Background:
Spring ligament reconstruction (SLR) has been suggested as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot ...deformity (PCFD) with severe abduction deformity. Most clinical reports present short-term follow-up data and a small number of patients. The purpose of this study was to examine the medium- to long-term outcomes of an SLR using allograft tendon augmentation as part of PCFD surgical reconstruction. This study to our knowledge represents the largest number of patients and the longest follow-up to date.
Methods:
This study retrospectively reviewed 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5-13.4). Radiographic evaluation consisted of 5 parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure.
Results:
Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction. All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except 1 patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and 1 (3.7%) developed nonunion of the lateral column lengthening osteotomy. No patient required conversion to talonavicular or subtalar fusion.
Conclusion:
This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation.
Level of Evidence:
Level IV, case series.
Background:
The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate ...(JACI-BMAC) for treatment of talar osteochondral lesions with those of patients who underwent microfracture (MF).
Methods:
A total of 30 patients who underwent MF and 20 who received DeNovo NT for JACI-BMAC treatment between 2006 and 2014 were included. Additionally, 17 MF patients received supplemental BMAC treatment. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score and Visual Analog pain scale. Postoperative magnetic resonance images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Average follow-up for functional outcomes was 30.9 months (range, 12-79 months). Radiographically, average follow-up was 28.1 months (range, 12-97 months).
Results:
Both the MF and JACI-BMAC showed significant pre- to postoperative improvements in all Foot and Ankle Outcome Score subscales. Visual Analog Scale scores also showed improvement in both groups, but only reached a level of statistical significance (P < .05) in the MF group. There were no significant differences in patient reported outcomes between groups. Average osteochondral lesion diameter was significantly larger in JACI-BMAC patients compared to MF patients, but size difference had no significant impact on outcomes. Both groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group had more patients with hypertrophy exhibited on magnetic resonance imaging (MRI) than the MF group (P = .009).
Conclusion:
JACI-BMAC and MF resulted in improved functional outcomes. However, while the majority of patients improved, functional outcomes and quality of repair tissue were still not normal. Based on our results, lesions repaired with DeNovo NT allograft still appeared fibrocartilaginous on MRI and did not result in significant functional gains as compared to MF.
Level of Evidence:
Level III, comparative series.
There are many challenges involved in obtaining diagnostic MR images of the foot and ankle. The complex anatomy and morphology, with curved and angular structures localized to the periphery of the ...body, make for an inherent challenge, let alone if an added level of complexity, such as orthopedic instrumentation, is added. This review outlines the technical considerations best designed to produce diagnostic images of the foot and ankle, with an emphasis on the postoperative state, including imaging in the presence of metal.
A bio-integrative fiber-reinforced implant (OSSIOfiber® Hammertoe Fixation Implant, OSSIO Ltd., Caesarea, Israel) for proximal interphalangeal joint (PIPJ) correction-arthrodesis showed partial ...bio-integration at 1-year follow-up (1FU) in a previous study. The study was prolonged to assess the bio-integration at 2-year-follow-up (2FU).
Twenty-four patients with proximal interphalangeal joint (PIPJ) correction-arthrodesis using the fiber-reinforced implant and analysed at 1FU, completed 2FU. Follow-up included clinical examination, patient reported outcomes, radiographs, MRI and bio-integration scoring. Results were compared between the 1FU and 2FU (paired t-test).
Radiographs confirmed fusion in 96 % (n = 23) at 2FU (1FU, 92 % (n = 22)). Implant was no longer visible in 21 % (n = 5), partially visible in 33 % (n = 8), and fully visible in 46 % (n = 11)(1FU, fully visible 100 % (n = 24)). The border between implant and surrounding bone was scored not visible in 88 % (n = 21) and partially visible in 12 % (n = 3) (1FU, border partially visible 100 % (n = 24)). There were no cyst formation or fluid accumulation findings 1FU/2FU. Mild bone edema was detected in 4 % (n = 1) (1FU, 29 % (n = 7)). None of the edema findings were considered as adverse implant related. The mean bio-integration score was 9.71 ± 0.69 at 2FU (1FU, 7.71 ± 0.46). The parameters of border between implant and bone and bone edema further improved at the 2FU compared to the 1FU, total bio-integration score was also higher at 2FU than 1FU (each p < 0.05).
