Recommendation:
The historical nomenclature for the adult acquired flatfoot deformity (AAFD) is confusing, at times called posterior tibial tendon dysfunction (PTTD), the adult flexible flatfoot ...deformity, posterior tibial tendon rupture, peritalar instability and peritalar subluxation (PTS), and progressive talipes equinovalgus. Many but not all of these deformities are associated with a rupture of the posterior tibial tendon (PTT), and some of these are associated with deformities either primarily or secondarily in the midfoot or ankle. There is similar inconsistency with the use of classification schemata for these deformities, and from the first introduced by Johnson and Strom (1989), and then modified by Myerson (1997), there have been many attempts to provide a more comprehensive classification system. However, although these newer more complete classification systems have addressed some of the anatomic variations of deformities encountered, none of the above have ever been validated. The proposed system better incorporates the most recent data and understanding of the condition and better allows for standardization of reporting. In light of this information, the consensus group proposes the adoption of the nomenclature “Progressive Collapsing Foot Deformity” (PCFD) and a new classification system aiming at summarizing recent data published on the subject and to standardize data reporting regarding this complex 3-dimensional deformity.
Level of Evidence:
Level V, consensus, expert opinion.
Consensus Statements Voted:
CONSENSUS STATEMENT ONE: We will rename the condition to Progressive Collapsing Foot Deformity (PCFD), a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus.
Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.
(Unanimous, strongest consensus)
CONSENSUS STATEMENT TWO: Our current classification systems are incomplete or outdated.
Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.
(Unanimous, strongest consensus)
CONSENSUS STATEMENT THREE: MRI findings should be part of a new classification system.
Delegate vote: agree, 33% (3/9); disagree, 67% (6/9); abstain, 0%.
(Weak negative consensus)
CONSENSUS STATEMENT FOUR: Weightbearing CT (WBCT) findings should be part of a new classification system.
Delegate vote: agree, 56% (5/9); disagree, 44% (4/9); abstain, 0%.
(Weak consensus)
CONSENSUS STATEMENT FIVE: A new classification system is proposed and should be used to stage the deformity clinically and to define treatment.
Delegate vote: agree, 89% (8/9); abstain, 11% (1/9).
(Strong consensus)
Background:
An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since ...the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair.
Purpose:
The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials.
Study Design:
Meta-analysis; Level of evidence, 1.
Methods:
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time.
Results:
There were 10 RCTs that qualified for the meta–analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference MD, –0.73 95% CI, –1.70 to 0.25; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio OR, 1.50 95% CI, 0.87-2.57; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 95% CI, 0.42-5.70; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 95% CI, 0.03-0.46; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 95% CI, 1.80-18.02; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 95% CI, 0.48-20.54; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 95% CI, 15.50-26.75; P < .001; I2 = 15%).
Conclusion:
Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high–quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.
This article describes approaches to and the management of complex cavus foot deformities. Correction of rigid multiplanar deformities can be very challenging, given the presence of skeletal ...deformities in multiple planes and combined with a varying degree of muscle imbalance. The complexity of these cases always requires a case-by-case approach. Some of the cases presented here occur in patients who have previously undergone surgical management for their deformity, several of which are complicated by additional deformities. With a firm understanding and application of the principles of deformity correction, however, one may reliably offer satisfactory results.
This article was updated on November 7, 2019, because of a previous error. On page 1909, in the section entitled “Discussion,” the sentence that had read “Radiographic nonunion rates of 69.2% and ...45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs” now reads “Radiographic nonunion rates of 69.2% and 45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do not account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs.”An erratum has been publishedJ Bone Joint Surg Am. 2019 Dec 18;101(24):e139.
BACKGROUND:Subtalar arthrodesis effectively treats subtalar joint arthritis when other interventions have failed. Nonunion is a known complication of subtalar arthrodesis, with reported rates ranging from 5% to 45%. Historically, open arthrodesis has been performed with use of autologous bone graft; however, there are inherent disadvantages to autologous bone graft, including donor-site morbidity. Mesenchymal stem cells, when placed on a cellular scaffold, have shown promise as an alternative to autologous bone graft. The purpose of this multicenter, randomized controlled trial was to assess the safety and efficacy of an adipose-derived cellular bone matrix (ACBM) composite made with live cells compared with autograft in subtalar arthrodesis.
