Background Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association. Methods: A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears. Results: The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch ( P = .0001), decreased AP talo–first metatarsal angle ( P = .0001), and increased talonavicular coverage angle ( P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura. Conclusion: This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears. Level of Evidence: Level III, retrospective comparative cohort study.
Category: Midfoot/Forefoot; Other Introduction/Purpose: Cheilectomy and arthrodesis are the primary surgical treatments of hallux rigidus. While cheilectomy preserves limited motion, that motion can be the source of persistent pain that later requires arthrodesis. Cheilectomy with interposition arthroplasty using a synthetic hydrogel implant (Cartiva) has been proposed as an alternative to arthrodesis. Previous studies compared Cartiva to arthrodesis, but Cartiva is really a modification of cheilectomy, meant to improve its results by distracting the bony surfaces of the first MTP joint. This study compared outcomes of cheilectomy with Cartiva to cheilectomy alone. Methods: A retrospective cohort study assessed the results at 1-year minimum follow-up, identifying patients by CPT code for cheilectomy with (28291) and without (28289) Cartiva interposition. There were forty-five patients: 26 in the Cartiva group and 19 in the cheilectomy group. Tabulated data included: age, gender; preoperative, 6-month, and final postoperative total first MTP ranges of motion (ROM); preoperative and final postoperative VAS and SF-36 scores; and reoperation information. Hallux rigidus grade was assessed by Coughlin and Shurnas criteria. First MTP joint space was measured at the medial, midline, and lateral portions of the joint on both AP and lateral radiographs before, immediately following, and at maximum postoperative follow-up (16 month mean). For analysis, medial, midline, and lateral joint measurements were averaged to generate a composite measure of radiographic joint space. Follow-up means were 23 months for all patients, 18 for Cartiva and 28 for cheilectomy. Results: Mean age was 54. Mean preoperative grade was 2.6 for Cartiva and 2.1 for cheilectomy (p=0.037). Mean preoperative ROM was 44°. At 1 year follow-up, ROM was 39° for Cartiva and 47° for cheilectomy (p=0.95). Mean VAS improved from 5.8 to 2.0 and 3.0 for Cartiva and cheilectomy, respectively, at final follow-up (p=0.002, p=0.004). Following Cartiva, two week postoperative joint space means increased: AP midline 1.4 to 2.6 mm, AP composite 1.4 to 2.2 mm, and lateral midline 1.3 to 2.7 mm (p<0.001). At final follow-up, joint space measures returned to levels similar to cheilectomy: AP midline 1.3 vs. 1.2 mm, AP composite 1.1 vs. 1.2 mm, and lateral midline 1.6 vs. 1.2 mm (p>0.3). Five patients in each group (22%) underwent revision. Conclusion:: Cartiva offers similar intermediate-term ROM preservation and pain relief as cheilectomy in a cohort with higher grade hallux rigidus. Joint distraction gained by synthetic hydrogel interposition subsides with time to levels similar to cheilectomy. Revision surgery for persistent pain is common in both groups.
