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Unlabelled: Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon.Level Of Evidence: Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Endoscopy of the tendons (tendoscopy) of the foot and ankle has become more frequently performed and reported. New, smaller endoscopic cameras and instruments have made tendoscopy more accessible and useful for sports medicine and related surgeries. The peroneal tendons are particularly accessible for tendoscopy owing to their subcutaneous position along the lateral ankle. Tendoscopy of the peroneal tendon sheaths can be used for diagnosis and minimally invasive treatment of certain disorders. In cases where open procedures are indicated, surgical exposure can be limited by tendoscopic identification of the exact location of the pathology, allowing repair through a limited or "mini" incision. This paper reviews the available literature and presents the authors technique for peroneal tendoscopy. Endoscopic photographs of normal anatomy and pathologic conditions are presented. [ABSTRACT FROM AUTHOR]

Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-
tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.

Ankle fractures in patients with diabetes can be difficult to manage, especially when patients present with hyperglycemia. Treatment often requires a combination of both medical and surgical care, especially in patients with poorly controlled diabetes. The goal of any treatment is to obtain a well-aligned ankle fracture that heals without any further displacement and to avoid the development of a Charcot joint. Nonsurgical treatment is usually reserved for nondisplaced fractures. Displaced fractures often require surgical treatment, and there are different options available, including standard fixation, fixation with multiple syndesmotic screw placement, external (thin wire) fixation alone, hybrid or combined internal and external fixation techniques, and primary arthrodesis. It is important to discuss the approach to the evaluation and treatment of these patients.

The goals of surgery for the rigid flatfoot are to achieve a painless, stable, functional plantigrade foot. Although triple arthrodesis affords predictable correction and pain relief, the long-term sequelae of extended hindfoot fusions include arthritis and often the need for further, more extensive fusion procedures. We propose that satisfactory results can be achieved in the rigid flatfoot by limiting fusion to joints that are arthritic, and correcting associated deformity with osteotomy and soft tissue reconstruction.

The historic treatment of Charcot foot has entailed non-weight-bearing immobilization during the acute active phase, followed by longitudinal management with accommodative bracing. This treatment plan yields poor outcomes, even in cases classified as successful. An appreciation of poor outcomes convinced experts to attempt correction of the resultant deformities. Early attempts at surgical correction of the acquired deformities in patients with medical comorbidities were complicated by infection, wound failure, and mechanical loss of correction. New surgical techniques have been designed to obtain and maintain correction and minimize the risks for complications and poor outcomes in this complex patient population.

Background: Pantalar arthrodesis is an important salvage option for stabilizing the hindfoot and salvaging the limb following trauma or collapse. This report evaluates the healing rates and complications which occur in diabetics and post-traumatic patients., Materials and Methods: Twenty patients presenting with post-traumatic arthritis of the ankle-hindfoot (twelve) or with Type II or Type IIIA Charcot arthropathy (eight) were managed with a pantalar fusion. Followup averaged 46 months. Patients were evaluated using the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Short Musculoskeletal Function Assessment (SMFA) and the Visual Analog Pain Scale (VAS)., Results: There were no amputations in either group. Casting averaged 14.9 weeks, full weightbearing was achieved at 25.1 weeks and time to union averaged 44.1 weeks. Average age was 56.3 yrs. and BMI averaged 34.2. Fourteen patients (70%) had their surgery performed in multiple stages. Acceptable outcomes were noted for all patients for the SF-36, AOFAS and SMFA scores. VAS scores averaged 2.2. There were ten complications (50%); four patients (two in each group) required additional surgery., Conclusions: Pantalar arthrodesis is a reasonable salvage option for patients with severe post traumatic arthropathy and neuropathic arthropathy. Patients should be informed of the increased risks as well as the long periods of postoperative immobilization and nonweightbearing. We believe a pantalar arthrodesis can produce acceptable outcomes regardless of the cause of disability, with a staged or single approach, and whether the surgery is performed with plates and screws or an intramedullary device.

Management of Charcot's deformity of the foot and ankle continues to challenge physicians. Medical co-morbidity, peripheral neuropathy, vascular disease, and immune impairment cause severe problems for these patients and, when combined with neuroarthropathy, can lead to amputation. Progressive bony deformity and bone resorption, which may accompany neuroarthropathy, only increase the challenge of surgical treatment. These challenges have led physicians to develop "superconstruct" techniques to improve fixation, whereby fusion is extended beyond the zone of injury to include joints that are not affected, bone resection is performed to shorten the extremity to allow for adequate reduction of deformity without undue tension on the soft tissue envelope, the strongest device is used that can be tolerated by the soft tissue envelope; and the devices are applied in a novel position that maximizes mechanical function. This article reviews three techniques designed to achieve lasting deformity correction and successful arthrodesis: plantar plating, locked plating, and axial screw fixation.