This study demonstrates 96 % PIPJ fusion rate and increased bio-integration from 1FU to 2FU, reaching advanced bio-integration of the fiber-reinforced implant at 2FU.
Background:
The proximal medial opening wedge (PMOW) osteotomy has become more popular to treat moderate to severe hallux valgus with the recent development of specifically designed, low-profile ...modular plates. Despite the promising results previously reported in the literature, we have noted a high incidence of recurrence in patients treated with a PMOW. The purpose of this study was to report the clinical and radiographic outcomes of an initial cohort of patients treated with a PMOW osteotomy for moderate hallux valgus.
Methods:
We retrospectively analyzed prospectively gathered data on a cohort of 17 consecutive patients who were treated by the senior author using a PMOW osteotomy for moderate hallux valgus deformity. Average time to follow-up was 2.4 years (range, 1.0-3.5 years). The intermetatarsal angle (IMA), the hallux valgus angle (HVA), and the distal metatarsal articular angle (DMAA) were assessed on standard weightbearing radiographs of the foot preoperatively and at all follow-up visits. The Foot and Ankle Outcome Score (FAOS) was collected on all patients preoperatively and at final follow-up.
Results:
Despite demonstrating good correction of their deformity initially, 11 of the 17 patients (64.7%) had evidence of recurrence of their hallux valgus deformity at final follow-up. Patients who recurred had a greater preoperative HVA (P = .023) and DMAA (P = .049) than patients who maintained their correction. Improvement in the quality-of-life subscale of the FAOS was noted at final follow-up for all patients (P = .05). There was no significant improvement in any of the other FAOS subscales.
Conclusions:
There was a high rate of recurrence of the hallux valgus deformity in this cohort of patients. Recurrence was associated with greater preoperative deformity and an increased preoperative DMAA. The PMOW without a concomitant distal metatarsal osteotomy may be best reserved for patients with mild hallux valgus deformity without an increased DMAA.
Level of Evidence:
Level IV, retrospective case series.
Category:
Hindfoot; Midfoot/Forefoot
Introduction/ Purpose:
Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). ...Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if its integrity of it changes with increasing axial plane deformity. We hypothesized that there will be a higher prevalence of cervical ligament insufficiency in a PCFD cohort compared to that of a control group. Additionally, we hypothesized that those with higher degrees of cervical ligament insufficiency will have a more severe abduction deformity and talocalcaneal subluxation.
Methods:
This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender- matched controls. A radiologist specializing in musculoskeletal disorders evaluated the structural derangement of the cervical ligament into five grades (Grade 0 indicating normal and Grade 4 indicating a tear greater than 50% of the cross-sectional area), as previously described. To compare its involvement in PCFD, two commonly involved ligaments (spring and interosseous) in PCFD were also evaluated. Plain radiographic parameters, including the talonavicular coverage angle (TNC), lateral talo-1st metatarsal (Meary’s) angle, calcaneal pitch, and hindfoot moment arm, as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal), were correlated with the cervical ligament MRI grading system.
Results:
The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P < .001, Table 1). MRI evidence of a tear (Grades 3 or 4) in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and greater than that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modelling demonstrated a predictive ability of TM-Calc (Odds ratio OR: 1.17, 95% confidence interval CI: 1.06-1.30, p=.004), Diff Calc- Tal (OR: 1.15, 95% CI: 1.06-1.26, p=.002), TNC (OR: 1.08, 95% CI: 1.03-1.13, p=.003), and Meary’s angle (OR: 1.05, 95% CI: 1.02-1.10, p=.006) in determining higher cervical ligament grade on MRI (Figure 1).
Conclusion:
We found that cervical ligament insufficiency is a significant component of PCFD and is more common than anticipated in this study. Based on the radiographic findings in the current study, cervical ligament insufficiency appears to be primarily associated with axial plane midfoot and hindfoot deformity. If its biomechanical properties are established in the future studies, we think the reconstruction of the cervical ligament may be a potential adjunct surgical procedure for PCFD patients with significant axial plane deformity.
