Orthopaedic Knowledge Home Study by R. Alexander

Knee Reconstruction and Replacement Orthopaedic Knowledge Update 8 polyethylene component was used. Two revisions demon- Extra-articular deformity can be corrected using intra- strated tibial post impingement and backside wear of the poly- articular bone resection and ligament balancing when coronal ethylene. plane deformity is less than 20° in the femur and less than 30° in the tibia. Parvizi J, Lajam CM, Trousdale RT, Shaughnessy WJ, Cabanela ME: Total knee arthroplasty in young patients Complications with juvenile rheumatoid arthritis. J Bone Joint Surg Am 2003;85:1090-1094. Crossett LS, Sinha RK, Sechriest VF, Rubash HE: Re- construction of a ruptured patellar tendon with Achilles TKA in patients with juvenile rheumatoid arthritis can be tendon allograft following total knee arthroplasty. successful, but poor preoperative function, involvement of J Bone Joint Surg Am 2002;84-A:1354-1361. multiple joints, and compromised immune system lead to in- creased rates of postoperative stiffness and infection. Rupture of the patellar tendon can be successfully man- aged by reconstruction using an Achilles tendon allograft. Puloski SKT, McCalden RW, MacDonald SJ, Rorabeck Technical details are critical with proper bone attachment to CH, Bourne RB: Tibial post wear in posterior stabilized the tibia and broad soft-tissue repair to the quadriceps. Recur- total knee arthroplasty: An unrecognized source of rent failure is minimized with this approach. polyethylene debris. J Bone Joint Surg Am 2001;83-A: 390-397. Dennis DA: Periprosthetic fractures following total knee arthroplasty. Instr Course Lect 2001;50:379-389. Retrieval analysis of posterior stabilized knee replacement identified that the tibial post can exhibit significant wear and The management of periprosthetic fractures around knee damage as a result of impingement. This phenomenon was de- arthroplasty is reviewed. Key determinants of treatment in- scribed for several implants and may be related to flexion of clude fracture displacement, bone quality, and status of im- the femoral component, or hyperextension of the knee. plant fixation. Closed treatment, open reduction and fixation, and component revision are the primary options. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS: Fac- Leopold SS, McStay C, Flafeta K, Jacobs JJ, Berger RA, tors affecting the durability of primary total knee pros- Rosenberg AG: Primary repair of intraoperative disrup- theses. J Bone Joint Surg Am 2003;85-A:259-265. tion of the medial collateral ligament during total knee arthroplasty. J Bone Joint Surg Am 2001;83-A:86-91. Total knee replacement is a successful procedure with long-term durability. Overall, survivorship at 10 years was Following intraoperative injury to the medial collateral lig- 91%, 84% at 15 years, and 78% at 20 years. Factors that favor- ament, primary repair with use of primary, nonconstrained im- ably affect durability were identified and include age over 70 plants resulted in satisfactory results similar to knees without years, rheumatoid arthritis, cemented fixation, female gender, this occurrence. Conversion to constrained implants was found and retention of the PCL. to be unnecessary. Saleh KJ, Sherman P, Katkin P, et al: Total knee arthro- Ortiguera CJ, Berry DJ: Patellar fracture after total plasty after open reduction and internal fixation of frac- knee arthroplasty. J Bone Joint Surg Am 2002;84-A:532- tures of the tibial plateau: A minimum five-year 540. follow-up study. J Bone Joint Surg Am 2001;83-A:1144- 1148. Patellar fracture occurs in less than 1% of cases. Nonsurgi- cal treatment is effective for nondisplaced fractures with intact Prior open reduction and internal fixation of the tibial pla- extensor mechanism. Surgical treatment for displaced frac- teau poses significant challenges for subsequent knee replace- tures or loose patella result in a high rate of complications. ment. Wound complications and infection can compromise outcome, and bony defects may dictate reconstruction meth- Revision Total Knee Arthroplasty ods. Babis GC, Trousdale RT, Morrey BF: The effectiveness Tanzer M, Smith KU, Burnett S: Posterior stabilized ver- of isolated tibial insert exchange in revision total knee sus cruciate retaining total knee arthroplasty: Balancing arthroplasty. J Bone Joint Surg Am 2002;84-A:64-68. the gap. J Arthroplasty 2002;17:813-819. Revision knee replacement consisting of isolated exchange A blinded, prospective randomized comparison of these of the polyethylene results in a high rate of failure, with 25% two designs using identical surgical technique reveals no ap- requiring rerevision. Preoperative instability resulted in the preciable difference in functional outcome at 2-year follow-up. highest failure rate. Wang JW, Wang CJ: Total knee arthroplasty for arthritis Christensen CP, Crawford JJ, Olin MD, Vail TP: Revi- of the knee with extra-articular deformity. J Bone Joint sion of the stiff total knee arthroplasty. J Arthroplasty Surg Am 2002;84-A:1769-1774. 2002;17:409-415. The stiff total knee can be successfully revised with com- plete exposure and revision of all components, with attention 468 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 38 Knee Reconstruction and Replacement to accepted techniques of gap balancing. All patients in this se- Blount WP: Don’t throw away the cane. J Bone Joint ries had improved motion and satisfactory pain relief and Surg Am 2003;85-A:380. function. Callaghan JJ, Squire MW, Goetz DD, Sullivan PM, Clatworthy MG, Balance J, Brick GW, Chandler HP, Johnston RC: Cemented rotating-platform total knee Gross AE: The use of structural allograft for uncon- replacement: A nine to twelve-year follow-up study. tained defects in revision total knee arthroplasty: A J Bone Joint Surg Am 2000;82:705-711. minimum five-year review. J Bone Joint Surg Am 2001; 83-A:404-411. Cartier P, Sanouiller JL, Grelsamer RP: Unicompart- mental knee surgery: 10-year minimum follow-up pe- Structural allograft used for the treatment of uncontained riod. J Arthroplasty 1996;11:782-788. bone loss around the knee demonstrated a 72% survivorship at 10-year follow-up. Failure occurred as a result of infection Chandler HP, Tigges RG: The role of allografts in the or nonunion. treatment of periprosthetic femoral fractures. Instr Course Lect 1998;47:257-264. Hansen AD: Bone grafting for severe patellar bone loss during revision knee arthroplasty. J Bone Joint Surg Am Colizza WA, Insall JN, Scuderi GR: The posterior stabi- 2001;83:171-176. lized total knee prosthesis: Assessment of polyethylene damage and osteolysis after a 10-year minimum follow- Severe patellar deficiency encountered during revision up. J Bone Joint Surg Am 1995;77:1713-1720. TKA that precludes reinsertion of a prosthetic component was treated with bone grafting inside a soft-tissue envelope, with Coventry MB, Ilstrup DM, Wallrichs SL: Proximal tibial improved tracking and restoration of patellar thickness. osteotomy: A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 1993;75:196-201. Mason JB, Fehring TK, Odum SM, Griffin WL, Nuss- man DS: The value of white blood cell counts before re- Coyte PC, Hawker G, Croxford R, Wright JG: Rates of vision total knee arthroplasty. J Arthroplasty 2003;18: revision knee replacement in Ontario, Canada. J Bone 1038-1043. Joint Surg Am 1999;81:773-782. Analysis of synovial fluid prior to revision TKA is useful Dennis DA, Konistek RD, Stiehl JB, Walker SA, Dennis in differentiating septic from nonseptic knees. White blood cell KN: Range of motion after total knee arthroplasty: The counts over 2,500/mm3 with over 60% polymorphonucleocytes effect of implant design and weight-bearing conditions. is highly suggestive of infection. J Arthroplasty 1998;13:748-752. Saleh KJ, Dykes DC, Tweedie RL, Heck DA: Functional Duff GP, Lachiewicz PF, Kelley SS: Aspiration of the outcome after total knee arthroplasty revision: A meta- knee joint before revision arthroplasty. Clin Orthop analysis. J Arthroplasty 2002;17:967-977. 1996;331:132-139. In this review of 42 studies on revision arthroplasty, the Healy WL, Wasilewski SA, Takei R, Oberlander M: Pa- procedure was shown to be effective in improving knee symp- tellofemoral complications following total knee arthro- toms and function. Complications occur in 26% of cases and plasty: Correlation with implant design and patient risk rerevision is necessary in 13% of cases for a variety of reasons factors. J Arthroplasty 1995;10:197-201. including infection, extensor mechanism failure, and loosening. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby Insall JN, Thompson FM, Brause BD: Two-Staged Reim- SM: Why are total knee arthroplasties failing today? plantation for the Salvage of Infected Total Knee Ar- Clin Orthop 2002;404:7-13. throplasty. J Bone Joint Surg Am 2002;84-A:490. The indications for revision arthroplasty were reviewed, Murray DW: Goodfellow JW. O’Connor JJ: The Oxford and in decreasing order of frequency were: wear, loosening, in- medial unicompartmental arthroplasty: A ten-year sur- stability infection, arthrofibrosis, malalignment, and extensor vival study. J Bone Joint Surg Br 1998;80:983-989. mechanism failure. More than half of all revisions occur within 2 years of implantation because of infection, instability, mala- Naudie D, Bourne RB, Rorabeck CH, Bourne TJ: Survi- lignment, or failure of fixation. Late revision is more com- vorship of the high tibial valgus osteotomy: A 10-22- monly a result of wear, implant loosening, or late instability. year follow up study. Clin Orthop 1999;367:18-27. Classic Bibliography Partington PF, Sawhney J, Rorabeck CH, Barrack RL, Moore J: Joint line restoration after revision total knee Arima J, Whiteside LA, McCarthy DS, White SE: Femo- arthroplasty. Clin Orthop 1999;367:165-171. ral rotational alignment, based and the anteroposterior axis, in total knee arthroplasty in a valgus knee: A tech- Ranawat CS, Flynn WF Jr: Saddler S. Hansraj KK, May- nical note. J Bone Joint Surg Am 1995;77:1331-1334. nard MJ: Long-term results of the total condylar knee American Academy of Orthopaedic Surgeons 469

Knee Reconstruction and Replacement Orthopaedic Knowledge Update 8 arthroplasty: A 15-year survivorship study. Clin Orthop Squire MW, Callaghan JJ, Goetz DD, Sullivan PM, 1993;286:94-102. Johnston RC: Unicompartmental knee replacement: A minimum 15-year follow-up study. Clin Orthop 1999; Ritter MA, Herbst SA, Keating EM, Faris PM, Meding 367:61-72. JB: Long-term survival analysis of a posterior cruciate- retaining total condylar total knee arthroplasty. Clin Stern SH, Insall JN: Posterior stabilized prosthesis: Re- Orthop 1994;309:136-145. sults after follow-up of nine to twelve years. J Bone Joint Surg Am 1992;74:980-986. 470 American Academy of Orthopaedic Surgeons

Chapter 39 Foot and Ankle Trauma Richard Marks, MD Ankle Fractures oblique, shear fractures of the medial malleolus. They correspond to supination-adduction injuries. In type B Classification injuries, the fibular fracture occurs at the level of the plafond, with varying degrees of obliquity and length of Ankle fractures may be classified by mechanistic or ra- the fibular fracture. Medial malleolar avulsion or deltoid diographic criteria. The Lauge-Hansen system consists ligament disruption is associated with more severe frac- of four hyphenated descriptions of the fracture mecha- tures, corresponding to the supination-external rotation nism (supination-external rotation, supination- and pronation-abduction injuries. Type C fractures occur adduction, pronation-external rotation, pronation- above the level of the plafond, with varying degrees of abduction) (Figure 1). The first word describes the syndesmotic involvement, corresponding to the position of the foot at the time of injury; the second pronation-external rotation pattern. Most type A frac- word describes the direction of the deforming force, and tures can be treated with early mobilization; however, if hence, the foot. All comprise several stages, based on se- medial malleolar displacement is present, casting or sur- verity. Supination-external rotation injuries are the most gical intervention may be required. Type B and C frac- common, accounting for approximately 85% of all ankle tures are frequently unstable, requiring surgical stabili- fractures. The first stage consists of a tear of the anterior zation. Neither classification scheme is entirely inclusive capsule and anterior tibiofibular ligament. In stage 2 the or predictive, and the Weber B/AO and supination- injury progresses laterally, resulting in an oblique or spi- external rotation patterns have great variability of frac- ral fracture of the fibula at the level of the plafond. ture presentation. Concomitant syndesmotic involve- Stage 3 involves a tear of the posterior capsule or poste- ment with widening of the mortise requires evaluation. rior malleolus fracture. Stage 4 consists of a transverse The medial clear space should equal the superior clear medial malleolus fracture or tear of the deltoid liga- space. Any inequality of these measurements or an ab- ment. The pronation-external rotation injury pattern be- solute value of greater than 4 mm is indicative of an un- gins medially, with injury to the deltoid ligament or me- stable fracture. Radiographic measurements, however, dial malleolus fracture. The second stage is may be influenced by radiographic rotation or magnifi- characterized by injury of the posterior malleolus or cation. posterior capsule, whereas the third stage involves a fracture of the fibula above the level of the plafond, Medial Malleolar Fractures with disruption of the syndesmosis. Supination- adduction injuries consist of an anterior talofibular liga- Isolated fractures of the medial malleolus occur with mentous tear or an avulsion fracture of the lateral mal- varying degrees of lateral ligamentous involvement. leolar tip, then advance to an oblique, shear-type Transverse fractures below the level of the plafond are fracture of the medial malleolus caused by medial trans- inherently stable and allow for early weight bearing and lation of the talus. Pronation-abduction injuries initially mobilization. A transverse fracture at the level of the place stress on the medial structures, resulting in deltoid plafond or an avulsion fracture with suspected medial ligament failure, or avulsion of the distal tip of the me- clear space widening may also involve syndesmotic dis- dial malleolus. The second stage involves injury to the ruption. The Maisonneuve fracture includes syndesmotic posterior complex, and the third stage involves an ob- disruption as well as a fracture of the fibular neck. In lique fracture of the distal fibula caused by shear of the addition to surgical treatment of the displaced medial abducted talus. malleolar fracture, syndesmotic stabilization is also re- quired. Treatment of oblique fractures at the level of the The Weber/AO classification is based on the level of plafond is dependent on lateral ligamentous involve- the fibular fracture (Figure 2). Type A fractures occur distal to the plafond and in more serious injuries involve American Academy of Orthopaedic Surgeons 471

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 Figure 1 A, Schematic diagram and case examples of Lauge-Hansen supination-external rotation and supination-adduction ankle fractures. A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The supination-external rotation mechanism has four stages of injury, and the supination-adduction mechanism has two stages. tib-fib = tibiofibular (Reproduced with permission from Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090.) 472 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma Figure 1 B, Schematic diagram and case examples of Lauge-Hansen pronation-external rotation and pronation-abduction ankle fractures. A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The pronation-external rotation mechanism has four stages of injury, and the pronation-abduction mechanism has three stages. tib-fib = tibiofibular (Reproduced with permission from Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090.) American Academy of Orthopaedic Surgeons 473

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 lique fractures without comminution. In bimalleolar equivalent injuries with deltoid disruption, medial mal- leolar clear space widening may require medial malle- olar arthrotomy to clean out entrapped deltoid ligament remnants. Repair of the deltoid ligament does not im- prove surgical outcome. Intraoperative arthroscopy of the ankle has revealed a high incidence of chondral in- juries; however, arthroscopy has not improved patient outcomes. Postoperative immobilization in a functional brace has not been superior to casting, with a higher in- cidence of wound complications. Additionally, early mo- tion has not improved functional outcome. Figure 2 Weber/AO fractures. The staging is completely determined by the level of Trimalleolar Fractures fibular fracture. Type A occurs below the plafond, whereas type C starts above the plafond. (Reproduced from Michelson JD: Ankle fractures resulting from rotational in- Fractures involving the posterior malleolus are a result juries. J Am Acad Orthop Surg 2003;11:403-412.) of posteroinferior tibiofibular ligament avulsion, or im- paction from the talus. Frequently, anatomic reduction ment and medial displacement. Medial shift of greater of the lateral malleolus and medial malleolus combined than 2 mm requires surgical intervention, typically with with dorsiflexion of the ankle reduces the posterior mal- two parallel 4.0-mm lag screws or a lag screw with dero- leolar fragment. Fragments with less than 25% involve- tation Kirschner wire. Poor bone quality or significant ment of the articular surface or those with less than 2 comminution may necessitate the use of tension band mm of displacement do not require internal fixation. wiring. If a vertical shear pattern is noted, the screws Anterior to posterior percutaneous fixation may be pos- should be placed perpendicular to the shaft, at times in sible, although at times a formal posterolateral or pos- conjunction with a medial buttress plate to avoid the teromedial approach is necessary to free up interposed risk of proximal migration of the medial malleolar frag- soft tissues. ment. Stress fracture of the medial malleolus has also been described, particularly in patients with a varus heel Syndesmotic Complex Injury and repeated adduction moments. Disruption of the inferior syndesmosis ranges from sub- Bimalleolar Fractures tle sprain to gross instability seen with pronation- external rotation and Weber C injuries. Patients with Bimalleolar fractures with displacement or rotational tenderness over the medial malleolus, proximal fibula, deformity at the time of injury frequently require open or interosseous membrane should be evaluated for syn- reduction and internal fixation. If the medial malleolar desmotic injury. With subtle injury, MRI or bone scan fracture occurs below the level of the plafond, closed may help in the diagnosis. Weight-bearing ankle views treatment may be possible; however, the risk of dis- can sufficiently stress the interosseous membrane and placement and the need for frequent reevaluation typi- anterior talofibular ligament to allow for evaluation of cally results in surgical intervention, if the patient’s the syndesmosis and should be obtained as pain allows. medical condition permits. The timing of surgical inter- As previously discussed, medial clear space widening vention is dependent on ankle edema and the quality of with loss of tibiofibular overlap indicates deltoid and the soft tissues. Restoration of lateral malleolar length syndesmotic disruption. In patients with isolated syndes- and rotation is key to reduction, and any significant lat- motic disruption, reduction with percutaneous internal eral shift or shortening of the lateral malleolus can re- fixation is possible if the medial clear space adequately sult in alterations of contact characteristics of the ankle reduces. If not, a medial arthrotomy is necessary to re- joint. A recent study indicated that both lateral and pos- move the interposed deltoid ligament. A fully threaded terior antiglide plating of the lateral malleolus have 3.5- or 4.5-mm screw is placed across three or four corti- equivalent clinical and radiographic results, with slightly ces, without compressive lagging. The screw should be more peroneal tendon irritation with the antiglide tech- placed 1.5 to 3.0 mm above the joint and directed 30° nique. The use of lag screws without plate application anteriorly. Both three- and four-cortex fixation has been has been successfully reported for management of ob- advocated, with four-cortex fixation offering greater sta- bility, but no study has shown superior results with ei- ther method of fixation. Although traditionally the syn- desmotic screw is placed with the ankle in a neutral position, the position of the ankle at the time of screw placement does not affect postoperative range of mo- 474 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma tion. Patients do not bear weight for 8 weeks to allow sive surgical dissection and soft-tissue stripping. Newer for sufficient syndesmotic healing, and screws are re- surgical techniques include percutaneous internal fixa- moved at 3 months to allow for restoration of normal tion, limited open reduction, and subcutaneous plating, distal fibular motion. Bioabsorbable screws have been thus avoiding soft-tissue healing complications. Care is shown to have equivalent clinical outcomes compared taken to perform a wound closure free of tension. If a with metallic screws and avoid the need for screw re- solid construct can be obtained, the external fixator can moval. For Weber B and C injuries, the fibular fracture be removed at the time of definitive treatment; how- is rigidly fixed, then the syndesmosis is stressed with ex- ever, this is generally only possible for type I fractures, ternal rotation of the talus within the mortise with the whereas the higher energy level injuries require a pro- ankle in a neutral position. Additionally, the fibula can longed course of fixator usage, frequently 2 to 3 months, be grasped with a towel clip, and distal syndesmotic sta- to provide additional stability. If extensive bone loss is bility evaluated. Typically, fractures less than 4.5 mm encountered, bone grafting at 6 to 8 weeks after injury above the joint do not require a syndesmotic screw, but is performed, with consideration given for the applica- this parameter is variable, and intraoperative stressing is tion of a bone stimulator. advised for all fibular fractures above the level of the joint. Hindfoot Fractures Pilon Fractures Talus Fractures Classification The talus acts as a link between the ankle, subtalar, and transverse tarsal joints. It is devoid of muscle or tendon Tibial pilon fractures occur as a result of either a low- attachments, and 70% of its surface is covered by articu- energy rotational mechanism with less comminution and lar cartilage for its five weight-bearing surfaces. Its soft-tissue damage or a high-energy injury secondary to blood supply is limited to the nonarticular surfaces; vertical compression that can result in significant com- therefore, vascular compromise may be associated with minution, chondral damage, and soft-tissue involvement. fractures, particularly those involving the talar neck. Foot position at the time of impact can also result in ad- Fractures are classified according to anatomic location: ditional injury to the malleoli, talus, and calcaneus. The body, neck, or head. Ruedi and Allgower classification remains the most commonly used for pilon fractures. Type I fractures are Talar Body intra-articular with minimal displacement. Type II frac- tures have significant articular displacement with little Talar body fractures involve the superior articular carti- comminution, whereas type III fractures have greater lage and may be classified as coronal, sagittal, or hori- comminution and metaphyseal involvement. CT is use- zontal fractures. These fractures are commonly associ- ful in determining the full extent of the injury and helps ated with high-energy ankle fractures. Osteochondral with definitive surgical planning. fractures are also associated with ankle fractures, partic- ularly supination-external rotation fracture patterns. Treatment Other anatomic locations include fracture of the lateral and posterior processes. Lateral process fractures, also Nonsurgical treatment is possible if articular incongruity described as snowboarder fractures, are created by is less than 2 mm and is generally reserved for low- forced dorsiflexion and external rotation of the foot. energy injuries. Many pilon fractures require surgical in- This fracture is commonly missed on initial presenta- tervention, which is performed in stages. The application tion, but is usually present on plain radiographs of the of an external fixator at the time of injury allows for ankle. CT is helpful to ascertain the extent of the frac- restoration of length and partial reduction via ligamen- ture, which may encompass a significant portion of the totaxis, while minimizing further soft-tissue damage. The lateral aspect of the posterior facet. If the fragment size fixator may be uniplanar or multiplanar, may cross the is large and displacement is greater than 2 mm, open re- ankle and subtalar joints, or be limited to the tibia. Plat- duction and internal fixation is performed. Comminuted ing of the fibula helps restore length, but is not neces- fractures may be initially treated with casting or imme- sary at the time of initial fixator stabilization. CT is per- diate excision with early range of motion. No prospec- formed after fixator application to better ascertain tive study has evaluated the superiority of either treat- fracture configuration and can help determine the ment method. The posterior process consists of proper surgical approach to limit soft-tissue stripping. posteromedial and posterolateral tubercles. Fractures Definitive treatment cannot be undertaken until the soft occur as a result of avulsion of the posterior talotibial tissues have healed and swelling has resolved, usually 10 and posterior talofibular ligaments, respectively. The to 21 days after injury. Treatment goals include restora- posterolateral tubercle is more frequently involved, and tion of articular congruity and reestablishing proper because of the close proximity of the flexor hallucis lon- length, rotation, and angulation, while avoiding exces- gus tendon in its posterior groove, flexion and extension American Academy of Orthopaedic Surgeons 475

