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Insertional Achilles tendinopathy can be a very challenging clinical syndrome with various nonoperative measures typically attempted before surgical intervention. Associated complications are known with surgical repair and can be limb altering. Owing to the longevity of clinical symptoms before clinical presentation, changing the pathophysiologic process and halting the inflammatory changes becomes paramount. Here we discuss nonoperative techniques and updates in the foot and ankle literature.

Lesser toe plantar plate injuries at the metatarsophalangeal (MTP) joint are a common source of metatarsalgia. Chronic pain with weight-bearing is the common presentation of lesser toe instability. Deformity occurs when the plantar plate is torn or attenuated. Crossover toe and MTP instability often occur with multiplane deformity, most commonly with dorsal contracture of the second toe and medial drift over the Hallux. In this article, the authors present a comprehensive stepwise approach to diagnosing and treating plantar plate injuries using both dorsal and plantar approach techniques.

This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.

There has been significant enhancement in surgical management of hallux valgus deformity. Recognition of the role of medial column hypermobility has resulted in better functional outcomes with decreased risk of recurrence. Modern techniques have evolved to include enhanced fixation in a move toward minimal postoperative downtime. Evolution to include true triplane correction, including frontal plane derotation of the first ray, has resulted in optimal functional outcomes. The addition of anatomic triplane restoration, enhanced internal fixation, and early return to weight-bearing activities are combined resulting in lifelong correction with excellent functional outcomes and a high degree of patient satisfaction.

Total ankle replacement (TAR) continues to increase in popularity as a motion-preserving option to ankle arthrodesis. TAR is indicated for primary, posttraumatic and inflammatory arthropathies as an alternative procedure to tibiotalar arthrodesis. Proper patient selection is paramount to a successful outcome in TAR. Contraindications to TAR include the presence of neuropathy, active infection, severe peripheral arterial disease, inadequate bone stock, and severe uncorrectable coronal plane deformity. This article is a brief overview of techniques and PEARLS on how to address a well-aligned ankle joint, varus deformity as well as valgus deformities as well as the authors' experience with single versus staging coronal plane deformities.

Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.

Pes cavus deformities have long been known to be complicated and require extensive preoperative evaluation, intraoperative surgical acuity, and postoperative rehabilitation. The reconstructive algorithm includes varying combinations of soft tissue releases, tendon lengthening and transfers, and corrective osteotomies. This is a disease process that evolves with time, and patients may present at different stages of the deforming process depending on the etiology. Some etiologies are continually progressive, and this is important to consider when formulating a corrective plan. Also, some or all of the deformity may be rigid which also needs to be appreciated during procedure selection. This chapter aims to cover the full spectrum of cavus reconstruction procedures with technical pearls and pitfalls for each.

The understanding of lesser metatarsophalangeal joint (MTP) instability has evolved over the years with a better understanding of the pathoanatomy and greater attention to the soft tissue derangement. Historically, lesser MTP pathology was often managed by addressing the osseous pathology alone, with oversight regarding the soft tissue stabilizing structures. The plantar plate is a fibrocartilaginous structure which is a dorsal restraint to the MTP. Deformity occurs when the plantar plate is torn or attenuated. Crossover toe and MTP instability often occur with multiplanar deformity, most commonly with dorsal contracture of the second toe and medial drift over the hallux. Although plantar plate instability can occur secondary to acute injury, the aim of this chapter is to describe cases where by chronic attenuation causes metatarsalgia and digital deformities and elaborate on preoperative work-up and surgical correction.

Hindfoot arthrodeses, in particular talonavicular (TN) joint arthrodeses, are versatile procedures which allow for dramatic positional correction in multiple planes. The indications range from post-traumatic arthropathy, moderate to severe hindfoot valgus, posterior tibial tendon dysfunction, Mueller-Weiss syndrome, and rheumatoid arthritis. These various disease processes and pathologies are discussed in detail in previous chapters. This chapter will focus on isolated TN fusion techniques and pearls.

Tarsometatarsal (TMT) joint arthrodesis is performed for a variety of etiologies including primary midfoot osteoarthritis, post-traumatic arthritis, complex multiplanar foot deformity, neuromuscular disease, and Charcot neuroarthropathy. Several of these etiologies and their associated management are covered in alternate pertinent chapters. The main focus of this chapter will be TMT arthrodesis related to primary osteoarthritis, post-traumatic arthritis, and some discussion regarding the procedures as they relate to associated foot deformities. TMT arthrodesis can be considered for an isolated, affected ray (i.e., 1st, 2nd, or 3rd), or for multiple adjacent rays.

