Painful Hardware Research Articles

Does Specific Height Placement of a Flexible Syndesmotic Devices Affect Patient Reported and Radiographic Outcomes after Syndesmotic ORIF in Ankle Fractures?

Category: Ankle; Trauma Introduction/Purpose: Flexible syndesmotic devices have been associated with a reduction in hardware complications, syndesmotic diastasis, and rehabilitation time. Current guidelines suggest syndesmotic devices should be placed specifically 1.5-3.0 cm above the tibiotalar joint, however some may argue that this precise guideline is not necessary. In many syndesmotic injuries, a fibula fracture can occur at this landmark, which may increase the risk of fracture displacement and entrapment of the non-absorbable suture within the fracture itself. The goal of placing a flexible syndesmotic device is to help the fibula “find its home” in the incisura. Therefore, specific proximity to the tibial plafond may be negligible. The current study compared outcomes, union rate, and complications associated with flexible syndesmotic device placement at varied distances from the tibial plafond. Methods: Flexible syndesmotic devices, were placed in patients with a confirmed fracture-associated syndesmotic injury on CT scan. Cases were retrospectively analyzed at a minimum one-year follow-up. 24 patients met our inclusion criteria for this study. 14/24 devices were placed between 1.5-3.0 cm from the tibial plafond (mean 2.26±0.35cm), while the other 10/24 were placed outside of this guideline (mean 4.30±0.64cm). On postoperative radiographs, the placement of each syndesmotic device was measured as a proximal distance from the tibial plafond. Cases were placed into cohorts, defined by device placement within or outside of the 1.5-3.0 cm guideline. Incidences of postoperative complication, revision surgery, radiographic nonunion, and hardware failure were recorded. Patient Reported Outcome Measurement System (PROMIS) pain, function, and mobility scores were recorded. Outcome measures of each study cohort were compared by t-test. Categorical data was compared by Chi-squared analysis. Results: Flexible syndesmotic device placement within current guidelines demonstrated improvement in PROMIS function (p=0.044), pain (p=0.032), and mobility (p=0.035) scores at postoperative follow-up. Similarly, device placement outside of the 1.5-3.0 cm guidelines demonstrated improvement in PROMIS function (p=0.010), pain (p=0.026), and mobility (p< 0.001) scores. There was one patient with a flexible syndesmotic device placed at 1.5-3.0 cm who experienced a traumatic break and wound infection secondary to noncompliance with non-weightbearing status. This patient required debridement, hardware removal, and eventually a below knee amputation. Amongst cases with devices placed outside current guidelines, there was one case of painful hardware, requiring removal (10.00%). There was no statistical difference noted in PROMIS pain scores or complications between the two cohorts. Conclusion: Current guidelines suggest the placement of flexible syndesmotic devices should be limited to 1.5-3.0 cm proximal to the tibiotalar joint. However, these guidelines may be outdated. The current study presents novel evidence that alternative placement of syndesmotic devices may lead to improvement in patient reported function, pain, and mobility, with a low complication rate. There was no evidence of nonunion in any patient in the current study; all cases maintained their syndesmotic reduction. This study may serve to better inform the scope of flexible syndesmotic device application in cases of ankle fractures requiring fixation of the syndesmosis.

Clinical and Radiographic Comparison of Lateral Malleolar Ankle Fractures Treated with or without Deltoid Fixation

Category: Ankle; Other Introduction/Purpose: There is a lack of consensus on how deltoid injuries should be addressed in the setting of acute ankle fractures. This study aims to evaluate whether deltoid repair during lateral malleolar fracture fixation leads to improved clinical outcomes compared to fixation without deltoid repair. Methods: This was a single-center retrospective study conducted from the institutional review board-approved Foot and Ankle Registry data, and the protocol was approved by the steering committee at the investigators’ institution. Patient-reported outcomes via PROMIS scores were collected preoperatively and at least one year postoperatively for all patients. Inclusion criteria included patients aged 18 or older who underwent open fixation for a SER IV equivalent lateral malleolar ankle fracture with a deltoid injury and had preoperative PROMIS scores. Excluded were patients without preoperative radiographs and patients with histories of previous ipsilateral ankle surgeries, rheumatoid arthritis, or gout. Retrospective review of the registry was performed, and 146 patients were included. 80 patients received a deltoid repair (DR) and 66 patients did not receive a deltoid repair (NDR). Preoperative and postoperative medial clear space (MCS) were reviewed for all patients. Results: Both DR and NDR cohorts demonstrated significant improvement in Physical Function, Pain Interference, Pain Intensity, and Global Physical Health. There were no significant differences in preoperative and postoperative PROMIS domains between the two cohorts. There were also no significant differences in preoperative MCS and postoperative MCS between the two cohorts. There were no significant differences in the incidence of subsequent procedures for removal of painful hardware, revisions, infections, progression to arthritis, and persistent pain. Conclusion: This study compares short- to medium-term patient-reported clinical outcomes and complications of lateral malleolar ankle fractures with and without deltoid repair. Repairing the deltoid did not increase the incidence of postoperative complications and produced similar PROMIS scores at 1-year minimum follow-up. This study suggests that any potential differences in outcomes between groups are not large enough to be clinically meaningful in the short term and that other factors may be more relevant in determining the best course of treatment. A longer follow-up is required to evaluate long-term functional and clinical outcomes.

