RESUMO
Subsidence of the talar component results in significant morbidity after total ankle replacement. When recognized, prompt revision could be needed to preserve the function of the implant; however, this is not always the case. In situations in which the implant cannot be revised, tibiotalocalcaneal arthrodesis might be necessary to salvage the extremity. The purpose of the present report is to describe the use of a custom titanium alloy truss to fill a bony void created by explantation of the implant components. Total ankle replacement was performed as the initial surgery to address end-stage osteoarthritis. Two years after the index procedure, the patient underwent revision of the polyethylene and talar components with subtalar arthrodesis secondary to progressive subtalar osteoarthritis and talar subsidence. The implant subsequently became infected and was removed. The patient underwent re-implantation after the infection had resolved, but significant talar subsidence required conversion to a tibiotalocalcaneal arthrodesis with a custom titanium alloy truss and retrograde intramedullary nail. At the most recent follow-up appointment, the patient was weightbearing on a stable extremity and pain free. Radiographic examination confirmed appropriate implant alignment and evidence of bone formation throughout the titanium truss. Although our results are restricted to a single case with initial, limited follow-up data, combining sound structural mechanics with an open architecture and unique texture, the custom titanium truss appears to maintain the limb length and promote healing across a large void.
Assuntos
Artrodese/instrumentação , Artroplastia de Substituição do Tornozelo/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Terapia de Salvação/instrumentação , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Artrodese/métodos , Artroplastia de Substituição do Tornozelo/métodos , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/diagnóstico por imagem , Osteoartrite/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia/métodos , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica , Reoperação/métodos , Medição de Risco , Terapia de Salvação/métodos , Titânio , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 ± 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 ± 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 ± 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 ± 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) = -6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed.
Assuntos
Articulação do Tornozelo/cirurgia , Artrodese/métodos , Cartilagem Articular/cirurgia , Fixação Intramedular de Fraturas/métodos , Articulação Talocalcânea/cirurgia , Idoso , Articulação do Tornozelo/fisiopatologia , Artrodese/instrumentação , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Radiografia/métodos , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Articulação Talocalcânea/diagnóstico por imagem , Resultado do TratamentoRESUMO
Evans calcaneal osteotomy remains a cornerstone in the correction of the flexible flatfoot. Although multiple techniques have been used to maintain the length of the lateral column, a low profile wedge locking plate was recently introduced as an alternative to the traditional tricortical allograft wedge. We hypothesized that the wedge locking plate would better maintain the mid-calcaneal length compared with the tricortical allograft wedge. To test this hypothesis, after Evans osteotomy, the mid-calcaneal length was measured in the immediate postoperative period and again at 3 and 6 months. A total of 24 patients met the inclusion criteria. The mean patient age was 48.1 years (range 11 to 66). Of the 24 patients, 9 (37.5%) were treated with a tricortical allograft wedge and 15 (62.5%) with a wedge locking plate. At 3 months postoperatively, the mean decrease in mid-calcaneal length was similar for the tricortical allograft wedge group (1.3 ± 1.9 mm) and the wedge locking plate group (0.5 ± 0.9 mm, p = .275). At 6 months postoperatively, however, the mean decrease in mid-calcaneal length was greater for the tricortical allograft wedge group (2.8 ± 1.7 mm) than for the wedge locking plate group (0.6 ± 0.7 mm, p = .004). The 2 groups demonstrated a similar incidence of dorsally displaced distal calcaneal fragments throughout the study endpoint (p ≥ .052). These results suggest that the wedge locking plate better maintains the mid-calcaneal length over time compared with the tricortical allograft wedge.