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 Figure 3 Hawkins classification. A, Type I: nondisplaced talar neck fractures. quired, with osteotomy of the medial malleolus B, Type II: displaced talar neck fractures, with subluxation or dislocation of subtalar performed if initial exposure is inadequate. Although joint. C, Type III: displaced talar neck fractures with associated dislocation of talar the strongest screw configuration is from a posterior to body from both subtalar and tibiotalar joints. D, Canale and Kelly type IV: displaced anterior direction, crossed screws from an anterior to talar neck fracture with associated dislocation of talar body from subtalar and tibiota- posterior direction are used for open reductions, lar joints and dislocation of head/neck fragment from talonavicular joint. (Reproduced whereas the posterior to anterior approach is reserved with permission from Sangeorzan BJ: Foot and ankle joint, in Hansen ST Jr, Swiont- for those fractures treated in a closed manner. Medial kowski MF (eds): Orthopaedic Trauma Protocols. New York, NY, Raven Press, 1993, comminution may require bone grafting and medial p 350.) plating to prevent subsequent varus malunion. Theoreti- cally, titanium screws offer an advantage if postopera- of the hallux may exacerbate symptoms. Fractures with- tive MRI is to be considered for evaluation of postoper- out significant subtalar involvement are initially treated ative osteonecrosis, which increases in incidence with with casting. If subtalar joint involvement is associated the severity of the fracture. Hawkins sign represents os- with displacement, then surgical reduction is required. teopenia that is seen beneath the subchondral surface of Fragment excision is reserved for symptomatic non- the talar dome and occurs 6 to 8 weeks after the frac- unions without significant subtalar joint involvement. ture, which is indicative of talar revascularization. If os- teonecrosis is suspected, MRI may be useful in making Talar Neck the diagnosis. If the fracture has healed and no cystic changes or collapse are noted, progressive, protected Talar neck fractures are grouped according to the weight bearing can be instituted at 8 weeks, with regular Hawkins classification (Figure 3). Type I is a nondis- clinical and radiographic reevaluation. Posttraumatic ar- placed fracture. Type II involves subluxation or disloca- throsis of the ankle and/or subtalar joints is present in tion of the subtalar joint, and type III involves sublux- two thirds of all talar fractures. Fusion procedures may ation or dislocation of the subtalar and ankle joints. be complicated by varying degrees of osteonecrosis and Type IV injuries, as described by Canale and Kelly, addi- may require an extended tibiotalocalcaneal arthrodesis. tionally involve displacement of the talonavicular joint. The incidence of osteonecrosis increases with degrees of Type I fractures can be treated with non–weight-bearing fracture severity; up to 13% for Hawkins type I frac- casting; however, many surgeons prefer surgical treat- tures, 20% to 50% for Hawkins type II, and 50% to ment to avoid the risk of late displacement. This frac- 100% for Hawkins type III. Data are incomplete for ture pattern is amenable to percutaneous internal fixa- Hawkins type IV fractures because of the infrequent tion from a posterolateral insertion site. Type II, III, and presentation of these fractures. The presence of sub- IV fractures require open reduction with internal fixa- chondral sclerosis, however, does not dictate the re- tion. Displacement of greater than 1 mm requires surgi- quirement for not bearing weight for prolonged periods. cal care to avoid further vascular and soft-tissue com- These patients are allowed progressive weight bearing promise. Irreducible fractures, particularly those with based on symptoms and radiographic appearance of the residual subluxation, dislocation, or threatened soft tis- talus. sues require emergent surgical intervention. Dual ante- rolateral and anteromedial incisions are usually re- Subtalar Dislocation High-energy mechanisms are responsible for most sub- talar dislocations and are frequently associated with open injuries and irreducible dislocation. Overall, the dislocations are closed in approximately 75% of pa- tients, and medial dislocations, with the foot medially displaced relative to the hindfoot, occur 65% of the time. Irreducible dislocations occur in 32% of patients; the peroneal area blocks reduction with medial disloca- tion, and the posterior tibial and flexor hallucis longus and flexor digitorum longus tendons can block reduc- tion with lateral dislocations. These injuries frequently require emergent open reduction, tendon relocation, and stabilization. Postreduction CT should be per- formed to fully ascertain the extent of associated inju- ries, which occur in virtually all patients with subtalar dislocations. 476 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma Calcaneal Fractures Figure 4 Schematic diagram of Sanders classification. (Reproduced with permission from Sanders R, Fortin P, Pasquale T, et al: Operative treatment in 120 displaced The calcaneus is the most frequently fractured tarsal intra-articular calcaneal fractures: Results using a prognostic computed tomography bone, with most fractures occurring as a result of axial scan classification. Clin Orthop 1993;290:87-95.) loading, such as a fall from a height or during a motor vehicle crash. Given the mechanism of injury, patients into account. Treatment options include no surgery, should be evaluated for associated injury of the lumbar closed reduction with manipulation with or without lim- spine, which occurs in approximately 10% of patients ited internal fixation, open reduction with internal fixa- with calcaneal fractures. Axial loading creates an ob- tion, and primary arthrodesis. Nonsurgical treatment is lique shear fracture caused by impaction of the lateral limited to patients with a type I fracture pattern or process of the talus that results in a superomedial frag- those with factors or comorbidities that preclude good ment that consists of the sustentaculum (“constant” surgical outcome. The fracture is immobilized until the fragment) and a superolateral fragment that has an soft-tissue swelling and fracture blisters resolve, then intra-articular component. In addition to this primary range-of-motion exercises are instituted. The patient is fracture line, a secondary fracture component may be to refrain from bearing weight for 10 to 12 weeks. created, based on additional energy imparted and the Closed reduction and manipulation with or without lim- position of the foot at the time of injury. ited internal fixation can be used for those fractures with mild shortening or lateral impingement, as well as Radiographic evaluation should include standard tongue-type fractures that are amenable to this form of foot views, as well as a Harris axial view, which can pro- treatment. As a result, the late complication of subfibu- vide information concerning shortening and varus angu- lar impingement with peroneal involvement can be lation of the heel. An AP ankle radiograph may also al- avoided and more normal hindfoot anatomy can be re- low for evaluation of lateral wall extrusion and stored, while avoiding potential complications associ- impingement. Although specialized projections of the ated with open techniques. subtalar joint have been described (Broden and Isher- wood projections), CT imaging provides the most com- Open reduction and internal fixation is indicated for plete, reliable assessment of these fractures. type II and III fractures. Surgery is delayed until swell- ing subsides, and a “wrinkle” sign is present on the lat- Fractures may be classified as either extra-articular eral aspect of the heel, usually 10 to 14 days after injury. or intra-articular. Avulsion injuries account for most If a fracture blister is present in the area of the pro- extra-articular fractures and result in fracture of the an- posed incision, it must resorb and begin to reepithelial- terior process, sustentaculum, or calcaneal tuberosity, ize before surgery. The lateral extensile right-angle inci- which is secondary to avulsion of the Achilles tendon in- sion is most commonly used, and although the medial sertion. Occasionally, oblique fractures that do not in- approach has been used successfully, it is typically re- volve the subtalar joint are seen as well. Surgical indica- served for fractures with an irreducible medial frag- tions are detachment of the Achilles tendon insertion, ment. A full-thickness flap is created to maintain soft- or displacement of greater than 2 mm of the sustentacu- tissue integrity, and the posterior facet is elevated and lum or anterior process. reduced. Manipulation of the tuberosity with a Schanz Intra-articular fractures occur in 75% of patients with calcaneal fractures, and characterization of the de- gree of displacement and number of posterior facet ar- ticular fragments is helpful for treatment recommenda- tions and predictive of treatment outcomes. The Sanders CT classification system is based on the number and lo- cation of articular fragments seen on coronal projec- tions (Figure 4). There are four types, based on the number of fragments of the posterior facet, with dis- placement of greater than 2 mm considered significant. Type I fractures are nondisplaced, regardless of the number of fragments. Types II, III, and IV have corre- sponding numbers of displaced articular fragments. In addition to displacement of the posterior facet, the sur- geon must take into account factors such as shortening and widening of the heel, lateral wall impingement, and peroneal subluxation/dislocation when making surgical decisions. Patient factors, such as overall medical condi- tion, peripheral vascular disease, compromised soft tis- sues, and a history of smoking also need to be taken American Academy of Orthopaedic Surgeons 477

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 or Steinmann pin can correct shortening and varus an- relative to the hindfoot. Given the extensive articular gulation and help with reduction of the posterior facet. surfaces of the navicular, vessels enter from the navicu- Following provisional reduction maintained by Kir- lar tuberosity and dorsal and plantar surfaces, with a rel- schner wires, a low profile lateral plate and screws are atively avascular central portion, which has implications applied, first stabilizing the posterior facet. Meticulous for fracture healing and the development of osteonecro- closure is performed, and the patient is immobilized in a sis. bulky posterior and U splint. Sutures are removed 10 to 14 days after surgery, and if the soft tissues allow, early Fractures can be described as avulsion (chip), tuber- range of motion is instituted. Patients do not bear osity, or body fractures. Avulsion fractures of the dorsal weight for 10 weeks, at which time progressive weight lip are the most common and occur secondary to a plan- bearing is begun. tar flexion force with varying degrees of inversion or eversion. The patient should be evaluated for associated Primary subtalar arthrodesis combined with open re- midfoot or ankle injury. Immobilization is used until duction and internal fixation to restore anatomic height, symptoms resolve, and for more severe fractures with a width, and calcaneal pitch is used for type IV fractures. larger avulsion fragment and soft-tissue swelling, a non– This approach appears to be superior to initial neglect weight-bearing cast should be used. Delayed excision of of the fracture followed by delayed subtalar fusion or fragments is undertaken if they remain symptomatic. If primary open reduction and internal fixation. a fragment includes more than 25% of the articular sur- face, open reduction and internal fixation is indicated to The surgical outcomes of calcaneal fractures corre- avoid midtarsal subluxation and posttraumatic arthrosis. late with the quality of reduction and number of intra- Navicular tuberosity fractures result from an eversion articular fragments. Two-part fractures are associated force applied to the foot, with resultant contraction of with a better outcome than three-part fractures, and the posterior tibial tendon and tension on the superficial four-part fractures have uniformly poor outcomes. The deltoid attachment to the navicular. This may also rep- extent of initial injury, initial nonsurgical treatment, and resent a diastasis of the synchondrosis of an accessory workers’ compensation cases are predictors for eventual navicular. Oblique foot radiographs obtained with the subtalar fusion. More than half of patients will require a foot in 45° of internal rotation may help identify the supportive device. Bilateral fractures treated surgically fracture, which is differentiated from an accessory bone have a worse outcome than unilateral fractures treated by the presence of sharp, irregular cleavage lines. Treat- surgically, but have a better outcome than those man- ment is based on the severity of symptoms; however, aged nonsurgically. A recent Canadian study has shown given the possible late sequelae of posttraumatic flat- comparable results in patients treated surgically and foot deformity, cautious treatment of these injuries is nonsurgically; however, when workers’ compensation warranted. Injuries with minimal symptoms may be patients were excluded, those managed surgically had treated with immobilization and weight bearing as toler- significantly higher satisfaction scores. Complications ated. In more symptomatic injuries with diastasis less occur in 18% to 40% of surgical cases. Falls from a than 3 mm, a non–weight-bearing cast is applied for 4 to height, surgical treatment earlier than 7 days after in- 6 weeks, followed by gradual mobilization of the foot. jury, longer surgical time, and a history of smoking were Diastasis greater than 3 mm usually requires open re- factors associated with complications. duction and internal fixation, with care taken to repair the posterior tibial tendon and deltoid ligament attach- Neglected displaced fractures often result in a wide, ments. shortened heel, problems with shoe wear, subfibular peroneal impingement, and posttraumatic arthrosis. This Body fractures of the navicular are the result of di- may necessitate decompression of the lateral wall of the rect axial loading, as occurs with a fall from a height. calcaneus, peroneal relocation, and subtalar distraction Given the strong ligamentous attachments, this probably arthrodesis to restore proper calcaneal pitch and height. requires a plantar flexion/dorsiflexion and rotational moment in addition to axial loading. Three fracture Midfoot Trauma types have been described. Type I is a transverse frac- ture in the coronal plane, with the dorsal fragment less Navicular Fractures than 50% of the body, and no angular deformity of the foot. Type II, the most common, is an oblique fracture, The midfoot consists of the navicular, cuboid, the me- from a dorsomedial to plantar lateral direction. The lat- dial, middle, and lateral cuneiforms, as well as the eral fragment is smaller and often comminuted. There metatarsal-cuneiform articulations. The midfoot has may be an adduction deformity of the foot. Type III constrained motion because of multiple recessed articu- fractures occur as a result of axial loading with lateral lations as well as strong ligamentous and capsular at- compression that results in central or lateral comminu- tachments. The navicular articulates with the cunei- tion and midfoot abduction deformity. The cuboid and forms, cuboid, calcaneus, and talus. Coupled motion anterior calcaneus may also be injured. between these structures (transverse tarsal joint) pro- vides inversion and eversion of the midfoot and forefoot 478 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma Figure 6 Bony avulsion at the base of the second metatarsal. This “fleck” sign (arrow) indicates a Lisfranc injury. Figure 5 Loss of colinearity between the medial aspect of the middle cuneiform and dial cuneiform. Injuries of the Lisfranc joint complex medial aspects of the second metatarsal base, as denoted by the black lines, is indic- can result from either direct or indirect mechanisms. Di- ative of a Lisfranc injury. rect injuries result from a dorsally applied force, which will result in plantar displacement of the metatarsals if Type I and II nondisplaced fractures may be treated the force is applied to the metatarsal base or dorsal with non–weight-bearing cast immobilization for 6 to 10 metatarsal displacement if the force is applied to the cu- weeks. Given the severity of type III fractures, these neiforms. There is a high incidence of associated tarsal fractures usually require surgical intervention. Dis- fracture, significant soft-tissue destruction, and compart- placed type I fractures are amenable to internal fixation ment syndrome. Indirect injuries occur from a combina- from the dorsal direction via an anteromedial approach. tion of axial loading and twisting on an axially loaded, Type II and III fractures may require intraoperative ex- plantar flexed foot. Because of the mechanism of injury, ternal fixator application to assist with reduction; fre- relatively weaker dorsal ligaments, and greater mobility quently bone grafting may be necessary for any large between the first and second metatarsals, displacement lateral defects, and it may be necessary to stabilize the is typically dorsal, with diastasis between the first and major medial fragment to the cuneiforms to restore nor- second metatarsals and their corresponding cuneiforms. mal midfoot alignment. If extensive comminution is AP, internal oblique, and lateral foot radiographs are present, immediate naviculocuneiform arthrodesis obtained to evaluate the tarsometatarsal articulations. should be considered. Normal radiographs include colinearity of the medial aspect of the second metatarsal base and medial cunei- Tarsometatarsal (Lisfranc) Fracture-Dislocations form, the medial aspect of the fourth metatarsal base with the medial aspect of the cuboid, and the medial as- The Lisfranc joint complex consists of the tarsometatar- pect of the third metatarsal with the lateral cuneiform. sal, intermetatarsal, and intertarsal joints. There is inher- Any incongruity is pathologic, as is any dorsal displace- ent osseous stability because of the recessed second ment of the metatarsals seen on a lateral radiograph metatarsal base between the medial and middle cunei- (Figure 5). Diastasis of 2 mm between the medial and forms, as well as the cross-sectional trapezoid shape of middle cuneiforms is considered pathologic. The “fleck” the first three metatarsals and their corresponding cune- sign represents an avulsion of the Lisfranc ligament off iforms. There are also strong capsuloligamentous attach- the base of the second metatarsal (Figure 6). If injury is ments, particularly on the plantar aspect of the foot, suspected despite normal radiographs, weight-bearing which provide additional stability. The Lisfranc ligament films are obtained once clinically feasible. Stress radio- runs from the base of the second metatarsal to the me- graphs, MRI, and CT can also be used to assist in the di- agnosis. Lisfranc complex injuries may be classified as American Academy of Orthopaedic Surgeons 479

