Acute Achilles tendon ruptures is routinely missed or undertreated, leading to functional deficits. The neglected Achilles ruptures often requires surgical repair to regain functional improvement. The tendon retraction and resultant necessary debridement of the rupture site leads to difficulty completing end-to-end repair. Advanced techniques, including fascial advancements, tendon transfers , and use of allografts , allow the treating surgeon many viable repair options for the neglected Achilles presentation. The article describes the neglected Achilles tendon , including the nature of the problem, repair options, surgical technique, and a discussion of the surgical outcomes.

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.

The Cotton osteotomy is a plantarflexion osteotomy of the medial cuneiform, which is typically utilized in the reconstruction of adult acquired pes planus, posterior tibialis tendon dysfunction stage II (Johnson and Strom), and forefoot varus. The purpose of this paper is to give an estimate of the angular correction in the sagittal plane for each millimeter of bone graft used in the Cotton osteotomy using 20 cadaveric specimens. We have demonstrated that a surgeon will gain roughly 1.9 degrees of plantar flexion of the medial column for every one millimeter graft inserted into the medial cuneiform. While we have not established the amount of correction that should be done, the effect of increasing the wedge size has been demonstrated and may be helpful to surgeons when performing the Cotton osteotomy.

Fractures occurring within the 1.5-cm proximal portion of the fifth metatarsal are commonly considered avulsion fractures. The exact mechanisms of such fractures are controversial. The present study focused on determining the likely mechanism of fracture according to the exact anatomy to allow for more successful treatment. The research sample included 10 frozen cadaveric specimens. The lateral band of the plantar fascia, peroneus brevis, and articular surface were identified and separated from their attachments, thereby splitting the fifth metatarsal base into zones A, B, and C. In zone A, the attachment of the plantar fascia was 6.6 ± 2.2 mm from the inferior aspect, 9.5 ± 2.9 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. In zone B, the attachment of the peroneus brevis was 12.0 ± 2.2 mm from the inferior aspect, 10.2 ± 2.2 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. Zone C was measured from the border of zone B and encompassed the articulation of the fifth metatarsal to the cuboid. We propose that fractures occurring in the most proximal end of the fifth metatarsal, zone A, are caused by a lateral band of plantar fascia and might be able to be treated conservatively by immobilization with weightbearing. We also propose that fractures occurring in zones B and C result from traumatic tension on peroneus brevis and might need to be treated with strict immobilization and non-weightbearing or open reduction internal fixation.

The management of ankle fractures with open reduction and internal fixation (ORIF) has been a proven method to help prevent deformity and posttraumatic arthritis. The incidence of continued ankle pain due to retained hardware after ORIF of ankle fractures has been documented. The goal of this study was to determine if the starting point for medial malleolus screw placement is associated with posterior tibial tendon (PTT) damage when performing ORIF of the medial malleolus. Patients that had ORIF of the medial malleolus and subsequent repair of the PTT with medial malleolar hardware removal were identified. Zones were established and labeled 1 through 3 as described in the literature. This template was used as an overlay on lateral ankle radiographs to analyze the position and assign zones to the medial malleolus screws. Fifteen patients met the inclusion criteria. Three screws were found in zone 1, 11 in zone 2, and 1 in zone 3. The middle and posterior zones (zones 2 and 3) contained 80% of the screws, which may potentially cause risk to the PTT. We conclude that there is an increased probability that medial malleolar hardware in zones 2 and 3 can compromise the PTT. Levels of Evidence: Therapeutic, Level IV: Case series

Placement of a screw from the lateral wall of the calcaneus into the constant sustentaculum tali fragment can be difficult when surgically repairing a calcaneal fracture. This screw serves to compress the fracture fragments and support the posterior facet. This difficulty results from the small landing zone of the sustentaculum tali with its nearby vulnerable soft tissue structures. We present an anatomic study of 10 cadavers to determine a starting point and angle of screw advancement when placing a constant fragment screw.

