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A review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty
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Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154
and 0.69, 0.63, 0.61 in validation cohort. The accuracy of models as ±2SD for D1, D2, D3 were 93.9%, 94.9%, 94.9%, respectively. Conclusion: This study predicted the sagittal length for preoperative planning by measuring coronal length of distal tibia. Prediction of sagittal length can help orthopedic surgeons fixate screws stably to prevent iatrogenic injury of posterior structures of distal tibia. http://dx.doi.org/10.1016/j.fas.2017.07.265
177 Triplane fracture during adolescence – A case report J.M. Rosa ∗ , M. Lopes, A. Couto, T. Freitas, T. Sacramento Centro Hospitalar do Algarve–Hospital de Faro, Portugal The triplane fracture predominantly affects young people and has a higher incidence in males. It is a complex fracture and its pathophysiology is directly related to the characteristic asymmetry at the closure of the distal tibia physis. Regarding the diagnosis, the X-ray assumes great utility in the initial evaluation, but does not clearly show the number of fragments. CT scan has great relevance in the correct characterization of all the fragments, as well as in the preoperative planning. Analysis of clinical history, complementary diagnostic exams, treatment and literature review. The authors present the case of a male patient, 15 years old, Parkour practitioner, who in the course of this activity suffered a left ankle trauma. The patient presented significant pain and edema with marked disability. The imaging study showed the presence of a Triplane fracture. ORIF of the external malleolus was performed with plate and screws and fixation of the posterior malleolus with screws using a postero-external approach, followed by the reduction and fixation of the anterior fragments with AP screws. He is currently 6 months postop, and presents no deficit in the mobilization of the ankle joint. Conclusion: The Triplane fracture presents a good long-term prognosis. An adequate diagnosis and treatment requires the evaluation of associated lesions and knowledge of possible fracture patterns. It is important to emphasize the importance of anatomical reduction as a way to prevent the evolution to degenerative disease, as well as growth changes due to physis lesion. http://dx.doi.org/10.1016/j.fas.2017.07.266
178 Minimally invasive distal linear metatarsal osteotomy for severe hallux valgus H. Seki 1,∗ , Y. Suda 1 , A. Waseda 2 , H. Ikezawa 3 , K. Takeshima 1 , K. Ishii 1 1
Department of Orthopedic Surgery, Mita Hospital, International University of Health and Welfare, Japan 2 Department of Orthopedic Surgery, Ogikubo Hospital, Japan 3 Department of Orthopedic Surgery, Eiju General Hospital, Japan Introduction: In the last decade, there has been a growing interest in the use of minimally invasive (MIS) techniques for correcting hallux valgus deformities. These techniques has been generally employed to treat mild to moderate hallux valgus deformities. The aim of this study was to evaluate the outcome of MIS technique for severe hallux valgus. Methods: 95 patients (140 ft) with severe hallux valgus (hallux valgus angle > 40◦ ) were performed distal lineal metatarsal osteotomies (DLMO) combined selectively with lateral soft tissue release (LSTR). The selection of LSTR depended on our original manual test (“squeeze test”). The LSTR was performed by stretching (17 ft) or open release (70 ft). Additional surgeries for recurrence, transfer metatarsalgia, and irritation were performed in 9 patients (11 ft), and the others were followed for mean 38.8 months (24–63). Results: The mean Japanese Society of Surgery of the Foot (JSSF) hallux scale significantly improved from 60.4 (44 to 73) to 92.0 (65 to 100). The rate of satisfaction was 85.9%. The mean hallux valgus and intermetatarsal angles significantly improved from 45.7◦ (40.0–60.0) to 10.2◦ (−28.0 to 40.9) and from 19.9◦ (14.0 to 28.7) to 8.2◦ (−1.6 to 18.5). The first metatarsal bone significantly shortened (mean 3.5 mm), dorsiflexed (mean 5.1◦ ), and elevated (mean 3.7 mm) on radiographs. Complications were delayed union (18 ft), metatarsalgia (16 ft), recurrence (22 ft), hallux varus (22 ft) and avascular necrosis (2 ft). Conclusion: DLMO with selective DSTR was an effective procedure for correcting severe hallux valgus. http://dx.doi.org/10.1016/j.fas.2017.07.267
179 A review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty C.K.K. King 1,∗ , C. Zheng 2 , N.N. Amatullah 2 , K.V. Mehta 1 , J.S.Y. Loh 1 1 2
Changi General Hospital, Singapore Singapore Clinical Research Institute, Singapore
Objective: We aim to provide an evidence-based literature review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty. Currently, there is very little in the literature on the review of evidence on salvage arthrodesis. Methods: A comprehensive evidence-based literature review of the PubMed, Embase and Cochrane database conducted in December 2016, identified 12 relevant articles out of 340 articles assessing the efficacy of salvage arthrodesis for failed joint arthroplasty of the first metatarsophalangeal joint. The 12 studies were then assigned a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against the non-operative modality.
Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154
Results: Based on the results of this evidence-based review, there is fair evidence (grade B) to support use of salvage arthrodesis with the use of allograft and autograft. There is poor evidence (grade C) for the use of salvage arthrodesis without the use of structural graft. There were no good evidence (grade A) recommending any interventions. Meta-analysis of the pooled studies showed that salvage arthrodesis resulted in better functional outcome over time. Conclusion: In general, most of the interventions showed improvement. All studies showed good bone union and patient satisfaction. However, clinical outcome with salvage arthrodesis is still inferior to primary arthrodesis and revision surgery is fraught with challenges.
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181 Bilateral peroneal tendon dislocation caused by an anomalous muscle: A case report K. Ito 1,∗ , M. Okuda 1 , Y. Shiota 2 , A. Taniguchi 3 , H. Kurokawa 3 , T. Kumai 3 , Y. Tanaka 3 1
Department of Orthopedic Surgery, Ishinkai Yao General Hospital, Japan 2 Department of Orthopedic Surgery, Yoshimoto Orthopedics Surgery Hospital, Japan 3 Department of Orthopedic Surgery, Nara Medical University, Japan
http://dx.doi.org/10.1016/j.fas.2017.07.268
180 Modified distal tibial rotational osteotomy for osteoarthritis of the ankle K. Watanabe 1,∗ , A. Teramoto 1 , T. Kobayashi 1 , Y. Sakakibara 1 , H. Shoji 1 , T. Kamiya 1 , T. Yamashita 1 , S. Nuka 2 1 Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Japan 2 Hakodate Goryokaku Hospital, Japan
Introduction: Low tibial osteotomy is an effective jointpreserving surgery for ankle arthritis. However, poor postoperative wound healing, infection, and delayed or non-union of bones remain significant concerns. We developed a modified distal tibial oblique osteotomy procedure to improve outcome and reduce complications. We introduce our procedure and report preliminary results for varus ankle arthritis. Methods: We evaluated 7 ankles from 6 osteoarthritis patients both clinically and radiographically following the procedure. The osteotomy path consisted of an oblique doglegged line from the lateral end of the distal tibia to a proximal point about one-third from the lateral edge and continuing along an arc defined by virtual coronal-plane rotation of the doglegged line to the medial edge. After osteotomy, the distal tibial fragment was rotated distally in the coronal plane for realignment while maintaining contact with the proximal tibia and the distal tibial fragment. The resulting wedge-shaped gap was filled with artificial bone blocks and tibial bone projecting medially from rotation. A locking plate was then applied for stabilization. Results: Bone union was achieved within 3 months for all patients. The clinical evaluation score significantly improved at the latest follow-up. No wound healing problems, infections, or nerve disturbances were observed. Multiple radiographic parameters were also improved following the operation. Conclusion: This procedure maintains close bone contact for better postoperative union, obviates the need for iliac bone harvesting, and reduces tension on medial soft tissue. We believe these modifications are potential advantages for achieving stable results in patients with ankle osteoarthritis. http://dx.doi.org/10.1016/j.fas.2017.07.269