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 total incongruity, partial incongruity, or divergent, but ated with a Lisfranc ligamentous injury at the tar- because of tremendous variation in mechanism of in- sometatarsal junction, surgical stabilization is necessary jury, there is great variation in radiographic presenta- because of inherent instability. Surgical stabilization tion. may be achieved with Kirschner wires, compression screws, or minifragment plating, as the fracture pattern Nonsurgical treatment is used for nondisplaced frac- dictates. tures and consists of a non–weight-bearing cast for 8 weeks, followed by gradual weight bearing in a remov- Treatment of fifth metatarsal base fractures is de- able boot brace. Surgery is performed for injuries with pendent on fracture location. It is helpful to separate any displacement seen on radiographs. If anatomic re- fractures of the base of the fifth metatarsal into three duction can be obtained by closed means, percutaneous types, based on location of the fracture. Type I fractures internal fixation is possible, but interposed Lisfranc liga- are true avulsion injuries of the tuberosity, or styloid ment remnant can frequently block reduction and result process, which occur secondary to contraction of the in the joint springing open once internal fixation is re- long plantar ligament and peroneus brevis insertion; moved. Therefore, open reduction is frequently neces- many are extra-articular. These fractures can typically sary through a single or dual longitudinal incision as dic- be treated with a stiff-soled shoe and weight bearing as tated by the injury pattern. Fixation is achieved with tolerated once symptoms diminish, with many patients either 3.5- or 4.0-mm screws for the medial (first tar- sufficiently asymptomatic after 3 weeks of treatment. If sometatarsal joint) and middle (second, third tarsometa- there is a large intra-articular fragment with displace- tarsal joints) columns and Kirschner wires for the lateral ment or if the base fragment has retracted proximally, (fourth, fifth tarsometatarsal joints) column. A severe indicative of peroneus brevis retraction, acute surgical abduction mechanism may result in compression of the intervention is occasionally necessary. Continued symp- cuboid, termed a nutcracker injury. This injury may re- toms after nonsurgical treatment are rare and may ne- quire lateral plating and bone grafting to avoid residual cessitate removal of the nonunion fragment, with evalu- abduction. Patients should not bear weight for 8 weeks, ation of the peroneus brevis for possible reattachment followed by gradual weight bearing in a removable boot directly to bone, or with the use of a suture anchor. brace. Screws are removed 3 to 4 months after surgery to avoid screw breakage and to allow restoration of sag- Type II fractures occur at the metaphyseal- ittal motion at the tarsometatarsal junction. Alterna- diaphyseal junction, approximately 2.5 cm distal to the tively, bioabsorbable screws may also be used, obviating base. This is a circulatory watershed region that is sub- the need for additional surgery for screw removal. Im- ject to nonunion secondary to poor blood supply. The mediate complete arthrodesis of the midfoot has poor acute Jones fracture should be treated with either a results, although partial arthrodesis tends to have better non–weight-bearing cast for 6 to 8 weeks, or in a high- results. Late arthrosis is common, even with anatomic performance athlete, with placement of an intramedul- reduction. Poor results are associated with nonanatomic lary screw, which allows for earlier mobilization. The op- reduction, open injury, and extensive comminution. timal screw size is largely dependent on the size of the intramedullary canal. One study has shown comparable Metatarsal Fractures initial and ultimate failure loads for 4.5- and 5.5-mm partially threaded cannulated screws, whereas another Acute metatarsal fractures may occur as a result of a di- study compared 5.0- and 6.5-mm partially threaded rect blow, which usually results in a transverse fracture, screws and found no difference in bending stiffness, but or as a result of an indirect twisting, or avulsion mecha- greater pull-out strength with the 6.5-mm screws. Clini- nism. Metatarsal base fractures are associated with mid- cally, failure of fixation has been noted in athletes who foot injury, and these fractures carry a high index of sus- returned to full activities before radiographic evidence picion for additional injury. Compartment syndrome can of complete radiographic union. be seen in patients with more severe fractures, particu- larly those resulting from a direct blow. Nonsurgical Type III fractures occur in the diaphysis and are typ- treatment is indicated if displacement is less than 3 mm ically stress fractures. Possible etiologic factors include or angulation is less than 10°. Treatment can vary from low arches and associated first metatarsal hypermobility, the use of a postoperative shoe with weight bearing as as well as cavovarus deformities, both of which can re- tolerated for a stable fracture to casting with no weight sult in abnormally high stresses placed on the lateral bearing for an unstable fracture pattern prone to dis- foot. Altered lateral stresses may also be seen in pa- placement. Surgery is indicated for displacement of tients with hereditary sensorimotor neuropathy and dia- greater than 3 to 4 mm or sagittal displacement of betic neuropathy. Poor blood supply in this region may greater than 10° because this can lead to either direct also predispose an individual to injury and impair injury overload of a displaced plantar fragment, or transfer healing, resulting in nonunion. Strict adherence to no metatarsalgia if dorsal displacement is noted. If associ- weight bearing is necessary after a proximal diaphyseal fracture is diagnosed and should be continued until ra- diographic evidence of fracture healing. Pulsed electro- 480 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma magnetic fields have been shown to accelerate healing. Compartment Syndrome If sclerosis is noted at the fracture site, this indicates cir- culatory compromise, and surgical intervention is neces- Acute compartment syndrome develops secondary to sary to remove avascular fibrous tissue, combined with local trauma that results in an increase of local tissue in- intramedullary screw fixation. Cancellous bone grafting terstitial pressure from bleeding and edema from soft- may also be necessary. Any contributing structural ab- tissue destruction. As a result, vascular occlusion occurs normality should also be addressed. and creates myoneural ischemia. Compartment syn- drome has been associated with calcaneal fractures, Lis- Complex Regional Pain Syndrome franc complex injuries, and crush injuries; however, com- partment syndrome should be suspected in any injury Complex regional pain syndrome, formerly referred to mechanism that creates significant swelling. If the is- as reflex sympathetic dystrophy, is a clinical entity that chemic process is left untreated for more than 8 hours, develops after a precipitating traumatic event. It in- irreversible myoneural necrosis and fibrosis occur; volves dysfunction of the sensory, autonomic, and motor therefore, prompt diagnosis and treatment are of great systems and frequently is missed on initial presentation. importance. The diagnosis relies on clinical signs and Patients with acute complex regional pain syndrome de- measurement of compartment pressures. Pain out of scribe antecedent trauma, which may be as severe as a proportion to injury severity is a classic sign; however, in crush injury or as nominal as a sprain or twisting injury. the multiply injured patient this symptom is unreliable. The onset of pain may also occur after surgical proce- Loss of two-point discrimination and light touch is more dures. In the acute phase, there is an abnormal dispro- reliable than loss of sensation, whereas pain is exacer- portional painful reaction to a stimulus (hyperpathia), bated with passive dorsiflexion of the toes, which places increased sensitivity to a stimulus (allodynia), hyper- the intrinsic muscles on stretch. The presence or absence hidrosis, and cyanosis. Swelling of the foot is typically of pulses and capillary refill is unreliable. The compart- seen, and radiographs will appear normal. The second ments of the foot should be measured in patients sus- phase occurs 2 to 4 months after onset and involves dys- pected of having compartment syndrome. Fasciotomy is trophic and ischemic changes. Hyperpathia and allo- indicated when the compartment pressures exceed 30 dynia continue, as does swelling, and hypohydrosis and mm Hg or is within 30 mm Hg of the diastolic pressure. pallor are experienced. Radiographs typically show demineralization. The third phase is characterized by ev- Nine compartments have been described: the medial, idence of joint stiffness, muscular atrophy, and contrac- lateral, four interosseous, and three central compart- ture. Swelling may persist, with the skin becoming shiny, ments, including the deep central (calcaneal) compart- dry, and cool. Radiographs show evidence of continued ment that contains the quadratus plantae muscle and demineralization. This syndrome may also be character- the posterior tibial neurovascular bundle. Decompres- ized into complex regional pain syndrome type I, which sion is performed with dual dorsal incisions, which allow occurs in a generalized area after a traumatic event, or for decompression of the first and second interosseous complex regional pain syndrome type II, which develops compartments, the medial compartment, and the deep in a discrete area secondary to peripheral nerve injury. central compartment. The lateral dorsal incision allows The diagnosis is assisted by the use of a triple-phase for decompression of the two lateral interosseous com- bone scan, which in the delayed phase will show diffuse partments, the superficial and middle central compart- radionuclide uptake throughout the foot. This procedure ments, and the lateral compartment. A single, medially is best performed within the first 6 months of the ap- based fasciotomy has been described, but is technically pearance of symptoms. MRI will also show typical mar- more difficult to perform. Sometimes the medially row edema during this time. Treatment consists of a based incision may be used in addition to the dorsal ap- combination of physical therapy, nerve blocks, and phar- proach to adequately ensure decompression of the deep macologic agents, and should be instituted as early as calcaneal compartment. Closure is performed in a de- possible. Physical therapy is designed to maximize mo- layed fashion, either with primary closure or with split- tion, in combination with desensitization exercises and thickness skin grafts. Exercise-induced compartment modalities. Sympathetic nerve blocks are used both for syndrome of the foot has been recognized, most com- diagnostic and treatment purposes. Failure to respond to monly affecting the medial compartment, and has been a sympathetic block should bring the diagnosis into shown to follow the same criteria for diagnosis of question. Several pharmacologic agents, including anti- chronic exertional compartment syndrome of the leg. depressants, anticonvulsants, and calcium channel block- ers have been used for the treatment of complex re- Annotated Bibliography gional pain syndrome, typically coordinated by a multidisciplinary pain center. Ankle and Pilon Fractures Day GA, Swanson CE, Hulcombe BG: Operative treat- ment of ankle fractures: A minimum ten-year follow-up. Foot Ankle Int 2001;22:102-106. American Academy of Orthopaedic Surgeons 481

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 In this study, 52% of patients with surgically treated bimal- postoperative wound healing complications was significantly leolar fractures had good or excellent results; 24% of patients higher with brace treatment. had a poor outcome. Loren GJ, Ferkel RD: Arthroscopic assessment of occult Dickson KF, Montgomery S, Field J: High energy intra-articular injury in acute ankle fractures. Arthros- plafond fractures treated by a spanning external fixator copy 2002;18:412-421. initially and followed by a second stage open reduction internal fixation of the articular surface: Preliminary re- Sixty-three percent of fractures showed chondral injury, port. Injury 2001;32(suppl 4):SD92-SD98. more frequently on the medial aspect of the talus. Pronation- external rotation fractures had a higher incidence of injury This protocol, used to treat patients with highly commi- (70%) than supination-external rotation fractures (46%). nuted fractures, resulted in 81% good or excellent results, a Seventy-five percent of fractures with syndesmotic disruption 35% complication rate, and 28% radiographic arthrosis. had chondral damage. Dietrich A, Lill H, Engel T, Schonfelder M, Josten C: Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino Conservative functional treatment of ankle fractures. SG: The effects of rotation on radiographic evaluation Arch Orthop Trauma Surg 2002;122:165-168. of the tibiofibular syndesmosis. Foot Ankle Int 2002;23: 107-111. Ninety percent of patients with an isolated Weber B frac- ture with less than 1 mm of displacement were treated suc- Comparisons were made between the tibiofibular clear cessfully with a functional brace. space, tibiofibular overlap, width of the tibia and fibula, and medial clear space. The width of the tibiofibular clear space Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti did not change with rotation, whereas the other parameters SF: Foot and ankle fractures in elderly white women: In- did. cidence and risk factors. J Bone Joint Surg Am 2003; 85:820-824. Sinisaari IP, Luthje PM, Mikkonen RH: Ruptured tibio- fibular syndesmosis: Comparison study of metallic to Fibular fractures were the most common ankle fracture bioabsorbable fixation. Foot Ankle Int 2002;23:744-748. (prevalence 57.6%) and occur in younger women with a high body mass index. Fractures of the fifth metatarsal are the most Poly-L-lactide bioabsorbable screws showed equivalent re- common foot fractures in women with low bone mineral den- sults with radiographic measurements, range of motion, and sity. subjective outcome compared with metallic fixation. Hovis WD, Kaiser BW, Watson JT, Bucholz RW: Treat- Tornetta P III, Creevy W: Lag screw only fixation of the ment of syndesmotic disruptions of the ankle with bio- lateral malleolus. J Orthop Trauma 2001;15:119-121. absorbable screw fixation. J Bone Joint Surg Am 2002; 84:26-31. Lag screw only fixation of simple oblique fractures, when compared with plate fixation, resulted in less lateral pain, no Polyevolactic acid screws were used to stabilize syndes- palpable hardware (56% plate), fewer shoe wear restrictions, motic disruptions in 33 patients. Twenty-four patients were fol- no hardware removal requirements (31% plate), and no loss lowed for 34 months after surgery. All patients healed un- of fracture reduction. eventfully, with or without fixation; no patient had osteolysis or inflammation. Tornetta P III, Spoo JE, Reynolds FA, Lee C: Overtight- ening of the ankle syndesmosis: Is it really possible? Lamontagne J, Blachut PA, Broekhuyse HM; O’Brien J Bone Joint Surg Am 2001;83-A:489-492. PJ, Meek RN: Surgical treatment of a displaced lateral malleolus fracture: The antiglide technique versus lat- There was no difference between the values for maximal eral plate fixation. J Orthop Trauma 2002;16:498-502. dorsiflexion before and after syndesmotic compression in ca- daveric specimens fixed with a syndesmotic screw while held In this study, surgical outcome, complication rate, and re- in plantar flexion. quirement for hardware removal was equivalent in the two groups. Hindfoot Fractures Lehtonen H, Jarvinen TL, Honkonen S, Nyman M, Vih- Bibbo C, Anderson RB, Davis WH: Injury characteris- tonen K, Jarvinen M: Use of a cast compared with a tics and the clinical outcome of subtalar dislocations: A functional ankle brace after operative treatment of an clinical and radiographic analysis of 25 cases. Foot Ankle ankle fracture: A prospective, randomized study. J Bone Int 2003;24:158-163. Joint Surg Am 2003;85-A:205-211. High-energy mechanisms accounted for 68% of subtalar The long-term functional outcome was equivalent between dislocations; 75% of dislocations were closed, 65% were me- the two groups, with similar fracture healing. The incidence of dial dislocations, and 32% of dislocations were irreducible. Ra- diographic evidence of arthrosis was noted in 89% of ankle 482 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma and subtalar joints; the subtalar joint was more frequently A 90% satisfaction rate was noted with surgical treatment. symptomatic. Bilateral injuries resulted in poorer outcome. Delay in opera- tion was associated in a higher infection rate, whereas smoking Bibbo C, Lin SS, Abidi N, et al: Missed and associated did not. injuries after subtalar dislocation: The role of CT. Foot Ankle Int 2001;22:324-328. Midfoot Trauma In all patients, CT scans identified additional injuries Fulkerson E, Razi A, Tejwani N: Review: Acute com- missed on plain radiographs, which altered treatment plans in partment syndrome of the foot. Foot Ankle Int 2003;24: 44% of patients. 180-187. Buckley R, Tough S, McCormack R, et al: Operative An excellent review of acute foot compartment syndrome compared with nonoperative treatment of displaced is presented. intra-articular calcaneal fractures: A prospective, ran- domized, controlled multicenter trial. J Bone Joint Surg Glasoe WM, Allen MK, Kepros T, Stonewall L, Ludewig Am 2002;84-A:1733-1744. PM: Dorsal first ray mobility in women athletes with a history of stress fracture of the second or third metatar- Equivalent outcomes were noted between the two groups; sal. J Orthop Sports Phys Ther 2002;32:560-565. however, when patients receiving workers’ compensation were removed from the comparison, significantly better results were First ray hypermobility is not associated with stress frac- noted with surgical treatment. ture of the second or third metatarsal. Csizy M, Buckley R, Tough S, et al: Displaced intra- Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA: In- articular calcaneal fractures: Variables predicting late tramedullary screw fixation of Jones fractures. Foot An- subtalar fusion. J Orthop Trauma 2003;17:106-112. kle Int 2001;22:585-589. Initial injury severity, Bohler angle less than 0, workers’ No significant difference was reported between failure compensation patients, heavy laborers, and those fractures ini- loads of 5.0- and 6.5-mm. screws. Pull-out strength was signifi- tially treated nonsurgically were factors that were more likely cantly higher for the 6.5-mm screws. to lead to fusion. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A: Huefner T, Thermann H, Geerling J, Pape HC, Pohle- Risk factors for recurrent stress fractures in athletes. mann T: Primary subtalar arthrodesis of calcaneal frac- Am J Sports Med 2001;29:304-310. tures. Foot Ankle Int 2001;22:9-14. Biomechanical factors associated with multiple stress frac- Primary fusion for extremely comminuted calcaneal frac- tures include a high longitudinal arch, forefoot varus, and leg- tures led to good functional outcome. length inequality. Nearly half of female runners reported men- strual irregularity. Ricci WM, Bellabarba C, Sanders R: Transcalcaneal tal- Mollica MB, Duyshart SC: Analysis of pre- and postex- onavicular dislocation. J Bone Joint Surg Am 2002;84-A: ercise compartment pressures in the medial compart- 557-561. ment of the foot. Am J Sports Med 2002;30:268-271. Dorsal dislocation of the navicular with an associated cal- Normative pressures of the medial foot compartment are caneal fracture is a severe injury, resulting in severe functional comparable to those in the leg. Previous criteria for diagnosis limitations, osteomyelitis, and amputation. of chronic exertional compartment syndrome of the leg may be used for diagnosis of chronic exertional compartment syn- Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G: drome of the foot. Surgical treatment of talus fractures: A retrospective study of 80 cases followed for 1-15 years. Acta Orthop Mulier T, Reynders P, Dereymaeker G, Broos P: Severe Scand 2002;73:344-351. Lisfrancs injuries: Primary arthrodesis or ORIF? Foot Ankle Int 2002;23:902-905. Ankle or subtalar arthrosis was noted in two thirds of frac- tures. Talar necrosis was noted in 11%; 44% had good or ex- Primary complete arthrodesis resulted in inferior pain cellent function. scores, more stiffness, a loss of longitudinal arch, and higher rate of sympathetic dystrophy. Tennent TD, Calder PR, Salisbury RD, Allen PW, East- Nunley JA, Vertullo CJ: Classification, investigation and wood DM: The operative management of displaced management of midfoot sprains: Lisfranc injuries in the intra-articular fractures of the calcaneum: A two-centre athlete. Am J Sports Med 2002;30:871-878. study using a defined protocol. Injury 2001;32:491-496. Primary fusion for extremely comminuted calcaneal frac- tures led to good functional outcome. American Academy of Orthopaedic Surgeons 483