METHODS:A total of 140 patients were enrolled in a prospective, randomized (1:1) controlled trial performed at 6 clinical sites in the U.S. End points, including radiographic, clinical, and functional outcomes, were assessed over 2 years of follow-up.
RESULTS:A total of 109 patients underwent arthrodesis with ACBM (52 patients) and autograft (57 patients). At 6 months, fusion was achieved in 16 patients (30.8%) in the ACBM group and 31 patients (54.4%) in the autograft group as measured on computed tomography (p = 0.024), and in 41 patients (78.8%) in the ACBM group and 50 patients (87.7%) in the autograft group as assessed on clinical and radiographic evaluation (p = 0.213). Quality-of-life outcome measures demonstrated significant functional improvement from baseline for both groups. Fewer cases of serious adverse events occurred in the autograft group (10.5%) compared with the ACBM group (23.1%) (p = 0.078).
CONCLUSIONS:In patients who require subtalar arthrodesis, the use of ACBM demonstrated lower rates of radiographic fusion compared with treatment with autograft. The nonunion rate in the autologous group, as measured on computed tomography, was high. Good clinical outcomes were achieved in spite of the high non-union rates.
LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND:Few studies have focused on treatment following failed total ankle replacement. The purpose of this study was to report the outcomes of patients undergoing revision total ankle replacement ...and to propose a talar component subsidence grading system that may be helpful in making decisions regarding how to revise failed total ankle replacements in the future.
METHODS:A retrospective review was performed of fifty-three patients who underwent revision total ankle replacement and had been followed for a minimum of two years. Patients were assessed radiographically and with outcome scores. The rates of conversion to amputation or fusion were also assessed.
RESULTS:The mean follow-up period was 49.1 months after the revision arthroplasty. The average time from primary total ankle replacement to revision was fifty-one months. Forty-one of the fifty-three patients (77%) were available for follow-up. The revision arthroplasty had been converted to an arthrodesis in five of the forty-one patients, and two additional patients had undergone amputation. The most common indication for revision total ankle replacement was talar subsidence (63%; twenty-six of forty-one). Twenty-two patients (54%) had a subtalar arthrodesis performed at the time of the revision arthroplasty, with nineteen of those having a custom-designed long-stem talar component placed simultaneously. The mean radiographic measurements of component position did not change significantly postoperatively. The mean postoperative scores for the thirty-four patients with a retained total ankle replacement were4.4 of 10 possible points on a visual analog pain scale (VAS), 65 of 100 possible points on the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, 93.5 of 100 possible points on the Short-Form 12 (SF-12), 137.9 of 204 possible points on the Revised Foot Function Index (FFI-R), and 64 of 180 possible points on the Ankle Osteoarthritis Scale (AOS). The mean arc of motion radiographically was 18° preoperatively and 23° postoperatively, with all improvement occurring in plantar flexion. A lesser amount of preoperative talar subsidence was a significant predictor of a good outcome based on the AOFAS hindfoot score (p < 0.03) and the AOS (p < 0.01) score.
CONCLUSIONS:Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
An association between hallux rigidus and metatarsus primus elevatus (MPE) has been suggested, although there remains no general consensus about the nature of this relationship. Past ...studies were limited due to inaccuracies of assessing MPE on 2-dimensional radiographs. The aims of this study were to (1) assess and compare foot alignment in patients with and without hallux rigidus using 3-dimensional (3D) reconstructions from weightbearing computed tomography (CT) and (2) assess intraobserver and interobserver reliability of these measurements.
Methods:
A prospective study was performed in 50 consecutive patients with symptomatic hallux rigidus and 50 control patients who underwent a weightbearing CT. Two investigators measured first and second metatarsal declination angles, first and second metatarsal lengths, first to second intermetatarsal angle (IMA), hallux valgus angle (HVA), and foot width on 3D CT reconstructions. Measurements were repeated after 1 month. Student t tests were performed to compare hallux rigidus and control groups. Intraclass and interclass correlation coefficients were calculated to evaluate reliability.
Results:
The first to second metatarsal declination ratio was less in patients with hallux rigidus (mean, 0.81) than controls (mean, 0.92; P < .001). Patients with Coughlin and Shurnas grade 3 and 4 hallux rigidus had greater first metatarsal declination than patients with grade 1 and 2 hallux rigidus. Last, IMA was higher (mean, 13 degrees) but HVA was lower (mean, 11 degrees) in patients with hallux rigidus than controls (IMA mean, 12 degrees; HVA mean, 15 degrees; P = .04). Intraobserver (ICC1,1 ≥ 0.93) and interobserver (ICC3,1 ≥ 0.85) reliability were good to excellent for all measured parameters.
