Correction of Severe Flexible Pes Planovalgus Deformity Using Trabecular Metallic Wedges

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening and a medial cuneiform plantarflexion (Cotton) osteotomy are procedures commonly used in the treatment of symptomatic flexible pes planovalgus. Traditionally, structural autograft or allograft have been used for both osteotomies. While union rates for both types of graft have been shown to be comparably high, the use of allograft or autograft each come with their own set of inherent risks and/or potential complications. A trabecular titanium wedge implant provides an attractive alternative that avoids the concerns associated with autograft and allograft use, and has previously been shown in the literature to demonstrate similar union rates. The purpose of this study was to retrospectively review the radiographic outcomes of corrective osteotomies utilizing trabecular metal wedges to address severe flexible pes planovalgus deformity. Methods: 115 feet in 109 patients who were treated with corrective osteotomies using a trabecular titanium wedges performed by one surgeon were retrospectively reviewed. All patients had symptomatic flexible pes planovalgus, mostly secondary to stage IIB posterior tibialis tendon dysfunction. Other diagnoses included pes planovalgus secondary to the adolescent idiopathic flexible subtype, traumatic posterior tibialis tendon rupture, coalition, or an accessory navicular. Preoperative radiographic parameters assessing severity of deformity were recorded and compared to the postoperative measurements taken at the time of most recent follow up visit to assess for correction. The radiographic measurements included the (1) AP talo-1st metatarsal angle (2) Lateral talo-1st metatarsal angle (3) Calcaneal pitch (4) Lateral talo-calcaneal angle and (5) Talonavicular uncoverage angle. All angles were measured off standard weight-bearing radiographs by one author using our institution’s picture archiving and communication system (PACS) software. All complications were also recorded. Results: At an average follow up time of 40 weeks, there were statistically significant corrective changes in the AP-talo-1st metatarsal angle (-12.56), lateral talo-1st metatarsal angle (+14.15), calcaneal pitch (+5.23), lateral talo-calcaneal angle (-3.87) and talonavicular uncoverage angle (-17.76). There were 3 nonunions (2.6%) confirmed by CT, 2 of which were eventually revised. There were a total of 9 complications (7.8%). Other than the nonunion revisions, none of these complications required a return to the operating room. There were no cases of collapse or loss of correction at the time of followup, as compared to the initial post-operative radiographs. Conclusion: In our study population corrective osteotomies using a trabecular titanium wedge was effective in improving radiographic parameters associated with flexible pes planovalgus deformity. The nonunion and overall complication rates using a trabecular titanium wedge were shown to be comparable or superior to what has previously been reported in the literature using allograft or autograft.

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Severe Flexible Pes Planovalgus Deformity Correction Using Trabecular Metallic Wedges

Foot & Ankle International ◽

10.1177/1071100718816054 ◽

2018 ◽

Vol 40 (4) ◽

pp. 402-407 ◽

Cited By ~ 2

Author(s):

Justin Tsai ◽

Elizabeth McDonald ◽

Ryan Sutton ◽

Steven M. Raikin

Keyword(s):

Case Series ◽

Deformity Correction ◽

Wedge Osteotomy ◽

Attractive Alternative ◽

Pes Planovalgus ◽

Lateral Column ◽

Metatarsal Angle ◽

Radiographic Measurements ◽

Functional Scores

Background: Lateral column lengthening and plantarflexion dorsal opening wedge osteotomy of the medial cuneiform are 2 commonly used procedures to address the deformity seen in severe flexible pes planovalgus deformity. Traditionally, iliac crest allograft or autograft has been used to fill the osteotomy sites. Porous metallic wedges can be used as an alternative to avoid the concerns associated with both autograft and allograft. Methods: We performed a retrospective review of patients who had corrective osteotomies utilizing metallic wedges to address flexible pes planovalgus with at least 2 years of follow-up data. Preoperative radiographic measurements (anteroposterior [AP] and talo-first metatarsal angle, calcaneal pitch, talocalcaneal angle, and talonavicular uncoverage angle) and functional scores (visual analog scale [VAS] pain, Foot and Ankle Ability Measure [FAAM] Activities of Daily Living [ADL], FAAM Sports) were compared to postoperative radiographic measurements and functional scores. Results: There were statistically significant improvements in all radiographic parameters and functional scores. Two nonunions were seen, one of which healed with revision surgery while the other was asymptomatic. At the time of last radiographic follow-up, there were no recurrences of deformity or collapse. Conclusion: Porous metallic wedges offer an attractive alternative to autograft and/or allograft in the setting of corrective osteotomies for severe flexible pes planovalgus. Patients who underwent corrective osteotomies using these wedges demonstrated reliable, effective, and stable radiographic correction as well as significant improvements in function and pain. Level of Evidence: Level IV, case series.