Foot and Ankle Trauma Orthopaedic Knowledge Update 8 Peicha G, Labovitz J, Seibert FJ, et al: The anatomy of Benirschke SK, Sangeorzan BJ: Extensive intraarticular the joint as a risk factor for Lisfranc dislocation and fractures of the foot: Surgical management of calcaneal fracture-dislocation: An anatomical and radiological fractures. Clin Orthop 1993;292:128-134. case control study. J Bone Joint Surg Br 2002;84:981-985. Blotter RH, Connolly E, Wasan A, Chapman MW: A decreased medial depth of the mortise between the me- Acute complications in the operative treatment of iso- dial and middle cuneiforms increases the risk of Lisfranc in- lated ankle fractures in patients with diabetes mellitus. jury. Lateral depth and second metatarsal length are not risk Foot Ankle Int 1999;20:687-694. factors. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby Boden SD, Labropolos PA, McCowin P, Lestini WF, SA, Chou LB: Intramedullary screw fixation of proximal Hurwitz SR: Mechanical considerations of the syndes- fifth metatarsal fractures: A biomechanical study. Foot mosis screw: A cadaver study. J Bone Joint Surg Am Ankle Int 2001;22:581-584. 1989;71:1548-1555. Initial failure loads and ultimate failure loads were not sig- Canale ST, Kelly FB Jr: Fractures of the neck of the ta- nificantly different for 4.5- and 5.5-mm cannulated screws. lus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156. Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R: Functional outcome following anatomic restoration Coughlin MJ: Calcaneal fractures in the industrial pa- of tarsal-metatarsal fracture-dislocation. Foot Ankle Int tient. Foot Ankle Int 2000;21:896-905. 2002;23:922-926. Folk JW, Starr AJ, Early JS: Early wound complications Anatomic reduction of the tarsometatarsal joints corre- of operative treatment of calcaneus fractures: Analysis lated with normal gait patterns, yet subjective patient out- of 190 fractures. J Orthop Trauma 1999;13:369-372. comes were less than satisfactory. Glasgow MT, Naranja RJ Jr, Glasgow SG, Torg JS: Anal- Theodorou DJ, Theodorou SJ, Kakitsubata Y, Botte MJ, ysis of failed surgical management of fractures of the Resnick D: Fractures of proximal portion of fifth meta- base of the fifth metatarsal distal to the tuberosity: The tarsal bone: Anatomic and imaging evidence of a patho- Jones fracture. Foot Ankle Int 1996;17:449-457. genesis of avulsion of the planter aponeurosis and the short peroneal muscle tendon. Radiology 2003;226:857- Gourineni PV, Knuth AE, Nuber GF: Radiographic 865. evaluation of the position of implants in the medial mal- leolus in relation to the ankle joint space: Anteroposte- Based on plain radiography, CT, and MRI, fracture of the rior compared with mortise radiographs. J Bone Joint base of the fifth metatarsal are reported to be related to avul- Surg Am 1999;81:364-369. sion injury of the plantar aponeurosis and peroneus brevis tendon fibers. Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg Am 1970;52:991-1002. Compartment Syndrome Kuo RS, Tejwani NC, Digiovanni CW, et al: Outcome af- Fulkerson E, Razi A, Tejwani N: Acute compartment ter open reduction internal fixation of Lisfranc joint in- syndrome of the foot. Foot Ankle Int 2003;24:180-187. juries. J Bone Joint Surg Am 2000;82:609-618. An excellent review of acute foot compartment syndrome Lauge-Hansen N: Fractures of the ankle: II. Combined is presented. experimental surgical and experimental-roentgenologic investigations. Arch Surg 1950;60:957-986. Mollica MB, Duyshart SC: Analysis of pre- and postex- ercise compartment pressures in the medial compart- Marsh JL, Bonar S, Nepola JV, Decoster TA, Hurwitz ment of the foot. Am J Sports Med 2002;30:268-271. SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77: Normative pressures of the medial foot compartment are 1498-1509. comparable to those in the leg. Previous criteria for diagnosis of chronic exertional compartment syndrome of the leg may O’Malley MJ, Hamilton WG, Munyak J: Fractures of the be used for diagnosis of chronic exertional compartment syn- distal shaft of the fifth metatarsal: Dancer’s fracture. Am drome of the foot. J Sports Med 1996;24:240-243. Classic Bibliography Al-Mudhaffar M, Prasad CV, Mofidi A: Wound compli- Myerson M, Manoli A: Compartment syndromes of the cations following operative fixation of calcaneal frac- foot after calcaneal fractures. Clin Orthop 1993;290:142- tures. Injury 2000;31:461-464. 150. 484 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 39 Foot and Ankle Trauma Myerson MS: Experimental decompression of the fas- reduction and internal fixation of talar neck fractures. cial compartments of the foot-basis for fasciotomy in Foot Ankle Int 1996;17:742-747. acute compartment syndromes. Foot Ankle 1988;8:308- 314. Wyrsch B, McFerran MA, McAndrew M, et al: Opera- tive treatment of fractures of the tibial plafond: A ran- Quill GE Jr: Fractures of the proximal fifth metatarsal. domized, prospective study. J Bone Joint Surg Am 1996; Orthop Clin North Am 1995;26:353-361. 78:1646-1657. Sasse M, Nigg BM, Stefanyshyn DJ: Tibiotalar motion: Yablon IG, Heller FG, Shouse L: The key role of the lat- Effect of fibular displacement and deltoid ligament eral malleolus in displaced fractures of the ankle. J Bone transaction: In vitro study. Foot Ankle Int 1999;20:733- Joint Surg Am 1977;59:169-173. 737. Yamaguchi K, Martin CH, Boden SD, Labropoulos PA: Sanders R, Fortin P, DiPasquale T, Walling A: Operative Operative treatment of syndesmotic disruptions without treatment in 120 displaced intraarticular calcaneal frac- use of a syndesmotic screw: A prospective clinical study. tures: Results using a prognostic computed tomography Foot Ankle Int 1994;5:407-414. scan classification. Clin Orthop 1993;290:87-95. Zufferey P, Boubaker A, Bischof Delaloye A, So AK, Thordarson DB, Motamed S, Hedman T, Ebramzadeh Duvoisin B: Prognostic aspects of scintigraphy and MRI E, Bakshian S: The effect of fibular malreduction on during the first 6 months of reflex sympathetic dystro- contact pressures in an ankle fracture malunion model. phy of the distal lower limb: A preliminary prospective J Bone Joint Surg Am 1997;79:1809-1815. study of 4 cases. J Radiol 1999;80:373-377. Thordarson DB, Triffon MJ, Terk MR: Magnetic reso- nance imaging to detect avascular necrosis after open American Academy of Orthopaedic Surgeons 485



Chapter 40 Foot and Ankle Reconstruction Mark E. Easley, MD Forefoot Figure 1 Schematic showing intermetatarsal, hallux valgus, and hallux valgus inter- phalangeus angles. The angles in parentheses are angles considered physiologic in Hallux Valgus patients without hallux valgus. (Reproduced with permission from Coughlin MJ: Hallux valgus in men: Effect of the distal metatarsal articular angle in the hallux valgus Hallux valgus deformity results from progressive devia- correction. Foot Ankle Int 1997;18:463-470.) tion and pronation of the great toe and medial deviation of the first metatarsal (metatarsus primus varus). Hallux described. Although the crescentic, (proximal) chevron, valgus deformity is most common in females and shoe- and proximal oblique osteotomies are most popular, the wearing societies; there is a high prevalence of bunion Scarf osteotomy has gained wider acceptance. A symp- deformity in American women in the fourth to sixth de- tomatic hallux valgus associated with hypermobility cades of life. and/or first TMT joint degeneration warrants correction via a combination first TMT joint arthrodesis and distal The patient with hallux valgus deformity experiences soft-tissue procedure (Lapidus procedure). A medial difficulty with shoe wear, particularly at the prominent closing wedge osteotomy of the proximal phalanx (Akin medial eminence. The patient should be evaluated while procedure) is performed to correct hallux valgus inter- standing to determine the presence of pes planus and phalangeus, but may also serve as an adjunctive proce- the severity of the deformity. With the patient seated, as- dure for severe hallux valgus addressed with proximal sessment of medial eminence tenderness, first metatar- correction and distal soft-tissue procedure. The Keller sophalangeal (MTP) joint range of motion, and hyper- resection arthroplasty (base of proximal phalanx resec- mobility of the first tarsometatarsal (TMT) joint are performed. First ray hypermobility remains a diagnostic challenge because physiologically normal values of first MTP joint mobility have not been defined. Weight- bearing radiographs are required to determine the se- verity of the bone and joint malalignment, presence of arthrosis, and other factors that influence surgical treat- ment. Radiographic assessment of the distal metatarsal articular angle (DMAA) continues to present diagnostic challenges, and interobserver reliability for DMAA as- sessment remains poor (Figures 1 and 2). Nonsurgical treatment involves shoe stretching at the medial eminence or shoes with a wider toe box. Sur- gical correction is indicated when shoe modifications prove ineffective; surgery should not be performed for cosmetic reasons alone. More than 100 procedures have been described for correction of hallux valgus; the or- thopaedic surgeon treating hallux valgus need not be fa- miliar with all of them but needs an adequate knowl- edge base to address all aspects of hallux valgus deformity (Figure 3). The distal chevron osteotomy is reserved for mild deformity. A combination of a proxi- mal metatarsal osteotomy and distal soft-tissue proce- dure is indicated for moderate to severe deformity. Many proximal first metatarsal osteotomies have been American Academy of Orthopaedic Surgeons 487

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Figure 3 A schematic representation of a variety of osteotomies used to correct hal- lux valgus deformity. (1) Akin procedure (corrects hallux valgus interphalangeus). (2) Reverdin distal medial closing wedge (corrects increased DMAA). (3) Proximal first metatarsal osteotomy (corrects increased intermetatarsal angle). (4) Medial cuneiform opening wedge osteotomy (corrects increased intermetatarsal angle). (Reproduced with permission from Coughlin M, Carlson R: Treatment of hallux valgus with an in- creased distal metatarsal articular angle: Evaluation of double and triple first ray osteotomies. Foot Ankle Int 1999;20:762-770.) Figure 2 Radiograph showing hallux valgus associated with an increased DMAA. Joint indications are not carefully followed (for example, a surfaces are congruent (not subluxated). (Reproduced from Coughlin MJ: Juvenile hal- distal metatarsal osteotomy is performed when proximal lux valgus, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Recon- metatarsal correction is required). Loss of correction at struction Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, the osteotomy is generally avoided with adequate fixa- 2004, pp 59-66.) tion and protected weight bearing in the immediate postoperative period. A proximal metatarsal osteotomy tion) risks creating a cock-up toe deformity and affords may result in a dorsiflexion malunion and transfer meta- a poor potential for correction of hallux valgus; this pro- tarsalgia (overload of lesser metatarsal heads). Proximal cedure has largely been abandoned. first metatarsal osteotomies performed from the medial aspect (oblique, chevron, Scarf) minimize the potential The DMAA must be considered in conjunction with for first metatarsal fixation in dorsiflexion. Hallux varus first ray malalignment. Typically, hallux valgus produces may occur with overcorrection of the first intermetatar- an incongruent joint, and joint congruency is reestab- sal angle, excessive lateral capsular release (and over- lished with surgical correction of the hallux valgus de- tightening of the medial capsule), overresection of the formity. However, hallux valgus may be associated with medial aspect of the first metatarsal head, and addition a congruent joint (increased DMAA) (Figure 2). Con- of lateral sesamoidectomy to the distal soft-tissue proce- ventional correction to realign the hallux creates an in- dure (original McBride procedure). Recurrence may be congruent MTP joint that will become stiff or lead to re- salvaged with revision of the original procedure, revi- currence of deformity. To correct the DMAA in patients sion to a more proximal procedure that affords greater with mild hallux valgus, a biplanar distal chevron osteot- correction, or first MTP or TMT joint arthrodesis. Con- omy is recommended; in patients with moderate to se- tinued pain and stiffness in the first MTP joint following vere disease, a proximal first metatarsal osteotomy or hallux valgus correction typically warrants first MTP Lapidus procedure should be combined with a distal joint arthrodesis. Mild hallux varus is rarely symptom- first metatarsal closing wedge osteotomy (Reverdin pro- atic. With severe hallux varus, however, revision surgery cedure) (Figure 3). may be necessary. The most common complication of hallux valgus sur- gery is recurrence. Recurrence is usually observed when 488 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction Hallux Rigidus uninvolved (contralateral) side, but gait analysis sug- gests that patients compensate well for the fused hallux. Hallux rigidus is degenerative joint disease of the first MTP joint. A positive family history of hallux rigidus is Multiple techniques have been described for first more common in patients with bilateral disease, whereas MTP joint arthrodesis. Even though flat cuts provide ex- patients with unilateral disease typically recall trauma to cellent surfaces for healing, cup-and-cone techniques fa- the great toe. The hallux MTP joint articular degenera- cilitate fine adjustments for proper alignment while tion is associated with osteophyte formation, particu- maintaining adequate bony contact. Biomechanical test- larly dorsally on the first metatarsal head that creates ing demonstrates that a combination of a compression dorsal impingement. Patients typically have great toe screw and a dorsal plate typically represents the most pain during push-off and forced dorsiflexion of the hal- stable construct. The hallux should be in slight valgus lux MTP joint. The first MTP joint is stiff and has a ten- relative to the first metatarsal without impinging on the der dorsal prominence. Dorsiflexion is limited and os- second toe and neutral to slight dorsiflexion relative to teophyte impingement is painful. Plantar flexion also the plantar aspect of the foot. Overpronation must also creates symptoms as the extensor tendons and sensory be avoided to prevent painful medial hallux callus for- nerve are stretched over the prominence. Pain at the mation. midrange of the motion arc is indicative of advanced (global) arthritis. Radiographic assessment demon- Sesamoid Disorders strates joint space narrowing; widening or flattening of the metatarsal head; and medial, lateral, and particularly The sesamoid complex includes the tibial and fibular dorsal osteophytes. An association of hallux rigidus with sesamoids, the intersesamoidal ligament, the flexor hal- metatarsus primus elevatus has not been substantiated. lucis brevis tendon, and the plantar plate. Disorders spe- cific to the sesamoids probably exist on a continuum Nonsurgical treatment includes activity modification and comprise sesamoiditis, stress fractures, and osteone- that does not require great toe dorsiflexion (bicycle), crosis. Any of these may involve arthritis of the metatar- stretching of the shoe toe box, a carbon fiber insert or sal head/sesamoid articulation. Females are more prone stiff-soled shoe, and/or a rocker bottom shoe modifica- to sesamoid problems, and the medial sesamoid is more tion. The mainstay of surgical management for mild to commonly affected than the lateral sesamoid. Sesamoid moderate disease remains dorsal cheilectomy to remove disorders typically produce pain on the plantar first dorsal osteophytes and one fourth to one third of the metatarsal head with weight bearing, particularly during dorsal articular surface from the metatarsal head. To im- push-off. Simple palpation may not clearly confirm the prove the relative dorsiflexion, a dorsiflexion osteotomy diagnosis; a passive axial compression test may facilitate of the proximal phalanx (Moberg procedure) can be a diagnosis of sesamoiditis. The sesamoids are palpated, added to decompress the joint. In patients with ad- the hallux MTP joint is maximally dorsiflexed, compres- vanced disease, the standard of surgical care remains sion is applied just proximal to the sesamoids, and the first MTP joint arthrodesis. However, capsular interposi- toe is passively plantar flexed. This generally reproduces tional arthroplasty has gained acceptance as a surgical the patient’s symptoms in sesamoiditis. Radiographs alternative for advanced hallux rigidus. Proximal pha- may reveal sesamoid irregularity, although lucency in a lanx base resection (Keller procedure) and dorsal chei- sesamoid may only represent bipartite sesamoid. Radio- lectomy are combined with joint soft-tissue interposition graphs of the asymptomatic contralateral foot are usu- of both the dorsal capsule and extensor hallucis brevis ally helpful in distinguishing a bipartite sesamoid from tendon. To avoid destabilizing the proximal phalanx, the an acute fracture. Lateral and oblique radiographs to di- Keller procedure may be performed obliquely to retain agnose sesamoid abnormalities may be difficult to inter- the attachment of the flexor hallucis brevis. Alterna- pret, and therefore dynamic fluoroscopy, bone scan, CT, tively, the proximal phalanx and metatarsal head can be and/or MRI are useful. Increased uptake on bone scan reamed with spherical reamers at the joint to stabilize and MRI signal changes may indicate acute or subacute an “anchovy” soft-tissue interposition. First MTP joint fracture. Sesamoid views (axial images of the foot with arthroplasty remains controversial. Although several the hallux dorsiflexed) may define sesamoid irregulari- new prosthetic designs and technique modifications ties such as fragmentation (osteonecrosis) or metatarsal have been introduced, risk of implant failure, osteolysis, head-sesamoid joint space narrowing (osteoarthritis). and synovitis have limited the use of first MTP joint ar- CT provides greater detail of metatarsal head-sesamoid throplasty in orthopaedic foot and ankle surgery. The degenerative changes and may confirm the diagnosis. most reliable surgical option for symptoms related to hallux MTP joint arthritis is arthrodesis. Successful fu- Nonsurgical treatment of sesamoid problems in- sion often reestablishes a more physiologic plantar pres- cludes sesamoid pressure relief/unloading with activity sure pattern. Gait pattern does not return to that of the modification, temporary avoidance of dorsiflexion, and a boot or cast. A 6- to 8-week period of unloading is fol- lowed by management with an orthotic device. Sesa- American Academy of Orthopaedic Surgeons 489