Assuntos
Placas Ósseas , Transplante Ósseo/métodos , Calcâneo/cirurgia , Pé Chato/cirurgia , Osteotomia/instrumentação , Adulto , Aloenxertos , Calcâneo/diagnóstico por imagem , Estudos de Coortes , Bases de Dados Factuais , Feminino , Pé Chato/diagnóstico por imagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteotomia/métodos , Radiografia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoRESUMO
Intraoperatively, foot and ankle surgeons will encounter peroneal pathologic features in patients with asymptomatic lateral ankles. The purpose of the present study was to review the ankle magnetic resonance imaging (MRI) scans of patients without a history of ankle trauma or lateral ankle pain to determine which anatomic variants correlate with peroneal tendon pathologic features and noted pathophysiology. A total of 500 MRI scans were screened, 108 (41.90 ± 20.42) of which met the inclusion criteria. The peroneus brevis tendon was intact in 104 MRI scans (96.30%), and the peroneus longus tendon was intact in 108 (100.00%). The results of the present study have confirmed statistically significant correlations between the presence of an os perineum and tendinopathy of the peroneus longus [rs(106) = 0.27], undulating peroneal grooves and the severity of peroneal brevis tears [rs(106) = 0.32], a boomerang-shaped peroneus brevis tendon and increasing tendinopathy of the peroneal tendons [brevis (rs(106) = 0.37; longus rs(106) = 0.33], and low-lying muscle bellies and chronic injuries of the superior peroneal retinaculum (rÏ = 0.19). However, the present study did not find evidence to support the presumed correlations between peroneal tendon pathologic findings and hypertrophied peroneal tubercles, low-lying muscle bellies, or the peroneus quartus muscle. Adding to the published data, the present study found a statistically significant correlation between undulating peroneal grooves and an increasing prevalence of osteophytes within the peroneal groove [rs(106) = 0.32]. MRI findings of anatomic variants or peroneal pathologic features might be useful for injury prevention; however, we advise caution from using the findings alone to advocate surgical intervention. To definitively assess causation, prospective, long-term cohort studies are warranted.
Assuntos
Tornozelo , Traumatismos dos Tendões/epidemiologia , Traumatismos dos Tendões/patologia , Adulto , Fatores Etários , Feminino , Humanos , Incidência , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Osteófito/epidemiologia , Osteófito/patologia , Osteófito/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Traumatismos dos Tendões/fisiopatologia , Adulto JovemRESUMO
Arthrodiastasis of the calcaneocuboid joint after medial double arthrodesis has been described, but the extent remains unreported. We present our comparative findings after medial double and Lapidus fusion on the effects of the calcaneocuboid joint. Adults undergoing medial column fusion with internal fixation and a minimal clinical and radiographic follow-up period of 3 months were included. Subjects were excluded for Charcot deformity, previous arthrodesis surgery, and history of calcaneocuboid joint trauma or surgery. Although 52 patients were identified, 32 (mean age 56.69 ± 12.56 years; 11 males) met the study criteria (15 medial double and 17 Lapidus procedures). The height of the calcaneocuboid joint on the lateral radiograph and width of the calcaneocuboid joint on the anteroposterior radiograph were measured postoperatively and fixed, given the overlap often noted preoperatively in flatfoot deformities. The joint depth was measured at 3 points and averaged both preoperatively and postoperatively on lateral and anteroposterior radiographs. The volume of the calcaneocuboid joint (mm(3)) was the primary endpoint. Medial column fusion elicited a statistically significant mean increase of 32% in calcaneocuboid joint diastasis (p < .001). The percent change in diastasis volume was statistically different between the medial double (61.90% ± 40.59%) and the Lapidus (5.71% ± 14.84%, p < .001) fusion procedures. These results confirmed our hypothesis that arthrodesis of the more proximal medial column joints would produce greater lateral column arthrodiastasis. Adding to the published data, medial double arthrodesis increased the volume of the calcaneocuboid joint by 62%.
Assuntos
Artrodese/métodos , Pé Chato/cirurgia , Articulações Tarsianas/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Cystic osteochondral lesions of the talus present a considerable challenge for foot and ankle surgeons. The purpose of the present study was to evaluate the effect of a medial malleolar osteotomy and implantation of demineralized allograft subchondral bone on pain and function 2 years after surgery. For inclusion, patients demonstrated radiographic evidence of a medial cystic full-thickness osteochondral defect of the talus and previously failed microfracture (N = 12). We hypothesized that improvements in pain and disability would be maintained across time. Compared with the preoperative values, 2 years after surgery, pain and disability had significantly reduced (p < .001). Significant reductions had occurred in postoperative pain from 6 months to 1 year (p = .001) and from 6 months to 2 years (p = .005). Similarly, significant reductions had occurred in postoperative disability from 6 months to 1 year (p = .008) and from 6 months to 2 years (p = .03). The reductions in postoperative pain and disability were maintained from 1 year to 2 years (p ≥ .79). Multiple regression analyses identified depression as a predictor of 2-year postoperative pain (R(2) = 0.36, p = .04). No variables were identified as significant predictors of postoperative disability at 2 years. Other than 1 previously reported peroneal deep venous thrombosis, no additional complications occurred. With successful graft incorporation, no inflammatory response, and no additional complications, the allograft subchondral plug appears to successfully treat osteochondral lesions of the talus and maintain improvements in pain and disability at intermediate follow-up.