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Radiographic Measurements Associated with the Natural Progression of the Hallux Valgus Deformity during at Least Two Years of Follow-up

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000255 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0002 ◽

Cited By ~ 1

Author(s):

Kyoung Min Lee ◽

Seung Yeol Lee ◽

Sonya Ahmed ◽

Byung Chae Cho ◽

Moon Seok Park ◽

...

Keyword(s):

Hallux Valgus ◽

Weight Bearing ◽

Binary Logistic Regression ◽

Valgus Deformity ◽

Binary Logistic Regression Analysis ◽

First Metatarsal ◽

Hallux Valgus Deformity ◽

Metatarsal Angle ◽

Radiographic Measurements

Category: Bunion Introduction/Purpose: There have been few longitudinal studies regarding hallux valgus deformity. This retrospective study aimed to investigate the radiographic measurements associated with the progression of hallux valgus deformity during at least two years of follow-up. Methods: Seventy adult patients (mean age, 58.0 years; standard deviation [SD], 12.3 years; 13 males and 57 females) with hallux valgus who were followed-up for at least two years and underwent weight-bearing foot radiography were included. Radiographic measurements included the hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle (IMA), metatarsus adductus angle, distal metatarsal articular angle (DMAA), tibial sesamoid position, anteroposterior (AP) talo-first metatarsal angle, and lateral talo-first metatarsal angle. Progression of hallux valgus deformity was defined as an increase of 5 degrees or more in the HVA during follow-up. Patients were divided into progressive and non-progressive groups. Binary logistic regression analysis was performed to identify factors that significantly affect the progression of hallux valgus deformity. The correlation between change in HVA and changes in other radiographic indices during follow-up was analyzed. Results: Eighteen out of 70 patients showed progression of 5 degrees or more in the HVA during the mean follow-up of 47.0 months (SD, 19.8 months). The DMAA (p=0.027) and AP talo-first metatarsal angle (p=0.034) at initial presentation were found to be significant factors affecting the progression of hallux valgus deformity. Change in the HVA during follow-up was significantly correlated with changes in the IMA (r=0.423; p=0.001) and DMAA (r=0.541; p<0.001). Conclusion: Special attention needs to be given to patients with pes planovalgus and increased DMAA during follow-up. Change in HVA was significantly correlated with changes in IMA and DMAA. Therefore, progression of hallux valgus deformity is considered to be closely related to the progressive instability of the first tarsometatarsal joint.

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Radiographic Evaluation of Adult Acquired Flatfoot Correction with Augmented Spring Ligament Repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00172 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0017

Author(s):

Jason Fogleman ◽

Christopher Kreulen ◽

Aida Sarcon ◽

Patrick Michelier ◽

Rachel Swafford ◽

...

Keyword(s):