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

The medial double arthrodesis, comprised of subtalar and talonavicular joint fusions, has become a popular way to correct hindfoot deformity. There is potential concern for an increase in ankle valgus postoperatively owing to extended medial dissection and possible disruption of the deltoid ligament. Although this approach is often used to correct a valgus hindfoot, little attention has been paid to date on this procedure's effect on the tibiotalar joint. Although the medial double arthrodesis has been shown to produce reproducible outcomes without violating the lateral hindfoot structures, our hypothesis was that this approach would increase the ankle valgus deformity compared with its triple counterpart. The primary goal of the present retrospective study was to identify the frequency and severity of ankle valgus after the medial double arthrodesis compared with the triple arthrodesis. A total of 77 patients (78 feet) met our inclusion criteria. Their mean age was 61.3 ± 10.7 (range 27 to 79) years, and the follow-up period was 15.7 ± 9.9 (range 6 to 46) months. There were 16 and 61 patients (62 feet) in the medial double and triple arthrodesis groups, respectively. Overall, the preoperative ankle valgus was 1.24° ± 2.02° (range 0° to 6°), and there was no statistical difference of preoperative ankle valgus noted between groups (p = .060). Collectively, postoperative ankle valgus was 3.01° ± 3.54° (0° to 17°) with an increase in ankle valgus in 4 of 16 medial double and 34 of 62 triple arthrodesis patients. With a mean follow-up of 8.75 ± 4.02 (6 to 21) months, the medial double arthrodesis cohort's ankle valgus increased from 0.5° ± 1.55° (0° to 6°) to 1.5° ± 3.14° (1° to 10°) postoperatively. The triple arthrodesis group had a mean follow-up 17.53 ± 10.17 (6 to 46) months and ankle valgus increased from 1.44° ± 2.09° (0 to 6°) to 3.40° ± 3.56° (0° to 17°). Postoperative ankle valgus was statistically significant between groups (U = 303.50, p = .013). The odds of having an increase in the valgus ankle angle for patients in the triple group was 3.64 times that for patients in the double group, while holding all other variables in the model constant.

Although discussed as an alternative to triple arthrodesis for hindfoot correction, the published data surrounding the medial double arthrodesis, or fusion of the subtalar and talonavicular joints, has not addressed the proximity of the anatomic structures at risk. A total of 10 cadaver specimens were used to examine the risk of damage to the neurovascular and tendinous structures of the posterior medial hindfoot when performing the medial double arthrodesis. The distance of the reviewed structures was measured in relation to the standardized point of the middle facet of the calcaneus (mean ± standard deviation and range). The proximity of the middle facet to the posterior tibial tendon was 1.88 ± 2.65 (range 0 to 6.65) mm, to the flexor digitorum longus tendon was 5.34 ± 4.79 (range -3.14 to 12.79) mm, to the flexor hallucis longus tendon was 19.08 ± 4.84 (range 13.04 to 27.31) mm, and to the neurovascular bundle was 21.19 ± 7.84 (range 8.36 to 34.26) mm. At the level of the middle facet, the posterior tibial tendon was the largest tendon, measuring 7.14 ± 2.21 (range 3.31 to 10.23) mm by 2.95 ± 0.88 mm (range 1.86 to 4.24 mm; area 22.37 ± 12.23 mm(2), range 6.16 to 43.38 mm) followed by the flexor digitorum longus tendon at 4.25 ± 1.25 (range 1.74 to 5.95) mm by 2.25 ± 0.96 mm (range 1.41 to 4.79 mm; area 8.88 ± 2.62 mm(2), range 6.12 to 14.52 mm) and flexor hallucis longus tendon at 5.75 ± 2.05 (range 2.27 to 8.91) mm by 2.75 ± 0.82 mm (range 1.35 to 4.13 mm; area 16.81 ± 10.05 mm(2), range 4.81 to 36.80 mm). During dissection for the medial double arthrodesis, one can encounter critical anatomic structures, including artery, vein, nerve, and tendon. Our cadaveric investigation found a mean safe distance of more than 2 cm between the middle facet of the talocalcaneal articulation and the inferiorly located neurovascular bundle using the medial double arthrodesis approach.