Many pathological deformities affect the midfoot joints including pes planovalgus, pes cavus, and Charcot neuroarthropathy. These joints are susceptible to primary and post-traumatic arthritic changes secondary to chronic instability or traumatic degeneration. The naviculocuneiform joint plays a unique role in midfoot articulations and maintenance of the medial longitudinal arch. The navicular itself can be prone to stress fractures and subsequent avascular process that contributes to damage of the articulating cuneiform surfaces. A common treatment for degenerative arthritis of the naviculocuneiform joint is arthrodesis. This chapter highlights the morphology recognition and fusion techniques that can be utilized for a successful arthrodesis of the naviculocuneiform joint.

Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out. We initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior ankle during total ankle replacement using a third-generation implant system. Ten fresh-frozen adult cadaveric below-the-knee specimens were positioned in the intraoperative positioning frame of an approved total ankle replacement system and adjusted to achieve proper foot alignment using fluoroscopic imaging. The relationship between the tibial cutting guide pins and the posterior neurovascular and tendon structures was measured using digital calipers. High rates of posterior structural injury were found. Nearly all proximal-medial pins encountered a posteromedial neurovascular structure, most commonly the tibial nerve. The distal-medial pins mainly encountered posteromedial tendinous structures, in particular, the flexor digitorum longus tendon. The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve. Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.

In ankle arthroplasty, little attention has been given to intraoperative nerve injury and its postoperative sequelae. The aim of the present anatomic study was to determine the relationship of the superficial peroneal nerve to the standard anterior approach for total ankle arthroplasty. The superficial peroneal nerve was dissected in 10 below-the-knee cadaver specimens. The medial and intermediate dorsal cutaneous branches were identified. A needle was placed at the ankle joint. The following measurements were recorded: bifurcation into the medial and intermediate dorsal cutaneous branches, reference needle to the branches of the medial and intermediate superficial peroneal nerve, and the crossing branches of the medial dorsal cutaneous nerve. Two specimens (20%) had a medial dorsal cutaneous branch cross from medially to laterally. Eight specimens (80%) had a crossing branch of the medial dorsal cutaneous branch within 5 cm of the incision. No intermediate dorsal cutaneous branches were within the incision. The results from the present cadaver study suggest that during an anterior ankle approach, aberrant branches of the superficial peroneal nerve could require transection in 20% of patients at the joint level and ≤80% of patients with distal extension >35 mm from the ankle joint. The risk of injury to branches of the superficial peroneal nerve is substantial. The risk of nerve injury can be decreased with meticulous operative technique, smaller incisions, and the avoidance of aggressive retraction.

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

The naviculocuneiform articulation is composed of the navicular proximally and the 3 cuneiforms distally. It is not uncommon to perform surgical interventions at this joint for multiple pathologic foot etiologies. To date, no detailed anatomic measurement is available for each cuneiform articulation on the navicular. The purpose of the present study was to present an anatomic description of this complex joint to aid in better surgical understanding and improve surgical outcomes. Ten fresh, frozen, and thawed below-the-knee cadaveric specimens were used for anatomic dissection of the navicular and associated cuneiforms. The height and width were recorded across the largest span of the entire navicular–cuneiform joint complex and each facet. The mean navicular height and width was 19.9 mm and 34.7 mm, respectively. The medial cuneiform facet mean height and width was 19.9 mm and 15.8 mm, respectively. The intermediate cuneiform facet mean height and width was 20.4 mm and 16.9 mm, respectively. The lateral cuneiform facet mean height and width was 17.5 mm and 14.7 mm, respectively. A detailed description of this joint complex will aid foot and ankle surgeons in screw placement and surgical decision-making when performing complex medial column fusions. Advanced 3-dimensional weightbearing computed tomography would give us a better idea of the motion that occurs within this complex joint.

Total ankle arthroplasty is an evolving treatment of ankle arthritis. One implant uses intramedullary guidance to enhance accuracy by accessing the tibial canal through the inferior aspect of the foot, potentially placing the subtalar joint articulation at risk. The purpose of the present cadaveric anatomic evaluation was to identify posterior subtalar articular facet joint involvement during intramedullary guidance to the tibial canal. Ten below-the-knee cadaveric specimens were used. After drilling into the tibial medullary canal with a 6-mm drill bit and using the standard targeting jig, the specimens were dissected, and the posterior facet was evaluated. We graded posterior facet involvement according to the location of the drill hole and, if within the facet, the percentage of the facet violated by the drill bit, with 100% representing the full circumference of the 6-mm drill bit. Of the 8 specimens in which the drill bit passed through the subtalar posterior articular facet, the encroachment was peripheral in all cases, with no specimen showing circumferential 6-mm drill bit articular penetration (no cases with 100%). Sinus tarsi penetration occurred in 20% of the cases. The dissections with articular involvement included 3 specimens with >50% of the drill bit penetrating and 5 with