Weight Bearing ◽

Radiographic Evaluation ◽

Ligament Repair ◽

First Metatarsal ◽

Spring Ligament ◽

Radiographic Parameters ◽

Metatarsal Angle ◽

Medial Cuneiform ◽

Suture Tape

Category: Flatfoot reconstruction Introduction/Purpose: Adult acquired flatfoot often results from posterior tibial tendon dysfunction followed by attenuation of the ligamentous support of the medial longitudinal arch of the foot. The spring ligament is the strongest ligamentous support for the talonavicular joint making it a viable target for flatfoot reconstruction procedures. There are concerns that direct repair of the spring ligament complex could result in failure as the already attenuated tissues of the ligament stretch out with mobilization and weight bearing. Suture tape augmentation of ligament repairs has shown greater loads to failure in biomechanical testing; however, there is a paucity of data surrounding clinical and radiographic outcomes of flatfoot reconstruction with augmented spring ligament repair. Methods: A retrospective review was performed of patients who underwent flatfoot reconstruction including spring ligament repair with suture tape augmentation between July 2014 and August 2017. Weight bearing radiographs were obtained for all patients both pre-operatively and at their last available follow-up. All radiographs were assessed by two surgeons for validated radiographic parameters including AP talocalcaneal angle, AP talo-first metatarsal angle, AP talar uncoverage, lateral talocalcaneal angle, lateral talo-first metatarsal (Meary) angle, lateral medial cuneiform-fifth metatarsal height, and lateral calcaneal pitch. Paired sample T-tests were used to compare pre-operative and post-operative radiographic measurements to assess for correction of these parameters. Results: 57 patients met inclusion criteria. The average time to final radiographic evaluation was 47 weeks (10 to 200 weeks). All radiographic parameters assessed showed significant correction when compared to pre-operative measurements. The average correction for each parameter included 6.02 degrees for AP talocalcaneal angle (p<0.001), 10.96 degrees for AP talo-first metatarsal angle (p<0.001), 12.65% for AP talar uncoverage percentage (p<0.001), 4.27 degrees for lateral talocalcaneal angle (p<0.001), 11.35 degrees for lateral talo-first metatarsal (Meary) angle (p<0.001), 8.31 mm for lateral medial cuneiform-fifth metatarsal height (p<0.001), and 2.91 degrees for lateral calcaneal pitch (p<0.001). Post-operative complications occurred in 5 patients. Conclusion: Reconstruction of adult acquired flatfoot with spring ligament repair using suture tape augmentation is a safe procedure that resulted in significant weight bearing radiographic correction at an average of 47 weeks follow-up.

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A Modified Extra-articular Lateral Column Lengthening Procedure for Adult Acquired Flatfoot Deformity

Foot & Ankle International ◽

10.1177/10711007211051359 ◽

2021 ◽

pp. 107110072110513

Author(s):

Yin-Chuan Shih ◽

Chui Jia Farn ◽

Chen-Chie Wang ◽

Chung-Li Wang ◽

Pei-Yu Chen

Keyword(s):

Subtalar Joint ◽

Case Series ◽

Stage Ii ◽

Posterior Tibial Tendon ◽

Lateral Column ◽

Metatarsal Angle ◽

Lateral Column Lengthening ◽

Adult Acquired Flatfoot Deformity ◽

The Mean

Background: Lateral column lengthening (LCL), originally described by Evans, is an established procedure to correct stage II adult acquired flatfoot deformity (AAFD). However, the relative position between the facets is violated, and other problems may include nonunion, malunion, and calcaneocuboid (CC) joint subluxation. Herein, we report a modified extra-articular technique of LCL with hockey-stick osteotomy, which preserves the subtalar joint as a whole, increases bony apposition to enhance healing ability, and preserves the insertion of the calcaneofibular ligament to stabilize the posterior fragment to promote adduction of the forefoot. Methods: We retrospectively recruited 24 patients (26 feet) with stage II AAFD who underwent extra-articular LCL. The mean age was 55.7 ± 15.7 years, and the mean follow-up period was 33.4 ± 12.1 months. Associated procedures of spring ligament repair/reconstruction and posterior tibial tendon plication or flexor digitorum longus transfer were routinely performed and may also include a Cotton osteotomy, heel cord lengthening, or hallux valgus correction. Clinical and radiographic outcomes at the final follow-up were compared with the preoperative assessments. Results: All patients achieved calcaneus union within 3 months of operation. The VAS pain score improved from 5.3 ± 0.75 preoperatively to 1.2 ± 0.79 at the final follow-up ( P < .001), and the AOFAS Ankle-Hindfoot Scale from 63.5 ± 8.5 to 85.8 ± 4.8 points ( P < .001). The radiographic measurements significantly improved in terms of the preoperative vs final angles of 8.9 ± 5.3 vs 15.2 ± 3.6 degrees for calcaneal pitch ( P < .001), 20.5 ± 9.2 vs 4.9 ± 4.8 degrees for Meary angle ( P < .001), 46.5 ± 5.2 vs 41.9 ± 3.2 degrees for lateral talocalcaneal angle ( P < .001), 23.9 ± 8.5 vs 3.9 ± 3.1 degrees for talonavicular coverage angle ( P < .001), and 18.2 ± 9.2 vs 7.3 ± 5.0 degrees for talus-first metatarsal angle ( P = .002). The CC joint subluxation percentage was 7.0% ± 5.4% preoperatively compared with 8.5% ± 2.4% at the final follow-up ( P = .101). No case showed progression of CC joint arthritis or CC joint subluxation (>15% CC joint subluxation percentage). One case showed transient sural nerve territory paresthesia, and 1 had pin tract infection. Three cases had lateral foot pain, which could be relieved by custom insoles. Conclusion: Modified extra-articular LCL as part of AAFD correction is a feasible alternative technique without subtalar joint invasion and may be associated with less CC joint subluxation compared with the Evans osteotomy. Level of Evidence: Level IV, retrospective case series.