A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique.

Long-term follow-up for anterior cruciate ligament reconstruction (ACLR) is limited due to heterogeneity in the number of techniques utilized, the number of surgeons included, and attrition bias. To analyze a single surgeon's 35-year experience with ACLR using the transtibial technique, with an emphasis on temporal trends in graft selection and subanalyses on rates of revision surgery, contralateral ACLR, and nonrevision reoperation among different demographic cohorts of patients. Case series; Level of evidence, 4. All patients who underwent arthroscopically assisted single-bundle ACLR between 1986 and 2021 were identified from a prospectively maintained single-surgeon registry. Outcomes of interest included revision, reoperation, and contralateral rupture rates. A total of 2915 ACLRs were performed during the senior surgeon's career. The mean age for primary ACLR was 29.4 ± 14.8 years. During primary ACLR, 98.4% of patients received a central-third bone-patellar tendon-bone (BPTB) graft. Increasing patient age was associated with increasing allograft usage (P < .01), with a significant temporal increase in allograft usage over the senior surgeon's career (P < .01). There was a higher revision rate among younger patients (P < .01), female patients aged 21 to 25 years (P = .01), and patients who received an allograft during the primary procedure (P = .04). The contralateral rupture rate showed no difference between sexes (P = .34); however, patients who underwent ACLR with autograft had a greater rate of contralateral injury compared with those with allograft (P < .01). The contralateral rupture rate was greater than the revision rate (P < .01). The most common causes of nonrevision reoperation were failed meniscal repair, new meniscal tears, arthrofibrosis, and painful hardware removal. The findings of this single-surgeon registry reveal temporal trends in ACLR over a 35-year career. There was a trend toward increasing BPTB allograft use in ACLR, especially in older patients and revision cases. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery. Contralateral ACLR was more common than revision surgery.

Poster 298: Complications Following Tibial Tubercle Osteotomy (TTO) at a Tertiary-Care Institution

Objectives: Tibial tubercle osteotomy (TTO) can be used to treat patellar instability, patellar maltracking/compression, and patellofemoral cartilage damage. Reported complication rates following TTO range from 1% to 46%, with varied definitions of complication. The purpose of our study was to define the incidence of complications following TTO in a large cohort at a tertiary-care institution. Methods: Patients who underwent TTO between 2011 and 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up were excluded. Revision cases were excluded. Information about complications was obtained through review of the electronic medical record. Major complications included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, re-dislocation, reoperation for other indications, readmission, and revision. Minor complications included superficial infection, deep venous thrombosis (DVT), wound dehiscence, and postoperative neurapraxia. Chi-square tests were used for categorical variables, t tests for continuous variables. Results: Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years. Patients were 68.5% female with average age 28.3 years.The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of patients, and minor complications in 8.4% of patients. Reoperation was required in 16.6% of patients at an average of 14 months after index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (5.0%). These and other complications are reported in Table 1 at 30 days, 90 days, 1 year, and final follow-up. Table 2 compares patient characteristics for those who had a major complication versus those who did not. Patients who had a major complication were older than those who did not (30.2 vs 27.7, p = .013). A higher proportion of patients who had a major complication had a previous ipsilateral surgery (57.5% vs. 36.6%, p &lt; .001), had an indication of cartilage lesion/arthritis (71.7% vs. 60.6%, p = .034), and underwent a concomitant cartilage reconstruction/repair procedure (51.8% vs. 39.1%, p = .012). A lower proportion of patients who had a major complication had an indication of instability (56.6% vs. 67.2%, p = .043) and underwent a soft tissue reconstruction (46.4% vs. 60.1%, p = .012). There were no differences in the proportion of major complications by sex or American Society of Anesthesiologists score. Mean body mass index (BMI) did not differ significantly between patients who had a major complication and those who did not. Hardware removal was required in 6.5% of patients. More patients with headed as compared to headless screws required hardware removal (13.2% vs. 1.7%, p &lt; .001). Arthrofibrosis requiring reoperation was observed in 5.7% of patients. A significantly higher proportion of patients who underwent a concomitant cartilage restoration/repair procedure had arthrofibrosis postoperatively (10.0% vs. 2.5%, p &lt; 001). There was no difference in arthrofibrosis requiring reoperation by race, sex, age, BMI, smoking status, prior ipsilateral surgery, or other concomitant procedures. Conclusions: The complication rate following TTO was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and a reoperation rate of 16.6% at a mean follow-up of 1.9 years. Major complications were observed in 23.7% of patients and were more common in older patients, patients with an indication of cartilage lesion/arthritis, patients who underwent a cartilage restoration/repair procedure, and patients with a previous ipsilateral surgery. Hardware removal was more common in patients with headed screws. Arthrofibrosis was more common in patients who underwent a concomitant cartilage restoration/repair procedure.