Background: Rupture of the tibialis anterior tendon is an uncommon disorder that can cause a substantial functional deficit as a result of loss of ankle dorsiflexion strength. We are not aware of any reports on a large clinical series of patients undergoing surgical repair of this injury., Methods: Nineteen tibialis anterior tendon ruptures were surgically repaired in eighteen patients ranging in age from twenty-one to seventy-eight years. Early repair was performed for one traumatic and seven atraumatic ruptures three days to six weeks after the injury. Delayed reconstruction was performed for two traumatic and nine atraumatic ruptures that had been present for seven weeks to five years. Direct tendon repair was possible for four of the early repairs and three of the delayed reconstructions. An interpositional autogenous tendon graft was used for four early repairs and eight delayed reconstructions. Patients were reassessed clinically and with the American Orthopaedic Foot and Ankle Society hindfoot score at an average of 53.3 months after surgery., Results: The average hindfoot score improved significantly from 55.5 points preoperatively to 93.6 points postoperatively. The surgical results did not appear to vary according to patient age, sex, or medical comorbidity. Complications requiring a second surgical procedure occurred in three patients. Recovery of functional dorsiflexion and improvement in gait was noted in eighteen of the nineteen cases. Ankle dorsiflexion strength was graded clinically as 5/5 in fifteen of the nineteen cases. Three patients regained 4/5 ankle dorsiflexion strength, and one patient had 3/5 strength with a poor clinical result., Conclusions: Surgical restoration of the function of the tibialis anterior muscle can be beneficial regardless of age, sex, medical comorbidity, or delay in diagnosis. Early surgical treatment may be less complicated than delayed treatment, and an intercalated free tendon graft and/or gastrocnemius recession may be necessary to achieve an appropriately tensioned and balanced repair.

Background: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique., Methods: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction., Results: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure., Conclusions: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.

Hallux valgus correction by distal soft-tissue release and proximal metatarsal osteotomy is the procedure of choice for most patients with moderate and severe hallux valgus deformity. Complications can be avoided by selecting a procedure that provides adequate correction of the intermetatarsal angle and ensuring proper balancing of the metatarsophalangeal joint though lateral soft-tissue releases and medial joint plication. Arthrodesis should be considered when revision of failed surgery is planned, degenerative joint disease is present, and where the likelihood of failure of a bunion procedure is high (such as in elderly individuals with osteoporosis, severe deformity with significant involvement of the lesser metatarsophalangeal joint, and when spasticity is present). A review of biomechanical data, clinical studies, and surgical techniques is important for successful treatment of moderate and severe hallux valgus deformity.

This article defines specific risks associated with rheumatoid arthritis, including an increased incidence of medical comorbidities, the use of steroids and other immunosuppressive agents, osteoporosis, vascular disease, and the common occurrence of severe deformity. This article suggests approaches for management and techniques that may improve specific surgical issues in this challenging patient population.

Background: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint., Method: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses., Results: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis., Conclusions: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

Background: Gastrocsoleus recession is commonly performed to correct equinus contracture of the ankle that may accompany foot and ankle disease in adults. There is concern that mechanical lengthening of the myotendinous unit causes permanent weakness and disability. This retrospective study reviewed the short-term and long-term objective and subjective results of patients who have had this procedure to determine if it is an appropriate adjunct to corrective foot surgery., Methods: Forty patients who had unilateral gastrocsoleus recession either as an isolated procedure or in conjunction with other surgeries were available for evaluation at an average 25.3 (range 6 to 50) months. Followup evaluation included the AOFAS ankle hindfoot score, subjective questionnaire, and physical examination. Preoperative and postoperative ranges of motion were compared. Mechanical strength testing was done using the contralateral extremity as a control. Maximal strength was measured by peak torque using a Cybex device (CYBEX International, Inc., Ronkonkoma, New York). Fatigue resistance was measured by comparing the maximal number of toe raises between the operative and nonoperative sides., Results: Range of motion improved from -3.5 to 15.3 degrees average dorsiflexion. Subjectively, two patients reported pain at the operative site, and one patient reported moderate weakness. The AOFAS score improved from 62.3 to 79.5. Strength testing of plantarflexion peak torque found the operative extremity to be 74% of the contralateral leg at followup. Peak torque improved from an average of 62.6% at 6 to 18 months to 82.2% after 18 months compared to the contralateral extremity. Fatigue resistance improved from 37.6% to 50.3% at 18 months. Two patients reported paresthesias in the sural nerve distribution., Conclusion: Gastrocsoleus recession is an effective procedure to correct equinus contracture either as an isolated procedure or as an adjunct to other foot surgery. While both fatigue resistance and strength decreased initially, both demonstrated improvement over time. Four patients had subjective complaints after the procedure.

