Foot & Ankle Surgeon

This pleasant 69 yo female fell going to feed her horses morning after a substantial snowfall in February.

She presented to the ED at 8am, and due to her coincidental NPO status, we were able to operate on her by ~1pm. That included time for H&P, pre-op imaging, and US guided pop/adductor blocks. Timing worked out well as we had just finished applying a delta frame on another fracture due to same storm.

It is evident on the CT at the lateral aspect of the PM fracture (PMF) there is incarcerated articular surface that would prevent reduction. To address this (after dissection of the most proximal aspect of the fracture only) we used a dental pick to distract the fragment posteriorly, & introduced a pituitary rongeur to snatch the articular fragment out.

Fixing these fractures within that 8-10 hour window prior to profound edema setting in seems to allow smooth reduction, and avoid soft tissue complications.

We elected to use screws and washers, rather than a buttress plate for the PMF.

The included articles were found without a thorough lit review. Regardless, they both demonstrate that not only is reduction better achieved directly, rather than via the lazy man’s “A-P screws”, but also that fixation method may not matter. The 2014 FAI article was a Level II prospective study that showed equivalent results when comparing buttress plating vs lag screws.
We have gone back and forth between plating, versus lag screws, and have anecdotally seen little difference in outcomes. Although, we tend to favor the plate for longer, larger PMF’s.

This patient ultimately healed well - the WB image was taken at 10 weeks from DOS. She does have occasional paresthesias along her post-lateral incision suggesting some mild Sural neuritis. She is in PT working on ROM, and limp elimination. She unfortunately had a retinal detachment surgery 14 weeks after the ORIF which set back her recovery.

Comment below whether you prefer buttress plate, or screws for PMF’s! ...

—This is a case from last year—

A seemingly innocuous bi-malleolar ankle fracture in a 24 yo female that fell down stairs at a belated Halloween party.

On closer inspection you can see her fibula broke in a less typical pattern at joint level with mild fragmentation in to the lateral gutter. Fibula almost broke in Salter Harris pattern we’ve seen in adolescents where physis is just closing, or has recently closed.

We used a pin distractor to span fracture and pull fibula out to length, and then rotate it anteriorly. We then used a lag screw and washer to better distribute pressure across a softer than expected anterior cortex.

Her medial malleolus, or rather anterior colliculus fracture was badly displaced. We were able to reduce it with very anterior lag screws.

We did use Nano arthroscopy to clean out the lateral gutter, and inspect joint surfaces.

Except for the 1 fluoro shot, the other post-op images are full weight bearing at 10 weeks. Pt left this visit in sneakers, and completed PT by 16 weeks with no complaints or bracing.

I hope in time individuals posting their cases to social media will refrain from using NWB images immediately post-op. Fluoro can be deceiving, and is not the final product. ...

16 yo male that presented with complaints of sinus tarsi syndrome, 1st MTP pain with exercise, and chronic foot fatigue/pain. Not an athlete, but has part time job, and is good student.

This is patient’s left foot. Post-op films were taken full weight bearing at 10 weeks demonstrating union. He was actually seen today in clinic for his 10 week visit for his right foot - same procedures minus 1st metatarsal osteotomy.

Patient was so excited to be done with his surgeries/recovery he brought brand new, custom, Nike Blazers in the box to wear out of the office.

Note: cuneiform osteotomy slightly distal. Typically try and make osteotomy parallel to 2nd TMT.

We chose to use double osteotomy rather than trying to excessively plantarflex a Lapidus. Retaining motion in the younger surgical population always make sense if the articulations are not intrinsically pathologic, and in this instance specifically the 1st ray is not unstable.

Patient is very happy with outcome.

Extremity hardware and allografts used for correction.

Disclosure: I am an XM consultant. ...

Intra-articular calcaneal fracture in a 27 yo male that was in a MVA. Pt broke his left wrist, sternum, and right calcaneus. Pt was referred for ORIF. He is a smoker but otherwise healthy.