Category:
Hindfoot; Midfoot/Forefoot
Introduction/Purpose:
Spring ligament reconstruction (SLR) has been proposed as an adjunct to other reconstructive procedures to potentially avoid talonavicular ...joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity.
However, most clinical reports present short-term follow-up data and include only a small number of patients. Recent cadaveric studies have demonstrated that the spring ligament maintains medial tibiotalar stability by forming a large confluent (tibiospring) ligament with the superficial deltoid ligament. Therefore, the purpose of this study was to investigate the medium to long-term results of our nonanatomic tibiospring ligament complex reconstruction using allograft tendon, as an adjunct to other reconstructive procedures in PCFD with severe abduction deformity. This study to our knowledge represents the largest number of patients and the longest follow-up to date.
Methods:
This study retrospectively reviewed prospectively collected data of 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5- 13.4). The SLR was performed when bony correction with lateral column lengthening (LCL) achieved at least 50% of abduction correction but failed to provide adequate abduction correction under intraoperative fluoroscopy. The tendon graft was positioned from the inferior navicular to the medial malleolus via bone tunnels and screw posts (Figure 1). Radiographic evaluation consisted of five parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure.
Results:
Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction (Table 1). All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except one patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and one (3.7%) developed non-union of the LCL osteotomy. No patient required conversion to talonavicular or subtalar fusion.
Conclusion:
This study demonstrates favorable medium- to long-term outcomes, as well as maintenance of the correction, following a nonanatomic tibiospring ligament complex reconstruction using allograft tendon augmentation in addition to other corrective procedures for the surgical treatment of PCFD with severe abduction deformity. As there is growing evidence of the potential for excessive foot stiffness following LCL, a remaining question is whether it is reasonable to use SLR to reduce the amount of LCL needed, as long as the bony procedure achieves at least 50% of the required abduction correction, as described in the current study.
Mechanical ankle instability can lead to isolated cartilage lesions or early osteoarthritis. Many of the signs and symptoms can be clinically elusive with the need to isolate and define primary and ...secondary injuries with imaging. Currently available imaging modalities to diagnose chronic ankle instability are presented here.
Level of Evidence:
Diagnostic level V.
Juvenile allogenic chondrocyte implantation (JACI; DeNovo NT Natural Tissue Graft®; Zimmer, Warsaw, IN) with autologous bone marrow aspirate concentrate (BMAC) is a relatively new all-arthroscopic ...procedure for treating critical-size osteochondral lesions (OCLs) of the talus. Few studies have investigated the clinical and radiographic outcomes of this procedure. We collected the clinical and radiographic outcomes of patients who had undergone JACI-BMAC for talar OCLs to assess treatment efficacy and cartilage repair tissue quality using magnetic resonance imaging (MRI). Forty-six patients with critical-size OCLs (≥6 mm widest diameter) received JACI-BMAC from 2012 to 2014. We performed a retrospective medical record review and assessed the functional outcomes pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short-Form 12-item general health questionnaire. MRI was performed preoperatively and at 12 and 24 months postoperatively. Cartilage morphology was evaluated on postoperative MRI scans using the magnetic resonance observation of cartilage tissue (MOCART) score. The pre- to postoperative changes and relationships between outcomes and lesion size, bone grafting, lesion location, instability, hypertrophy, and MOCART scores were analyzed. Overall, the mean questionnaire scores improved significantly, with almost every FAOS subscale showing significant improvement postoperatively. Concurrent instability resulted in more changes that were statistically significant. The use of bone grafting and the presence of hypertrophy did not result in statistically significant changes in the outcomes. Factors associated with outcomes were lesion size and hypertrophy. Increasing lesion size was associated with decreased FAOS quality of life subscale and hypertrophy correlating with changes in the pain subscale. Of the 46 patients, 22 had undergone postoperative MRI scans that were scored. The average MOCART score was 46.8. Most patients demonstrated a persistent bone marrow edema pattern and hypertrophy of the reparative cartilage. Juvenile articular cartilage implantation of the DeNovo NT allograft and BMAC resulted in improved functional outcome scores; however, the reparative tissue still exhibited fibrocartilage composition radiographically. Further studies are needed to investigate the long-term outcomes and determine the superiority of the arthroscopic DeNovo procedure compared with microfracture and other cartilage resurfacing procedures.