The use of biologics, namely demineralized bone matrix, bone marrow aspirate (BMA), and other growth factors, has gained popularity in foot and ankle surgery for use in compromised hosts or high-risk situations. Our research has shown the concentration of these pluripotent cells was greatest in the iliac crest. A medical record and radiographic review was performed to compare the effect of BMA harvest site osteogenic progenitor cells on the incidence of fusion. Radiographs were reviewed for radiographic evidence of trabecular bridging in 2 or more views. If fusion occurred, the number of osteogenic progenitor cells found in the combined BMA at surgery was recorded. A total of 33 patients were included in the present study. Of the 33 patients, 32 (97.0%) had radiographic fusion at a mean of 13 ± 6 (range 8 to 30) weeks, and 1 (3.0%) experienced nonunion and required revision. The patient procedures were as follows: 18 (54.5%) hindfoot arthrodeses, 8 (24.2%) forefoot arthrodeses, 4 (12.1%) fractures, and 3 (9.1%) isolated ankle fusions. The mean colony-forming units for the patients with fusion was 20.3 ± 23.5 (range 0.0 to 107.0). In the patient with nonunion, it was 0.20 colony-forming unit. Our comparison of the incidence of fusion with the use of osteogenic progenitor cells from 3 anatomic sites showed a low incidence of complications and a high incidence of fusion. No association was found between the BMA concentration and the incidence of fusion, suggesting a minimum concentration and biologic potential of pluripotent cells is necessary to achieve the clinical effect of fusion.

Detachment with reattachment of the Achilles tendon is a common surgery for debridement of retrocalcaneal exostosis, bursitis, and other insertional pathologic entities. The technique involves a midline skin incision on the posterior Achilles to the tendon. The distal Achilles attachment is removed in a U-shaped manner, leaving the medial and lateral flares, but exposing the posterior spur. This midline approach provides excellent exposure and allows for rapid and efficient surgical debridement. The tendon is reapproximated and repaired with a suture anchor to facilitate fixation to the posterior calcaneus. Some surgeons have expressed concerned that the rupture risk could be increased in the postoperative period using this technique. The present study was a retrospective medical record review of 98 patients (100 feet) who had undergone a midline approach with Achilles reattachment after insertional Achilles debridement during a 3-year period. The demographic and comorbidity data were collected and analyzed. The outcome measures were postoperative rupture and the need for revision surgery. The mean age was 51.9 years, and the patients included 59 females (60.2%) and 39 males (39.8%). The complications included 4 rupture or avulsion revisions (4.0%) and 2 recurrent pain and tendinitis revisions (2.0%). The most common repeat repair procedure included hardware removal and a flexor hallucis longus transfer or augmentation. Nine patients (9.0%) had wound complications, 7 (77.8%) of which necessitated incision and drainage. The midline approach with Achilles detachment and reattachment is a safe and effective method of surgical treatment of insertional Achilles pathologic entities. The low reoperation rate of 4.0% will allow foot and ankle surgeons to safely rely on this approach.

Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.

Moderate to severe hallux valgus (HV) has traditionally been treated with a corrective osteotomy or a tarsometatarsal arthrodesis. Tarsometatarsal arthrodesis can be performed as a planar wedge resection or using a joint curettage technique. Little is known about whether adequate correction can be obtained with purely a joint curettage technique. The purpose of this study is to evaluate the corrective power of a first tarsometatarsal joint (TMTJ) arthrodesis using a nonplanar wedge curettage technique. A retrospective radiograph and chart review was performed on 99 consecutive patients (110 feet) who underwent a first TMTJ arthrodesis for primary HV correction utilizing a curettage technique. The radiographic measurements collected were the first intermetatarsal angle, HV angle, and tibial sesamoid position and were obtained at the following intervals: preoperative, immediate postoperative, and 6 months postoperative. In all, 91 patients (100 feet) qualified for statistical analysis. There was a significant decrease in all 3 measurements from the preoperative throughout the entire postoperative time period ( P < .001). The authors demonstrate the ability to achieve significant angular correction with a joint curettage method for a tarsometatarsal arthrodesis. Levels of Evidence: Therapeutic, Level IV: Case series

First metatarsophalangeal joint arthritis can stem from a biomechanical imbalance as in hallux abducto valgus, metabolic arthritidies such as rheumatoid or gout, and even in posttraumatic cases. Advanced arthritis in the foot and ankle can often become debilitating. Surgical intervention is often necessary. Revision of failed first metatarsophalangeal joint arthroplasty is often in the setting of bony erosion and lysis, cystic changes, and loss of bone stock. In this article, we describe first metatarsophalangeal distraction arthrodesis technique using tricortical calcaneus autograft with the aim of simplifying donor site graft harvesting and decreasing donor site morbidity while attaining successful osseous union. Levels of Evidence: Level V

Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh-frozen below-the-knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0-mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0-mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction.