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Figure 4 Schematic lateral view of a Weil lesser metatarsal shortening osteotomy stabilized with screw fixation. (Reproduced from Deland JT: Angular deformities of the second toe, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 77-84.) moiditis is usually receptive to nonsurgical manage- Nonsurgical treatment of flexible deformities in- ment; successful conservative management of fractures cludes pads, inserts, and extra depth to the toe box. and osteonecrosis is less predictable. Repair with bone Hammer toe slings (Budin slings) extend the flexible grafting may be possible, but generally excision of the hammer or claw toes while orthotic device or metatarsal diseased sesamoid is necessary. The entire sesamoid pad can provide support to compensate for the distally need not be routinely excised; instead, depending on migrated fat pad. Intra-articular steroid injections can specific pathology, excision of only the proximal pole or be useful to decrease symptoms related to synovitis, but plantar shaving suffices. must be used judiciously as excessive exposure to ste- roid may further weaken the attenuated capsular struc- Lesser Toes tures and worsen deformity. A flexible hammer or claw toe can be corrected with a flexor-to-extensor tendon Lesser toe deformities include hammer toes (extended transfer, whereas a fixed toe deformity requires a proxi- MTP joint, flexed proximal interphalangeal joint, ex- mal interphalangeal joint resection arthroplasty or ar- tended distal interphalangeal joint), mallet toes (flexed throdesis. Long-standing fixed hammer or claw toe de- distal interphalangeal joints), and claw toes (extended formity may also require extensor tendon lengthening, MTP joint, flexed proximal interphalangeal and distal dorsal MTP joint capsulotomy, and collateral ligament interphalangeal joints). Hammer toes often arise sec- release. If associated with a relatively long second meta- ondary to tight shoe wear and are sometimes associated tarsal, a metatarsal shortening osteotomy can be per- with long second and/or third rays. Mallet toes may re- formed with preservation of the collateral ligaments be- sult from tighter shoe wear but are associated with de- cause the osteotomized metatarsal head relies solely on generative distal interphalangeal joint arthritis. Claw its extracapsular blood supply through the collateral lig- toes occur with intrinsic muscle weakness, creating an aments. Although multiple bony procedures for metatar- imbalance of the extrinsic and intrinsic foot muscula- sal shortening have been described, the Weil osteotomy ture, and may be linked to neuromuscular disease, cavus is currently favored (Figure 4). A transverse metatarsal foot deformity, neuropathy, and sequelae of compart- cut is made in line with the plantar foot through the ment syndrome. Chronic MTP joint synovitis and/or in- dorsal 5% to 10% of the articular cartilage. The meta- flammatory arthritis may lead to attenuation of the tarsal head is translated proximally several millimeters, plantar plate and capsule, resulting in MTP joint exten- but not beyond the adjacent lesser metatarsal head un- sion and eventual clawing. If simultaneous collateral lig- less it is to be shortened as well. Fixation is typically ament attenuation should occur, medial or lateral devia- performed with a low-profile screw. The overlapping tion ensues, ultimately leading to a crossover toe bone on the proximal fragment is resected to create the deformity. Frequently, a crossover second toe deformity new contour of the shortened metatarsal. is observed with hallux valgus. With hammer and claw toe deformities, the plantar fat pad may be displaced Bunionette Deformity distally, subjecting the metatarsal head to overload, cal- lus formation, and potential intractable plantar kerato- Bunionette deformities, to an extent, mirror hallux val- sis. Radiographs demonstrate toe deformity and may re- gus deformities. Bunionette deformities can be grouped veal a relatively long metatarsal that contributes to the into three types: type I, enlarged/prominent fifth meta- deformity. tarsal head; type II, congenital lateral fifth metatarsal bow; and type III, increased 4-5 intermetatarsal angle. 490 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction Patients present with pain over the lateral fifth metatar- iform and/or first through third TMT joints because sal head and difficulty with shoe wear because of fifth these are considered nonessential joints and physiologi- metatarsal head pressure. Occasionally, a bunionette will cally the foot should be relatively rigid in this location. be associated with plantar fifth metatarsal head pain In contrast, it is essential to maintain motion of the 4-5 and remain symptomatic even when shoes are removed. metatarsal-cuboid articulations to preserve the foot’s ac- Physical examination reveals lateral and/or plantar fifth commodative function during the stance phase of gait. metatarsal head tenderness, a wide forefoot (in types II Infrequently, advanced degeneration involves the 4-5 and III) and medial deviation of the fifth toe. AP radio- metatarsal-cuboid articulations, and use of interposi- graphs define the deformity. Shoe stretching over the tional tendon arthroplasties have proven effective in se- lateral fifth metatarsal and shoes with a wider toe box lect patients. In rare instances, such as Charcot midfoot are usually sufficient to relieve symptoms. Surgical neuroarthropathy with midfoot collapse, the lateral col- treatment is indicated for bunionettes not responding to umn of the midfoot may also be fused to ensure ade- shoe modifications. All three types generally require a quate stability. lateral capsulotomy, lateral eminence excision, and lat- eral capsular plication. Type II can be corrected with a Hindfoot and Ankle distal metatarsal osteotomy that displaces the metatar- sal head medially. More severe type II and type III de- Ankle/Subtalar Instability formities are managed with a midshaft long oblique os- teotomy analogous to the proximal oblique osteotomy Although ankle sprains are the most common sports in- of the first metatarsal head. In the fifth metatarsal, the jury, only 20% of patients develop residual symptoms. osteotomy is not performed proximally, given the water- Many of these symptoms represent associated injuries shed area complicating healing of Jones’ fractures. such as peroneal tendon tears, peroneal tendon subluxation/dislocation, fractures of the lateral process Midfoot Arthritis of the calcaneus, and osteochondral lesions. These diag- noses, among others, should be considered in patients Midfoot arthritis may be primary, inflammatory, or post- with chronic symptoms following ankle sprain. Ankle in- traumatic, with primary arthritis as the most common stability that is not related to any associated pathology cause. The midfoot articulations comprise the naviculo- is categorized into functional instability (pain that cuneiform and metatarsocuneiform/cuboid joints. Pa- causes the ankle to give way) and mechanical instability tients have pain with weight bearing in the dorsal mid- (weakened static ankle restraints that are responsible foot and arch, particularly during push-off. Examination for excessive lateral ankle subluxation and resultant reveals tenderness at the midfoot joints, especially with pain). Furthermore, ankle (tibiotalar) instability is fre- stress at the TMT joints (dorsiflexion/plantar flexion, quently associated with subtalar (talocalcaneal) instabil- twisting of midfoot, and forced forefoot abduction). Be- ity. CT analysis suggests that hindfoot varus and an al- cause the TMT joints may be difficult to differentiate, a tered mortise position (with a more posterior fibular “piano key” test has been proposed in which the hind- position) is more prevalent in patients with chronic lat- foot is stabilized while a plantar force is applied to the eral ankle instability. Patients with mechanical instabil- associated metatarsal head (like striking an individual ity report a history of chronic ankle sprains but are rela- piano key). With the patient bearing weight, loss of the tively pain free if the ankle is not injured. Examination longitudinal arch is appreciated and is often associated may reveal tenderness over the anterior talofibular liga- with forefoot abduction. Radiographs confirm these ment and/or the calcaneofibular ligament, and the diag- findings with forefoot abduction (AP radiographs) and nosis is confirmed with anterior drawer and inversion a break in the physiologic talar declination angle (lat- testing. Although a clinical grading scheme (grades I eral radiographs). Subtle joint space narrowing in the through III) and mechanical devices to test anterior TMT and naviculocuneiform joints may be detected drawer/talar tilt exist, stress radiographs probably offer with standard weight-bearing foot radiographs. Nonsur- the best objective demonstration of tibiotalar instability. gical treatment includes longitudinal arch support, Abnormal tibiotalar tilt has been defined anywhere stiffer soled shoes or orthotic devices, and/or rocker bot- from 3° to 15° relative to the contralateral side and for- tom shoes. Steroid injections may be both diagnostic ward talar translation on the tibia greater than 3 mm and temporarily therapeutic. Because these are small than on the contralateral side. Subtalar instability re- joints, fluoroscopic guidance is helpful to deliver the ste- mains a diagnostic challenge. Clinical examination typi- roid directly to the involved articulation(s). Surgical cally fails to distinguish tibiotalar from subtalar instabil- management is indicated when conservative measures ity. Broden’s views have limited value. A recently fail. The recommended surgical treatment of midfoot developed ultrasound method may be useful, but re- degenerative arthritis is arthrodesis of the naviculocune- mains operator dependent. American Academy of Orthopaedic Surgeons 491

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Ankle and hindfoot sprains are initially treated with teonecrosis of the talus, and inflammatory arthritides, the familiar regimen of rest, ice, application, compres- but may also develop as primary ankle degeneration. sion, and elevation, early weight bearing, and functional The incidence of primary and inflammatory ankle ar- rehabilitation. Generally, 15% to 30% of residual symp- thritis is uncommon relative to the incidence of hip and toms after routine initial management can be attributed knee arthritis. Comparative studies of ankle versus hip to peroneal weakness caused by inadequate rehabilita- and knee cartilage suggest that cartilage in the ankle tion. Treatment with more directed and supervised phys- possesses factors that protect it from primary degenera- ical therapy is usually successful in these situations. tion; by far the most common etiology of ankle arthritis is trauma. With isolated ankle arthritis, the patient re- Surgical intervention is considered when propriocep- ports pain in the anterior aspect of the ankle with tive and peroneal rehabilitation for chronic mechanical weight bearing and particularly with push-off. Whereas instability is unsuccessful. Currently, anatomic recon- diffuse ankle arthritis may also produce medial and lat- struction is favored. When the condition of residual lat- eral pain, early degenerative disease creates symptoms eral ligamentous tissues is adequate for anatomic repair, confined to the anterior ankle. Physical examination a modified Broström procedure is recommended, with demonstrates tenderness about the ankle, pain with imbrication of the anterior talofibular ligament and/or range of motion, and restricted range of motion (partic- the calcaneofibular ligament and augmentation with the ularly ankle dorsiflexion). Evaluation while the patient inferior extensor retinaculum (Gould modification). is bearing weight may reveal malalignment, which is of- This anatomic reconstruction has been shown to have ten most evident during ambulation. Weight-bearing ra- superior outcome when compared with a functional re- diographs of the ankle confirm the diagnosis, and habilitation program and to a nonanatomic reconstruc- weight-bearing radiographs of the foot are important tion using the peroneus brevis tendon (Evans proce- to identify any associated hindfoot malalignment/ dure). Recently, advanced methods of lateral ankle degeneration that may have a bearing on surgical man- stabilization have been introduced; suture anchors (bio- agement. absorbable and metallic) to reattach/advance the ante- rior talofibular ligament and calcaneofibular ligament to Nonsurgical treatment includes anti-inflammatory the distal fibula have gained popularity. Traditionally, agents, activity modification, bracing, rocker bottom with insufficient residual lateral ankle ligamentous tis- shoe modification, and corticosteroid injection. Failure sue, reconstruction involved harvest of part or all of a of conservative management is an indication for surgical peroneal tendon. However, concerns over loss of the dy- management. Mild degenerative disease with impinge- namic stabilizers have prompted greater interest in au- ment during dorsiflexion can be effectively managed tologous tendon transfers. Hamstring autografts, includ- with anterior ankle cheilectomy (exostectomy of ante- ing the semitendinosus or gracilis, have been used with rior ankle osteophytes). Ankle arthrodesis remains the greater frequency to reestablish the deficient anterior gold standard for surgical treatment of diffuse ankle ar- talofibular ligament and calcaneofibular ligament with- thritis. With minimal malalignment, arthroscopic or out compromising the dynamic stabilizing effect of the mini-arthrotomy techniques offer the advantage of a intact peroneal tendons. If hindfoot varus coexists with minimally invasive approach and generally shorter time mechanical lateral ankle instability, then a valgus- to fusion when compared with traditional arthrotomy producing calcaneal osteotomy is typically recom- techniques. The transfibular approach is recommended mended. Furthermore, hindfoot varus may be driven by with increased malalignment. Because long-term a plantar flexed first metatarsal, which can be diagnosed follow-up of ankle arthrodesis demonstrates that many via the Coleman block test. In this situation, surgical patients develop adjacent hindfoot arthritis, some sur- correction should include a dorsiflexion first metatarsal geons advocate that ankle arthrodesis be performed osteotomy performed judiciously to avoid overload of through an anterior approach to facilitate potential fu- the lesser metatarsal heads. ture conversion of the fusion to an ankle replacement. Improved union rates have been reported in complex Although isolated subtalar instability may exist, re- hindfoot arthrodeses with increased risk for nonunion constructive procedures restricted to the subtalar joint using implantable bone stimulation. Smokers are at 2.7 have not been clearly defined. Reconstructive proce- times greater risk for nonunion than nonsmokers. In pa- dures that cross both the ankle and subtalar joints (cal- tients with concomitant ankle and hindfoot arthritis, ti- caneofibular ligament repair/reconstruction and aug- biotalocalcaneal or pantalar arthrodesis may be consid- mentation with the inferior extensor retinaculum) ered. Reported techniques of retrograde intramedullary remain the mainstay of treatment. nailing and blade plate fixation (inserted via lateral or posterior approaches) have favorable union rates and Ankle Arthritis provide acceptable pain relief. Ankle arthritis may develop secondary to trauma To limit development of hindfoot arthritis following (ankle/pilon fractures), chronic ankle instability, os- ankle fusion or to manage patients with concomitant an- 492 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction kle and hindfoot arthritis, several attractive surgical al- reveals a high incidence of osteochondral injuries. No ternatives to ankle arthrodesis that maintain ankle mo- clear association between focal osteochondral lesions of tion continue to show promise. Joint distraction the talus and development of diffuse ankle osteoarthri- arthroplasty with or without joint débridement involves tis has been identified. Although radiographs often sug- maintaining 5 mm of ankle joint distraction with thin gest an osteochondral lesion of the talus, findings may wire ring fixation. Patients are allowed to bear weight be subtle. Occasionally, a loose body (detached frag- during the 3 months of joint distraction. Early to inter- ment) is evident. MRI is the favored screening tool to mediate results suggest that 75% of patients experi- identify osteochondral lesions of the talus, and both enced improvement of symptoms and did not require MRI and CT provide useful information in defining spe- further surgical management. Fresh tibiotalar “shell” al- cific characteristics. Although classification schemes for lografts have been used in carefully selected patients. osteochondral lesions of the talus have been developed An osteochondral allograft comprising both aspects of using both MRI and CT, arthroscopic evaluation is the tibiotalar joint replaces the patient’s corresponding probably most accurate. resected articular surfaces. To optimize the fit of the al- lograft, total ankle replacement cutting guides are used. Nonsurgical management of symptomatic osteo- Early results are encouraging, but the technique remains chondral lesions of the talus consists of immobilization experimental. Improved component design and surgical and protective weight bearing to promote stabilization technique for modern-generation total ankle arthro- of the osteochondral fragment and nonsteroidal anti- plasty have improved results over those for first- inflammatory drugs and/or steroid injection for pain generation implants. Although several different prosthe- relief/controlling inflammation. Adult patients rarely ex- ses, each with unique design features, have been perience spontaneous healing of osteochondral lesions introduced worldwide, only the semi-constrained, fixed- of the talus, but some authors have recently reported bearing Agility ankle (DePuy, Warsaw, IN) has been ap- good to excellent results at intermediate-term follow-up proved by the US Food and Drug Administration with nonsurgical treatment of osteochondral lesions of (FDA) (Figure 5). The Agility ankle technique warrants the talus thought only to respond to surgical interven- a syndesmotic arthrodesis to increase the surface area tion. Although arthroscopic débridement and drilling/ and support for the tibial component. The mobile bear- microfracture remains the standard of surgical care for ing Scandinavian Total Ankle Replacement (Waldemar- symptomatic osteochondral lesions of the talus (good to Link, Hamburg, Germany) prosthesis affords the advan- excellent results of 70% to 90% at intermediate follow- tage of limited bone resection, a resurfacing talar up), the concern remains that replacing larger defects component, and the mobile bearing that reduces con- with fibrocartilage and not hyaline cartilage may not be straint and provides modularity to improve soft-tissue a sensible solution. Although cartilage resurfacing pro- balance. As of this writing, the Scandinavian Total Ankle cedures, including osteochondral autograft/allograft Replacement implant was in clinical trial, awaiting FDA transfer (mosaicplasty) and autologous chondrocyte approval. Although techniques for total ankle arthro- transplantation (Carticel procedure), continue to be plasty have been refined, the procedure remains techni- viewed as salvage procedures, some consideration is be- cally demanding. A steep learning curve has been dem- ing given to applying these techniques as primary surgi- onstrated for total ankle arthroplasty. As with total hip cal treatment of larger osteochondral lesions of the ta- and total knee arthroplasty, proper alignment and soft- lus, particularly those associated with subchondral cysts tissue balance are crucial for successful outcome. Cur- (Figure 6). Outcome of osteochondral transfer from the rent recommendations are for total ankle arthroplasty knee to the ankle (osteochondral autograft/allograft to be performed by surgeons who have completed spe- transfer and mosaicplasty) have been promising at cial training for this technique, either through fellowship short- to intermediate-term follow-up, with 88% to 94% or learning center experience. good to excellent results for primary and revision sur- geries. Autologous chondrocyte transplantation has also Osteochondral Lesions of the Talus proven effective at early follow-up. Cartilage resurfacing in the ankle often warrants medial or lateral malleolar Osteochondral lesions of the ankle are commonly ob- osteotomies to provide adequate access to the osteo- served anterolaterally and posteromedially on the talar chondral lesions of the talus. Currently, malleolar os- dome. Not all of these lesions are symptomatic and may teotomy techniques are being refined and potential lo- represent incidental findings. Most osteochondral le- cal cartilage harvest sites are being identified to sions of the talus are a result of ankle trauma (sprain/ decrease the morbidity to the ankle and ipsilateral knee. fracture), but patients do not always recall a specific Lateral defects, particularly those associated with lateral traumatic event. Ankle arthroscopy performed simulta- ligamentous instability, may be treated with release and neously with open reduction and internal fixation of an- subsequent tightening of the anterior talofibular liga- kle fractures or in patients with chronic ankle sprains ment and calcaneofibular ligament. American Academy of Orthopaedic Surgeons 493

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Figure 5 Several currently available total ankle prosthesis are shown. A, Agility Total Ankle System. (Courtesy of DePuy, Warsaw, IN.) B, STAR system. (Courtesy of Waldemar-Link, Hamburg, Germany.) C, Buechel-Pappas ankle system. (Courtesy of Endotec, South Orange, NJ.) D, Hintegra ankle system. (Courtesy of New Deal, Vienne, France.) Insertional Achilles Tendinopathy the Achilles tendon on the calcaneus with direct pres- sure and during push-off; swelling at the insertion limits Insertional Achilles tendinopathy is an enthesopathy of shoe wear with a hard heel counter. Symptoms are exac- the Achilles tendon insertion that most likely is a result erbated by walking an incline or during activities that of cumulative trauma/repetitive stress. Although inflam- cause dorsiflexion of the ankle. Physical examination mation accompanies this disease process, the primary will demonstrate an intact Achilles tendon, but often pathology is tendon degeneration at the Achilles tendon with hyperdorsiflexion of the ankle (secondary to Achil- insertion. Patients report pain directly at the junction of 494 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction les tendon attenuation). Lateral radiographs demon- Figure 6 CT scan showing a subchondral cyst of the medial talar dome. Subchondral strate calcification at the Achilles tendon insertion and cysts generally respond poorly to arthroscopic débridement and drilling. Recently de- frequently a prominent posterior calcaneal tuberosity. veloped cartilage repair techniques have shown promise in the primary and secondary surgical treatment of these lesions. (Reproduced from Scranton PE Jr: Osteochondral Nonsurgical treatment is successful in most in- lesions of the talus, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced stances, and includes activity modification, use of a cam Reconstruction Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Sur- walker with a posterior heel relief, modalities to dimin- geons, 2004, pp 261-266.) ish associated inflammation, and a heel lift. In approxi- mately 20% to 25% of patients, failure of nonsurgical ing by the navicular demonstrates forefoot abduction. measures (after at least 6 months) prompts surgical Weight-bearing AP and mortise ankle radiographs must management. Current surgical treatment includes débri- be obtained to detect valgus talar tilt indicative of del- dement of the Achilles tendon insertion and calcaneal toid ligament attenuation. exostectomy. Medial and/or lateral approaches have been described for this procedure, but may not permit Treatment of stage I flatfoot deformity (posterior adequate débridement of the Achilles tendon insertion. tibial tendinitis) is nonsurgical with initial immobiliza- A central approach facilitates such débridement, but ne- tion and the administration of nonsteroidal anti- cessitates detachment of at least 50% of the Achilles inflammatory drugs, followed by gradual progression to tendon from the calcaneus, and usually requires reat- physical therapy and orthotic use. In selected patients, tachment of the residual tendon fibers with suture an- surgical débridement of the posterior tibial tendon chors to the residual calcaneus. When the tendon inser- sheath may relieve recalcitrant stenosing tenosynovitis. tion is severely degenerated, necessitating resection of a Stage II flatfoot deformity (posterior tibial tendinopa- substantial portion of the insertion, then augmentation thy with flexible hindfoot) can be effectively managed with a flexor hallucis longus tendon transfer is recom- with functional bracing using a University of California mended. A long flexor hallucis longus tendon harvest at Berkely Laboratory or ankle-foot orthosis. Although (flexor hallucis longus division in the plantar foot) deliv- bracing supports the foot, it cannot reverse posterior ers approximately 3 cm more tendon than a short flexor tibial tendinopathy. Surgical management is typically hallucis longus tendon harvest (flexor hallucis longus di- joint sparing with flexor digitorum or flexor hallucis lon- vision at posteromedial ankle). gus tendon transfer combined with either medial dis- placement calcaneal osteotomy or lateral column Acquired Flatfoot Deformity lengthening. Medial displacement calcaneal osteotomy is effective in protecting a posterior tibial tendon recon- Posterior tibial tendon dysfunction is the most common struction and at least partially restoring longitudinal etiology for the adult acquired flatfoot deformity. Poste- arch alignment and correcting hindfoot valgus, but rior tibial tendon insufficiency leads to gradual loss of proves less effective than lateral column lengthening the longitudinal arch, hindfoot valgus, forefoot abduc- when deformity is associated forefoot abduction. The tion and forefoot varus/supination. Over time, the defor- medial displacement calcaneal osteotomy generally is mity may become fixed and even result in deltoid liga- associated with high union and low complication rates; ment attenuation with resultant valgus talar tilt. This progressive deformity has been categorized into four stages. Clinical evaluation is characterized by pain and tenderness along the posterior tibial tendon and inabil- ity to perform a single limb heel rise. In the early stages of the disease, single limb heel rise may be possible but painful; eventually, the heel fails to turn into physiologic varus, and ultimately unsupported single limb heel rise is no longer possible. With advancing disease, subfibular (calcaneofibular) impingement develops with tender- ness over the compressed peroneal tendons. In fact, ini- tial medial pain subsides and subfibular lateral foot pain produces the greatest symptoms. Loss of the longitudi- nal arch, hindfoot valgus, and forefoot abduction (too many toes sign) are evident with progressive posterior tibial tendon attenuation. Radiographic evaluation con- firms pes planus alignment. The lateral radiograph dem- onstrates loss of the longitudinal arch; moderate to se- vere talonavicular subluxation suggests spring ligament compromise. On the AP radiograph, talar head uncover- American Academy of Orthopaedic Surgeons 495