Salvage First Metatarsophalangeal Joint Fusion with a Three-Dimensional-Printed Implant for Osseous Defects: A Case Series.

In this study, we aimed to describe a case series of revision first metatarsophalangeal joint fusion with a three-dimensional (3-D)-printed implant for osseous deficits of the first metatarsophalangeal joint. Bone defects of the first ray are a common problem in foot and ankle surgery. Etiologies include nonunion, avascular necrosis, osteomyelitis, failed first metatarsophalangeal joint implant arthroplasty, and failed hemijoint resection arthroplasty. Treatment options include acute shortening, block allograft, block autograft, distraction osteogenesis, vascularized free fibula, Masquelet technique, and partial first-ray amputation. Three-dimensional printing provides an opportunity to improve outcomes, with less donor site morbidity and less extensive recovery time than an external fixation device. It has been used in other facets of foot and ankle surgery with encouraging results. Three patients (four feet) underwent revision first metatarsophalangeal joint fusion with a 3-D-printed implant. Reasons for revision included avascular necrosis after distal metatarsal osteotomy in one patient and bone deficit after failed first metatarsophalangeal joint implant in two patients. All patients had a minimum follow up of 12 months. Two patients had painful hardware and had to undergo revision due to implant design. At most recent follow up all patients were pain free with improved pain scores. In revisional first metatarsophalangeal joint surgery with osseous deficits, the goal is to restore length and alignment, which improves function of the medial column. Custom 3-D-printed implants for first metatarsophalangeal joint revision can provide an opportunity for improved outcomes and healing.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation

BackgroundPeriprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. MethodsWe retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as “early” if they occurred within 90 days of THA (n = 117) or “late” if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. ResultsEarly PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). ConclusionsThere are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Midterm Survivorship and Complications of the Cadence Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: The Cadence total ankle arthroplasty (TAA) system first entered clinical use in 2016. Short-term outcomes with a minimum of two-year follow-up time have demonstrated survivorship between 93.7% and 100% with improvements in patient-reported outcomes measures, coronal alignment, and range of motion1–4. The purpose of this study is to report the midterm survivorship and complications of Cadence TAA patients with a minimum of 4.5-year radiographic follow-up. Methods: A retrospective chart review was conducted to identify a total of 22 TAA patients with the Cadence implant and a minimum follow-up time of 4.5-years. Patient age, sex, body mass index, diabetes mellitus status, rheumatoid arthritis status, smoking status, laterality, and diagnosis for TAA were collected from patient chart reviews. Preoperative FAAM-ADL subscore, FAAM-Sport subscore, and VAS pain scores and the postoperative scores at the last follow-up visit was also collected. 13 out of 22 patients had preoperative FAAM-VAS scores available while 10 out of 22 patients had postoperative FAAM-VAS scores available. Postoperative complications in the form of wound-related issues and those requiring reoperation or revision were noted, with revision defined as removal or exchange of metal component. 5-view radiographs obtained preoperatively and at the last follow-up visit were used to measure coronal alignment, range of motion, evidence of subsidence or loosening, and osteolysis as previously described1. Results: 3 out of 22 patients required a revision surgery, 1 for loosening of tibial component and 2 for infection. 4 out of 22 patients underwent a reoperation, 2 for gutter debridement due to impingement or heterotopic ossification, 1 for periprosthetic medial malleolar fracture, and 1 for removal of painful medial malleolar screws. The average FAAM-ADL, FAAM-Sport, and VAS pain scores improved from 50.6, 26.5, and 59.9 to 69.5, 35.5, and 23.6, respectively. The coronal alignment angle decreased from 5.96 degrees from neutral to 2.31 degrees. The average dorsiflexion and plantarflexion angles were 14.74 and 17.18 degrees, respectively, for an average range of motion of 31.9 degrees. 3 out of 22 patients had evidence of osteolysis while no patients had evidence of loosening or subsidence. Conclusion: The midterm survivorship of Cadence TAA system in 22 patients was 86.4%. Excluding the two cases of infection which are typically not attributed to implant performance, the survivorship was 95.4%. The reasons for reoperation included impingement, heterotopic ossification, periprosthetic fracture, and removal of painful hardware. The average FAAM-ADL, FAAM- Sport, VAS pain scores and coronal alignment improved. Analysis of longer follow-up time in greater patient cohorts is necessary for clearer understanding of this fixed-bearing implant’s performance.

