Objective. We undertook this study to test our postulate that leukocytes extend the zone of injury in cartilage after acute mechanical trauma.Methods. Fresh cadaveric canine femoral condyles were subjected to 20-25-MPa impact injury. Condyle explants or dispersed chondrocytes were cultured with autologous blood mononuclear leukocytes (MNLs). Viability of chondrocytes at varying distances from the impact site was assessed by trypan blue exclusion.Results. Mechanical injury caused a significant loss of viable chondrocytes over 7 days, even in cartilage >10 mm from the impact site. After biomechanical stress, death of cells within 10 mm of the impact could be largely prevented by addition of N G -monomethyl-Larginine to inhibit nitric oxide (NO) generation. Chondrocytes within 10 mm of the impact were also susceptible to killing by living MNLs, but not by incubation with the supernatants of endotoxin-activated MNLs. Chondrocytes in this vulnerable zone expressed intercellular adhesion molecule 1 (ICAM-1) (CD54), facilitating attachment of MNLs that localized adjacent to the chondrocytes. Leukocytes killed dispersed chondrocytes harvested from the impact zone by generation of reactive oxygen species. Leukocyte-mediated killing could be blocked by desferoxamine or by antibodies to CD18, which prevent attachment of leukocytes to ICAM-1-expressing chondrocytes. Conclusion.Our data suggest that after mechanical injury, chondrocytes distant from the site may be killed through the generation of NO. Inflammatory leukocytes further extend the zone of chondrocyte death by adhering to chondrocytes expressing ICAM-1 and by inducing the accumulation of free oxygen radicals in the chondrocyte cytoplasm. Patients may benefit from therapies that reduce infiltration of inflammatory leukocytes into acutely injured cartilage.

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Background: Methodological quality and author internationality are increasing in orthopaedic surgery. The purpose of this study was to evaluate the methodological quality and author geography trends from 1994 to 2019 in high-quality foot and ankle journals. Methods: Analyses of 1,242 foot and ankle publications in Foot and Ankle International , American Journal of Bone and Joint Surgery , and American Journal of Sports Medicine were done for 1994, 1999, 2004, 2009, 2014, and 2019. Articles were classified according to study type, level of evidence (LOE), and author's country of publication. Results: The most common clinical study was therapeutic (65.4). Significant increases were noted in the proportion of therapeutic ( P < 0.01) and prognostic ( P < 0.01) articles. The average LOE increased from 3.96 ± 1.01 to 3.19 ± 0.97 ( P < 0.01). The proportion of Level I ( P = 0.29) and level IV articles ( P = 0.21) remained constant, level II ( P < 0.01) and level III ( P < 0.01) articles increased, and level V ( P < 0.01) articles decreased. United States authorship decreased from 78.1% in 1994 to 44.8% in 2009, then remained constant through 2019 ( P < 0.01). Conclusion: This study demonstrated an improvement in LOE of foot and ankle publications across a 25-year period in three high-quality orthopaedic journals. Increasing internationality was also observed.

Strategies to minimize mechanical stress during the early postinjury period may help to preserve cartilage integrity and forestall the development of osteoarthritis.

