Search

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund’s deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Category: Hindfoot; Basic Sciences/Biologics; Other Introduction/Purpose: Minimally Invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr, leading to nonunion of the osteotomy. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing this risk remains an understudied area. The purpose of this study was to evaluate the effect of cooled versus room-temperature irrigation on thermal energy dissipation on a temperature curve during calcaneal osteotomy using a Shannon burr. Methods: Ten cadaveric limbs (5 pairs) at room temperature (68 0F) were randomized to receive either cooled saline or room temperature irrigation during MIS calcaneal osteotomy. Two thermocouple probes (EL-USB-TC-LCD, Lascar Electronics) were inserted 5mm away from the plane of the osteotomy, on proximal and distal sides respectively (Fig. 1). The probes were inserted to a depth of 2cm. A 3 x 30mm Shannon burr was used to perform the osteotomy. The burr was run continuously under continuous irrigation using either room temperature (680F) and chilled (370F) irrigation, until the osteotomy was completed. All osteotomies were performed in approximately 60 seconds. Temperature was recorded at 15sec, 30sec, 45 sec and 60 sec for the two groups and used as a measure of thermal energy generation. Results: Both room temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.60F (70.60F) with room temperature irrigation and a mean increase of 0.70F (68.70F) with chilled irrigation were observed at the 60 sec interval (p=0.09). On the distal side both irrigation methods were more effective in heat control (70.20F vs 67.10F; p=0.17). Conclusion: For the duration of a MIS calcaneal osteotomy, both continuous room temperature and chilled irrigation can reduce thermal energy generation. Use of chilled irrigation can be considered for osteotomies of denser bone that may take longer to perform and generate higher temperatures.

Background: Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr. Methods: Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation. Results: Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval ( P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation ( P = .05). Conclusion: For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion. Clinical Relevance: Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient’s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient’s decisions. Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic Level of Evidence: Level III.

Category: Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports Introduction/Purpose: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the U.S. to divert healthcare resources and limit exposure. Little is known about the impact of COVID-19 on patient’s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across six U.S. Orthopedic Institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient’s decisions. Results: A total of 150 patients participated in this study. N=21 (14%) opted not to proceed with surgery once restrictions were lifted. 43% (N=9) listed concern for COVID infection as the reason, however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs. 14%) and lower increase in pain medication used (5% vs. 12%). Conclusion: COVID-19 has made a significant impact on the healthcare. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.

Category: Ankle Introduction/Purpose: Highly crosslinked polyethylene (HXLPE) was developed for its superior wear properties in comparison to conventional polyethylene (CPE). The higher dose irradiation required for HXLPE may also cause embrittlement, which reduces fatigue resistance and leads to surface cracking or fracture of the polyethylene bearing. Concern over fatigue resistance has prevented widespread adoption of HXLPE for use in in total ankle arthroplasty (TAA). The aim of this study was to determine whether HXLPE has sufficient fatigue strength for total ankle arthroplasty under simulated physiologically relevant motion profiles and loading in the ankle. Methods: A bicondylar, semi-constrained HXLPE TAA design was subjected to 10 million cycles (Mc) of fatigue testing under loading conditions representative of a walking gait. Kinetics and kinematics of gait were incorporated into a computational model (Dassault Systemes / SIMULIA, Johnston, RI), for prediction of peak stresses on the HXLPE insert. Based on predicted peak stresses, worst case component size and loading configuration were identified. Ten samples were tested on a closed loop servohydraulic test frame (MTS Systems Corp., Minneapolis, MN) for 10Mc. Testing was conducted to a peak load of 5600 N (1259lbs), representing approximately 5 times body weight for a 240 lb individual. Following testing, all samples were evaluated for evidence of polyethylene fracture or surface cracking. Results: Peak stresses in the HXLPE insert occurred during heel off, closely corresponding to both peak axial force and dorsiflexion during gait. The smallest sized component had the highest polyethylene insert stresses, whereas larger sized components had more material to bear the same load, resulting in up to a 30% decrease in stress. All 10 specimens completed 10Mc of testing at 5 times body weight without fracture or surface cracking of the polyethylene insert. Conclusion: HXLPE has sufficient fatigue strength to withstand 10Mc of loading at 5 times body weight at the point of peak stresses during gait in total ankle arthroplasty, and therefore, may be mechanically strong enough to withstand the demands of the ankle. Further clinical evidence is necessary to determine if these results translate to adequate fatigue strength with clinical use of HXLPE.