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Short Term Radiographic and Patient Outcomes of a Novel Biplanar Plating System for Hallux Valgus Correction

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00291 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0029

Author(s):

Kshitij Manchanda ◽

Stephen Blake Wallace ◽

Junho Ahn ◽

George T. Liu ◽

Michael D. Van Pelt ◽

...

Keyword(s):

Hallux Valgus ◽

Statistical Significance ◽

Retrospective Chart Review ◽

Complication Rates ◽

Time Of Surgery ◽

Radiographic Parameters ◽

Valgus Angle ◽

Patient Reported ◽

Outcome Scores

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a complex deformity of the great toe and is a major cause of pain for patients. Despite the variety of techniques, traditional osteotomies often do not address rotational deformities. A novel biplanar plating system was used to perform correction of metatarsal rotation at our institution starting in 2017. The purpose of this study was to determine the correction of rotational deformity and of radiographic parameters, maintenance of this correction (versus recurrence of hallux valgus), complication rates and patient-reported objective survey scores. We sought to determine prognostic factors for successful correction, including age, gender, and time of surgery. Methods: By retrospective chart review, we identified all patients treated by the novel biplanar plating at our institution. We recorded patient demographics, pre-operative range of motion and maltracking, surgical details, operative complications, and any subsequent surgery. Imaging was reviewed at pre-operative and post-operative visits to approximate the hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP). Outcome scores (AOFAS, FAAM, SF12 PCS and MCS) pre- operatively and post-operatively at 3 months, 6 months and 12 months were also recorded. The changes in these radiographic parameters and scores were then computed and analyzed to determine if there was an improvement with surgery. Results: Fifty-seven procedures (in 55 patients) were performed and evaluated. There were 8 complications and average follow- up time was 27.1 weeks (+13.8 weeks). Older age was significantly associated with more complications (p = 0.018). Gender and time of surgery did not show any significant association with complications. Radiographic parameters including HVA, IMA, and TSP were analyzed. At 3 and 6 months post-operatively, these parameters were significantly reduced from pre-operative values. At 12 months, there was a trend towards significant reduction (p values of 0.06, 0.06, and 0.053 respectively); however, there were fewer patients who maintained follow-up during this period. The Outcome scores showed improvement post-operatively, but only the AOFAS score showed statistical significance at 3 and 6 months. Conclusion: Although statistical analysis was limited due to our population size and the retrospective nature of the study, there was an overall improvement in both radiographic parameters and clinical outcome scores. Older patients are also at higher risk of complications. Malrotation correction with this biplanar plating system is a novel technique and does require meticulous training. With continued expansion of our patient database and further longitudinal analysis, we hope to determine not only if correction is maintained over time, but also if the steepness of the learning curve affects the number of complications earlier versus later in each individual surgeon’s experience.