Conclusions:
Patients with hallux rigidus had MPE. Patients with grade 3 and 4 hallux rigidus had more MPE than patients with grade 1 and 2 hallux rigidus. There was no clear correlation between hallux rigidus and bunions. Finally, weightbearing CT proved to be a reliable method of assessing all measured parameters.
Level of Evidence:
II, prospective comparative series.
Background:
The Cotton osteotomy has been used to correct residual forefoot supination in flexible flatfoot deformity reconstruction. The purpose of this study was to delineate the radiographic ...effects of the Cotton osteotomy by controlling for concomitant procedures used for deformity correction.
Methods:
We retrospectively analyzed 67 patients who underwent a Cotton osteotomy as part of a flatfoot reconstructive procedure. We evaluated 12 radiographic parameters including the articular surface angles of the foot, Meary angle, and a newly defined medial arch sag angle (MASA). Twenty-eight of these patients were matched to a cohort that did not undergo a Cotton osteotomy.
Results:
In all patients who underwent a Cotton osteotomy, there were statistically significant changes in the articular surface angles and medial arch height (P < .05). No radiographic secondary sag of the medial column was seen at final follow-up. Compared to 28 matched controls, the Cotton osteotomy did not improve Meary angle but provided an additional 6.5 degrees correction of the MASA (P = .002). After reliability testing, the intraclass correlation coefficient was found to be substantial for the MASA compared to Meary angle.
Discussion:
The data suggest that the MASA was a useful radiographic tool for assessing midfoot collapse in the setting of pes planovalgus. The current study demonstrated the corrective capacity of the Cotton osteotomy on the MASA; at final follow-up, there was no evidence of radiographic instability. This is suggestive that a naviculocuneiform arthrodesis may not be warranted for medial column stabilization in the setting of flatfoot reconstruction.
Level of Evidence:
Level III, case control study.
The severe foot and ankle deformities the authors' organization has encountered in humanitarian programs worldwide are more complicated than those surgeons treat in daily practice in developed ...countries. Severity of deformity, patients' economic limitations, patients' expectations and realistic needs in life, availability of surgical instrumentation, the local team's understanding of foot and ankle surgery and their ability to do consultation for patients postoperatively, and compliance of patients all account for success of the surgery. Regardless of the effort surgeons make, complications and recurrence occur. Educating and training local surgeons to take over medical care are the most important goals of the programs.
Background:
Little has been published on the management of infected total ankle replacements. This study reviewed our experience with this difficult clinical problem.
Methods:
From 2002 to 2011 we ...retrospectively evaluated patients requiring prosthesis removal for infection following primary or revision total ankle replacement. Infections were classified as acute postoperative, late chronic, or remote hematogenous. The demographics, treatment, and outcome of the infected replacements were evaluated.
Results:
Of 613 replacements performed during this time period, 15 infections occurred at our institution and 4 from other institutions were treated. These 19 cases included 15 late chronic infections, 3 early postoperative infections, and 1 acute hematogenous infection. Fourteen of the infections occurred in a subset of 433 prostheses (3.2%) placed between 2002 and 2009 when we used an implant with a unique design that necessitated a tibiofibular syndesmosis fusion for the tibial component support (Agility, Depuy). One infection occurred out of 139 other prostheses (0.7%) between 2009 and 2011 when we switched to an anatomic design fixed bearing implant system. Prosthesis salvage was attempted in the 3 early postoperative and 1 acute hematogenous cases, however they all required subsequent removal of the prosthesis. Mean time to removal of the prosthesis after the index arthroplasty was 18 months. Mean follow-up was 19 months from the time of prosthesis removal. Three of the 19 patients underwent successful revision with replacement, 6 with arthrodesis, 7 with a permanent antibiotic spacer, and 3 patients required a transtibial amputation.
Conclusion:
Only a limited number of patients who develop a deep infection following primary or revision total ankle arthroplasty can expect to undergo successful joint-preserving revision ankle arthroplasty.
Level of Evidence:
Level III, retrospective case series.
