Achilles tendon rupture in 54 yo female. Patient fell at home going up the stairs. Previous history of Achilles rupture during college. Patient is asleep for surgery – we are demonstrating a positive Thompson’s test on the right side where the calf is squeezed, and the toes do not plantarflex (point). Whereas on the the left side when the calf is squeezed the toes do point towards the floor.
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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....
My rules for favoring open allograft vs scope microfracture are:
-Talar shoulder lesions
-Full thickness delamination apparent on MR
-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
-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....