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Suture anchor stabilization of symptomatic accessory navicular in adolescents: Clinical and radiographic outcomes

Journal of Orthopaedic Surgery ◽

10.1177/2309499020918949 ◽

2020 ◽

Vol 28 (2) ◽

pp. 230949902091894

Author(s):

Masataka Kakihana ◽

Yuki Tochigi ◽

Takayuki Yamazaki ◽

Masanori Ohashi ◽

Satoru Ozeki

Keyword(s):

Tilt Angle ◽

Suture Anchor ◽

Weight Bearing ◽

Bone Union ◽

First Metatarsal ◽

Radiographic Outcomes ◽

Metatarsal Angle ◽

Radiographic Measurements ◽

Accessory Navicular ◽

Stabilization Technique

Background: Screw fixation used in modified Kidner procedures to treat persistent symptomatic accessory navicular in adult cases is often challenging in adolescent cases with a small accessory fragment. The present study aimed to document the clinical effect of a suture anchor stabilization technique applicable to such cases where osteosynthesis is considered an ideal outcome. Methods: Consecutive clinical cases who received this surgical treatment from 2009 to 2016 were retrospectively reviewed. The focus of interest included radiographic union of the accessory bone, changes in symptoms evaluated using a validated clinical outcome scale introduced by the Japanese Society for Surgery of the Foot, and changes in the medial arch bony alignment measured in lateral weight-bearing plain radiographs. Results: Twenty-two feet in 15 individuals (11 females and 4 males, age at surgery 10–16 years) were identified. In 14 feet (64%), radiographic bone union was confirmed within 8 weeks postoperatively. At the final follow-up ranging 12–51 months postoperation, the clinical scores have significantly improved ( p < 0.001) to 96 ± 5.71 (mean ± standard deviation, range 87–100), from 54 preoperatively. Radiographic measurements revealed significant postoperative increase of the sagittal talar tilt angle ( p < 0.001, increment 4 ± 3°, range 0–11) and the talo-first metatarsal angle ( p < 0.001, increment 5 ± 4°, range 0–12). No significant changes were identified in the calcaneal pitch angle, first metatarsal tilt angle, calcaneo-navicular angle, and the navicular height. Conclusion: Despite the modest bone union rate, the clinical outcomes suggest distinct symptom-relieving effect, at least in the short- to midterm, while the radiographic measurements suggest positive biomechanical effects. The present suture-anchor stabilization concept appears to be a promising treatment option for persistent symptomatic accessory navicular in adolescent cases.

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Radiographic Union of Evans Osteotomy Without Fixation

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00358 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0035

Author(s):

Megan R. Miles ◽

Brian P. Gallagher ◽

Katherine L. Mistretta ◽

Nigel N. Hsu ◽

Haijun Wang ◽

...

Keyword(s):

Allogenic Bone ◽

Lateral Column ◽

First Metatarsal ◽

Calcaneocuboid Joint ◽

Calcaneal Osteotomy ◽

Metatarsal Angle ◽

Flexible Flatfoot ◽

Lateral Column Lengthening ◽

Allogenic Bone Graft

Category: Hindfoot; Other Introduction/Purpose: The Evans osteotomy is a lateral column lengthening procedure of the calcaneus that is commonly used to correct flexible flatfoot deformities. There is no consensus on whether fixation is needed to avoid nonunion and calcaneocuboid subluxation when performing this osteotomy. We assessed the nonunion rate and correlated extent of subluxation with graft size in an unfixed Evans osteotomy with an allograft wedge and no pinning of the calcaneocuboid joint at any point in the largest series of the procedure to date. Surgeries were performed in patients undergoing flexible flatfoot reconstruction. Methods: We retrospectively reviewed 120 consecutive patients who had undergone 145 unfixed Evans osteotomies by a single surgeon with allogenic bone graft for flatfoot reconstruction between January 2013 and October 2017, with a mean follow-up of 62.5 (range 9.4-266.7) weeks. The calcaneocuboid joint was not pinned during the procedure. Data were collected using clinical and radiographical examination during regular follow-up. Results: A total of 137 feet (94.5%) underwent a double calcaneal osteotomy with an associated medial displacement calcaneal osteotomy (MDCO). There was one nonunion (0.69%). The mean time to union was 10.8 (range, 6.7-17.9) weeks. There was significant improvement in all radiographic parameters postoperatively, including calcaneal pitch, talonavicular uncoverage, anteroposterior and lateral talo-first metatarsal angle, lateral column length, and naviculocuboid overlap (p<0.05). Minor postoperative calcaneocuboid joint subluxation (1.51 +- 2.3 mm) occurred in 72 of 118 feet (61.0%) and had no correlation with wedge size (r=0.06; 95% CI, -0.13, 0.24; p=0.6). Conclusion: An unfixed Evans osteotomy for symptomatic flatfoot deformity resulted in a significant improvement in the radiographic alignment of the foot with an exceptionally rare nonunion rate. Detectable calcaneocuboid subluxation was common but minimal in extent and was not correlated with wedge size in this series in which wedges were less than 12 mm in the maximum dimension. This report represents the largest series of the Evans procedure to date.

