Femoroacetabular impingement (FAI) and labral pathology are associated with pain, decreased function, and hip strength deficits. Existing data are in conflict regarding when hip strength normalizes following arthroscopic treatment of FAI. The objective of this study was to identify preoperative hip strength relative to the contralateral hip not undergoing surgery as well as when postoperative strength in 4 functional muscle groups normalizes following arthroscopic treatment of FAI. Ninety-eight individuals with radiographic evidence of FAI and labral pathology underwent arthroscopic labral repair. Pre-surgical hip strength testing was performed in the symptomatic “surgical hip” and the contralateral “non–surgical hip.” Hip strength measurements were repeated at 8 and 16 weeks postoperatively. Significant preoperative hip strength deficits were noted in the surgical hip compared with the non–surgical hip in flexion, extension, and adduction. At 8 weeks postoperatively, hip strength in the surgical hip improved to being equivalent to that in the non–surgical hip in adduction and extension, remained equivalent to that of the non–surgical hip in abduction, and decreased in flexion relative to the non–surgical hip. At 16 weeks, hip strength remained equivalent in the surgical hip and the non–surgical hip in abduction and adduction, but the surgical hip exceeded the non–surgical hip in extension. While flexion strength improved between 8 and 16 weeks postoperatively for the surgical hip, it had not fully recovered to that of the non–surgical hip. Using a structured postoperative rehabilitation protocol, abduction strength was maintained at 8 weeks postoperatively, while adduction and extension strength had improved to those of the non–surgical hip. At 16 weeks postoperatively, hip abduction and adduction had strength equivalent to those of the non–surgical hip. Despite preoperative improvement, flexion of the surgical hip lagged behind that of the non–surgical hip 16 weeks postoperatively. [ Orthopedics . 2021;44(3):148–153.]
Category: Hindfoot; Other Introduction/Purpose: Although the diagnosis, treatment, and natural history of tarsal coalitions has been well described in the adolescent population, there remains a paucity of orthopaedic literature on outcomes associated with coalition resection with or without interposition in the adult population. This study is the first to evaluate clinical and radiographic outcomes in adult patients with tarsal coalition resection without interposition. Methods: All patients with symptomatic tarsal coalition (subtalar, calcaneonavicular, or talonavicular) who failed conservative management and underwent coalition resection with concomitant procedures as indicated by their pathology between January 2006 and December 2014 were included in our retrospective case series. Demographics, clinical outcomes, patient comorbidity information, visual analogue scale (VAS) pain scores were collected. Advanced imaging (CT or MRI) was reviewed to determine fibrocartilaginous or osseous coalition. The primary outcome was reoperation. Secondary outcomes were change in visual analog score (VAS), and minor complications (local wound care, use of antibiotics, and skin dehiscence). Results: 68 patients (52.9% males, 47.1% females; average age 35.9 years old, range 18 to 70) met inclusion. Calcaneonavicular, subtalar, and talonavicular coalitions were resected in 45.6% (n=31), 54.4% (n=37), and 0% of patients, respectively. At average final clinical follow up of 36 months, there were a total of 33 reoperations in 33.8% of patients (n=23) most commonly including subsequent fusion (n=11), exostectomy (n=10), and removal of hardware (n=15). There was no significant difference in reoperation (42.3% versus 63.1%, p=0.454) or fusion (19.4% versus 19.2%, p=0.99) following subtalar or calcaneonavicular coalition resection. Average VAS score preoperatively and postoperatively was 5.8 to 3.0. Minor complications were present in 16.2% of patients (n=11; 3 local wound care, 10 use of antibiotics, and 0 skin dehiscence). Conclusion: The present study demonstrates overall improvement in VAS score by an average of 2.8 points following subtalar and calcaneonavicular coalition resection. Although 33.8% of patients may anticipate additional surgery, the majority of patients may expect long-term maintenance of improvement in pain without subsequent fusion.
Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first tarsometatarsal (TMT-1) joint is a widely accepted procedure for treatment of hallux valgus (HV) with medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high intermetatarsal angles (IMA). Similarly, metatarsophalangeal fusion (MTP-1) has been suggested for severe hallux valgus, metatarsophalangeal arthritis, and severe or recurrent deformities. Prior studies have demonstrated early outcomes in a small sample of patients. This study aimed to evaluate clinical and radiographic outcomes in patients with severe HV who underwent concomitant TMT-1 and MTP-1 arthrodesis for severe HV. Methods: All patients with symptomatic severe HV who failed conservative management and underwent concomitant MTP-1 and TMT-1 arthrodesis between January 2006 to December 2018 were included in our retrospective case series. Patients were operated on by one of three senior foot and ankle surgeons at a single tertiary center. Demographics, clinical outcomes, patient comorbidity information, and radiographic outcomes including baseline hallux valgus angle (HVA), IMA 1-2, hallux valgus interphalangeus angle, distal metatarsal articular angle, and sesamoid station were collected. The primary outcome was reoperation. Secondary outcomes were minor complications (local wound care, use of antibiotics, and skin dehiscence), visual analogue scale (VAS) pain scores, and change in radiographic measurements. Results: From 2006 to 2018, 42 patients (21.4% male, 78.6% female) at an average age of 62.6 years (range 48 to 80) met inclusion. At final average clinical follow up of 28 months, there were a total of 23 reoperations in 35.7% of patients at an average 18.5 months from index surgery (n=15; 1 revision TMT, 2 revision MTP, 1 hallux interphalangeal (IP) fusion, and 11 hardware removal). Minor complications were present in 7.1% of patients (n=3; 3 local wound care, 2 use of antibiotics, and 3 skin dehiscence). Average VAS score preoperatively and postoperatively was 5.5 to 1.9, respectively. Average preoperative HVA and IMA 1-2 angles were 35.6 and 15.3 degrees compared to postoperative angles of 9.0 and 9.3 degrees, respectively. Conclusion: The present study demonstrates concomitant MTP-1 and TMT-1 arthrodesis in cases of HV secondary to medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high IMA has a high correction capability and achieved normal HVA as well as normal IMA 1-2 at greater than two years. Concomitant MTP-1 and TMT-1 arthrodesis in patients with severe HV appeared to be safe and clinically successful.