Purpose: We report the case of an anomalous muscle resection and closure of a false pouch for bilateral peroneal tendon dislocation. Case: A 35-year-old man consulted his local physician for frequent feelings of prolapse after straining his left ankle. He noted peroneal tendon muscle dislocation and referred the patient to our hospital. Physical findings showed that the dislocation could be manually or voluntarily reproduced. Surgery was scheduled because the pain during the dislocation was strong. Tenoscopy revealed dislocation of the short and long peroneal tendons. Behind that, an anomalous tendon was seen, which made prolapse easy on pushing the peroneal tendons forward. After resecting the anomalous muscle, the false pouch was closed. Two months postoperatively, the patient’s right peroneal tendon was dislocated when falling down, and an anomalous muscle was seen on MRI. The same surgery was performed on the right, considering the strong possibility of repetitive injury. One year postoperatively, the patient is progressing well without recurrence. MRI images revealed that the muscles were the peroneus quartus on the left and the peroneus digiti minimi on the right. Discussion: Bilateral peroneal tendon dislocation caused by anomalous muscles is an extremely rare condition that has not been previously reported. Predisposing factors include a shallow tendon groove, damage to the fibrocartilaginous ridge, and anatomical anomalies in the peroneal muscle. During surgery, it is important to confirm and treat anomalous muscles in order to prevent recurrence. Careful interpretation of preoperative MRI images taking anomalous muscles into account is also important. http://dx.doi.org/10.1016/j.fas.2017.07.270
182 Investigation of the role of extensor digitorum longus (EDL) in foot biomechanics C.Y. Tan ∗ , M. Farhan Mohd Fadil Tan Tock Seng Hospital, Singapore Introduction: We aim to investigate the role of extensor digitorum longus (EDL) in foot biomechanics, which were never described in the current literature. Methods: 2 fresh frozen cadaveric specimens were used in our study. 4th toe metatarsophalangeal joint (MTPJ) and proximal interphalangeal joint (PIPJ) range of motion (ROM) at ankle resting position, maximum plantarflexion and dorsiflexion were measured. 4th toe EDL branch was then identified over dorsal aspect of metatarsal shaft and cut transversely. Same measurements were repeated. Dissection was then carried out over dorsum of foot to identify any tendinous interconnections between EDL branches.
Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154
and 0.69, 0.63, 0.61 in validation cohort. The accuracy of models as ±2SD for D1, D2, D3 were 93.9%, 94.9%, 94.9%, respectively. Conclusion: This study predicted the sagittal length for preoperative planning by measuring coronal length of distal tibia. Prediction of sagittal length can help orthopedic surgeons fixate screws stably to prevent iatrogenic injury of posterior structures of distal tibia. http://dx.doi.org/10.1016/j.fas.2017.07.265
177 Triplane fracture during adolescence – A case report J.M. Rosa ∗ , M. Lopes, A. Couto, T. Freitas, T. Sacramento Centro Hospitalar do Algarve–Hospital de Faro, Portugal The triplane fracture predominantly affects young people and has a higher incidence in males. It is a complex fracture and its pathophysiology is directly related to the characteristic asymmetry at the closure of the distal tibia physis. Regarding the diagnosis, the X-ray assumes great utility in the initial evaluation, but does not clearly show the number of fragments. CT scan has great relevance in the correct characterization of all the fragments, as well as in the preoperative planning. Analysis of clinical history, complementary diagnostic exams, treatment and literature review. The authors present the case of a male patient, 15 years old, Parkour practitioner, who in the course of this activity suffered a left ankle trauma. The patient presented significant pain and edema with marked disability. The imaging study showed the presence of a Triplane fracture. ORIF of the external malleolus was performed with plate and screws and fixation of the posterior malleolus with screws using a postero-external approach, followed by the reduction and fixation of the anterior fragments with AP screws. He is currently 6 months postop, and presents no deficit in the mobilization of the ankle joint. Conclusion: The Triplane fracture presents a good long-term prognosis. An adequate diagnosis and treatment requires the evaluation of associated lesions and knowledge of possible fracture patterns. It is important to emphasize the importance of anatomical reduction as a way to prevent the evolution to degenerative disease, as well as growth changes due to physis lesion. http://dx.doi.org/10.1016/j.fas.2017.07.266