Is There a Benefit to Rigid Fixation in Calcaneal Lengthening Osteotomy in Painful Pediatric Idiopathic Flatfoot Deformity? Comparing Results of Kirschner Wire Versus Plate Fixation.

Flexible flatfoot (FF) is a common pediatric condition that is mostly asymptomatic, and surgical intervention is only considered when painful FF is refractory to conservative treatment. Calcaneal lengthening osteotomy (CLO) is one of the most commonly used procedures to address painful FF. Traditionally, Kirschner wires (K-wires) were used for fixation, but there has been a recent increase in the use of plates. We compared the clinical and radiographic outcomes of these 2 fixation methods. This single-center retrospective study included children aged 8 to 18 years with symptomatic FF that received CLO using K-wire or plate fixation. Primary outcomes include weight-bearing radiographic measurements and complications after surgery. Secondary outcomes included patient-reported outcomes. Statistical significance was held at 0.05. Among 102 feet (65 patients), 42 feet (41.2%) underwent K-wire and 60 feet (58.8%) underwent plate fixation. No differences in casting duration ( P =0.525) and time-to-radiographic healing ( P =0.17) were noted. Total complications were higher in the plate cohort (12 vs. 2, P =0.04) due to a higher rate of reoperations (16.7%) for hardware-related pain [10 vs. 0; odds ratio 17.74, 95% CI (1.01, 310.54), P <0.05], and infection rates were similar. Both interventions significantly improved ( P ≤ 0.001) aneteroposterior (AP) Talo-first metatarsal and calcaneal pitch angles. Irrespective of intervention, CLO significantly improved pain at 6 months and mobility scores at 12 months. Neither modality demonstrated superior pain or mobility scores at final follow-up. Both K-wire and plate fixations lead to similar radiographic and functional outcomes after CLO in painful, pediatric flatfeet. Compared with K-wire fixation, plates cause a 17.7-fold increased risk of reoperations for painful hardware, with 16.7% of plated cases requiring reoperation. Noting this, along with the higher costs associated with using plates, our study advocates for K-wire fixation for children undergoing CLO. Level III.

OSSEOINTEGRATION OUTCOMES FOLLOWING AMPUTEE LENGTHENING

IntroductionPercutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputees discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14–16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL.Materials &amp; MethodsRetrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma.ResultsThe average age at which DO commenced was 39.4±15.9 years, and seven patients had their amputation more than ten years prior (average 25.5±18.8 years). The residual femurs on average started at 102.2±39.7 mm and were lengthened 58.1±20.7 mm, 98±45% of goal (99±161% of the original bone length). Five patients (56%) had a complication requiring additional surgery: four events of inadequate regenerate were managed with continued lengthening to desired goal followed by autograft placement harvested from contralateral femur reaming; one patient had the cerclage wires break which required operative replacement. All patients had osseointegration performed, at 355±123 days after the initial lengthening nail surgery. One patient had K-level &gt;2 before DO, at a mean of 3.4±0.6 (2.6–4.4) years following osseointegration six patients had K-level &gt;2. The 6 Minute Walk Test remained unchanged (267±56 vs 308 ± 117 meters). Patient self-rating of prosthesis function, problems, and amputee situation did not significantly change from before DO to after osseointegration. Six patients required additional surgery following osseointegration: six to remove fixation plates placed to maintain distraction osteogenesis length at osseointegration; two required irritation and debridement for infection.ConclusionsExtremely short residual femurs which make TSP use troublesome can be lengthening with externally controlled telescoping nails, and successfully achieve osseointegration. However, it is imperative to counsel patients that additional surgery to address inadequate regenerate or to remove painful hardware used to maintain fixation may be necessary. This may improve the amputee's expectations before beginning on a potentially arduous process.

Arthroscopically Assisted, Minimally Invasive Percutaneous Fixation of a Patellar Fracture

Operative fixation of a patellar fracture can be accomplished through a variety of techniques. However, drawbacks have been associated with many of these techniques, including painful hardware, poor skin healing due to bruising and swelling, inadequate cartilage reduction, and eventual post-traumatic osteoarthritis. Throughout the orthopaedic field, minimally invasive approaches have become popular. We describe an arthroscopically assisted method for ensuring fracture reduction intraoperatively and addressing associated defects while the patella is stabilized using a minimally invasive percutaneous fixation technique with screws and a tension band construct.

