon. In group 2, the tendon releases were performed in a reverse order to that of group 1, with the Thompson test performed after each release. In group 1, the Thompson sign remained intact in all specimens after sectioning of 25%, 50%, and 75% of the tendon. After complete (100%) release of the tendon, the Thompson sign was absent in all specimens. In group 2, the Thompson sign remained intact after sectioning of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons in all specimens. The Thompson sign remained intact in all specimens after sectioning of 25%, 50%, and 75% of the Achilles tendon. After complete release of the tendon, the Thompson sign was absent in all specimens.The Thompson test is an accurate clinical test for diagnosing complete Achilles tendon ruptures. However, it might not be a useful test for diagnosing partial Achilles tendon ruptures. Our findings also call into question the usefulness of the Thompson test in the intraoperative setting.
Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomech... more Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomechanical outcomes. It has been postulated that augmenting a primary Achilles tendon repair with a collagen ribbon will improve the repair construct's initial strength, thereby facilitating early motion. The purpose of the present study was to compare the failure load of Achilles tendon defects repaired with suture, with or without augmentation with a collagen ribbon. Ten matched pairs of cadaveric feet and tibiae underwent simulated Achilles tendon tear in the watershed area and were then repaired with 4-strand Krackow sutures only or were sutured and augmented with a box weave collagen ribbon xenograft. The specimens were prepared for testing by keeping the insertion of the Achilles to the calcaneus intact and dissecting the gastrocnemius at its origin, leaving the repair undisturbed. The mean load at failure for the augmented (suture plus collagen ribbon) specimens was 392.4 AE 74.9 N. In contrast, the mean load at failure for the suture-only (control) construct was 98.0 AE 17.6 N (p < .001). The augmented specimens demonstrated a greater mean strength of 4.1 AE 0.9 N (range 3.2 to 5.6). After cyclic loading, the mean gap across the Achilles repair was significantly smaller in the augmented group than in the control group (p ¼ .006). We have concluded that box weave collagen ribbon augmentation of the primary suture Achilles tendon repairs can provide enhanced gap resistance and strength under cyclic loading and ramped tensile testing.
Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Current available total ankle re... more Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Current available total ankle replacement constructs offer either proximal projecting pegs (non- stemmed) in various shapes or large stem (stemmed) designs to the superior aspect of the tibia component. Each design offers inherent stability and unique function. Periprosthetic radiolucency can develop post-operatively and lead to adverse effects. However, the incidence and clinical significance of lucency formation amongst stemmed and non-stemmed constructs is poorly understood. Methods: A retrospective radiographic and chart analysis was performed of 256 patients, under a single orthopedic practice, who underwent primary TAA between 2013-2019 with one of 3 total ankle systems. Pre-operative ankle characteristics, intraoperative procedures, as well as post-operative angles, lucency formation, region of lucency formation, and patient outcomes were analyzed. Results: Patients' mean age 65.5 yrs., male n=126 and female...
Background Gastrocnemius recession is a popular procedure utilized to treat chronic conditions re... more Background Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability. Methods Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession “Baumann” procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry. Results Medial gastrocnemius recession and Baumann procedures were equally effect...
Category: Midfoot/Forefoot Introduction/Purpose: The first metatarsophalangeal joint (MTPJ) is on... more Category: Midfoot/Forefoot Introduction/Purpose: The first metatarsophalangeal joint (MTPJ) is one of the most common locations for arthritis in the foot. When conservative methods fail, two main surgical treatment options exist, fusion or joint implant. For various reasons these surgeries can fail leaving relatively few salvage options. A common salvage option is the first MTPJ distraction arthrodesis. Use of allograft discs to decrease surgical time and donor site morbidity has become an increasingly popular option for MTP distraction arthrodesis. The purpose of this study was to look at the maintenance of the first ray length in first MTPJ distraction arthrodesis using allograft discs. Methods: We reviewed 14 patients who underwent first MTPJ distraction arthrodesis, measuring first ray length at the first post- operative weightbearing radiograph and most recent weightbearing radiograph. Average follow up was 12.75 months between radiographs. Results: Average shortening was 3 mm on the lateral measurements and 2.3 mm on the AP measurements. CT verified overall nonunion rate was 43% whereas, symptomatic nonunion rate was 21%. Conclusion: Amount of shortening and graft size did appear to have a positive correlation. Union rate did not affect shortening of first ray, but revision for a failed implant arthroplasty did correlate with increased shortening compared to revision for a failed first MTPJ fusion. Our data suggests a 2-3 mm shortening of the first ray can be predicted over the first 12 months after a first MTPJ distraction arthrodesis using allograft discs. Longer term studies with larger patient populations, and a comparative study to cortical autograft would provide more accurate insight to outcomes of first MTPJ distraction arthrodesis.