While the medial double arthrodesis has gained significant popularity for hindfoot arthrodesis in recent years, much has been touted about the efficiency and cost savings of the procedure in comparison to its triple counterpart without any literature to reinforce this claim. The purpose of this retrospective study was to compare the hardware costs and operative time between the medial double and triple arthrodeses. A total of 276 patients (277 feet) were identified via CPT codes with 47 hindfoot cases (47 feet) meeting the inclusion criteria consisting of 21 medial double (6 males, 15 females) and 26 triple (8 males, 18 females) arthrodeses. No significant difference was noted in age, body mass index, gendr, chronic steroid use, preoperative osteopenia/osteoporosis, tobacco abuse, surgical side, presence of diabetes, immune compromised state, kidney disease, rheumatoid arthritis, or liver disease. Mean medial double operative (OR) time 106 ± 31 minutes (range = 73-201 minutes) with a procedure time of 84 ± 29 minutes (range = 44-163 minutes) was identified versus an OR time of 127 ± 23 minutes (range = 91-200 minutes) and procedure time of 104 ± 23 minutes (range = 50-169 minutes) for the triple arthrodesis group. The mean fixation cost for the triple arthrodesis was found to be higher with the mean triple hardware cost $2932.75 ± $736.60 (range = $1434.00 to $3980.00) against the medial double’s $1197.59 ± $635.57 (range = $463.20 to $2019.00). Both efficiency and cost were found to favor the medial double for hindfoot arthrodesis at a level of statistical significance level ( P = .0028 for OR time, P = .0033 for procedure time, and P < .0001 for cost). Levels of Evidence: Therapeutic, Level III, a retrospective comparative series

Hallux rigidus is a term describing degenerative joint disease (DJD) to the first metatarsal phalangeal joint (MTPJ). It is the most common DJD encountered in the foot and is the second most common pathology of the great toe behind hallux valgus. The goal of a cheilectomy is to relieve pain and increase MTPJ motion. Critical evaluation of the cheilectomy must include longevity of desired results. The primary goal of this study was to determine how long a cheilectomy can be expected to last before an arthrodesis or joint destructive procedure is performed, if ever. We examined 189 cheilectomies with a mean radiographic follow-up of 235 days and mean chart review follow-up of 1184 days (3.2 years). Analysis showed 5 repeat cheilectomies, 1 interpositional arthroplasty, and only 2 arthrodeses subsequently performed. This retrospective study provides intermediate term evidence that cheilectomy is an appropriate procedure for stages 1, 2, and 3 first MTPJ DJD with reliable, lasting results.

Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic connective tissue progenitor cells. Alternative harvest sites in foot and ankle surgery include the distal aspect of the tibia and the calcaneus. To our knowledge, no previous studies have characterized the quality of bone marrow aspirate obtained from these alternative sites and compared the results with those of aspirate from the iliac crest. The goal of this study was to determine which anatomic location yields the highest number of osteoblastic progenitor cells.Methods: Forty patients were prospectively enrolled in the study, and separate bone marrow aspirate samples were harvested from the ipsilateral anterior iliac crest, distal tibial metaphysis, and calcaneal body. The aspirate was centrifuged to obtain a concentrate of nucleated cells, which were plated and grown in cell culture. Colonies that stained positive for alkaline phosphatase were counted to estimate the number of osteoblastic progenitor cells in the initial sample. The anatomic locations were compared. Clinical parameters (including sex, age, tobacco use, body mass index, and diabetes) were assessed as possible predictors of osteoblastic progenitor cell yield.Results: Osteoblastic progenitor cells were found at each anatomic location. Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < 0.0001). There was no significant difference in concentration between the tibia and the calcaneus (p = 0.063). Age, sex, tobacco use, and diabetes were not predictive of osteoblastic progenitor cell yield.Conclusions: Osteoblastic progenitor cells are available in the iliac crest, proximal aspect of the tibia, and calcaneus. However, the iliac crest provided the highest yield of osteoblastic progenitor cells.Clinical Relevance: The study demonstrated that osteogenic progenitor cells are available in bone marrow aspirate harvested from the tibia or calcaneus as well as the iliac crest. All three sites are easily accessed, with a low risk of adverse events. However, larger volumes of aspirate may be needed from the tibia or calcaneus to approach the yield of cells from the iliac crest.