Getting the tuber out of varus is always important. Using a large bicortical pin helps tremendously to exaggerate, distract, and rotate into valgus. Shenton’s line is nice to line up if possible. However, facet reduction is what matters most to limit arthrosis long term.

Arthrex Nanoscope allows some nice images to be captured during the case. @arthrexmeded

Having a dedicated console, and having images directly imported to an Ipad afterwards has been incredible for showing families images immediately following the case. ...

Reducing comminuted calcaneal fractures is always a challenge.

In this case a late 50s female, smoker, missed a step or two at church landing with force on her heel.

We used the @arthrexmeded
1.9mm Nano scope to debride the joint and assist reduction. A small locking plate, and FT screws were used for our fixation.

We have found using this tiny, pliable, sterile packed scope is more efficient than traditional arthroscopes, and due to size and flexibility less violating to the joint tissues.

Due to some bone/chondral loss perfect reduction was not possible, but restoration was certainly better than a cast, vs primary arthrodesis.

Many patients go on to STJ arthrodesis after inevitable post traumatic arthritis ensues. However, a heel bone with good morphology is wonderfully more ample for long term success post fusion. Literature supports this.

Lastly, …lateral extensile is a paradise for complications.

“Michael P Clare, William E Lee III, Roy W Sanders
JBJS 87 (5), 963-973, 2005
Background: Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions.

Conclusions: This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.”

#calcanealfracture #acfas #trauma #footankle ...

This 77 yo gentleman whom still works full time finally decided to have his “crooked toe” fixed.

Due to some osteopenia and severe deformity we felt the Extremity Medical post device was the perfect construct to resist the forces present. Z-lengthening of the EHL tendon was necessary.

The post device allows excellent compression, both dorsal and plantar. Despite the osteopenic bone we allowed this patient to bear weight immediately. He did well, and developed nice union by 10wk x-ray. He was back in work boots after 8 wk visit, which of course was his primary concern.

I am a paid consultant. ...

9 month neglected Achilles Tendon rupture in a healthy 51 yo female. She ruptured it in an alumni volleyball game.

Plantaris was intact as seen on the axial STIR….. The ends of the tendon were not connected at all by a fibrous plug like they often are. I attribute this to her never quitting yoga, post-injury, despite her profound weakness.
Which was also her main complaint, rather than pain.

We did weave plantaris through the repair as @dkblacklidge recommends. Fortunately, all that was needed to bring the ends together was ~10 degrees plantarflexion and 3cm Allograft we folded on itself to replicate native thickness. Her tissues closed with little tension. We do try and avoid sacrificing FHL unless there are concerns of durability, or the gap size is excessive. Her gap on MR pre-op measured between 5-7cm.

#achillesrupture #acfas #fellowship ...

We have such a funny dichotomy in our industry right now between the Lapidus and MIS bunionectomy. It seems many surgeons, industry reps, and even patients have such strong opinions on which method is best. I think in reality there will never be a “standard approach” for correcting painful hallux valgus deformities, ….as each patient and deformity is a little different. We’ve seen in our own practice that the Lapidus arthrodesis offers the attractive ability to help stabilize the medial arch of the foot.

In this case, a healthy 23 yo female had profound gastroc equinus, mild flexible flatfoot deformity, and a painful bunion. We utilized a small 2 incision Lapidus, and a Baumann gastroc recession. If you look close you can observe subtle improvement in the talar head coverage without any bony work at the hindfoot.
This patient was FWB in boot at 2 weeks.

The JFAS article here nicely demonstrated this…. ...

Acute Charcot event in 54yo male with rare extruded navicular. This gentleman lived alone, which made things even more interesting for the recovery. Ultimately he healed wonderfully, and developed great unions at every fusion site (with exception of CCJ - 50% union). Admittedly Charcot cases are insanely difficult, and unpredictable - luckily this one turned out well for this patient.

Extremity Medical Charcot specific hardware used.

#charcotfoot #footsurgery #acfas ...