Loss of the hallux can lead to significant gait problems and cause difficult biomechanical problems with weight bearing. Amputation of the first ray should be avoided when possible. Soft tissue defect of the hallux can be particularly difficult to manage because of the absence of local muscle tissue for coverage. In younger patients, soft tissue loss usually is related to trauma; an understanding of the techniques that are available for coverage are important to maintain length and function of the first ray. Diabetic neuropathy and resultant ulceration of the hallux or metatarsophalangeal joint is another common cause of soft tissue deficiency that may lead to deep infection and potentially result in amputation. Certain systemic problems, such as inflammatory diseases or gout, can cause significant degeneration of the local tissues which also can be problematic. Wound dehiscence or loss of skin flaps that are created during surgery represent further difficulties that may be encountered. This article reviews the common causes of amputation of the hallux and the principles that are necessary for salvage of the digit.

Numerous surgical procedures are available for the treatment of hallux rigidus. The choice of a particular one depends on the severity of the disease, patient activity level, and expectations about the surgery. Cheilectomy is recommended for early disease and may be associated with an osteotomy of the proximal phalanx. For active patients who have severe hallux rigidus, arthrodesis and biologic interposition arthroplasties have shown good results. Keller arthroplasty is reserved for low demand patients; prosthetic replacements are not recommended at this time.

Most disease conditions that affect the hallux are amenable to conservative treatment. Most of the literature that addresses the treatment of hallux rigidus, bunions, sesamoid problems, and arthritis focus on surgical management, although operative indications stress the need for attempted conservative treatment of these processes. This article reviews the technical considerations that are required for successful orthotic management of disease of the first ray. Mechanical terminology and principles of management are reviewed and examples of orthotic prescriptions for specific disease entities are included to facilitate communication between the orthopedist and orthotist.

The transverse tarsal plays a critical role in allowing the foot to transition from a flexible structure that dissipates impact as the foot strikes the ground and accepts the body's weight to the rigid structure that is required for efficient propulsion during toe off.Similarly, the medial longitudinal arch of the foot is controlled by the supportive structures of the talonavicular joint. A fine balance exists between muscular control and static support structures of the talonavicular joint. Failure of one support structure is often followed by fatigue of the remaining support and loss of function of the entire joint complex. This article describes the osseous and ligamentous anatomy of the talonavicular and calcaneocuboid joints and describes the biomechanical role of the transverse tarsal joint in standing and gait. Biomechanical principles are used to illustrate orthotic management of diseases that affect the transverse tarsal joint.

Background: Achieving stable fixation when performing tibiotalocalcaneal arthrodesis can be challenging, especially in osteopenic bone. The purpose of the current investigation was to compare the stiffness and fatigue endurance of blade-plate-and-screw fixation with intramedullary rod fixation in a cadaveric model., Methods: In ten matched pairs of fresh-frozen cadaveric legs, a tibiotalocalcaneal arthrodesis was performed with use of a blade-plate and a 6.5-mm sagittal screw in one leg and with use of an intramedullary rod in the contralateral leg. After an initial load-deformation curve was obtained, each specimen was loaded to 270 N through 250,000 cycles at a rate of 3 Hz., Results: Blade-plate-and-screw fixation resulted in significantly higher mean initial and final stiffness and decreased plastic deformation than did intramedullary rod fixation. In addition, there was an inverse correlation between bone-mineral density and the difference in plastic deformation noted between the specimens of each pair., Conclusions: Blade-plate fixation is biomechanically superior to intramedullary fixation for tibiotalocalcaneal arthrodesis.

The purposes of the current study were: 1. to analyze the relative fatigue endurance of five different first metatarsal shaft osteotomies (proximal crescentic, proximal chevron, Ludloff, Mau, and Scarf), as performed on sawbone models using the most common fixation techniques (part I); and 2. to compare the two more commonly used techniques (per part I results) in matched-pair cadaver specimens (part II). In part I, the proximal chevron and Mau osteotomies were significantly more stable (P < or = 0.005) than all other osteotomies except the Ludloff. In part II, there was no significant difference in fatigue endurance between the proximal chevron and Ludloff osteotomies.