Circular external fixation is a useful treatment option for the correction of complex trauma, extremity deformity, osteomyelitis, and reconstruction of the foot and ankle. The goal of the present study was to determine the degrees of bolt rotation required to create enough wire tension to cause structural failure of the lateral calcaneal wall when stressed with both olive and smooth wires in a cadaveric model. Ten fresh, thawed, below-the-knee specimens were tested at the San Diego Cadaveric Academic Research Symposium. The mean bolt rotation required to pull an olive wire through the lateral wall of the calcaneus was 79.8° ± 32.81°, and the mean bolt rotation required to "walk" a skinny wire (narrow diameter) and create 1 mm of cortical bone failure was 50.5° ± 30.91°. The results of the present investigation further define and elucidate the appropriate "Russian tensioning" technique applicable for external fixation of the calcaneus using olive or skinny wires in the case of fracture repair or compression arthrodesis.

The Evans lateral column lengthening procedure allows correction of abduction, improved talar head coverage, decreased forefoot and rearfoot valgus, and improvement of medial column arch height. However, identifying the structures at risk when performing this osteotomy has proved difficult in vivo. Using 10 cadaveric lower limbs, we performed the Evans calcaneal osteotomy and determined whether violation of the calcaneal facets and the sustentaculum tali occurred. Based on our findings, we recommend directing the osteotomy from posterolateral to anteromedial.

Hallux abducto valgus surgery is in a constant state of evolution. Innovation is driven by surgeons pursuing the perfect procedure for any clinical scenario. The end point is to eliminate complications and produce satisfied patients. Medical device technology has helped pave the way for some recent advances in bunion surgery. The use of opening base wedge plates, locking plates for the Lapidus fusion, suture endobuttons, and staples for the Akin procedure are the focus in this review of modern techniques.

Orthobiologics are helping surgeons to manipulate healing and reduce delayed unions and nonunions. Surgeons are no longer limited to harvesting the iliac crest to obtain osteoconductive, osteoinductive, and osteogenic materials for grafting purposes. Synthetic substitutes have evolved that have nearly unlimited volume, no associated harvest site morbidity, and may even eclipse the healing capabilities of autogenous grafts. Mesenchymal stem cells, available both by bone marrow aspirate harvest and by commercially available allografts, provide adjuncts to facilitate bone healing in foot and ankle surgery.

A review of the literature yields few reported cases of industrial-strength high-pressure water injection injuries involving the foot, and sources of information for industrial-strength high-pressure water injection injuries reside primarily in the hand surgical literature. Toxic materials, such as grease, paint, and diesel oil, are relatively common agents involved in injection injuries, and these substances are associated with increased morbidity in comparison with injection of water or air. Treatment of high-pressure injection of a toxic substance is a surgical emergency requiring irrigation, debridement, antibiotic administration, and monitoring for signs and symptoms of compartment syndrome. There are, however, documented cases where less extreme treatment regimens have met with success. We report a successful limb salvage case, and review of the literature, related to a high-pressure water injury involving the foot with associated extensive subcutaneous emphysema.

Posterior tibial tendon dysfunction is a common clinical entity treated by foot and ankle specialists, and numerous surgical treatments are available to the modern foot and ankle surgeon. Fixation methods are constantly evolving as new products are developed and new uses for existing products are attempted. Interference screw fixation is the gold standard fixation for tendon autograft and allograft in orthopedic sports medicine. The technique that we describe in this article uses a less extensive harvest of the flexor digitorum longus tendon and a sound fixation method using an interference screw positioned in the tarsal navicular.