Medium- to Long-term Results of Nonanatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity With Severe Abduction Deformity.

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. 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. 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. This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation. Level IV, case series.

OSSEOINTEGRATION OUTCOMES FOLLOWING AMPUTEE LENGTHENING

Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputee's discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14-16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL.Retrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma.The residual femurs on average started at 102.2±39.7 mm and were lengthened 58.1±20.7 mm, 98±45% of goal (99±161% of the original bone length). Five patients (56%) had a complication requiring additional surgery. At a mean of 3.4±0.6 (2.6-4.4) years following osseointegration six patients had K-level &gt;2. The 6 Minute Walk Test remained unchanged (267±56 vs 308 ± 117 meters). Patient self-rating of prosthesis function, problems, and amputee situation did not significantly change from before DO to after osseointegration. Six patients required additional surgery following osseointegration: six to remove fixation plates placed to maintain distraction osteogenesis length at osseointegration; two required irritation and debridement for infection.Extremely short residual femurs which make TSP use troublesome can be lengthening with externally controlled telescoping nails, and successfully achieve osseointegration. However, it is imperative to counsel patients that additional surgery to address inadequate regenerate or to remove painful hardware used to maintain fixation may be necessary. This may improve the amputee's expectations before beginning on a potentially arduous process.

The Double Calcaneal Osteotomy for Pediatric Flatfoot

Category: Hindfoot Introduction/Purpose: The double calcaneal osteotomy combines a medial calcaneal sliding osteotomy and lateral column lengthening. Corrective osteotomies, as opposed to arthrodesis and arthroereises, are preferred for foot deformity correction in children and adolescents because they preserve joint mobility, shock absorption, and avoid concerns about adjacent joint degeneration. Individually, both types of osteotomies have demonstrated efficacy in achieving deformity correction and improved functional outcomes for patients. The literature regarding outcomes of this procedure in children is sparse. This retrospective study objectively analyzes outcomes of children who underwent double calcaneal osteotomies at our institution by comparing pre and postoperative radiographs and reporting postoperative complications. To our knowledge, this study contains the largest sample size of symptomatic flatfeet analyzed with regards to double calcaneal osteotomies in children. Methods: Patients who underwent a double calcaneal osteotomy over the past 5 years at our institution were analyzed. Pre and postoperative weightbearing radiographs of the foot were measured (Figure 1). Paired t tests were used to compare pre and postoperative measurements. Statistical significance was set at α &lt; 0.05. Additional factors analyzed for each procedure include total operative time, torniquet time, hardware used for fixation, type of graft, concomitant procedures, and post-operative complications such as infection, nerve injury, nonunion, and reoperation. Results: A total of 20 patients and 26 feet were studied. Significant correction from pre to postoperative radiographic measurement was noted for the talo-first metatarsal angle, talonavicular coverage angle, calcaneal pitch, and tibiocalcaneal angle (p &lt; 0.001). Complications were noted in 3 of the 20 patients, or 3 of 26 feet, and included infection, painful hardware, and hardware failure. Conclusion: The double calcaneal osteotomy was found to be effective in correcting the radiographic parameters associated with flatfoot deformity in children and adolescents with symptomatic flatfeet. The average postoperative radiographic measurements for the 26 feet analyzed were significantly improved from preoperative measurements. Pediatric orthopedists should strongly consider the double calcaneal osteotomy for appropriate surgical candidates.

2022 IFFAS Award for Excellence Winner: Minimally Invasive Chevron-Akin for Correction of Moderate and Severe Hallux Valgus Deformities