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 in contrast, lateral column lengthening (either through standing. The point of maximal tenderness is usually at the anterior calcaneus or calcaneocuboid joint) is associ- the plantar fascia origin on the plantar medial heel; ten- ated with a higher complication rate, particularly with derness slightly more proximal and medial is suggestive regard to nonunion. With proper technique, use of struc- of compressive neuropathy. tural autograft and allograft yields equal and favorable results. Associated spring ligament attenuation can usu- Treatment of plantar fasciitis is rarely surgical; tradi- ally be corrected with soft-tissue plication; however, tional treatment with Achilles tendon stretching, night larger spring ligament defects represent a greater chal- splinting, heel cushion, and nonsteroidal anti- lenge. The optimal spring ligament reconstruction has inflammatory drugs continues to be recommended. A yet to be defined. Currently, arthrodesis is usually re- prospective, randomized trial suggests that a stretching quired to manage large spring ligament tears. Subtalar protocol specific to the plantar fascia may provide ad- arthroereisis, a technique traditionally reserved for pedi- vantages over Achilles tendon stretching. Low- and atric patients, has been introduced as an adjunctive pro- high-energy extracorporeal shock wave therapy are cedure in the management of the flexible adult acquired available to treat plantar fasciitis. Prospective random- flatfoot deformity; preliminary results and anecdotal ex- ized studies and meta-analyses demonstrate that both perience with this sinus tarsi implant that distracts the the low- and high-energy devices are safe; however, subtalar joint show promise. In some patients, a double whether extracorporeal shock wave therapy is effective calcaneal osteotomy (medial displacement calcaneal os- for recalcitrant plantar fasciitis remains a controversial teotomy and lateral column lengthening) has proved ef- issue. Surgical treatment is reserved for patients in fective in correcting hindfoot valgus and forefoot abduc- whom 6 months to 1 year of nonsurgical treatment is tion when combined with tendon reconstruction. Fixed unsuccessful. Only the medial third of the plantar fascia stage III flatfoot deformity cannot be corrected with should be released; complete release may result in per- joint-sparing procedures and requires realignment sistent lateral foot pain. Plantar fascia release may be through arthrodesis, typically triple arthrodesis. Because performed with open or endoscopic techniques. Given posterior tibial tendon dysfunction often is associated the overlap of plantar fasciitis and compression neurop- with an equinus contracture, correction of deformity re- athy, open plantar fascia release can be combined with quires Achilles tendon lengthening. Traditionally, the distal tarsal tunnel decompression; good to excellent re- Hoke triple cut percutaneous lengthening technique has sults can be expected in more than 85% of patients with been used, but anatomic studies demonstrate that the recalcitrant symptoms who undergo the combined pro- triple cut technique generally fails to follow the orienta- cedure. tion of the Achilles tendon fibers. Recently, gastroc- nemius-soleus recession has gained popularity as an ef- Diabetic Foot/Ankle and Charcot Neuroarthropathy fective method for Achilles tendon lengthening; although the traditional open technique is most com- More than 16 million people in the United States have monly used, interest has been generated for a less inva- diabetes, and foot problems related to diabetes repre- sive endoscopic technique. Stage IV flatfoot deformity sent 20% of hospital admissions for diabetics. The life- remains difficult to treat because an ideal deltoid liga- time incidence for foot ulceration in diabetic patients is ment reconstruction has not been developed. When as- 15%, and 3% to 5% of diabetic patients are amputees. sociated with ankle arthritis, pantalar arthrodesis may More than 50% of all amputations performed in the be required for severe stage IV disease. United States are for diabetics. Within 3 years of lower extremity amputation, 30% of diabetic patients lose Plantar Fasciitis their contralateral leg, and 50% die. Up to half of these amputations are considered preventable. Diabetic risk The etiology of plantar fasciitis is not fully understood, factors for foot ulceration include neuropathy (sensory, but the condition is believed to result from cumulative motor, and autonomic), vascular insufficiency, poor gly- trauma or repetitive stress. Symptoms usually are con- cemic control, malnutrition, and impaired wound heal- centrated at the plantar fascia origin on the plantar me- ing. Sensory neuropathy (Semmes-Weinstein monofila- dial heel and typically have an insidious onset. Occa- ment < 5.07) leaves patients without protective sionally, plantar heel pain may be associated with a sensation. Motor neuropathy may lead to joint compressive neuropathy of the first branch of the lateral deformities/contractures that create areas of pressure plantar nerve (Baxter’s nerve). A heel pain triad has concentration and difficulties with shoe wear. Auto- been described with the coexistence of posterior tibial nomic neuropathy results in dry skin with fissures (risk tendon dysfunction, plantar fasciitis, and tarsal tunnel bacterial penetration) and peripheral edema (reduces syndrome. Patients typically report start-up pain (heel collateral blood flow/healing potential). Vascular insuffi- pain experienced with initial weight bearing after a pe- ciency (ankle brachial index < 0.45, absolute toe pres- riod of rest) and increasing heel pain after prolonged sures < 50 to 60 mm Hg, transcutaneous oxygen mea- sures < 30 mm Hg) diminishes the patient’s ability to 496 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction heal. Furthermore, poor glycemic control and malnutri- Charcot Neuroarthropathy tion contribute to impaired wound healing mechanisms. Charcot neuroarthropathy remains a treatment chal- Suspected infection requires further work-up that lenge. The exact etiology of Charcot neuroarthropathy is can be performed by the orthopaedist or in conjunction poorly understood, but neurotraumatic and/or neu- with an infectious disease specialist. Calluses should be rovascular theories are currently favored. The neu- trimmed because they may mask underlying infection. rotraumatic theory suggests fracture or fracture- Probing to bone through an ulceration is approximately dislocation without protective sensation and a healing 80% reliable in diagnosing osteomyelitis. Radiographs response of hypertrophic bone formation in an inher- demonstrate cortical erosions, but it may take 7 to 14 ently unstable fracture that has not been stabilized. days before these erosions become radiographically Conversely, the neurovascular theory suggests nonphysi- detectable. Therefore, MRI and/or combination techne- ologic vascular inflow resulting in resorption and subse- tium bone scan/white blood cell-labeled indium (or gal- quent fracture-dislocation. lium) scan may be required to determine if osteo- myelitis is present. MRI has high sensitivity, specificity, Eichenholtz staging defines the clinical and radio- and accuracy in diagnosing osteomyelitis, but provides graphic progression of the neuroarthropathy. Stage I is poor localization and may in fact overrepresent the area characterized by edema, warmth, erythema, and radio- of involvement, thereby leading to overresection of graphic evidence of bony acute fracture and/or disloca- bone. Technetium bone scan is specific only for inflam- tion (fragmentation); the neuroarthropathy develops mation but combined with white blood cell-labeled in- during this initial stage. In stage II, the proliferative dium scanning the sensitivity, specificity, and accuracy phase, bony destruction is combined with the fracture/ approaches that of MRI. Limitations to technetium dislocation. Edema and warmth are generally dimin- bone scanning and white blood cell-labeled indium ished relative to stage I. Progression to stage III is de- scanning include poor circulation and prior administra- fined by coalescence and remodeling with healing in a tion of antibiotics, respectively. The most reliable means foot position resulting from the fracture/dislocation and of detecting osteomyelitis involves obtaining a deep sur- bony displacement. Typically, patients who were not im- gical specimen of infected tissue with the patient re- mobilized and restricted from bearing weight tend to fraining from antibiotic administration for at least 48 consolidate in a less favorable, nonplantigrade foot posi- hours. An abscess is a surgical emergency because this tion. As for diabetic ulceration/infection, treatment of space-occupying lesion will quickly dissect more proxi- Charcot neuroarthropathy is improved through patient mally through potential spaces (such as tendon sheaths) and physician education. A heightened awareness and and may create a mass effect on delicate vessels, leading appropriate differentiation from osteomyelitis generally to forefoot ischemia. Typically, the only means of eradi- can lead to earlier diagnosis, immobilization, and re- cating osteomyelitis in diabetic foot infections is to re- stricted weight bearing. The advantage to identifying the sect the infected bone. Calcaneal osteomyelitis does not Charcot process early is that progression through the necessitate transtibial amputation; partial calcanectomy three stages can occur while the foot is maintained in followed by appropriate protective bracing in diabetic this near anatomic position. If the Charcot process can patients can lead to successful limb salvage. course through to the consolidation/remodeling phase while avoiding deformity such as arch collapse, outcome Most foot ulcers may be treated nonsurgically with may be markedly improved. Unfortunately, the painless proper wound care and appropriate pressure relief. Fol- Charcot foot often does not prompt immediate medical lowing satisfactory ulcer débridement, total contact cast- care and proper diagnosis is frequently delayed. Use of ing remains the gold standard for forefoot/midfoot ulcer a total contact cast and no weight bearing traditionally management; hindfoot ulcers respond poorly to total have been effective in the management of Charcot neu- contact casting. To better monitor skin and address the roarthropathy, but external fixation recently has gained ulcer with wound management, improvements have popularity for initial stabilization. Even with deformity been made to various removable diabetic cam walker following progression to stage III, most Charcot defor- boots. The devices have proven at least equally effective mities can be managed nonsurgically with total contact in pressure unloading for forefoot and midfoot ulcers as inserts, extra-depth shoes, stiffer soles, rocker bottom total contact casting. Forefoot ulceration associated with shoe modification, and bracing above the ankle. Severe equinus contractures will quickly resolve with Achilles deformities may warrant use of a functional total con- tendon lengthening, particularly if treated in conjunc- tact cast (such as the Charcot restraining orthotic tion with total contact casting. Without equinus, percuta- walker). Some deformities are predisposed to ulcer- neous flexor tenotomies and/or dorsiflexion metatarsal ation, infection, and amputation, and brace treatment is osteotomies may prove beneficial for recalcitrant fore- not possible. Salvage procedures have been effective. foot ulcers. Exostoses in the midfoot (frequently associ- Several classification schemes have been developed to ated with Charcot neuroarthropathic midfoot collapse) better define deformity patterns and develop treatment may be excised to effectively unload ulcerated skin. American Academy of Orthopaedic Surgeons 497

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 algorithms. Although complex, such classification 9°. Complications included three nonunions, all in patients schemes demonstrate good interobserver and intraob- who smoked. server reliability. It is predicted that such schemes may facilitate treatment strategies. Surgical salvage proce- Coughlin MJ, Freund E: The reliability of angular mea- dures for ankle, hindfoot, and midfoot Charcot defor- surements in hallux valgus deformities. Foot Ankle Int mity typically require multiplanar realignment osteoto- 2001;22:369-379. mies with arthrodesis and tend to ignore traditional anatomic landmarks. Techniques for internal fixation Interobserver and intraobserver reliability within 5° is high have been described, but recently developed methods of for the intermetatarsal angle (97%), good for the hallux valgus external fixation for Charcot neuroarthropathy for the angle (86%), and poor for the distal metatarsal articular angle diabetic foot and ankle have shown promise. Whereas (59%). resolution of ulceration and infection is typically neces- sary before internal fixation of Charcot deformity, exter- Faber FW, Kleinrensink GJ, Mulder PG, Verhaar JA: nal fixation affords the potential advantage of single- Mobility of the first tarsometatarsal joint in hallux val- stage resection of the osteomyelitic prominence, ulcer gus patients: A radiographic analysis. Foot Ankle Int excision, multiplanar realignment osteotomy, and arth- 2001;22:965-969. rodesis stabilized without implanted hardware. Ninety-four feet with symptomatic hallux valgus deformity Salvage procedures may be successful in limb preser- prompting surgical correction were evaluated clinically and ra- vation for diabetic patients with ulceration, infection, diographically using the modified Coleman block test. The and/or Charcot neuroarthropathy; however, amputation mean first ray motion was 13° and proved to be significantly may remain the only recourse in some situations. If fea- greater in the group that demonstrated clinical hypermobility. sible, partial foot amputations provide the advantage of limb support without a prosthesis. However, the patient Glasoe WM, Allen MK, Saltzman CL: First ray dorsal still may be predisposed to ulceration, and transtibial mobility in relation to hallux valgus deformity and first amputation may be the safest solution. intermetatarsal angle. Foot Ankle Int 2001;22:98-101. Annotated Bibliography A comparison of 14 hallux valgus patients and asymptom- atic controls demonstrated increased mobility in the hallux Forefoot: Hallux Valgus valgus group. A load-cell device was used to determine the de- gree of hypermobility. Chi TD, Davitt J, Younger A, Holt S: Intra-and inter- observer reliability of the distal metatarsal articular an- Kristen KH, Berger C, Stelzig E, Thalhammer E: The gle in adult hallux valgus. Foot Ankle Int 2002;23:722- SCARF osteotomy for the correction of hallux valgus 726. deformities. Foot Ankle Int 2002;23:221-229. Preoperative and postoperative radiographs of 32 patients A retrospective analysis of 111 Scarf osteotomies in 89 undergoing hallux valgus correction using a proximal bony consecutive patients with moderate to severe hallux valgus re- procedure demonstrated a reduction in the DMAA by an av- vealed an average hallux valgus angle improvement of 19° and erage of 3.9°, noted by all observers. However, interobserver intermetatarsal angle improvement of 7°. The average Ameri- reliability of preoperative and postoperative DMAA was can Orthopaedic Foot and Ankle Society forefoot score im- poor. proved from 50 to 91 points. Seven patients (6%) experienced a recurrence of deformity and 5% suffered either superficial Coetzee JC: Scarf osteotomy for hallux valgus repair: wound infection, displacement of the distal fragment, or hallux The dark side. Foot Ankle Int 2003;24:29-33. MTP joint stiffness. The Scarf osteotomy was performed in 20 consecutive pa- Nery C, Barroco R, Ressio C: Biplanar chevron osteot- tients, resulting in a high complication rate, limited improve- omy. Foot Ankle Int 2002;23:792-798. ment in the American Orthopaedic Foot and Ankle Society forefoot score, and only a 55% patient satisfaction rate. Fifty-four biplanar distal chevron osteotomies were per- formed in 32 patients to correct moderate hallux valgus defor- Coetzee JC, Resig SG, Kuskowski M, Saleh KJ: The lapi- mity associated with an increased distal metatarsal articular dus procedure as salvage after failed surgical treatment angle. With follow-up of 2 years or longer, the average Ameri- of hallux valgus. J Bone Joint Surg Am 2003;85-A:60-65. can Orthopaedic Foot and Ankle Society forefoot score im- proved from 50 to 90 points, the average hallux valgus angle Twenty-four patients with 26 symptomatic hallux valgus improved 9°, the intermetatarsal angle improved 4°, and the recurrences were selected to undergo the Lapidus procedure. distal metatarsal articular angle improved from 15° to 5°. At an average follow-up of 24 months, the average American Orthopaedic Foot and Ankle Society score improved from 47 Nyska M, Trnka HJ, Parks BG, Myerson MS: The Lud- to 88 points, with average improvements in the hallux valgus loff metatarsal osteotomy: Guidelines for optimal cor- angles from 37° to 17° and intermetatarsal angles from 18° to 498 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction rection on a geometric analysis conducted on a sawbone bility: Long-term results of treatment. Foot Ankle Int model. Foot Ankle Int 2003;24:34-39. 2002;23:1018-1025. Using a saw bone model, the authors describe technical as- Twenty percent (24 of 121 consecutive patients (131 feet pects to achieving desired correction for the modified Ludloff and 136 neuromas) were treated for concomitant excision of a proximal oblique first metatarsal osteotomy for hallux valgus second web space neuroma and stabilization of a second MTP correction. joint capsular instability. At an average follow-up of 80 months, 21 feet were available for evaluation. In 15 feet, the Forefoot: Hallux Rigidus procedures were performed simultaneously; in 6 feet, the pro- cedures were staged. Subjective patient satisfaction was high; Coughlin MJ, Shurnas PS: Hallux rigidus: Demograph- subjective and objective results were lower in patients with ics, etiology, and radiographic assessment. Foot Ankle Int persistent MTP joint instability. 2003;24:731-743. Koti M, Maffulli N: Bunionette. J Bone Joint Surg Am This retrospective review of 114 patients treated surgically 2001;83-A:1076-1082. for hallux rigidus demonstrated that hallux rigidus was associ- ated with hallux valgus interphalangeus, female gender, unilat- This article presents an excellent current review of evalua- eral disease (history of trauma), and bilateral disease (family tion and management of bunionette deformity. history). The condition was not associated with metatarsus pri- mus elevatus, a long first metatarsal, or first ray hypermobility. Petersen WJ, Lankes JM, Paulsen F, Hassenpflug J: The arterial supply of the lesser metatarsal heads: A vascular Coughlin MJ, Shurnas PS: Hallux rigidus: Grading and injection study in human cadavers. Foot Ankle Int 2002; long-term results of operative treatment. J Bone Joint 23:491-495. Surg Am 2003;85-A:2072-2088. Epoxy resin injections performed in cadaveric foot speci- A retrospective review of 114 patients treated surgically mens demonstrated an anastomosis of arteries about the lesser for hallux rigidus is presented. Eighty patients (93 feet) had metatarsal heads arising from both the dorsalis pedis and pos- undergone cheilectomy; 30 patients (34 feet) were treated with terior tibial arteries. This vascular network is closely associated first MTP joint arthrodesis. Based on 96% of patients avail- with the joint capsule. The authors caution that extensive cap- able at an average follow-up of 8.9 years, 97% of patients had sular stripping during metatarsal osteotomies may damage this good or excellent results (American Orthopaedic Foot and vascular network. Ankle Society forefoot scoring system). Cheilectomy was pre- dictable in lesser grades or first MTP arthritis; arthrodesis was Trnka HJ, Gebhard C, Muhlbauer M, et al: The Weil os- favored for greater degrees of arthritis. teotomy for treatment of dislocated lesser metatar- sophalangeal joints: Good outcome in 21 patients with DeFrino PF, Brodsky JW, Pollo FE, et al: First metatar- 42 osteotomies. Acta Orthop Scand 2002;73:190-194. sophalangeal arthrodesis: A clinical, pedobarographic and gait analysis study. Foot Ankle Int 2002;23:496-502. A retrospective review of 60 Weil metatarsal osteotomies performed in 31 patients for dislocated lesser MTP joints at an Clinical outcome, dynamic pedobarography (EMED) anal- average follow-up of 30 months showed 42 excellent results ysis, and kinematic and kinetic gait analysis were studied in (21 patients). A major complication was penetrating hardware 9 patients (10 feet) who underwent first MTP joint arthrodesis in 10 patients. for severe hallux rigidus. The mean American Orthopaedic Foot and Ankle Society score improved from 38 to 90 points, Trnka HJ, Nyska M, Parks BG, Myerson MS: Dorsiflex- and the EMED analysis demonstrated restoration of the ion contracture after the Weil osteotomy: Results of ca- weight-bearing function of the first ray. Kinematic data indi- daver study and three-dimensional analysis. Foot Ankle cated a shorter step length/loss of ankle plantar flexion and Int 2001;22:47-50. the kinetic data indicated a reduction in ankle power push-off. Using both cadaver and saw bone models, the authors Forefoot: Sesamoid Disorders demonstrated that the Weil metatarsal osteotomy always cre- ates plantar fragment depression that changes the center of Allen MA, Casillas MM: The Passive Axial Compres- rotation of the MTP joint, causing the interosseous muscles to sion (PAC) test: A new adjunctive provocative maneu- act more as dorsiflexors than plantar flexors. These findings ver for the clinical diagnosis of hallucal sesamoiditis. are believed to be responsible for the high rate of dorsiflexion Foot Ankle 2001;22:345-346. contractures following Weil metatarsal osteotomies. The authors describe a new provocative test that clinically Midfoot Arthritis reproduces the symptoms of sesamoid disorders. The maneu- ver may be useful in initial diagnosis and monitoring response Berlet GC, Anderson RB: Tendon arthroplasty for basal to treatment of sesamoid problems. fourth and fifth metatarsal arthritis. Foot Ankle Int 2002; 23:440-446. Forefoot: Lesser Toes and Bunionette Deformity At an average follow-up of 25 months, 12 patients under- Coughlin MJ, Schenck RC, Shurnas PJ, Bloome DM: going tendon interpositional arthroplasty for fourth and fifth Concurrent interdigital neuroma and MTP joint insta- American Academy of Orthopaedic Surgeons 499