Lateral column lengthening is a common procedure for correction of pes planovalgus. A tricortical bone graft has been a standard among foot and ankle surgeons. The purpose of the present study was to compare the union rates and complications between the 2 forms of fixation for lateral column lengthening. The present study was a retrospective medical record and radiograph review of 52 patients divided into 2 equal groups, allograft (group A) and opening wedge plate (group B). The radiographic analyses compared the preoperative, postoperative and long-term measurements of cuboid abduction and talonavicular angles. The outcome measures included nonunion, hardware removal, and infection. The median follow-up duration for each group was 34.5 (range 6.3 to 89.5) months and 12.6 (range 6.5 to 56.8) months for groups A and B, respectively. Group A had 4 nonunions (15.4%) and group B had 2 nonunions (7.7%). The mean radiographic measurements of cuboid abduction and talonavicular articulation for each group improved significantly. The incidence of hardware removal was greater for group A than for group B (30.8% versus 15.4%), although the difference was not statistically significant. The median time to osseous healing for group A was 12.0 (range 8.0 to 80.0) weeks and for group B was 10.0 (range 6.0 to 36.0) weeks. The interposition plating techniques for lateral column lengthening procedures had a lower nonunion rate and incidence of hardware removal compared with the traditional use of tricortical bone grafting. The findings from the present study will aid surgeons in alternative fixation for lateral column lengthening procedures.

The classic foot type of Charcot-Marie-Tooth type 1A is pes cavovarus with associated digital contractures. In this article, we describe a painful pes planovalgus foot type in a 10-year-old child with progressive Charcot-Marie-Tooth type 1A polyneuropathy. The authors discuss possible etiologies and treatment options in this isolated case. The value of gait analysis in preoperative planning and postoperative surveillance are also discussed. Level of Clinical Evidence: 4

Numerous advancements in prosthesis design and surgical techniques have greatly contributed to an evolving role for total ankle replacement as a motion-sparing option for the treatment of end-stage ankle arthritis. Patient-specific instrumentation and preoperative navigation technologies, well elucidated in total knee arthroplasty, have helped to optimize component positioning and in turn improve prosthesis durability and survivorship. This chapter aims to review the PROPHECY INBONE II and INFINITY preoperative navigation technology and its evolving role in improving outcomes in total ankle replacement.

The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes.

Persistent medial column sagittal mobility can be encountered despite successful first tarsometatarsal stabilization if fixation has been limited to the first tarsometatarsal joint. The purpose of the present cadaveric research was to quantify the effect of a third point of fixation from the base of the first metatarsal to the middle cuneiform compared with the traditional isolated first tarsometatarsal fixation. Ten matched pairs of below-the-knee specimens, with a known cause of death, sex, ethnicity, and age, height, weight, and body mass index at death, were used for our examination. Portable fluoroscopy aided with the accurate placement of all points of fixation. Measurements of movement were obtained using the validated Klaue device. The 20 matched below-the-knee specimens were from 10 cadavers (2 female and 8 male donors, aged 72.8 ± 9.3 years, body mass index 21.1 ± 4.2 kg/m(2)). The sagittal plane motion of the first ray was 7.45 ± 1.82 mm before fixation. With isolated first tarsometatarsal fixation, the sagittal motion decreased to 4.41 ± 1.51 mm and decreased further to 3.12 ± 1.06 mm, with the addition of middle cuneiform fixation. Statistically significant enhancement of the stability of sagittal first ray motion was noted with the addition of the first metatarsal to middle cuneiform pin, even after simulated Lapidus fixation. Our findings suggest that first metatarsal to middle cuneiform fixation can be beneficial if excessive sagittal motion is present after standard 2-point fixation and can play a role in the prevention of recurrence and complications.

Background: Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. Methods: The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). Results: Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). Conclusion: This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. Level of Evidence: Level IV, case series.

Lesser metatarsophalangeal (MTP) joint instability is a common and painful condition that can severely limit activity and recreation. Synovitis and joint effusion may be seen early on with progression of instability to encompass predislocation and eventual complete dislocation of the MTP joint. Various surgical techniques have been described to treat lesser MTP joint instability and associated hammertoe deformities. Many surgeons experience frustration with the surgical outcome of metatarsal osteotomies and flexor transfers commonly used for this condition. The plantar plate apparatus is felt to be at the heart of the pathomechanics of this condition in many instances and is often misunderstood or even overlooked. Indirect dorsal approaches to plantar plate repair often require reliance on complex instrumentation and provide a limited view of the involved structures. The authors describe a direct plantar approach technique for plantar plate repair with realignment of the lesser MTP joint and hammertoe pathologies. Level of Evidence: V