This 23 yo female suffers from tethered spinal cord syndrome. She has already had multiple back surgeries. Part of the disease process includes lower extremity muscle weakness, and neuropathy. This patient had decent epicritic sensation, but as seen - has profound genu recurvatum due to weakness. She had complaints of chronic ankle instability, forefoot instability (mostly due to bunion deformity), symptomatic pes planus and general gait problems due to the aforementioned.

Her chief complaint was unsteady gait. She also had an extremely tight heel cord - inability to get to 90 with knee extended and flexed. (toe walking common in these patients, which often allow the ankle instability)

To address as many complaints at once, but also not “over cook” the recipe we performed a TAL , ATF repair with modified Bröstrum, Evans osteotomy, and 1st MTP arthrodesis. We felt lesser toes would improve with TAL and Evans - they did (decrease pull of FDL).

Notes:
-when women in particular have narrow 1st phalanx we will abstain from lag screw at MTP, and it does not seem to effect union rate - she was NWB for Evans for 6 wks regardless…. Recovery more conservative in these instances
-Oblique view allows best view of Evans union
-Anytime neuropathy is considered we gravitate towards arthrodesis, however, hers is incomplete
-Over time she will likely become fully neuropathic - likely not her last procedures
-Xrays taken at 12 wk follow up visit
-She’s very happy with result - in her words, she liked result of TAL and 1st MTP the most. But would not change any of the above thus far.

Implants used; Extremity Medical purely cancellous Evans allograft, and 1st MTP locking plate

Arthrex internal brace, and Fibertak suture anchors ...

We met this 74 yo female 4 years ago, and started her in custom orthotics, and custom AFOs due to stage 2b PTTD. Despite this she still eventually tore PT, and spring ligament. She swore she’d never have corrective surgery when we met….She is now 12 wks s/p triple arthrodesis, with nice unions, and walking in sneakers. , No bracing, or even orthotic (so far). …. She was mildly osteopenic clinically (in OR), and moderately osteopenic based on her DEXA scan in some areas, however, this didn’t seem to effect bony healing.

Bracing and inserts are great conservative options, but they also fail contrary to what some practitioners believe. ...

Stage 3 PTTD patient that was referred with MRI already performed….PT tendon ruptured, and spring ligament torn.

Interestingly, the spring ligament damage is evident on lateral plain film with dorsal cortices of TN not matching up. Additionally, profound supination weakness seen on exam provides enough info to confirm PT is insufficient….X-rays and exam give you Stage 3, without necessity for MRI….. At Stage 3, coupled with morbid obesity, patient is guaranteed triple arthrodesis. Painful bunion was also consideration so we chose osteotomy rather than arthrodesis.

Due to severity of deformity and foot type - we felt addition of CC fusion allowed some mild forefoot varus to be addressed without need for opening wedge osteotomy at midtarsal articulation, or plantarflexory TMT arthrodesis.

Post op films were taken at 10 wks from date of surgery with nice unions evident.

Stage 3 patients are stiffer for sure. But seemingly some of the happiest post-operatively, as we’ve found they learned to live with bad deformity and pain longer than necessary. ...

An isolated CC arthrodesis is not a common procedure. However, in certain instances like large non-united anterior process fractures, it may be the best option. Fixating the CC whether isolated or not, can be a challenge. When performed in addition to a STJ and TN fusion, the fixation is probably less important due to the inherent stability afforded with the fixation of adjacent hindfoot joints. However, in the isolated scenario, fixation is crucial as the non-union rate is much higher. We have utilized a variety of constructs; staples, screws, small plates, headless beam screws from P to A, etc….We have found firsthand the IO Fix device by Extremity Medical not only allows exceptional compression, but also addresses the ever present hardware irritation concern in thinner patients. The intramedullary IO Fix device eliminates the concern for peroneal tendon irritation, and offers superior compression. It has been a great tool for this procedure.

Case examples show good union at 8+ wks from date of surgery. ...