Category: Other; Sports Introduction/Purpose: While it is a commonly accepted principle peroneal tendon (PT) tears are associated with cavovarus deformity, this is the first study that both quantifies deformity in patients with surgically proven tears using sophisticated and reproducible methods to compare radiographic measurements to a matched control group. Understanding of the anatomy and mechanism of injury affecting the PTs has led to greater recognition of PT tears as an important cause of lateral sided foot and ankle pain. The literature reports a presumed correlation between the cavus foot and PT tears. Little data exist quantifying the correlation between PT tears and the alignment of the foot. We hypothesize the cavovarus foot applies stress over the lateral border of the foot leading to degenerative changes in PTs. Methods: A cohort of 252 consecutive patients operatively treated for peroneal tendon tears (PT) were compared to an age- and sex- matched control (C) group of 104 outpatients treated for isolated forefoot problems. Calcaneal pitch, calcaneal - first metatarsal, talometatarsal, and talocalcaneal angles were compared on standing lateral radiographs. Talometatarsal and talocalcaneal angles, and talonavicular coverage, were compared on standing anteroposterior radiographs. Published radiographic criteria were used to determine cavovarus. ANOVA analysis detected statistically significant differences between patients and controls and a subsequent Tukey-Kramer test compared the control group with each type of PT tear. An a prioripower analysis was performed to calculate the minimum sample size in each cohort to detect a 90% effect size for a significance level of p<0.05. Results: Radiographic cavovarus was found in 9.4% (74/252) of PT group, and 6.7% (7/104) in controls. On lateral radiographs a significant greater calcaneal pitch (p=0.0001), and significant smaller calcaneal-first metatarsal angle (p=0.0084) was noted with PT tears (p=0.0001). On anteroposterior radiographs a significant smaller talometatarsal angle (p=0.0001) and talonavicular coverage (p=0.0001) were noted in PT tears. AP talocalcaneal and lateral talometatarsal and talocalcaneal angles were not correlated with PT tears. Patients treated for PT tears, isolated peroneus brevis tears (PB) accounted for 67.9% (171/252), isolated peroneus longus (PL) tendon tears were 7.5% (19/252), PB and PL tears accounted for 17.5% (44/252). A smaller talometatarsal angle on the AP was associated with PL (0.0098) and combined PB and PL tears (<0.0001) but not PB tears alone (0.1162). Conclusion: The correlation between cavovarus and peroneal pathology in the literature is highly anecdotal. Few studies report objective measures. This is the first study to our knowledge comparing nature and severity of cavovarus according to location of peroneal tear. This study proves and quantifies objective measures of cavovarus that correlate with peroneal tendon tears, when compared to a cohort of matched controls.
Category: Other Introduction/Purpose: Foot and ankle (FA) pain can be found in up to 20% of the adult population.1 Etiologies are multifactorial and include neurologic injury, trauma, deformity, tendinopathies and psychological factors. The purpose of this investigation is to assess psychological factors contributing to FA pain in surgical and nonsurgical patients. By identifying how psychological factors influence patient reported pain and disability, clinicians may be able to develop interventions to decrease catastrophic thinking and improve psychological well-being prior to considering surgical intervention Methods: All patients seen in a FA clinic by a single fellowship trained orthopaedic surgeon from August 2016 to October 2016 were included. All patients completed 5 functional assessments prior to their visit (PHQ-2, VAS Pain Scale, FAAM, PSEQ, PCS). We divided the patients into two groups based on their performance on the PHQ (PHQ < 3, or PHQ = 3), which measures depression. Scores = 3 are indicative of clinical depression. Nonparametric Wilcoxon testing was used to determine whether the distributions of the other scores (VAS Pain Scale, FAAM, PSEQ and PCS) were significantly different between these two groups. Results: Of the 225 patients included in our analysis, there were 175 (88%) had PHQ-2 depression scores of < 3 (Group 1) and 50 (22%) had scores = 3 (Group 2). Group 2 demonstrated a statistically significant increase in VAS Pain Scale and PCS. In addition, patients in Group 2 showed statistically significant decreases in FAAM and PSEQ. Patients in Group 2 were statistically more likely to be obese, use tobacco, and be unemployed. Conclusion: In patients with common FA complaints, those with clinical depression, as assessed by the PHQ-2, demonstrated increased pain scores, decreased ability to cope with pain, and lower functional outcome scores compared to patients without depression. Tobacco use, obesity and employment status were found to independently affect pain, coping, and function of patients. These data suggest that depression can significantly affect a patient’s ability to cope with pain and to achieve a higher functional outcome. This data suggests patients with depression may have increased difficulty coping with their FA ailment leading to the need for increased counseling regarding expected outcomes.
Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: Preoperative factors influencing functional disability imparted on the patient by ankle arthritis have not previously been assessed with gait analysis. The purpose of this study was to assess the influence of ankle arthritis etiology and deformity, measured radiographically, on gait performance in a dedicated gait lab utilizing a multisegment foot model. With three calcaneal and four metatarsal markers in addition to standard lower extremity markers, the modified Helen Haynes model allows for the evaluation of range of motion (ROM) within the 'ankle-hindfoot segment.' The primary hypothesis was that three- dimensional ankle-hindfoot segment ROM would be more restricted in patients with post-traumatic ankle arthritis than other etiologies. The secondary hypothesis was that temporospatial and kinetic measures would not vary by etiology. Methods: A longitudinal cohort of 183 patients with end-stage ankle arthritis were prospectively enrolled from 2008-2018. Mean age was 61, BMI 29, and 56% were male. Four etiologic groups were defined: Post-fracture (100), arthritis caused by planovalgus foot deformity (23), chronic instability associated with cavovarus (32), and miscellaneous (28), comprised of inflammatory (7), idiopathic (6), instability without deformity (5), septic (2), and avascular necrosis (3) as causes. The four-segment Milwaukee foot model was used in a dedicated gait lab with a 12-camera motion capture system. Gait data was collected over a minimum 20 gait cycles across a 10-meter walkway. Kinetic data was simultaneously collected with two force plates embedded in the walkway operating at 1 MHz. AP and lateral tibiotalar angles, lateral talus-first metatarsal angles, calcaneal pitch, and tibiotalar ratio were measured. Multivariate regression analyzed the effect of etiology and radiographic measures on gait function, controlling for age, gender, and BMI. Results: The primary hypothesis was confirmed. Sagittal plane ankle-hindfoot segment ROM was lower in post-traumatic and higher in valgus patients compared to other etiological groups (P<0.0001) (Figure 1). Sagittal plane ankle-hindfoot segment ROM restriction relative to the contralateral limb was also more severe in the post-traumatic group than others (P=0.0005). Valgus AP tibiotalar angles were associated with greater sagittal plane ankle-hindfoot ROM (P=0.0016). The secondary hypothesis was disproven. Post-traumatic patients ambulate with greater maximum ankle moment than other groups (P=0.0043). Valgus patients ambulate with a comparatively longer step length (P<0.0001). Significant reductions in affected limb walking speed (P<0.0001), step length (P<0.0001), and maximum ankle moment (P=0.036), as well as increases in double limb (P=0.0007) and total support percentage (P<0.0001) were found among the miscellaneous etiology group. Conclusion: Of the four groups, patients with post-traumatic ankle arthritis ambulated with the greatest ankle and hindfoot stiffness, but also the greatest ankle moment. Patients with valgus ankle arthritis had the greatest ROM through the ankle and hindfoot and the longest step length. In addition to diminished ROM, patients in the miscellaneous group had the lowest cadence, symmetry, and torque of gait. The etiology of severe ankle arthritis can predict the pattern of gait dysfunction, which, in turn, may inform choices of surgical reconstruction.
Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: Despite substantial advancements in Total Ankle Arthroplasty (TAA), catastrophic failure due to implant subsidence remains a common and serious problem. While there are many studies of short and some of intermediate term follow- up of TAA, the number of long-term studies, especially with prospectively collected data, is much fewer, and the data on the incidence and impact of talar subsidence on those results is even more limited. Talar subsidence can be especially challenging to manage, given the limited talar bone stock and revision options as compared to the larger tibial bone stock. The purpose of this study was to evaluate the long-term incidence and characteristics of TAA implant failure. Methods: A prospectively collected database of TAAs performed in a tertiary referral center began enrolling in 1999. Medical records/radiographs were reviewed to evaluate outcomes of TAA and final radiographs were reviewed to identify implant failure from 1999-2016. Minimum radiographic follow-up was two years. Pre-operative and post-operative radiographs were measured for ankle, foot, and implant coronal and sagittal alignment Failure and reoperation rates of two different implants, the mobile bearing Scandinavian Total Ankle Replacement (STAR) and the fixed bearing Salto Talaris (Salto) were analyzed. Paired Student t- tests were performed between groups. TAA revision surgeries were excluded if the primary TAA was performed at another institution. Reoperations were recorded according to the Reoperations Coding System (CROCS) classification of the Canadian Orthopaedic Foot and Ankle Society (COFAS). There were 149 TAAs reviewed in 146 patients (136 STARs and 13 Saltos), with an average follow-up of 7.03 years (range 2-20 years). Results: Implant survival was 85.8% at mean 7 years. 