Journal of Bone and Joint Surgery, American Volume, Jul 1, 2013
Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic... more Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic connective tissue progenitor cells. Alternative harvest sites in foot and ankle surgery include the distal aspect of the tibia and the calcaneus. To our knowledge, no previous studies have characterized the quality of bone marrow aspirate obtained from these alternative sites and compared the results with those of aspirate from the iliac crest. The goal of this study was to determine which anatomic location yields the highest number of osteoblastic progenitor cells. Methods: Forty patients were prospectively enrolled in the study, and separate bone marrow aspirate samples were harvested from the ipsilateral anterior iliac crest, distal tibial metaphysis, and calcaneal body. The aspirate was centrifuged to obtain a concentrate of nucleated cells, which were plated and grown in cell culture. Colonies that stained positive for alkaline phosphatase were counted to estimate the number of osteoblastic progenitor cells in the initial sample. The anatomic locations were compared. Clinical parameters (including sex, age, tobacco use, body mass index, and diabetes) were assessed as possible predictors of osteoblastic progenitor cell yield. Results: Osteoblastic progenitor cells were found at each anatomic location. Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < 0.0001). There was no significant difference in concentration between the tibia and the calcaneus (p = 0.063). Age, sex, tobacco use, and diabetes were not predictive of osteoblastic progenitor cell yield. Conclusions: Osteoblastic progenitor cells are available in the iliac crest, proximal aspect of the tibia, and calcaneus. However, the iliac crest provided the highest yield of osteoblastic progenitor cells. Clinical Relevance: The study demonstrated that osteogenic progenitor cells are available in bone marrow aspirate harvested from the tibia or calcaneus as well as the iliac crest. All three sites are easily accessed, with a low risk of adverse events. However, larger volumes of aspirate may be needed from the tibia or calcaneus to approach the yield of cells from the iliac crest.
Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of... more Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of implants has gained increased popularity in total ankle replacement surgery. With the integration of porous coating into the newer generation of implants, this theoretically increases the chances of osseous ingrowth and survivorship in total ankle replacements. Alternatively, literature in hip replacement surgery has shown increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects this may have on longevity or aseptic loosening secondary to a stress shielding effect. Methods: Our study identified 9 patients who underwent total ankle arthroplasty via a smooth-stemmed tibial prosthesis and matched these patients based on implant age with patients who received fully porous-coated tibial implants. We reviewed radiographs and compared postoperative rates of backside loosening and cystic formation secondary to stress shielding between the two groups. We also compared rates of heterotopic ossification between the two groups. A homoscedastic t-test was used to identify any statistical significance, which was defined as P &lt; 0.05. Results: While the smooth-stem group showed no rates of backside cystic formation or stress shielding, the follow-up matched porous-coated group showed a rate of 55% of cystic formation and potential loosening secondary to stress shielding observed on final radiographic follow up (P &lt; 0.01). There was no statistical difference between the two groups in their rates of heterotopic bone formation (P = 0.37). Conclusion: Despite having a relatively small sample size, this data shows that there is some consistency with the hip arthroplasty literature suggesting an increased risk for stress shielding in fully porous-coated stemmed tibial implants compared to smooth- stemmed tibial implants in total ankle arthroplasty.