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 TMT joint arthritis recalcitrant to nonsurgical treatment were Sabonghy EP, Wood RM, Ambrorse CG, McGarvey evaluated. In eight patients, the diagnosis was confirmed with WC, Clanton TO: Tendon transfer fixation: Comparing a preoperative differential injections; six of the eight patients tendon to tendon technique versus bioabsorbable inter- would undergo the procedure again. Outcome, based on the ference. Fit screw fixation. Foot Ankle Int 2003;24:260- American Orthopaedic Foot and Ankle Society midfoot scale, 262. was most favorable in patients who had a positive response to a preoperative differential injection. In 10 paired fresh cadaver specimens, load to failure was greater using bioabsorbable tendon fixation when compared Keiserman LS, Cassandra J, Amis JA: The Piano Key with traditional fixation techniques. However, the authors sup- Test: A clinical sign for the identification of subtle tar- ported the use of bioabsorbable screw as the mean fixation sometatarsal pathology. Foot Ankle Int 2003;24:437-438. strength provides physiologic strength at the tendon-bone in- terface. The authors describe a simple test to identify and isolate TMT synovitis and/or arthritis. Van Bergeyk AB, Younger A, Carson B: CT Analysis of hindfoot alignment in chronic lateral ankle instability. Hindfoot and Ankle: Ankle/Subtalar Instability Foot Ankle Int 2002;23:37-42. Jeys LM, Harris NJ: Ankle stabilization with hamstring The authors compared simulated weight-bearing hindfoot autograft: A new technique using interference screws. CT scans of 14 ankles with chronic ankle instability to 12 con- Foot Ankle Int 2003;24:677-679. trols in a prospective case control format. Patients with ankle instability had statistically significantly greater hindfoot varus An anatomic reconstruction of the lateral ankle ligaments based on the radiographic parameters evaluated. The authors is described using bioabsorbable interference screw fixation of suggested that although a valgus-producing calcaneal osteot- a hamstring autograft. omy is not routinely indicated, it may have a role in selected patients who fail to respond to isolated lateral ankle ligament Keefe DT, Haddad SL: Subtalar instability: Etiology, di- reconstruction. agnosis, and treatment. Foot Ankle Clin 2002;7:577-609. Hindfoot and Ankle: Ankle Arthritis The authors present a comprehensive review of the cur- rent state of the art for the evaluation and treatment of subta- Anderson T, Montgomery F, Carlsson A: Uncemented lar joint instability. STAR total ankle prostheses: Three- to eight-year follow-up of fifty-one consecutive ankles. J Bone Joint Krips R, Brandsson S, Swensson C, et al: Anatomical re- Surg Am 2003;85-A:1321-1329. construction and Evans tenodesis of the lateral liga- ments of the ankle: Clinical and radiological findings af- Fifty-one consecutive cementless mobile-bearing Scandi- ter followup for 15-30 years. J Bone Joint Surg Br 2002; navian Total Ankle Replacement ankle procedures were eval- 84:232-236. uated at intermediate follow-up. The median Kofoed score im- proved from 39 to 70 points at the time of follow-up. Twelve This retrospective review compares 54 patients undergoing ankles had to be revised (seven loosening, two bearing frac- an anatomic reconstruction of the lateral ankle ligaments and ture, three other complications) and eight other ankles had ra- 45 patients treated with an Evans tenodesis for lateral ankle diographic signs of loosening. Median range of motion was the instability. The study demonstrated that the functional out- same preoperatively and postoperatively. With revision as the come of the Evans tenodesis deteriorated more rapidly than end point, the estimated 5-year survival was 70%. the anatomic reconstruction. Good to excellent results were noted in 43 patients in the anatomic reconstruction group and Buechel FF, Buechel FF Jr, Pappas MJ: Ten-year evalua- 15 in the Evans tenodesis group. tion of cementless Buechel-Pappas meniscal bearing to- tal ankle replacement. Foot Ankle Int 2003;24:462-472. Pijnenburg AC, Bogaard K, Krips R, et al: Operative and functional treatment of rupture of the lateral liga- Fifty cementless Buechel-Pappas mobile-bearing total an- ment of the ankle: A randomized, prospective trial. kle replacements in 49 patients were evaluated. Good to excel- J Bone Joint Surg Br 2003;85:525-530. lent results were observed in 88% of patients. Postoperative range of motion was similar to preoperative motion. Revision The authors prospectively randomized 370 patients with a was required in 4% of patients. Cumulative survivorship (us- rupture of at least one lateral ankle ligament to undergo ei- ing revision as an end point) was 94% at 10 years. ther functional or surgical treatment. At a median follow-up of 8 years, 86% of patients were available for evaluation with the Coester LM, Saltzman CL, Leupold J, Pontarelli W: Povacz score and anterior drawer testing. Surgical treatment Long-term results following ankle arthrodesis for post- gave better long-term outcome with regard to residual pain, traumatic arthritis. J Bone Joint Surg Am 2001;83-A:219- recurrent sprains (22% versus 34%), and stability (anterior 236. drawer positive, 30% versus 54%). At a mean follow-up of 22 years, 23 patients who had a successful isolated ankle arthrodesis for posttraumatic tibiota- lar arthritis were evaluated. Most patients had substantial, ac- 500 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction celerated arthritic changes in the ipsilateral foot that often 46 to 53 (mental). Four of seven patients reported good to ex- limited function when compared with the contralateral foot. cellent results; follow-up radiographs revealed joint space nar- Osteoarthritis did not develop more frequently in the ipsilat- rowing, osteophytes, and sclerosis even in patients with excel- eral knee or contralateral foot. lent clinical status. There was a 42% failure rate. Improvements in technique may lead to a more favorable out- Coull R, Raffiq T, James LE, Stephens MM: Open treat- come. ment of anterior impingement of the ankle. J Bone Joint Surg Br 2003;85:550-553. Marijnissen AC, Van Roermund PM, Van Melkebeek J, Lafeber FP: Clinical benefit of joint distraction in the The outcome for the open treatment of anterior ankle im- treatment of ankle osteoarthritis. Foot Ankle Clin 2003; pingement was evaluated at a mean follow-up of 7.3 years in 8:335-346. 23 patients. The Ogilvie-Harris score improved in all patients. Ankle dorsiflexion did not return to normal, but symptomatic The authors describe their technique and results with dis- relief allowed 79% of patients to return to athletic activity at traction arthroplasty for ankle osteoarthritis. the same level. Two patients with preoperative joint space nar- rowing had a poor result. Myerson MS, Mroczek K: Perioperative complications of total ankle arthroplasty. Foot Ankle Int 2003;24:17-21. Donley BG, Ward DM: Implantable electrical stimula- tion in high-risk hindfoot fusions. Foot Ankle Int 2002; This retrospective review of a single surgeon’s experience 23:13-18. with 50 consecutive total ankle replacements compares the first 25 with the second 25 procedures. The distinct improve- The authors report a single surgeon’s experience with 13 ment in component position and fewer complications in the implantable bone stimulators used as an adjunct for ankle/ second group suggest that a learning curve exists in perfor- hindfoot arthrodeses performed in patients with increased risk mance of total ankle arthroplasty. for nonunion. At an average follow-up of 25 months, 92% of patients achieved successful fusion. The subcutaneous device Saltzman CL, Amendola A, Anderson R, et al: Surgeon was bothersome to eight patients. training and complications in total ankle arthroplasty. Foot Ankle Int 2003;24:514-518. Fuchs S, Sandmann C, Skwara A, et al: Quality of life 20 years after arthrodesis of the ankle: A study of adjacent The first 10 total ankle replacements of nine orthopaedic joints. J Bone Joint Surg Br 2003;85:994-998. foot and ankle surgeons were reviewed. No method of training (observing inventor, hands-on surgical training course, foot Retrospective, long-term follow-up of 18 successful ankle and ankle fellowship) had a statistically demonstrable positive arthrodeses (17 patients) demonstrated significant deficits of impact on preparing surgeons for total ankle replacement. functional outcome, limitations of activities of daily living, and radiographic changes in adjacent foot articulations, based on Thomas RH, Daniels TR: Current concepts review: An- the Olerud Molander Ankle score, radiographic evaluation, kle arthritis. J Bone Joint Surg Am 2003;85-A:923-936. and the Medical Outcomes Study Short Form-36 outcomes in- strument. The authors present a review of the current standards for evaluation and treatment of ankle arthritis. Ishikawa SN, Murphy GA, Richardson EG: The effect Wood PL, Deakin S: Total ankle replacement: The re- of cigarette smoking on hindfoot fusions. Foot Ankle Int sults in 200 ankles. J Bone Joint Surg Br 2003;85:334- 2002;23:996-998. 341. In a group of 160 patients who had hindfoot fusions, smok- At a mean follow-up of 46 months, the authors reviewed ers had a significantly higher nonunion rate than nonsmokers the results in 200 mobile-bearing cementless Scandinavian To- (19% versus 7%). The relative risk of nonunion was 2.7 times tal Ankle Replacements. The cumulative survival rate at 5 higher for smokers than nonsmokers. No statistically signifi- years was 93%, with decision for revision used as an end cant difference was noted in the rate of infection or delayed point. Most frequent complications were delayed wound heal- wound healing between the groups. ing and malleolar fracture. A complication requiring further surgery developed in 8 ankles, and 14 ankles were either re- Kim CW, Jamali A, Tontz W Jr, et al: Treatment of post- vised or converted to arthrodesis. traumatic ankle arthrosis with bipolar tibiotalar osteo- chondral shell allografts. Foot Ankle Int 2002;23:1091- Hindfoot and Ankle: Osteochondral Lesions of the 1102. Talus Seven patients undergoing fresh tibiotalar osteochondral Al Shaikh RA, Chou LB, Mann JA, et al: Autologous shell allografts for posttraumatic ankle arthrosis were evalu- osteochondral grafting for talar cartilage defects. Foot ated at an average follow-up of 12 years. The ankle scores in- Ankle Int 2002;23:381-389. creased from 25 to 43 points; the Medical Outcomes Study 12- Item Short Form scores increased from 30 to 38 (physical) and At an average follow-up of 16 months, 19 osteochondral lesions of the talus treated with osteochondral autograft trans- American Academy of Orthopaedic Surgeons 501

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 fer system from the ipsilateral knee trochlear border were findings have implications should cartilage repair procedures evaluated. All patients had failed to respond to nonsurgical be planned based on arthroscopic sizing of osteochondral de- measures and 68% had failed to respond to débridement/ fects of the talar dome. excision. The average size of the lesions before the autologous osteochondral grafting procedure was 10 mm × 12 mm. Four- Shearer C, Loomer R, Clement D: Nonoperataively teen patients required malleolar osteotomy (13 medial, 1 lat- managed stage V osteochondral talar lesions. Foot Ankle eral). The average postoperative American Orthopaedic Foot Int 2002;23:651-654. and Ankle Society score at follow-up was 91; the average Ly- sholm knee score was 97. Based on nonsurgical treatment of 25 osteochondral le- sions of the talus associated with subchondral cysts, the au- Hangody L, Kish G, Modis L, et al: Mosaicplasty for the thors suggested that (1) most lesions remain radiographically treatment of osteochondritis dissecans of the talus: Two stable, (2) nonsurgical management is a viable option for stage to seven year results in 36 patients. Foot Ankle Int 2001; V osteochondral lesions with little risk of developing signifi- 22:552-558. cant osteoarthritis, (3) the general course of stage V lesions is benign in most patients, and (4) the development of mild ra- Intermediate follow-up of a single surgeon’s experience diographic changes of osteoarthritis does not correlate with with 36 osteochondral lesions of the talus treated using the outcome. However, the authors acknowledged that lesions that mosaicplasty technique he invented demonstrated 94% good increase significantly in size correlate with poor outcome. to excellent results (Hannover scoring system for ankle func- tion). Osteochondral plugs were transferred from the ipsilat- Schimmer RC, Dick W, Hintermann B: The role of ankle eral knee; no long-term donor site morbidity was observed. arthroscopy in the treatment strategies of osteochondri- tis dissecans lesions of the talus. Foot Ankle Int 2001;22: Hintermann B, Boss A, Schafer D: Arthroscopic findings 895-900. in patients with chronic ankle instability. Am J Sports Med 2002;30:402-409. The authors report that arthroscopy represents a helpful diagnostic tool in assessing extent and, in particular, stability Based on a cohort of 148 patients with symptomatic and integrity of the osteochondral talar defect. They recom- chronic ankle instability undergoing ankle arthroscopy, 66% of mend that arthroscopy be performed in all patients with os- ankles with lateral ligament instability and 98% with deltoid teochondral lesions of the talus to define the treatment strat- ligament injuries were noted to have associated cartilage dam- egy. age, respectively. Schuman L, Struijs PA, Van Dijk CN: Arthroscopic Peterson L, Brittberg M, Lindahl A: Autologous chon- treatment for osteochondral defects of the talus: Results drocyte transplantation of the ankle. Foot Ankle Clin at followup at 2 to 11 years. J Bone Joint Surg Br 2002; 2003;8:291-303. 84:364-368. The inventors of autologous chondrocyte transplantation Thirty-eight patients who had been treated with arthro- (Carticel procedure) present their experience with this tech- scopic débridement and drilling for osteochondral lesions of nique in the management of osteochondral lesions of the talus. the talus were evaluated at a mean follow-up of 4.8 years. Twenty-two patients underwent a primary procedure, and 16 Sammarco GJ, Makwana MK: Treatment of talar osteo- had failed previous surgery. Good to excellent results were chondral lesions using local osteochondral graft. Foot found in 86% of the primary procedures and 75% of revision Ankle Int 2002;23:693-698. cases. The authors describe a technique for local osteochondral Scranton PE Jr, McDermott JE: Treatment of Type V transfer in the management of osteochondral talar dome le- osteochondral lesions of the talus with ipsilateral knee sions; the graft was harvested from the medial or lateral talar osteochondral autografts. Foot Ankle Int 2001;22:380- articular facet. Exposure to the defect was facilitated through 384. a replaceable bone block removed from the anterior tibial plafond. In 12 patients with an average follow-up of 25 Ten consecutive patients who had osteochondral lesions of months, the average American Orthopaedic Foot and Ankle the talus were treated with osteochondral autograft transplan- Society score improved from 64 to 91 points. No complications tation and were evaluated at short-term follow-up. All lesions were reported. were associated with subchondral cysts. These preliminary re- sults suggest significant improvement in all 10 patients, with an Schafer D, Boss A, Hintermann B: Accuracy of arthro- average increase in the American Orthopaedic Foot and An- scopic assessment of anterior ankle cartilage lesions. kle Society ankle/hindfoot score of 27 points. Foot Ankle Int 2003;24:317-320. Thordarson DB, Bains R, Shepherd LE: The role of an- The authors demonstrated that iatrogenically created talar kle arthroscopy on the surgical management of ankle dome defects were overestimated and underestimated when fractures. Foot Ankle Int 2001;22:123-125. evaluated arthroscopically in 10 cadaver specimens. These 502 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction Nineteen patients with surgical treatment of their unstable Hindfoot and Ankle: Acquired Flatfoot Defromity ankle fractures were prospectively randomized to include or not include ankle arthroscopy. Eight of nine patients random- Choi K, Lee S, Otis JC, Deland JT: Anatomical recon- ized to the arthroscopy group had articular damage that struction of the spring ligament using peroneus longus prompted arthroscopic treatment. At an average follow-up of tendon graft. Foot Ankle Int 2003;24:430-436. 21 months, no difference was noted in the Medical Outcomes Study Short Form-36 Health Survey or lower extremity scores Using a cadaver foot-ankle flatfoot model comparing between the two groups. three methods of spring ligament reconstruction using the per- oneus longus tendon, it was shown that a superomedial/ Hindfoot and Ankle: Insertional Achilles Tendinopathy plantar passage of tendon through the calcaneus and navicular was most effective. Calder JD, Saxby TS: Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int 2003;24:119-121. Coetzee JC, Hansen ST: Surgical management of severe deformity resulting from posterior tibial tendon dys- A chart review of 49 open débridements of insertional function. Foot Ankle Int 2001;22:944-949. Achilles tendinosis in which less than 50% of the tendon was excised suggested that early mobilization does not predispose A retrospective review of 12 feet in 11 patients undergoing to postsurgical rupture. At a minimum follow-up of 6 months, major hindfoot corrective surgery with an extended triple ar- only two failures were noted: one patient with psoriatic arthri- throdesis for severe acquired pes planovalgus deformity dem- tis and another who had bilateral simultaneous procedures. onstrated a statistically significant improvement in the average American Orthopaedic Foot and Ankle Society hindfoot score Den Hartog BD: Flexor hallucis longus transfer for (30 to 74) and radiographic parameters. Despite multiple com- chronic Achilles tendinosis. Foot Ankle Int 2003;24:233- plications (wound problems, delayed unions) requiring revi- 237. sion surgery, the extensive procedure provided a justifiable im- provement in patients’ quality of life. Twenty-nine tendons (26 patients) undergoing reconstruc- tion for chronic Achilles tendinosis using a flexor hallucis lon- Guyton GP, Jeng C, Krieger LE, Mann RA: Flexor digi- gus augmentation were evaluated at an average follow-up of 3 torum longus transfer and medial displacement calca- years. Time to maximum improvement was 8.2 months. The av- neal osteotomy for posterior tibial tendon dysfunction: erage American Orthopaedic Foot and Ankle Society ankle- A middle-term clinical follow-up. Foot Ankle Int 2001; hindfoot score improved from 42 to 90 points. No patient had 22:627-632. a clinically significant functional deficit of the hallux. At an average follow-up of 32 months, 26 patients under- McGarvey WC, Palumbo RC, Baxter DE, Leibman BD: going flexor digitorum longus tendon transfer with medial dis- Insertional Achilles tendinosis: Surgical treatment placement calcaneal osteotomy for stage II posterior tibial through a central tendon splitting approach. Foot Ankle tendon dysfunction were evaluated. Only 16 patients were Int 2002;23:19-25. evaluated by physical examination for the follow-up evalua- tion. The average American Orthopaedic Foot and Ankle So- Twenty-two patients with insertional Achilles tendinosis ciety hindfoot pain subscale score was 35 of 40 and the Ameri- were treated through a central tendon splitting approach with can Orthopaedic Foot and Ankle Society functional score was tendon débridement, retrocalcaneal bursectomy, and partial 27 of 28. Three failures included two early failures of fixation calcanectomy. This approach revealed that the disease process of the flexor digitorum longus tendon and one failure at ap- was isolated to the central tendon insertion in 21 of the pa- proximately 6 years during pregnancy. tients. At an average follow-up of 33 months, 82% of patients were satisfied with the surgery, 77% would have the surgery Louden KW, Ambrose CG, Beaty SG, et al: Tendon again, but only 59% were completely pain free and could re- transfer fixation in the foot and ankle: Biomechanical turn to unlimited activities. study evaluating two sizes of pilot holes for bioabsorb- able screws. Foot Ankle Int 2003;24:67-72. Tashjian RZ, Hur J, Sullivan RJ, et al: Flexor hallucis longus transfer for repair of chronic achilles tendinopa- Bioabsorbable screw fixation for tendon transfer proce- thy. Foot Ankle Int 2003;24:673-676. dures, including flexor digitorum longus or flexor hallucis lon- gus transfer to the navicular for correction of posterior tibial Using 14 fresh-frozen cadaver lower limbs, a short flexor tendon insufficiency, is being used with greater frequency in hallucis longus tendon harvest (posteromedial ankle incision) foot and ankle surgery. This biomechanical study performed in was compared with a long (traditional) flexor hallucis longus cadaver specimens demonstrates that initial pull-out strength tendon harvest (second medial midfoot incision). The short for 5- or 7-mm screws exceeds the requisite strength for ten- flexor hallucis longus tendon harvest yielded an average ten- don transfer to the navicular. The 7-mm screw diameter with don length of 5.2 cm; the long flexor hallucis longus harvest pilot holes of 5.5 mm or 6.5 mm may be preferable given the yielded and average tendon length of 8.1 cm. average flexor digitorum longus or flexor hallucis longus ten- don diameter approaching 5 mm. American Academy of Orthopaedic Surgeons 503