Assuntos
Transplante Ósseo , Cartilagem Articular/cirurgia , Tálus/cirurgia , Adulto , Aloenxertos , Cartilagem Articular/lesões , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Masculino , Tálus/lesões , Escala Visual AnalógicaRESUMO
Given the frequency and burden of ankle sprains, the pathologic features identified on magnetic resonance imaging (MRI) scans are widely known in the symptomatic population. Ankle MRI pathologic features in the asymptomatic population, however, are poorly understood. Such examinations are rarely undertaken unless an ankle has been injured or is painful. We report the systematic MRI findings from the reports of 108 consecutive asymptomatic lateral ankles (104 patients). Our purpose was to (1) report the prevalence of osteochondral lesions of the talus (OLTs) and pathologic features of the medial and lateral ligaments, peroneal tendons, and superior peroneal retinaculum (SPR); (2) correlate the presence of OLTs with the pathologic features of the medial and lateral ligaments, peroneal tendons, and SPR; and (3) correlate ligamentous discontinuity with the peroneal pathologic features, OLTs, and SPR pathologic features. A total of 16 OLTs (14.81%) were present (13 medial and 3 lateral). Of the 16 patients with OLTs, 8 (50.00%) had concomitant peroneal pathologic findings. Healthy medial and lateral ligaments were noted in 41 patients (37.96%), and ligamentous discontinuity was grade I in 25 (23.15%), II in 32 (29.63%), III in 5 (4.63%), and grade IV in 5 patients (4.63%). A weak positive correlation was found between attenuation or tears of the superficial deltoid and medial OLTs (phi coefficient = 0.23, p = .0191) and a moderate positive correlation between tears of the posterior talofibular ligament and lateral OLTs (phi coefficient = 0.30, p = .0017). Additionally, a moderate positive correlation between ligamentous discontinuity and tendinopathy of the peroneus brevis was noted [Spearman's coefficient(106) = 0.29, p = .0024]. These findings add to the evidence of concomitant pathologic features in the asymptomatic population. To definitively assess causation and evaluate the clinical evolution of radiologic findings, future, prospective, longitudinal cohort studies are necessary.
Assuntos
Articulação do Tornozelo/patologia , Doenças das Cartilagens/diagnóstico , Ligamentos Articulares/patologia , Lesões dos Tecidos Moles/diagnóstico , Tálus/patologia , Tendões/patologia , Adulto , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
Kirschner wire (K-wire) fixation across the metatarsophalangeal joint (MTPJ) is commonly used in hammertoe repair surgery. The purpose of the present study was twofold: (1) to determine where the K-wire penetrates the metatarsal articular surface to achieve a rectus digit; and (2) to quantify the percentage of cartilage disruption to better understand the consequences of K-wire transfixation of the MTPJ. Arthrodesis was conducted on the second, third, and fourth proximal interphalangeal joints of 10 below-the-knee cadaver specimens, using a 1.6-mm K-wire. Digital alignment was confirmed with simulated weightbearing intraoperatively and radiographically. The K-wire was removed, and the MTPJ was dissected until the metatarsal head was fully exposed. The penetration point was plotted on a quadrant system with deviation noted from the epicenter. Center was defined as the point equidistant from the medial-to-lateral and superior-to-inferior edges on the distal surface of the metatarsal head, excluding the plantar condyles. Statistically significantly deviations were found in the K-wire placement from the center (35.9% ± 17.5%, p < .001), medial-to-lateral width (22.2% ± 19.2%, p < .001), and dorsal-to-plantar height (15.8% ± 25.0%, p = .002). Relative to the center, the K-wire was superior in 22 (79%), inferior in 6 (21%), medial in 22 (79%), and lateral in 6 (21%) of the cadaveric MTPJs. The mean percentage of disruption of the articular cartilage was 1.8% ± .4% and was similar for the second, third, and fourth MTPJs (p = .13) and for the left and right feet (p = .75). This information could be used to guide surgeons when they transfixate the MTPJ during hammertoe correction and might contribute to preservation of the articular cartilage.