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The Minimally Invasive Chevron-Akin (MICA) technique has already demonstrated efficacy compared with other known surgical treatments for mild to moderate Hallux Valgus (HV) deformities. MICA combines percutaneous osteotomies with the benefits of modern rigid internal fixation. By minimizing soft-tissue disruption and allowing large translation of the metatarsal head up to 100%, surgeons have used this technique to address severe deformities as well. The study aim was to evaluate the radiographic parameters, clinical improvement, and potential complications in moderate to severe hallux valgus cases, operated using the MICA technique. Methods: This is a retrospective study conducted between January 2017 and December 2020, that included patients with moderate to severe HV, who underwent surgical correction using the MICA technique. The sample size calculation was based on the AOFAS questionnaire. Thus, to obtain the 0.8 power, including 70 cases in this study, was necessary. The AOFAS score and weight-bearing AP radiographic views for hallux valgus evaluation were applied pre-operatively, after a follow-up period of 6 months, after one year of follow-up, and after two years of follow-up. Visual Analogic Scale (VAS) was applied pre-operatively, after 1 year of follow-up, and after 2 years of follow-up. The following radiographic parameters were measured: metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and intermetatarsal angle (IMA) between the first and second metatarsals. To compare the measurements over time, Friedman's test was used. p&lt;0.05 was considered to be statistically significant. Results: The average preoperative AOFAS score was 43.97 +- 17.89 and varied positively in the 6-month postoperative period, which was 90.17 +- 10.21 (p&lt;0.01), maintained at 12 and 24 months. Preoperative VAS scores averaged 8.24 +- 1.51 and decreased to 1.37 +- 2.27 after 1 year and to 1.19 +- 2.23 after 2 years The initial IMA was 14.84 +- 3.57 degrees compared with a mean value of 8.1 +- 2.87 degrees (p&lt;0.01) at six months and further decrease at 24 months postoperatively. The HVA showed a mean value of 30.37 +- 9.75 degrees preoperatively and 11.14 +- 6.8 degrees (p&lt;0.01) at six months postoperatively, remaining stable in the postoperative evaluations at 12 and 24 months. The preoperative DMAA mean was 16.3 +- 8.55 degrees preoperatively and presented a significant drop (p&lt;0.01) at the 6-months to 7.77 +- 5.44 degrees. Complications included painful hardware, neuropathic pain, and loss of correction. Conclusion: This study demonstrates that the MICA technique is a safe and effective procedure for correcting moderate to severe HV long-term, with a low rate of recurrence and severity of complications. Patients undergoing the surgical procedure in our series showed a significant reduction in radiographic parameters and a significant improvement in clinical scores, maintaining these results over time.The good results of this study justify the continued use of the technique and suggest the need to compare its results with other long-term studies and compare their effectiveness with open techniques.

90-Day Reoperation and Wound Complication Rates in Lateral Approach to Total Ankle Replacement for Post-Traumatic Arthritis

Category: Ankle Arthritis; Ankle; Diabetes Introduction/Purpose: Total ankle replacement (TAR) has achieved relatively successful outcomes with respect to postoperative complications; however, mixed evidence exists regarding early complication rates, reoperation, and infection1-5. The largest study of TAR to date indicates a statistically significant risk of postoperative infection in tobacco users and diabetic patients6. Unlike currently established anterior approaches to arthroplasty, the lateral transfibular approach potentially avoids disruption of perfusion to the skin, possibly decreasing postoperative complications7. The lateral ankle allows surgeons to correct malunion of the fibula in post-traumatic arthritis deformity cases and achieve appropriate coronal and sagittal implant alignment to achieve similar physiological joint orientation8,9. The purpose of this study was to report 90-day reoperation and wound complication rates in lateral approach to total ankle replacement for post-traumatic arthritis (PTA). Methods: A retrospective chart review of lateral TAR cases from 2016-2022 was conducted at a single institution. Only patients undergoing TAR for post-traumatic arthritis were included in this review. A total of 49 patients (22 females and 27 males) underwent total ankle replacement with the Zimmer Biomet Trabecular MetalTM Total Ankle by a single surgeon. Patient demographics, operative data, complications, and adverse events requiring corrective surgery were recorded within 90 days of arthroplasty. Results: The patient sample included 6 active smokers, 11 diabetics, and 32 patients with hypertension with an average age of 60.7 and average BMI of 34.3 (Table 1). Three of the 49 (6.1%) patients required secondary surgery within 3 months of surgery (Table 2). Revision surgery indications included: 1 (2.0%) for removing painful hardware, 2 (4.1%) due to infection, and 1 (2.0%) for tarsal tunnel syndrome after surgery. There were 0 nonunions of the fibula at 90 days and through 1 year follow up. Of the patients requiring secondary surgery for infection, 1 was a smoker and 1 had a history of ankle fusion nonunion and avascular necrosis which was converted to a TAR (Table 4). Conclusion: This retrospective study demonstrates a comparable rate of secondary surgeries following TAR via lateral approach in the early postoperative period (6.1%) while having a slightly higher rate of infection than those previously reported (4.1%)7,8. Notwithstanding, we observed a 100% healing rate of fibula osteotomies; however, we failed to demonstrate a lower incidence of wound complications than previously reported. Surgeons should counsel patients of these risks in those with PTA undergoing lateral TAR, especially in smokers and diabetics.