Category: Hindfoot; Sports Introduction/Purpose: Achilles debridement and secondary reconstruction is a widely accepted procedure for treatment of insertional Achilles tendonopathy with or without Haglund resection, calcaneus exostectomy, retrocalcaneal bursectomy, and possible flexor hallucis longus tendon transfer. When less than 50% of the tendon is pathologic and elevated from the calcaneus, primary reconstruction with or without bony fixation (bone tunnels or anchors) has been advocated. Postoperative protocols demonstrate wide variability in the orthopaedic literature. This study is the first to evaluate clinical and radiographic outcomes in patients with insertional Achilles tendonopathy who underwent soft tissue only Achilles debridement and secondary reconstruction with immediate plantigrade weightbearing in plantigrade foot ankle stabilizer (FAS) high walking boot. Methods: All patients with symptomatic insertional Achilles tendonopathy who failed conservative management underwent Achilles debridement and secondary reconstruction with or without Haglund resection, calcaneus exostectomy, and retrocalcaneal bursectomy by a single senior foot and ankle surgeon at a single tertiary center between January 2006 to December 2013 were included in our retrospective case series. Patients with greater than 50% involvement of the tendon requiring flexor hallucis longus transfer were excluded. Demographics, clinical outcomes, patient comorbidity information, and Coughlin satisfaction scores were collected. The primary outcome was change in visual analog scale (VAS) pain score. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence). Results: From 2006 to 2013, 66 patients (40.9% male, 59.1% female) at an average age of 53.6 years (range 19 to 78) underwent Achilles debridement and secondary reconstruction. At final average follow up of 4.3 years, average VAS score improved from 5.9 to 2.3 preoperatively to postoperatively. There were a total of 10 reoperations in 9.1% of patients (n=6). Minor complications were present in 12.1% of patients (n=8; 3 local wound care, 8 use of antibiotics, and 5 skin dehiscence). Physical therapy desensitization was utilized in 25.8% of patients (n=17). Conclusion: The present study demonstrates a significant improvement in VAS pain scores following Achilles debridement and secondary reconstruction for treatment of insertional Achilles tendonopathy with immediate plantigrade weightbearing in plantigrade FAS high walking boot. This technique appears to be safe and effective.
Category: Bunion; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first tarsometatarsal (TMT-1) joint is a widely accepted procedure for treatment of hallux valgus (HV) with medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high intermetatarsal angles (IMA). This study aimed to evaluate clinical and radiographic outcomes in patients with mild-to-severe HV who underwent TMT-1 arthrodesis and proximal hindfoot correction for adult acquired flatfoot deformity (AAFD). Methods: All patients with symptomatic HV and AAFD who failed conservative management underwent TMT-1 fusion and proximal hindfoot correction (medial displacement calcaneal osteotomy, lateral column lengthening, subtalar fusion, or tibiotalocalcaneal fusion) by one of three senior foot and ankle surgeons at a single tertiary center between January 2006 and December 2018 were included in our retrospective case series. Demographics, clinical outcomes, patient comorbidity information, and radiographic outcomes including hallux valgus angle (HVA), IMA 1-2, hallux valgus interphalangeus angle, distal metatarsal articular angle, and sesamoid station were collected. The primary outcome was change in HVA measured as the difference between final postoperative and preoperative weight bearing HVA measurements. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence), and change in radiographic measurements. Results: With an average follow up of 26 months, 155 patients (17.4% male, 82.6% female; average age 59.0 years old, range 18 to 84) met inclusion. The average change in HVA was -18.6 degrees (range +15.8 to -81.0). There was a total of 85 reoperations in 35.5% (n=55; 48 hardware removal). Minor complications were present in 18.7% (n=29; 25 local wound care, 23 use of antibiotics, and 10 skin dehiscence). 44.5% (n=69) had no evidence of recurrent HV while mild, moderate, and severe grade bunions were present in 40.0% (n=62), 5.2% (n=8), and 0.6% (n=1). Improvement in overall bunion grade was maintained in 69.7% (n=108) with no change in 19.4% (n=30). Hallux varus was present in 9.7% (n=15; 3 underwent TMT-1 arthrodesis). Conclusion: The present study demonstrates a significant improvement in HVA following TMT-1 arthrodesis and proximal hindfoot correction for AAFD. The majority of patients undergoing TMT-1 arthrodesis and proximal hindfoot correction for AAFD obtain and maintain improvement in the radiographic severity of their bunions. However, patients should be counseled concerning expectations with regards to outcomes associated with complex AAFD reconstructions.
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