25 TAAs demonstrated radiographic catastrophic failures, 21 underwent re- operation, and 4 declined revision surgery (Table 1). One failure was due to infection (CROCS 10), others were aseptic (CROCS 9). 13/25 failures were related to talar subsidence, all STARs (9.6% of all STARs in the series). Nine STARs (6.4%) had less severe talar subsidence but were asymptomatic, The STAR talar component, in total, subsided in 17.6% (24/136) of STARs, requiring revision in 13 (9.6%) of cases at mean 3.8 years post-op. There was no difference in pre-operative/post-operative radiographic alignment between the TAAs that did and did not fail. Twenty-six ankles (17.4%) underwent additional surgery with retention of metal components, bringing the total reoperation rate to 47/149 (31.5%). Conclusion: At long-term follow-up, TAA demonstrates reasonable implant survival rates, especially given the learning curve that includes STARs implanted prior to the Food and Drug approval study. We describe a unique mode of failure in STARs that highlights one of the risk factors for failure in total ankle arthroplasty. This represents the highest reported rate of talar subsidence in the literature with almost 10% of STARs demonstrating talar-sided failure at mean 7-year follow-up. Surgeons who utilize the STAR total ankle should be vigilant for talar subsidence given the high rates reported in this series.
Category: Bunion Introduction/Purpose: Compared to women, hallux valgus in men is less common, more severe, and has higher rates of undercorrection, recurrence and greater distal metatarsal articular angle (DMAA). Bunionectomies that correct metatarsus primus varus (MPV) by valgus rotation paradoxically increase 1stMTP valgus in high DMAA, contributing to recurrence and undercorrection. While proximal valgus osteotomy or arthrodesis plus distal varus-producing metatarsal osteotomy can correct both components, there is a simpler solution. A modified Scarf osteotomy technique was developed in which the osteotomy is simultaneously translated laterally to correct MPV, while rotating the distal metatarsal in varus to correct DMAA. While previous literature on male hallux valgus is comprised of many studies using a combination of surgical techniques, all patients in this series had the same procedure. Methods: A retrospective review of prospectively collected data was performed in male patients treated with modified scarf osteotomy and soft tissue realignment for symptomatic hallux valgus, who failed conservative treatment. Preop and postop range of motion (ROM), radiographs, and validated patient reported outcome (PROM) scores including Pain VAS and SF-36, were tabulated, as well as complications, and AOFAS Hallux scores for historical comparison. There were 22 patients (26 feet), mean age 53 (17-79). Mean clinical and radiographic follow up was 24 months, and mean postop PROM’s follow up was 4.7 years. Six of 26 feet (23%) required a modified Akin osteotomy for a congruent 1stMTP joint. A subset of patients with minimum 4-year and mean 7.6 -year follow up (9 patients, 10 feet), was also analyzed. Weightbearing radiographs were evaluated for DMAA, hallux valgus angle (HVA) and 1st-2ndintermetatarsal angles (IMA). Results: Statistically significant improvements were found in VAS scores (5.8 to 1, p<0.001); SF-36 physical (44 to 56.7, p<0.001); IMA (15.9 to 8.7, p<0.001), HVA (36.1 to 15.1, p<0.001), DMAA (12.7 to 6.9, p=0.01) and AOFAS scores (44 to 79, p<0.001). Total 1stMTP ROM decreased from 60.9 to 50.8 degrees (p=0.06). One patient had delayed wound healing requiring oral antibiotics and wound vacuum application. Statistically significant improvements were maintained over time in the 7.6-year follow up sub-group, with VAS scores 6.2 to 1.3 (p<0.001), SF-36 physical from 40.8 to 61.3 (p=0.008), and SF-36 mental from 55.7 to 62.3 (p=0.002). Conclusion: This study found statistically significant improvements in both subjective validated PROM’s and objective radiographic measures using a special modification of the scarf osteotomy to address the characteristic increased DMAA that underlies complications and under correction previously reported in male hallux valgus. The corrections were well maintained at long-term follow-up including a robust correction of the DMAA.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.