Hardware Removal in Orthognathic Surgery Patients: A 20 Year Retrospective Study

In the United States, the standard of care for rigid fixation in orthognathic surgery is titanium plates and screws. This hardware is meant to remain implanted indefinitely, but the potential for hardware removal is always mentioned in preoperative discussions. The incidence of titanium hardware removal after orthognathic surgery has been reported to range from 0.4% to 27%, and the largest study previously published included 570 patients over 5 years.1,2 The purpose of this study is to examine the incidence of titanium hardware removal after orthognathic surgery over a 20-year period and to identify factors associated with removal. A retrospective study was performed involving subjects who underwent orthognathic surgery including a combination of Le Fort osteotomy, bilateral sagittal split osteotomy, genioplasty, subapical osteotomy, and vertical ramus osteotomy. The primary outcome variable was titanium hardware removal. Other predictor variables included age, sex, simultaneous removal of third molars, simultaneous bone grafting, and medical comorbidities. Patients met inclusion criteria if they had undergone orthognathic surgery with titanium fixation at a single institution by a single surgeon between the years of 2000 and 2020. Patients with cleft and craniofacial syndromes and those fixated with resorbable hardware were excluded. A total of 738 patients met inclusion criteria with 1,483 orthognathic surgery procedures performed. The mean age at the time of surgery was 23.2 years, and 57% of subjects were female. Ultimately, 43 of the 738 patients required hardware removal (5.8% of patients), and 48 of the 1,483 procedures resulted in hardware removal (3.4%). The average time to hardware removal was 2.3 years (ranging 6 weeks to 9.7 years) with a median of 1.3 years. The most common indication for removal was surgical site infection (17 patients), followed by palpable, painful hardware (12 patients), exposed hardware (6 patients), maxillary sinusitis (4 patients), adjacent tooth external root resorption (1 patient), loose hardware (1 patient), prophylactic removal after previous infection (1 patient), and thermal sensitivity (1 patient). Patients who required hardware removal were more often female (69.8%), were older (average 29.9 years), and were more likely to have multiple jaws operated (79.1%). Of the 43 patients with hardware removed, 19 had hardware removed from the mandible (44.2%), 18 from the maxilla (41.9%), 2 from the genioplasty (4.6%), and the remainder had multiple sites removed (9.3%). The laterality of hardware-associated symptoms was more often right-sided (51.1%) than left-sided (39.5%), and bilateral symptoms were less common (9.3%). A history of obstructive sleep apnea was documented in 9.3% of patients with hardware removed, as compared to 4.5% of the general population of orthognathic surgery patients. The population of patients with cleft and craniofacial syndromes was examined separately, and the rate of removal in this population of 121 patients was slightly lower than that of the general population (5%). The incidence of titanium hardware removal in this population of orthognathic surgery patients was 5.8%. Our findings suggest that there are patient-specific and procedure-specific factors associated with increased rates of titanium hardware removal after orthognathic surgery. Based on descriptive and multivariate analyses, higher risk groups include female patients, older patients, patients with obstructive sleep apnea, and patients in whom multiple jaws are operated. These patients may be counseled accordingly about the risk of future hardware removal.

Minimally Invasive Chevron-Akin for Correction of Moderate and Severe Hallux Valgus Deformities: Clinical and Radiologic Outcomes With a Minimum 2-Year Follow-up.

The minimally invasive chevron-Akin (MICA) technique has already demonstrated efficacy compared with other known surgical treatments for mild to moderate hallux valgus (HV). MICA combines percutaneous osteotomies with the benefits of modern, rigid internal fixation. The aim of study was to evaluate the radiographic parameters, clinical improvement, and potential complications in moderate to severe HV cases, operated using the MICA technique. Retrospective study including 70 feet with HV operated using the MICA technique. The AOFAS hallux MTP-IP score and radiographics for HV evaluation were applied preoperatively, and after 6 months, 1 year, and 2 years of follow-up. The following radiographic parameters were measured: metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), interphalangeal angle (IPA), and intermetatarsal angle (IMA). The average preoperative VAS pain score was 8.2 ± 1.5, which improved to 1.2 ± 2.2 at 24 months. The mean preoperative IMA was 14.8 ± 3.6 degrees compared with a mean of 7.5 ± 2.1 degrees (P < .01) at 24 months. The preoperative HVA value averaged 30.4 ± 9.8 degrees and at 6 months postoperatively 11.1 ± 6.8 degrees (P < .01), which remained stable until measured at 24 months. The mean preoperative DMAA was 16.3 ± 8.6 degrees and at the 6-month follow-up was 7.8 ± 5.4 degrees (P < .01). The mean preoperative IPA was 7.63 ± 4.4 degrees compared with a mean of 6.28 ± 3.5 degrees (P > .05) at 24 months. Complications included painful hardware (14.28%), neuropathic pain (2.85%), and loss of correction (4.28%). In this retrospective review from a single center, we found the MICA technique to be an effective procedure for correcting moderate to severe HV, with a low rate of recurrence and an acceptable rate of complications. Patients undergoing the surgical procedure in our series showed a significant reduction in radiographic parameters and a significant improvement in clinical scores, maintaining these results over time. Level IV, retrospective study.