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Roentgenographs Study of Cavus Foot Deformity in Friedreich Ataxia Patients: Preliminary Report

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100043791 ◽

1982 ◽

Vol 9 (2) ◽

pp. 113-117 ◽

Cited By ~ 3

Author(s):

P. Allard ◽

J.P. Sirois ◽

P.S. Thiry ◽

G. Geoffroy ◽

M. Duhaime

Keyword(s):

Inclination Angle ◽

Weight Bearing ◽

Friedreich Ataxia ◽

Quantitative Description ◽

Foot Deformity ◽

First Metatarsal ◽

Metatarsal Angle ◽

Cavus Foot ◽

Three Stages

SUMMARY:The preliminary results based on a three year retrospective study in cavus foot deformity of forty-four Friedreich ataxia patients regularly seen at the Neuromuscular Disease Clinic of Sainte-Justine Hospital have been presented. An accurate “weight-bearing” foot stereoradiographic technique has been recently developed by our group. Since the follow-up period with this device is not sufficient to provide statistical information, the conventional non-weight bearing technique has been utilized in this study to enable a possible comparison between the radiographs of ambulant and non-ambulant patients. Due to the present technique, the results of this study must be interpreted with caution.For 132 pairs of radiographs, 28 parameters have been analyzed. Four of these, namely the calcaneal inclination angle, the first metatarsal inclination angle, the inferior cortex of calcaneus-first metatarsal angle and the first-fifth metatarsals angle, were of particular interest. From these parameters, a preliminary quantitative description of cavus foot deformity in Friedreich’s ataxia has been attempted. Three stages of evolution have been tentatively identified for this type of neurological disorder.

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Dynamic First Tarsometatarsal Instability During Gait Evaluated by Pedobarographic Examination in Patients with Hallux Valgus

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00304 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0030

Author(s):

Byung Jo Min ◽

Seungbum Koo ◽

Won-keun Park ◽

Ki-bum Kwon ◽

Kyoung Min Lee

Keyword(s):

Hallux Valgus ◽

Joint Instability ◽

Weight Bearing ◽

Binary Logistic Regression ◽

Valgus Deformity ◽

Binary Logistic Regression Analysis ◽

Tarsometatarsal Joint ◽

Hallux Valgus Deformity ◽

Metatarsal Angle ◽

Radiographic Measurements

Category: Midfoot/Forefoot Introduction/Purpose: This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus deformity. Methods: Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15° were included. All patients underwent a pedobarographic examination along with weight-bearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the two groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability. Results: HVA (p<0.001), the intermetatarsal angle (p=0.001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instabilities of the first tarsometatarsal joint (p=0.924). HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability (p=0.001). Conclusion: The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus deformity. Patients with greater HVA need to be carefully monitored for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.

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Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases

10.21203/rs.3.rs-24951/v2 ◽

2020 ◽

Author(s):

Hong-An Zhang ◽

Chun-Hao Zhou ◽

Xiang-Qing Meng ◽

Jia Fang ◽

Cheng-He Qin

Keyword(s):

Intramedullary Nailing ◽

Distraction Osteogenesis ◽

Intramedullary Nail ◽

Calcium Sulfate ◽

Bone Fractures ◽

Weight Bearing ◽

Bone Transport ◽

Complication Rates ◽

Nail Removal

Abstract Background: The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis. Methods: We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed. Results: A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively. Conclusion: Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

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