19 yo falls off rope swing

1 year later still in pain….

Advanced imaging to eval quality of lesion

….Original ER plain film shows OLT

My rules for favoring open allograft vs scope microfracture are:

-Talar shoulder lesions
-Full thickness delamination apparent on MR
-11-12mm +
-Depth is of concern

Patient also received direct ATF ligament repair with Fibertak suture anchors.

I like BioCartilage as it is half the cost of De Novo, BMAC included. You get the best of both worlds - host cells, and graft. It has been proven to have favorable MOCART scores, and robust thickness as compared to fibrocartilage, when looked at up to 19 months post-op. ...

71 yo nurse falls at home after neck surgery. …. The most heart warming debate out there….ORIF vs Arthrodesis for Lisfranc injuries - both ligamentous, and osseous/ligamentous combined.

In my mind, patients have the last say as long as it’s reasonable.

The most important feature of the TMT complex is stability, not motion. Arthrodesis provides that, especially in patients where demand requires it. Counterintuitively active patients need this the most. Shannon Rush hammers that point. This particular patient hikes with spouse, was about to retire, and wanted the closest thing to a guarantee of 1 procedure allowing success that could be provided.

Trauma to the TMT complex inherently changes the articulation permanently, true. The advantages arthrodesis affords vs ORIF;

-1 procedure assuming union
-Superior stability
-No risk of re-injury to ligament that doesn’t exist
-Decreased risk of complications due to statistically less surgeries required
-Patients have been shown to reach pre injury activity levels up to 30% better in arthrodesis group
-Improved pain scores

Literature defines arthrodesis patients as partial vs total.
Partial = 1-3 TMT fusion
Total = 1-5 TMT fusion

Coetzee’s study is really still the best study because he compares his own patients, fusion vs ORIF, with a 3.5 yr follow up. Of course the limitation to his study is follow up time. If the ORIF group is followed for 20 yrs we would presumably see 100% post traumatic OA in the ORIF group.
Counterpoint would be prevalence of adjacent joint arthritis in arthrodesis group.
My argument to that is - does a joint that does not have exceptional motion to begin with place much burden on an adjacent joint, post fusion?

Yes - ORIF’s are quick, and easy, but do they last?

In our own patients, the arthrodesis patients are happier than the open and perc ORIF patients.

This case was fixated with Extremity Medicals IO Fix device which affords incredible compression with intramedullary fixation.

NOTE: Post-op images demonstrate union at 10th week visit. ...

This patient had an Achilles tendon rupture in 2015 while on vacation in the Bahamas. A mostly sensate IDDM ... 4 surgeries later, and a finally healed Achilles tendon, unfortunately however left her with chronic osteomyelitis of her calcaneus. She was referred to us in 2019. At that point she had failed 3+ yrs of wound care, immobilization, antibiotics (both oral and IV), and was living with a draining sinus tract at her medial heel. I suggested to the patient further surgery. She had multiple MRI's, and a CT scan demonstrating the chronic OM. She declined surgery however, and even cancelled after she scheduled with us twice, due to admitted PTSD from the ordeal spanning the course of 6 years. I suggested to her (not in order) we debride the bone through the sinus tract -take cultures, irrigate, excise the wound, fill the void with a non-phosphate antibiotic impregnated bone filler (Cerament), close with heavy suture, and hope for the best. After 2 years of deliberation under our care she finally agreed, and that's what we did. A culture in our office taken from active purulence in 2019 grew Enterobacter Cloacae, the repeat culture in the OR in July of 2021 also grew Enterobacter Cloacae. We used Gent/Vanc for the Cerament, although Cerament does not recommend using Gent. During surgery as soon as we started to debride the bone with a small curette, a long, purulent strand of fiberwire shot out from the intramedullary canal. This answered the question of the non-healing tract.
She is now 2 months out from surgery, and doing great. Wound free for the first time since 2015.

Note; classic chronic OM cloaca as seen on CT. ...