Autogenous bone grafting is the gold standard in repair of bony defects, fracture nonunion, and promoting arthrodesis. The complications related to obtaining autogenous grafts can be significant, and numerous materials are now available for augmentation or substitution. Allograft materials are highly effective for most applications; however, the surgeon needs to be acutely aware of the source of the tissue, for some tissue banks still use unacceptable processing techniques that destroy the structural and osteoinductive capacities of the graft. DBM products are unregulated and serious concerns exist as to the distribution of inactive products as commercially available to the practicing surgeon. Pressure from the orthopedic community has caused some manufacturers to test their products for activity before distribution. Calcium-based ceramic materials are effective as osteoconductive agents and work well alone as bone void fillers; however, augmentation of these implants with osteoinductive materials should be considered for use in nonunions and arthrodesis. Composite materials that incorporate osteoinductive materials in osteoconductive scaffolds are promising. New technology in isolation and creation of recombinant human bone morphogenic proteins and growth factors, and in the application of autogenous stem cells are emerging as the future of bone grafting procedures.

Osteotomy of the first metatarsal is a common procedure for correction of hallucal disease. Metatarsals are unique in that they are the only long bones in the human body that support load perpendicular to their longitudinal axis during standing. Thus, osteotomy of the first metatarsal may be complicated by loss of fixation, resulting in nonunion or malunion. The authors review the forces that must be resisted by the osteotomy of the first metatarsal as postoperative weight bearing is initiated, and explore the principles of osteotomy geometry and different fixation techniques to maximize stability of the final construct and to minimize the risk of displacement.

Background: Os acromiale is present when the anterior portion of the acromion has one or more separate ossicles. Its frequency has been documented, in radiographic and anatomical studies, to be between 1 and 15 percent. Reports of os acromiale associated with subacromial pathology have been cited to imply that this entity is a cause of subacromial impingement; however, no study has demonstrated an increased frequency of os acromiale in patients with shoulder pain compared with the frequency in the general population. Inconsistencies in the literature concerning anatomy, development, and frequency prompted the current anatomical study. The purpose of this study was to better define the frequency and anatomy of os acromiale in the general population., Methods: Two thousand three hundred and sixty-seven scapular bones from 1198 human skeletons from the Hamann-Todd Osteological Collection were studied for evidence of os acromiale. The sample consisted of specimens from 1033 men and 165 women, 843 of whom had been white and 355, black. The mean age of the individuals at the time of death was 44.7 years (range, eighteen to eighty-nine years). The frequency of os acromiale was noted, and the specimens were measured., Results: There were 128 cases of os acromiale in ninety-six (8.0 percent) of the 1198 skeletons, and the condition was bilateral in thirty-two (33.3 percent) of the ninety-six skeletons. In twenty cases, the free fragment had been lost but it was assumed that a fragment had been present because the acromion was truncated. Os acromiale was more frequent in blacks than in whites (13.2 compared with 5.8 percent; p < 0.001) and in men than in women (8.5 compared with 4.9 percent; p = 0.09). The mean proportional length of the free fragment was 0.42 compared with the overall length of the acromion. Care was taken to differentiate os acromiale from a normal immature acromion. Six skeletons demonstrated persistent acromial apophyses. All six cases were bilateral; seven fragments were fusing, and five were free. The oldest age at which a persistent normal apophysis was found was twenty-one years. The frequency of os acromiale in specimens from individuals who had been less than twenty-two years old was not significantly different from that in the remainder of the collection (p = 0.74). Twenty-one scapulae had a distinct circumferential line that was suggestive of an acromial joint, but the distal and proximal portions were solidly fused. However, the findings on plain axillary radiographs of sixteen of these specimens were indistinguishable from those of specimens with os acromiale., Conclusions: An anatomical study, performed to better define the frequency and anatomy of os acromiale in the general population, showed that fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting.

The viability of transplanted articular cartilage is one of the determinants of outcome following the transplantation of osteochondral allografts. Disappointing results from cryopreservation have led to the practice of fresh transplantation of articular segments, especially for posttraumatic defects. To date, no studies have demonstrated in vitro viability rates for refrigerated human cartilage awaiting transplantation. This study evaluates the effects of storage on the viability of human chondrocytes using cell culture medium. Human articular cartilage obtained from notchplasties was stored for up to 48 hours in cell culture medium. Radioactive 35S-sulfate uptake was determined at 0, 24, and 48 hours, as a measure of protein, synthesis, and chondrocyte viability. Specimens were stored at 4 degrees C in culture medium. Results showed an average decrease in 35S-sulfate uptake of 0.8% at 24 hours and 6.4% at 48 hours, indicating a high level of chondrocyte viability after refrigeration. Because transplantation typically is performed within 24 hours of tissue harvest, it appears that nearly 100% of chondrocytes should survive fresh transplantation.