Focal damage to articular cartilage and the supporting subchondral plate, commonly referred to as... more Focal damage to articular cartilage and the supporting subchondral plate, commonly referred to as an osteochondral defect (OCD), can be a cause of joint pain and subsequent decreased range of motion. There are few studies specifically describing these lesions in the first metatarsophalangeal (MTP) joint, where they are traditionally grouped into hallux rigidus. There exists an opportunity for early detection and intervention with the intent to prevent deterioration and improve patient outcomes. One contemporary treatment concept is to implant particulated juvenile cartilage allograft to restore articular cartilage. The aim of our study was to review the clinical results of patients that had undergone this procedure for first metatarsal head OCDs. Methods: After IRB approval, a retrospective review of a consecutive case series was studied utilizing the records of three foot and ankle surgeons. Inclusion criteria included all adult patients who were a minimum of one year post surgery and consented to participate. Patient demographics and preoperative visual analog scale (VAS) pain level were recorded from a standardized intake sheet. From the operative note, the OCD size and location was recorded, as well as any concomitant procedures. At a minimum follow up of one year, we obtained objective measurements of arthritis grade and subjective considerations of pain and function, including VAS pain level, Foot Function Index (FFI) questionnaire, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal scale, and an overall patient satisfaction score. Results: Nine patients met inclusion criteria, 4 males and 5 females. The average age was 41 years old (±11.77, range 21-65). The mean preoperative VAS pain score was 57.50 (±18.32, range 30-80). Four OCDs were located centrally on the first metatarsal head. The average OCD size intraoperatively was 30 mm2 (range 16-49). The average time since surgery was 3.26 years (±1.21, range 1.41-5.62). Average first MTP dorsiflexion was 41.78 degrees (±20.70, range 6-70). The average postoperative hallux rigidus classification was grade 2 (range 1-3). The mean VAS pain score improved to 5.22 (±8.44, range 0-20). The average AOFAS score was 88 (±15.91, range 52-100). The average FFI score was 8.04 (±12.60, range 0-30.6). All but one patient were satisfied or very satisfied with their results. At an average of 3.26 years postoperatively, patients had improved pain, did not show significant progression of their first MTP joint degeneration, and were satisfied with their results. Patients reported very little, if any, limitations in their activity level. We believe that articular damage of the first MTP should be viewed in the same way as OCD lesions in larger joints with emphasis on early detection and treatment to avoid the progression to arthritis. Particulated juvenile cartilage allograft is a valuable tool for surgeons to use in treating focal articular defects of the first metatarsal head.
Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral... more Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.
The purpose of this article is to report the complications associated with autogenous bone marrow... more The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation. 4 (Case Series; Therapeutic Study).
INTRODUCTION. The role of total ankle replacement (TAR) is expanding in the United States. As the... more INTRODUCTION. The role of total ankle replacement (TAR) is expanding in the United States. As the number of ankles implanted increases, undoubtedly the number of failures will increase. Several reports in the literature have dealt with salvage of the failed TAR through various methods. MeTHODS. A retrospective chart and radiographic review was performed on all patients who had conversion from a failed Agility TAR to an INBONE TAR at 2 centers and had been performed at least 12 months prior to the study. Exclusion criteria included any patient converted from a different type of TAR, primary TAR, patients followed less than 12 months, and surgical approach other than the standard anterior incision. RESULTS. Five patients met inclusion criteria. The average age was 65.6 ± 13.6 years (range = 45-79 years). Complicating comorbidities were found with 4 patients. The average follow-up was 17.2 ± 6.6 months (range = 7-25 months). The cause of failure of the original Agility TAR was coronal plane deformity in 3 patients, and 1 patient each failed from extensive heterotopic ossification or infection. All patients presented with pain. In 4 cases, there was component subsidence at the talus, tibia, or both. All patients had adjunctive procedures at the time of the revision, including malleolar screw placement in 4 patients and hindfoot arthrodesis in 2 patients. All patients had either 4 or 5 tibial stem components placed. During the follow-up period, 3 patients required additional surgery, including 2 patients classified as failures (1 transtibial amputation and 1 tibiotalocalcaneal arthrodesis). DISCUSSION. This salvage option is technically demanding. The authors caution against TAR revision by conversion in the place of previous infection and in ankle imbalance not amenable to reconstruction. In all cases the initial deformity was corrected. The early results, however, demonstrate high risk of early failure and positional changes.