178 Minimally invasive distal linear metatarsal osteotomy for severe hallux valgus H. Seki 1,∗ , Y. Suda 1 , A. Waseda 2 , H. Ikezawa 3 , K. Takeshima 1 , K. Ishii 1 1
Department of Orthopedic Surgery, Mita Hospital, International University of Health and Welfare, Japan 2 Department of Orthopedic Surgery, Ogikubo Hospital, Japan 3 Department of Orthopedic Surgery, Eiju General Hospital, Japan Introduction: In the last decade, there has been a growing interest in the use of minimally invasive (MIS) techniques for correcting hallux valgus deformities. These techniques has been generally employed to treat mild to moderate hallux valgus deformities. The aim of this study was to evaluate the outcome of MIS technique for severe hallux valgus. Methods: 95 patients (140 ft) with severe hallux valgus (hallux valgus angle > 40◦ ) were performed distal lineal metatarsal osteotomies (DLMO) combined selectively with lateral soft tissue release (LSTR). The selection of LSTR depended on our original manual test (“squeeze test”). The LSTR was performed by stretching (17 ft) or open release (70 ft). Additional surgeries for recurrence, transfer metatarsalgia, and irritation were performed in 9 patients (11 ft), and the others were followed for mean 38.8 months (24–63). Results: The mean Japanese Society of Surgery of the Foot (JSSF) hallux scale significantly improved from 60.4 (44 to 73) to 92.0 (65 to 100). The rate of satisfaction was 85.9%. The mean hallux valgus and intermetatarsal angles significantly improved from 45.7◦ (40.0–60.0) to 10.2◦ (−28.0 to 40.9) and from 19.9◦ (14.0 to 28.7) to 8.2◦ (−1.6 to 18.5). The first metatarsal bone significantly shortened (mean 3.5 mm), dorsiflexed (mean 5.1◦ ), and elevated (mean 3.7 mm) on radiographs. Complications were delayed union (18 ft), metatarsalgia (16 ft), recurrence (22 ft), hallux varus (22 ft) and avascular necrosis (2 ft). Conclusion: DLMO with selective DSTR was an effective procedure for correcting severe hallux valgus. http://dx.doi.org/10.1016/j.fas.2017.07.267
179 A review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty C.K.K. King 1,∗ , C. Zheng 2 , N.N. Amatullah 2 , K.V. Mehta 1 , J.S.Y. Loh 1 1 2
Changi General Hospital, Singapore Singapore Clinical Research Institute, Singapore
Objective: We aim to provide an evidence-based literature review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty. Currently, there is very little in the literature on the review of evidence on salvage arthrodesis. Methods: A comprehensive evidence-based literature review of the PubMed, Embase and Cochrane database conducted in December 2016, identified 12 relevant articles out of 340 articles assessing the efficacy of salvage arthrodesis for failed joint arthroplasty of the first metatarsophalangeal joint. The 12 studies were then assigned a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against the non-operative modality.
Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154
Results: Based on the results of this evidence-based review, there is fair evidence (grade B) to support use of salvage arthrodesis with the use of allograft and autograft. There is poor evidence (grade C) for the use of salvage arthrodesis without the use of structural graft. There were no good evidence (grade A) recommending any interventions. Meta-analysis of the pooled studies showed that salvage arthrodesis resulted in better functional outcome over time. Conclusion: In general, most of the interventions showed improvement. All studies showed good bone union and patient satisfaction. However, clinical outcome with salvage arthrodesis is still inferior to primary arthrodesis and revision surgery is fraught with challenges.