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Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Cavovarus foot alignment has been significantly associated with increased rates of chronic ankle instability and osteochondral lesions of the talus. Clinical wisdom suggests that cavovarus foot alignment causes varus stress to the ankle and also predisposes individuals to peroneal tendon pathology. However, no studies have specifically explored this relationship. The purpose of this research is to investigate the association between foot alignment and peroneal tendon pathology. Methods: A retrospective case-control study was conducted of all adult patients in whom a magnetic resonance image (MRI) of the ankle was obtained for any reason at a single institution from 2015-2017. Patients were excluded if they had a charcot foot deformity or if they had undergone prior peroneal tendon, ankle, or hindfoot surgery. Arch alignment was evaluated on lateral weightbearing radiographs of the foot by measuring the adjusted navicular height. Hindfoot alignment was assessed using the Saltzman apparent moment arm method. Peroneal tendon pathology including tears, tendinosis, and tenosynovitis was documented by a fellowship-trained musculoskeletal radiologist using the MRI scan. All numerical variables were converted to categorical variables (e.g. varus, valgus, and normal alignment). Chi-square testing was utilized to determine the association between variables. Results: 195 patients were included in the study (average age 47 years, 61% female). Patients with hindfoot varus had significantly higher rates of peroneus longus (PL) and peroneus brevis (PB) tendon pathology than patients with neutral or valgus alignment (Figure 1 A, B)(PL 39% vs. 31% vs. 20%, p=0.01; PB 44% vs 27% vs. 27%, p=0.04). Patients with pes cavus demonstrated extremely high rates of peroneal tendon pathology, which was significantly higher than patients with neutral or pes planus alignment (Figure 1 C, D)(PL 71% vs. 28% vs. 9%, p<0.0001; PB 75% vs 30% vs. 26%, p<0.0001). Amongst patients with peroneal tendon pathology, there was no difference in the rates of symptomatic vs. asymptomatic findings based on hindfoot or pes alignment. Conclusion: This is the first study to demonstrate a statistically significant association between cavus foot alignment, hindfoot varus alignment, and peroneal tendon pathology. Interestingly, this study demonstrates that patients with cavovarus alignment are not more likely to be symptomatic than patients with normal and planovalgus alignment. This study also reinforces the idea that peroneal pathology found on MRI may not necessarily need surgery, as it is frequently seen in patients without symptoms. This information may be useful in counseling patients considering operative treatment for peroneal tendon pathology and alignment abnormalities.

Category: Lesser Toes Introduction/Purpose: The rigid hammertoe deformity requires realignment of the proximal interphalangeal joint. Traditionally this has been achieved with resection arthroplasty with K-wire fixation of the joint. However, this method is prone to complications such as pin migration, pin tract infection, pin breakage, nonunion, and malunion. Recently, a variety of treatment options have been developed to achieve appropriate PIP joint fusion while minimizing these risks. This study investigates the fusion rate and outcomes of a novel internal fixation screw. Methods: A retrospective review was done to determine the short term fusion and satisfaction rate of hammertoe corrections performed by 2 surgeons utilizing a specifically designed longitudinal compression screw. A typical dorsal approach to the PIP joint was performed, followed by a resection arthroplasty, and the screw was inserted in the appropriate described manner. At the last follow up, the radiographs and clinical condition was observed. The fusion and alignment of the joint were then analyzed by an orthopaedic resident (PGY3), an orthopaedic attending, and a musculoskeletal radiologist. Clinical satisfaction and appearance was derived from chart review. A total of 55 screws were placed in 40 patients. Thirty-nine of these toes were second toes, 12 were third toes, and 4 were fourth toes. This implant was not designed for the fifth toe. The median final X-ray follow up was 10 weeks (range 5 to 40 weeks). Results: After evaluation of the post-operative X-rays by all 3 evaluators, at least 76% of these toes were definitively fused. About 13% of the joints were difficult to judge for radiological union based on the available X-rays. Approximately 11% of the joints went into nonunion or were not fused by final (typically asymptomatic) follow up. Two toes (3.6%) had persistent pain and swelling at the last visit. Two toes (3.6%) had slight misalignment (more than 5 degrees of varus/valgus), and only one was a cosmetic issue. No toes changed in alignment from the immediate post-operative position. There was no evidence of post- operative infection in the entire series. None of the toes required a return to the operating room for any reason. Conclusion: Compression screw fixation for the treatment of hammertoe deformities is a relatively effective method in that it demonstrates reasonable rates of radiographic union with very high rate of symptomatic relief. There were no complications associated with infection or loss of alignment. Furthermore, even in patients without firm evidence of bony union, the presence of an intramedullary implant maintains alignment while relieving symptoms.

Background: While proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyperobliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus. Methods: Fourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively. Results: A mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions-one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear. Conclusion: Medial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint. Level of Evidence: Level IV, case series.