Background: Access to the medial half of the talus can be challenging even with an osteotomy. Alt... more Background: Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy. Methods: A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications. Results: At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation. Conclusion: Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement. Level of Evidence: Level IV, retrospective case series.
The use of metals as implant materials has become common practice in the field of orthopaedics. A... more The use of metals as implant materials has become common practice in the field of orthopaedics. A wide variety of conditions are treated with metallic implants, and designers have used an assortment of materials to meet the unique mechanical demands of each application. The majority of implants used today, whether pins, plates, screws, or total joints, are made of cobalt-chrome alloy, stainless steel, or titanium. Common metallurgic wisdom cautions against bonding dissimilar metals in a biologically active environment. Surgeons have therefore shied away from combining dissimilar metal implants because of the fear of inciting corrosion that could potentially compromise the implants and lead to aseptic loosening, implant failure, or adverse biological reaction in host tissue. As surgical reconstruction and arthroplasty options expand with the advent of newer implants and expanded operative techniques, the orthopaedic surgeon will increasingly be faced with weighing the risks and benefits of combining implants made of dissimilar metals in a patient. Here, the authors examine the origins of the concern over using mixed metals, discuss mechanisms of corrosion as they relate to surgical implants, and review both in vitro and in vivo studies concerning the most common combinations of dissimilar metals in order to guide the surgeon in choosing implants.
Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treat... more Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. Methods: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. Results: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 ± 13.7 (range, 12 to 73) years. The average followup was 37.2 ± 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 ± 0.67 cm 2. There were 20 lesions larger than 1.5 cm 2 and 110 lesions smaller than 1.5 cm 2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm 2 and uncontained lesions were associated with a poor clinical outcome. Conclusions: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions
Category: Ankle Arthritis; Ankle; Hindfoot; Trauma Introduction/Purpose: The etiology of ankle ar... more Category: Ankle Arthritis; Ankle; Hindfoot; Trauma Introduction/Purpose: The etiology of ankle arthritis is multifactorial and secondary osseous changes to the tibiotalar joint can be variable. The relationship of bone density within the tibia and talus with respect to type of ankle arthritis is not well understood. Improved insight of osseous characteristics amongst ankle arthritis patients is helpful in determining optimal implant selection for total ankle arthroplasty. The purpose of this study is to retrospectively analyze pre-operative total ankle arthroplasty patients' films for osseous characteristics associated traumatic ankle arthritis compared to other forms of arthritis using computed tomography (CT) generated Hounsfield units (HU) to analyze bone mineral density and rate of cyst formation. Methods: A retrospective analysis was performed of 440 patients, under a single orthopedic practice, who underwent primary TAA between 2013-2019. Pre-operative HU of tibia and talus were analyzed amongst two groups (Non-traumatic OA, Post- traumatic OA) within one year prior to TAA. Results: Forty-nine qualified patients (23 NTA, 26 PTA) with mean follow-up in months of 19.98 (SD 15.22) were analyzed. Cystic changes at level of TAA cuts or retained bone: 5 tibia (10.2%), 7 talus (14.29%), 16 combined (32.65%). Overall tibial HU mean 270.23 (SD 91.28) and talus 463.26 (103.65). HU of the tibia amongst post-traumatic and non-traumatic patients was 257.21 (SD 93.9) and 284.94 (SD 87.9) (p=0.29137) and talus 434.53 (104.7) and 495.75 (94.33) (p=0.0365). Conclusion: Our results suggest with tibiotalar arthritis HU is a useful tool to predict bone quality. Clinical results amongst the NTA and PTA groups was comparable. Significantly lower HU values were recorded for the PTA groups. Rate of cystic formation within bone of distal tibia does not necessarily correlate with overall HU measured bone mineral density.