Use of the Locking Attachment Plate for Internal Fixation of Periprosthetic Femur Fractures.

IntroductionThe locking attachment plate (LAP) can be added to a locking compression plate (LCP) to allow the fixation of locking screws bicortically around a femoral implant. We aimed to examine surgical and fracture characteristics associated with healing for periprosthetic femur fractures (PPFFx) treated with constructs employing LAP fixation. We hypothesize that the addition of an LAP provides stable peri-implant fixation.Materials &MethodsWe retrospectively reviewed a consecutive series of 28 PPFFx surgically treated with LCP-LAP constructs by 4 surgeons from 2015-2020. Fractures were classified and grouped using the Vancouver Classification System and included 12 B1, 2 B2, 11 C fractures, and 3 fractures around other stemmed implants. Primary outcome measures included hardware failure such as screw pullout, broken screws, and plate fracture. Clinical complications including infection, non-union, malunion, and reoperation were recorded.ResultsNo LAP failures, screw pullout, or broken screws were observed. Two fractured plates (7.1%) occurred in patients with Vancouver C fracture types. Overall complication rate was 17.9% and included 3 non-unions, 1 deep infection, and 1 implant loosening with painful hardware, each requiring reoperation. Differences were observed between unions and nonunions for total number of screws (12.4 vs 14.7, P = .005) and number of locking screws used (8.04 vs 11.3, P = .03).ConclusionThe LAP provides adequate fixation and low failure rates where fixation is required around a well-fixed stem. When failures occur, it is from plate breakage and not due to failure of fixation at the area of plate-stem overlap.

Are Outcomes Following Crossed Lag-Screw Modified Lapidus Technique for Hallux Abductovalgus Comparable to Plate-Screw Fixation Technique? A Study of Costs, Radiographic and Patient Reported Outcomes

Category:Bunion; DiabetesIntroduction/Purpose:The modified Lapidus (ML) for tri-planar HAV correction is a powerful procedure for correcting hallux valgus (HV) and metatarsal rotation. We assessed implant costs, radiographs, and pre and postoperative patient reported outcome measures of Patient Reported Outcome Information System Physical Function (PROMIS-PF) Computerized Adaptive Test scores (CAT) at an average of 20.2 months followup.Methods:We examined patients retrospectively from January 2014 to December 2019. Pre and postoperative PROMIS-PF, radiographic parameters (intermetatarsal angle, IMA and HV angle, HVA), complications, and total surgical time were reviewed from the medical chart. Estimated surgical implants costs were obtained from manufacturers.Results:83 patients underwent lag screw lapidus. All had radiographs, 71 had complete PROMIS-PF. Patients were a median age 55.80 (45.55, 53.85), 6.7% male, and 20% diabetic (median A1c 6.4%). Complications included 6.7% delayed wound healing, 13.3% painful hardware, 13.3% superficial infections. Others (7/83 or 8.4%) included complex regional pain syndrome in one, overcorrection in two, paresthesia in one and symptomatic nonunion in three. Preoperative angles were hallux valgus angle 33 (30, 40), IMA 15 (12, 16) which improved at final postoperative follow up to HVA 9 (5, 15) and IMA 7 (6, 9). PROMIS-PF was 43 (37,52) preoperatively, 37 (31, 39) at six weeks, 46 (42, 51) at three months, and 49 (41, 53) at > 360 days. The drop in PROMIS- PF between preop and 6 weeks and the rise from 6 weeks to 3 months were significant. There was no difference between pre and postoperative PROMIS-PF. Implants averaged $140 USD.Conclusion:Patients achieved good radiographic correction of HV following ML by our technique. While physical function, measured by the PROMIS-PF, decreased in the acute postoperative period, it increased to near final levels by three months postoperatively. Low complication rate, low cost, and high patient postoperative functional expectations with excellent radiographic correction were demonstrated.

Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft

Category:Bunion; Midfoot/Forefoot; OtherIntroduction/Purpose:Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft.Methods:A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2019. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test.Results:There were 336 feet included in the final analysis, and 140 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 89.9% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (87.9%) compared to without autograft (91.4%; p = 0.302). Hallux valgus was the preoperative diagnosis in 52.7% of cases followed by hallux rigidus (39.9%). The most common fixation method was a lag screw with a dorsal plate (80.5%). Painful hardware was the next most common complication (8.6%), and smoking and diagnosis of diabetes demonstrated no effect on union rates. In the autograft group, there were no complications related to the calcaneus autograft donor site.Conclusion:As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.