61
181 Bilateral peroneal tendon dislocation caused by an anomalous muscle: A case report K. Ito 1,∗ , M. Okuda 1 , Y. Shiota 2 , A. Taniguchi 3 , H. Kurokawa 3 , T. Kumai 3 , Y. Tanaka 3 1
Department of Orthopedic Surgery, Ishinkai Yao General Hospital, Japan 2 Department of Orthopedic Surgery, Yoshimoto Orthopedics Surgery Hospital, Japan 3 Department of Orthopedic Surgery, Nara Medical University, Japan
http://dx.doi.org/10.1016/j.fas.2017.07.268
180 Modified distal tibial rotational osteotomy for osteoarthritis of the ankle K. Watanabe 1,∗ , A. Teramoto 1 , T. Kobayashi 1 , Y. Sakakibara 1 , H. Shoji 1 , T. Kamiya 1 , T. Yamashita 1 , S. Nuka 2 1 Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Japan 2 Hakodate Goryokaku Hospital, Japan
Introduction: Low tibial osteotomy is an effective jointpreserving surgery for ankle arthritis. However, poor postoperative wound healing, infection, and delayed or non-union of bones remain significant concerns. We developed a modified distal tibial oblique osteotomy procedure to improve outcome and reduce complications. We introduce our procedure and report preliminary results for varus ankle arthritis. Methods: We evaluated 7 ankles from 6 osteoarthritis patients both clinically and radiographically following the procedure. The osteotomy path consisted of an oblique doglegged line from the lateral end of the distal tibia to a proximal point about one-third from the lateral edge and continuing along an arc defined by virtual coronal-plane rotation of the doglegged line to the medial edge. After osteotomy, the distal tibial fragment was rotated distally in the coronal plane for realignment while maintaining contact with the proximal tibia and the distal tibial fragment. The resulting wedge-shaped gap was filled with artificial bone blocks and tibial bone projecting medially from rotation. A locking plate was then applied for stabilization. Results: Bone union was achieved within 3 months for all patients. The clinical evaluation score significantly improved at the latest follow-up. No wound healing problems, infections, or nerve disturbances were observed. Multiple radiographic parameters were also improved following the operation. Conclusion: This procedure maintains close bone contact for better postoperative union, obviates the need for iliac bone harvesting, and reduces tension on medial soft tissue. We believe these modifications are potential advantages for achieving stable results in patients with ankle osteoarthritis. http://dx.doi.org/10.1016/j.fas.2017.07.269
Purpose: We report the case of an anomalous muscle resection and closure of a false pouch for bilateral peroneal tendon dislocation. Case: A 35-year-old man consulted his local physician for frequent feelings of prolapse after straining his left ankle. He noted peroneal tendon muscle dislocation and referred the patient to our hospital. Physical findings showed that the dislocation could be manually or voluntarily reproduced. Surgery was scheduled because the pain during the dislocation was strong. Tenoscopy revealed dislocation of the short and long peroneal tendons. Behind that, an anomalous tendon was seen, which made prolapse easy on pushing the peroneal tendons forward. After resecting the anomalous muscle, the false pouch was closed. Two months postoperatively, the patient’s right peroneal tendon was dislocated when falling down, and an anomalous muscle was seen on MRI. The same surgery was performed on the right, considering the strong possibility of repetitive injury. One year postoperatively, the patient is progressing well without recurrence. MRI images revealed that the muscles were the peroneus quartus on the left and the peroneus digiti minimi on the right. Discussion: Bilateral peroneal tendon dislocation caused by anomalous muscles is an extremely rare condition that has not been previously reported. Predisposing factors include a shallow tendon groove, damage to the fibrocartilaginous ridge, and anatomical anomalies in the peroneal muscle. During surgery, it is important to confirm and treat anomalous muscles in order to prevent recurrence. Careful interpretation of preoperative MRI images taking anomalous muscles into account is also important. http://dx.doi.org/10.1016/j.fas.2017.07.270
182 Investigation of the role of extensor digitorum longus (EDL) in foot biomechanics C.Y. Tan ∗ , M. Farhan Mohd Fadil Tan Tock Seng Hospital, Singapore Introduction: We aim to investigate the role of extensor digitorum longus (EDL) in foot biomechanics, which were never described in the current literature. Methods: 2 fresh frozen cadaveric specimens were used in our study. 4th toe metatarsophalangeal joint (MTPJ) and proximal interphalangeal joint (PIPJ) range of motion (ROM) at ankle resting position, maximum plantarflexion and dorsiflexion were measured. 4th toe EDL branch was then identified over dorsal aspect of metatarsal shaft and cut transversely. Same measurements were repeated. Dissection was then carried out over dorsum of foot to identify any tendinous interconnections between EDL branches.