Clinical Orthopaedics and Related Research, Aug 1, 2011
Background Fresh osteochondral allograft transplantation can be used to replace talar osteochondr... more Background Fresh osteochondral allograft transplantation can be used to replace talar osteochondral defects (OCDs) with single bulk osteochondral graft. While limited studies report improvement of function, improvement in quality of life and radiographic durability is unknown. Questions/purpose We therefore determined if this technique improved function, increased quality of life, and provided durable graft stability radiographically and by MRI. Patients and Methods We prospectively followed 19 patients (19 OCDs). We excluded seven patients (four with insufficient followup, two who were lost to followup, and one with graft failure), leaving 12 patients with a minimum followup of 2 years (average, 3.3 years; range, 2.0-4.6 years). Functional and quality of life outcomes were quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the SF-12 Health Survey. Graft incorporation and stability were assessed through radiographs and MRI. Results Mean total AOFAS scores (61 ± 9 to 79 ± 6), pain subscores (17 ± 8 versus 26 ± 5), and function subscores (34 ± 3 versus 42 ± 4) improved from preoperatively to last followup. We observed no improvements of the physical and mental health components of the SF-12 Health Survey from preoperatively to last followup. At last followup, three of the 12 grafts had radiolucencies, four had edema, one failed to incorporate, and none had subsidence. One of the 19 patients in the overall series underwent graft revision. Conclusions Patients with talar OCDs can expect functional improvement after this technique. The majority will have stable grafts at least short term. Larger studies with longer followup are needed to determine if this procedure substantially improves quality of life, if graft radiolucencies and edema have any long-term implications, and whether the grafts are durable. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical mana... more Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years. Levels of Evidence: A retrospective case series
Coronal plane deformity is a common consideration in endstage ankle arthritis. Historically, it h... more Coronal plane deformity is a common consideration in endstage ankle arthritis. Historically, it has been suggested that coronal plane deformities exceeding 10 to 15 degrees would be better served with ankle arthrodesis due to increased failure rates. 15,25,26 More recent literature has shown comparable outcomes for deformities between 15 and 30 degrees. 10,13,17,20,21 All authors emphasize the importance of correction of the coronal plane deformity prior to placing the ankle arthroplasty. It has been shown that preoperative deformity that is not corrected at the time of total ankle arthroplasty may cause increased rates of wear and recurrence of deformity. 4,5,7,10,17,21 Interventions to achieve and maintain coronal plane correction include soft tissue releases, ligament reconstruction, and osseous procedures. Modern total ankle arthroplasty systems are 3-component designs with the polyethylene being either fixed or mobile. Coronal stability provided through articular geometry varies according to the implant design. Tibial component instability has been documented with incomplete coverage of the anterior and posterior cortices, resulting in 862744F AIXXX10.
The purpose of the present study was to assess the validity of the Thompson sign and determine wh... more The purpose of the present study was to assess the validity of the Thompson sign and determine whether the deep flexors of the foot can produce a falsely intact Achilles tendon.Ten unmatched above-the-knee lower extremity cadaveric specimens were studied. In group 1, the Achilles tendon was sectioned into 25% increments. The Thompson maneuver was performed after each sequential sectioning of the Achilles tendon, including after it had been completely sectioned. If the Thompson sign was still intact after complete release of the Achilles tendon, we proceeded to release the tendon, and tendon flexor hallucis longus, flexor digitorum longus, and posterior tibial tendons. The Thompson test was performed after the release of each tendon. In group 2, the tendon releases were performed in a reverse order to that of group 1, with the Thompson test performed after each release. In group 1, the Thompson sign remained intact in all specimens after sectioning of 25%, 50%, and 75% of the tendon. After complete (100%) release of the tendon, the Thompson sign was absent in all specimens. In group 2, the Thompson sign remained intact after sectioning of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons in all specimens. The Thompson sign remained intact in all specimens after sectioning of 25%, 50%, and 75% of the Achilles tendon. After complete release of the tendon, the Thompson sign was absent in all specimens.The Thompson test is an accurate clinical test for diagnosing complete Achilles tendon ruptures. However, it might not be a useful test for diagnosing partial Achilles tendon ruptures. Our findings also call into question the usefulness of the Thompson test in the intraoperative setting.
Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomech... more Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomechanical outcomes. It has been postulated that augmenting a primary Achilles tendon repair with a collagen ribbon will improve the repair construct's initial strength, thereby facilitating early motion. The purpose of the present study was to compare the failure load of Achilles tendon defects repaired with suture, with or without augmentation with a collagen ribbon. Ten matched pairs of cadaveric feet and tibiae underwent simulated Achilles tendon tear in the watershed area and were then repaired with 4-strand Krackow sutures only or were sutured and augmented with a box weave collagen ribbon xenograft. The specimens were prepared for testing by keeping the insertion of the Achilles to the calcaneus intact and dissecting the gastrocnemius at its origin, leaving the repair undisturbed. The mean load at failure for the augmented (suture plus collagen ribbon) specimens was 392.4 AE 74.9 N. In contrast, the mean load at failure for the suture-only (control) construct was 98.0 AE 17.6 N (p < .001). The augmented specimens demonstrated a greater mean strength of 4.1 AE 0.9 N (range 3.2 to 5.6). After cyclic loading, the mean gap across the Achilles repair was significantly smaller in the augmented group than in the control group (p ¼ .006). We have concluded that box weave collagen ribbon augmentation of the primary suture Achilles tendon repairs can provide enhanced gap resistance and strength under cyclic loading and ramped tensile testing.
Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Current available total ankle re... more Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Current available total ankle replacement constructs offer either proximal projecting pegs (non- stemmed) in various shapes or large stem (stemmed) designs to the superior aspect of the tibia component. Each design offers inherent stability and unique function. Periprosthetic radiolucency can develop post-operatively and lead to adverse effects. However, the incidence and clinical significance of lucency formation amongst stemmed and non-stemmed constructs is poorly understood. Methods: A retrospective radiographic and chart analysis was performed of 256 patients, under a single orthopedic practice, who underwent primary TAA between 2013-2019 with one of 3 total ankle systems. Pre-operative ankle characteristics, intraoperative procedures, as well as post-operative angles, lucency formation, region of lucency formation, and patient outcomes were analyzed. Results: Patients' mean age 65.5 yrs., male n=126 and female...
Background Gastrocnemius recession is a popular procedure utilized to treat chronic conditions re... more Background Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability. Methods Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession “Baumann” procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry. Results Medial gastrocnemius recession and Baumann procedures were equally effect...
Category: Midfoot/Forefoot Introduction/Purpose: The first metatarsophalangeal joint (MTPJ) is on... more Category: Midfoot/Forefoot Introduction/Purpose: The first metatarsophalangeal joint (MTPJ) is one of the most common locations for arthritis in the foot. When conservative methods fail, two main surgical treatment options exist, fusion or joint implant. For various reasons these surgeries can fail leaving relatively few salvage options. A common salvage option is the first MTPJ distraction arthrodesis. Use of allograft discs to decrease surgical time and donor site morbidity has become an increasingly popular option for MTP distraction arthrodesis. The purpose of this study was to look at the maintenance of the first ray length in first MTPJ distraction arthrodesis using allograft discs. Methods: We reviewed 14 patients who underwent first MTPJ distraction arthrodesis, measuring first ray length at the first post- operative weightbearing radiograph and most recent weightbearing radiograph. Average follow up was 12.75 months between radiographs. Results: Average shortening was 3 mm on the lateral measurements and 2.3 mm on the AP measurements. CT verified overall nonunion rate was 43% whereas, symptomatic nonunion rate was 21%. Conclusion: Amount of shortening and graft size did appear to have a positive correlation. Union rate did not affect shortening of first ray, but revision for a failed implant arthroplasty did correlate with increased shortening compared to revision for a failed first MTPJ fusion. Our data suggests a 2-3 mm shortening of the first ray can be predicted over the first 12 months after a first MTPJ distraction arthrodesis using allograft discs. Longer term studies with larger patient populations, and a comparative study to cortical autograft would provide more accurate insight to outcomes of first MTPJ distraction arthrodesis.
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