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST transfer for posterior tibial tendon dysfunction. American Or- Jr, Sangeorzan BJ: Talocalcaneal and subfibular im- thopaedic Foot and Ankle Society hindfoot scores and radio- pingement in symptomatic flatfoot in adults. J Bone graphic parameters were significantly improved for both Joint Surg Am 2002;84-A:2005-2009. groups. The complication rate (reported for 34 feet) was high for both groups; the rate of nonunion (12%) and delayed Nineteen patients with symptomatic acquired flatfoot de- union (18%) was considerable for the calcaneocuboid distrac- formity were evaluated with simulated weight-bearing CT tion arthrodesis group. analysis of the hindfoot and compared with a control group. In the study group, sinus tarsi impingement was noted in 92% Viladot R, Pons M, Alvarez F, Omana J: Subtalar arthro- and subfibular impingement was observed in 66% versus 0 ereisis for posterior tibial tendon dysfunction: A prelim- and 5% in the control group, respectively. inary report. Foot Ankle Int 2003;24:600-606. Moseir-LaClair S, Pomeroy G, Manoli A: Intermediate Twenty-one patients with stage II flexible posterior tibial follow-up of the double osteotomy and tendon transfer tendon dysfunction were treated with flexor digitorum longus procedure for stage II posterior tibial tendon insuffi- augmentation or flexor hallucis longus tendon transfer and ciency. Foot Ankle Int 2001;22:283-291. subtalar arthroereisis (sinus tarsi implant). Nineteen patients reviewed at an average 27-month follow-up had an average Twenty-six patients with 28 acquired pes planovalgus feet improvement in the American Orthopaedic Foot and Ankle (Johnson stage II) were managed with flexor digitorum longus Society score from 47 to 82 points. Two patients required re- transfer, Achilles tendon lengthening, and a double calcaneal moval of the implant secondary to pain. osteotomy (medial displacement and lateral column lengthen- ing). At a mean follow-up of 5 years, the mean American Or- Wacker JT, Hennessy MS, Saxby TS: Calcaneal osteot- thopaedic Foot and Ankle Society ankle-hindfoot score was omy and transfer of the tendon of flexor digitorum lon- 90. All osteotomies united and average radiographic parame- gus for stage-II dysfunction of tibialis posterior: ters remained improved at follow-up. Fourteen percent of pa- Three-to five-year results. J Bone Joint Surg Br 2002;84: tients demonstrated radiographic signs of calcaneocuboid ar- 54-58. thritis. At mean follow-up of 51 months, 44 patients treated with Sammarco GJ, Hockenbury RT: Treatment of stage II flexor digitorum longus transfer and medial displacement cal- posterior tibial tendon dysfunction with flexor hallucis caneal osteotomy had an average improvement in the Ameri- longus transfer and medial displacement calcaneal os- can Orthopaedic Foot and Ankle Society hindfoot score from teotomy. Foot Ankle Int 2001;22: 305-312. 49 to 88 points. The outcome was good to excellent in 43 pa- tients for pain and function, and good to excellent in 36 pa- At an average follow-up of 18 months, 17 patients who tients for alignment. No poor results were observed. had undergone medial displacement calcaneal osteotomy and flexor hallucis longus tendon reconstruction for stage II poste- Hindfoot and Ankle: Plantar Fasciitis rior tibial tendon reconstruction were evaluated. The average American Orthopaedic Foot and Ankle Society hindfoot score DiGiovanni BF, Nawoczenski DA, Lintal ME, et al: Tis- improved from 62 to 84 points. Despite radiographic assess- sue specific plantar fascia-stretching exercise enhances ment demonstrating that there was no statistically significant outcomes in patients with chronic heel pain. J Bone improvement in the medial longitudinal arch in the study Joint Surg Am 2003;85-A:1270-1277. group, good to excellent results were reported in most pa- tients. One hundred one patients with chronic plantar fasciitis were randomized to undergo either plantar fascia tissue− or Tashjian RZ, Appel AJ, Banerjee R, DiGiovanni CW: traditional Achilles tendon−stretching regimen. Greater im- Endoscopic gastocnemius recession: evaluation in a ca- provement was observed in the plantar fascia−stretching pro- daver model. Foot Ankle Int 2003;24: 607-613. gram with regard to pain, activity limitation, and patient satis- faction. Endoscopic gastrocnemius recession was evaluated in 15 cadaver specimens. The sural nerve was definitively visualized Haake M, Buch M, Schoellner C, Goebel F: Extracorpo- in 33% of the procedures and an average of 83% of the gas- real shock wave therapy for plantar fasciitis: Random- trocnemius aponeurosis was transected. Improvement in mean ized controlled multicentre trial. BMJ 2003;327:75. ankle dorsiflexion with the knee flexed was 20°. This multicenter study of 272 patients with chronic plantar Thomas RL, Wells BC, Garrison RL, Prada SA: Prelimi- fasciitis compared extracorporeal shock wave therapy with a nary results comparing two methods of lateral column placebo group. The success rate at 12 weeks was 34% in the lengthening. Foot Ankle Int 2001;22:107-119. shock wave therapy group and 30% in the placebo group. The authors concluded that extracorporeal shock wave therapy is At a minimum follow-up of at least 1 year, 10 Evans open- ineffective in treating chronic plantar fasciitis. ing wedge osteotomies were compared with 17 calcaneocuboid distraction arthrodeses, both of which were performed with structural iliac crest autograft and flexor digitorum longus 504 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 40 Foot and Ankle Reconstruction Labib SA, Gould JS, Rodriguez-del-Rio FA, Lyman S: At an average follow-up of 27 months, 22 patients with Heel Pain Triad (HPT): The combination of plantar fas- nonhealing heel wounds were treated with partial calcanec- ciitis, posterior tibial tendon dysfunction and tarsal tun- tomy. Wounds healed in all patients; none required subsequent nel syndrome. Foot Ankle Int 2002;23:212-220. transtibial amputation. Twelve patients had delayed wound healing, and 11 additional procedures were performed on the Fourteen patients were surgically treated for a combina- heels of 9 patients. tion of plantar fasciitis, posterior tibial tendon dysfunction, and tarsal tunnel syndrome. At a mean follow-up of 17 Cooper PS: Application of external fixators for manage- months, a marked improvement was noted in 88% of patients ment of Charcot deformities of the foot and ankle. Foot for pain, activity level, walking distance, walking surface, and Ankle Clin 2002;7:207-254. limp. A single surgeon’s experience with external fixation for Rompe JD, Schoellner C, Nafe B: Evaluation of low- the management of infected and noninfected Charcot neuro- energy extracorporeal shock-wave application for treat- pathic deformities of the foot and ankle is presented. ment of chronic plantar fasciitis. J Bone Joint Surg Am 2002;84-A:335-341. Guyton GP, Saltzman CL: The diabetic foot: Basic mechanism of disease. Instr Course Lect 2002;51:169- This prospective, randomized, controlled trial of 112 pa- 181. tients with chronic plantar fasciitis compared three applica- tions of 1,000 low-energy shock wave impulses (group I) to The authors present a review of the pertinent basic sci- three applications of 10 low-energy shock wave impulses ence, evaluation, and current state of the art in the manage- (group II). At 6 months, the rate of good to excellent results ment of diabetic foot problems. was significantly better (47%) in group I than in group II. By 5 years, 13% of patients in group I and 58% in group II had Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of undergone surgical plantar fascia release. The authors con- Achilles tendon lengthening on neuropathic plantar ul- cluded that treatment with 1,000 impulses of low-energy shock cers. J Bone Joint Surg Am 2003;85-A:1436-1445. waves may be an effective therapy for plantar fasciitis and may help patients avoid surgery. Sixty-four patients with neuropathic ulcers were random- ized to receive total contact casting alone or combined with Speed CA, Nichols D, Wies J, et al: Extracorporeal percutaneous Achilles tendon lengthening. Eighty-eight per- shock wave therapy for plantar fasciitis: A double blind cent of the ulcers in the total contact cast group and 100% in randomized controlled trial. J Orthop Res 2003;21:937- the Achilles tendon lengthening group healed after a mean 940. duration of 41 days and 58 days, respectively. The risk for ulcer recurrence was 75% less at 7 months and 52% less at 2 years This double-blind randomized controlled trial compared in the Achilles tendon lengthening group than in the isolated active therapy (moderate-dose shock wave therapy) to sham total contact cast group. therapy for 88 patients with plantar fasciitis of at least 3 months duration. Over a 6-month period, both groups showed Classic Bibliography significant improvement, but no statistically significant differ- ences were observed in any outcome measures. Berndt A, Hardy M: Transchondral fractures (osteo- chondritis dissicans) of the talus. J Bone Joint Surg Am Watson TS, Anderson RB, Davis WH, Kiebzak GM: Dis- 1959;41:988. tal tarsal tunnel release with plantar fasciotomy for chronic heel pain: An outcome analysis. Foot Ankle Int Brostrom L: Sprained ankles: V. Treatment and progno- 2002;23:530-537. sis in recent ligament ruptures. Acta Chir Scand 1966; 132:537-550. Seventy-five patients (80 heels) with an average of 20 months of nonsurgical treatment underwent distal tarsal tun- Brostrom L: Sprained ankles: VI. Surgical treatment of nel release with a partial plantar fasciotomy. Eighty-eight per- “chronic” ligament ruptures. Acta Chir Scand 1966;132: cent of patients had good to excellent results at final follow- 551-565. up; 52% of patients required in excess of 6 months to reach maximum medical improvement. In the 44 patients (46 heels) Coughlin MJ, Carlson RE: Treatment of hallux valgus who responded to a Medical Outcomes Study Short Form-36 with an increased distal metatarsal articular angle: Eval- and foot function index questionnaire, 91% were somewhat to uation of double and triple first ray osteotomies. Foot very satisfied with their outcomes. Ankle Int 1999;20:771-776. Hindfoot and Ankle: Diabetic Foot/Ankle and Charcot Gould N, Seligson D, Gassman J: Early and late repair Neuroarthropathy of lateral ligament of the ankle. Foot Ankle 1980;1:84-89. Bollinger M, Thordarson DB: Partial calcanectomy: An alternative to below knee amputation. Foot Ankle Int 2002;23:927-932. American Academy of Orthopaedic Surgeons 505

Foot and Ankle Reconstruction Orthopaedic Knowledge Update 8 Hattrup SJ, Johnson KA: Subjective results of hallux Myerson MS, Henderson MR, Saxby T, Short KW: Man- rigidus following treatment with cheilectomy. Clin agement of midfoot diabetic neuroarthropathy. Foot Orthop 1988;226:182-191. Ankle Int 1994;15:233-241. Hepple S, Winson IG, Glew D: Osteochondral lesions of Papa J, Myerson M, Girard P: Salvage, with arthrodesis, the talus: A revised classification. Foot Ankle Int 1999; in intractable diabetic neuropathic arthropathy of the 20:789-793. foot and ankle. J Bone Joint Surg Am 1993;75:1056-1066. Johnson KA, Strom DA: Tibialis posterior tendon dys- Pell RF, Myerson MS, Schon LC: Clinical outcome after function. Clin Orthop 1989;239:196-206. primary triple arthrodesis. J Bone Joint Surg Am 2000; 82:47-57. Kumai T, Takakura Y, Higashiyama I, Tamai S: Arthro- scopic drilling for the treatment of osteochondral le- Sangeorzan BJ, Hansen ST Jr: Modified Lapidus proce- sions of the talus. J Bone Joint Surg Am 1999;81:1229- dure for hallux valgus. Foot Ankle 1989;9:262-266. 1235. Toolan BC, Sangeorzan BJ, Hansen ST: Complex recon- Mann RA, Clanton TO: Hallux rigidus: Treatment by struction for the treatment of dorsolateral peritalar sub- cheilectomy. J Bone Joint Surg Am 1988;70:400-406. luxation of the foot: Early results after distraction arthro- desis of the calcaneocuboid joint in conjunction with Mann RA, Rudicel S, Graves SC: Repair of hallux val- stabilization of, and transfer of the flexor digitorum lon- gus with a distal soft-tissue procedure and proximal gus tendon to, the midfoot to treat acquired pes planov- metatarsal osteotomy. A long-term follow-up. J Bone algus in adults. J Bone Joint Surg Am 1999;81:1545-1560. Joint Surg Am 1992;74:124-129. 506 American Academy of Orthopaedic Surgeons

Chapter 41 Adult Spine Trauma David H. Kim, MD Steven Zeiller, MD Alan S. Hilibrand, MD Cervical Spine Trauma ary survey. Absence of a neurologic deficit is not suffi- cient to exclude such an injury, and a hard cervical col- Clinical Evaluation lar should be applied until the cervical spine has been formally cleared and patients are considered with rea- The initial evaluation and management of patients with sonable certainty to be stable and free of significant in- spinal injuries is usually initiated in the field by para- jury. Motorcyclists in particular have a higher incidence medical personnel. These injuries are frequently the re- of thoracic spinal injuries, and evidence of blunt chest sult of high-energy trauma, and patients may require trauma should lead to further evaluation of the thoracic rapid evaluation and resuscitation according to the spine. Abdominal ecchymoses or abrasions from lap belt guidelines established by the American College of Sur- injury are associated with flexion-distraction injury of geons. Treatment of potential spinal injury begins at the the thoracolumbar spine. Extremity fractures may dis- accident scene with proper immobilization using a rigid tract the emergency personnel from identification of a cervical collar, tape, or straps to secure the patient’s spinal injury requiring treatment. Every multiple trauma neck, and transport on a firm spine board with lateral patient should undergo visual inspection of the back. A support devices. In the setting of sports-related injuries, thorough neurologic examination including sensorimo- helmet and shoulder pads should be left on until arrival tor function and level of consciousness is the final com- at the hospital where experienced personnel can per- ponent of the secondary survey. Any neurologic deficit form simultaneous removal of both in controlled fash- suggests the possibility of an injury to the spinal axis. ion. Patients with ankylosing spondylitis or diffuse idio- During the primary survey, protection of the spine pathic skeletal hyperostosis represent a special subpop- and spinal cord is the important management principle. ulation for which extra vigilance is required. Spinal in- It should be assumed that all trauma patients have a volvement with these conditions, particularly ankylosing cervical spine injury until proven otherwise, especially spondylitis, appears to increase the risk of fracture, and those with altered mental status or following blunt head patients reporting neck or back pain after even rela- or neck trauma. Inadequate initial stabilization can con- tively minor trauma should be considered for supple- tribute to further neurologic deterioration in a patient mental evaluation with CT. Nondisplaced fractures com- with an acute spinal cord injury and significantly worsen monly occur in this setting, most frequently through an eventual outcome. It has been estimated that 3% to ankylosed disk space, and carry a high rate of delayed 25% of spinal cord injuries may occur after the initial or missed diagnosis. These fractures are typically unsta- traumatic episode during early management or trans- ble and can lead to spinal cord injury if not stabilized port. While securing an airway, excessive head and neck appropriately. movement should be avoided and manual in-line immo- bilization of the head and neck should be maintained A variety of clinical grading systems have been de- whenever immobilization devices are removed. Over veloped for assessing and reporting neurologic status in the past 30 years, significant improvements in the sur- spinal cord injury patients. The Frankel scale has been vival and outcome of patients with spinal cord injuries supplanted in clinical use by the American Spinal Injury have been observed, primarily because of improved ini- Association (ASIA) scale (Figure 1). This scale was first tial management and rapid delivery by emergency ser- introduced in 1984 and has undergone revisions in 1989, vices. 1992, and most recently in 1996. The most recent version includes separate motor and sensory scores as well as a Although the initial neurologic evaluation only as- general impairment scale and incorporates the func- sesses the patient’s level of alertness and consciousness, tional independence measure, a tool that assesses the a more thorough assessment of neurologic status and functional effect of spinal cord injury. The motor score potential spinal injury is performed during the second- American Academy of Orthopaedic Surgeons 509

Adult Spine Trauma Orthopaedic Knowledge Update 8 Figure 1 ASIA form for standard neurologic classification of spinal cord injury. (Reproduced from the American Spinal Injury Association.) Figure 2 Photograph showing submandibular full-thickness skin necrosis from hard be associated with numerous potential complications in- collar immobilization in an elderly multiple trauma patient. cluding an increased risk of aspiration, limitation of res- piratory function, development of decubitus ulcers in has been shown to correlate with potential for func- the occipital and submandibular areas, and possible in- tional improvement and performance during rehab- creases in intracranial pressure (Figure 2). Moreover, ilitation. collars limit access for devices such as endotracheal tubes and central lines. Therefore, several strategies The optimal algorithm for cervical spine clearance in have been developed to allow for rapid collar removal trauma patients remains one of the most controversial in patients for whom continued immobilization is un- areas in spinal trauma care. Prolonged cervical collar necessary. immobilization in multiple trauma patients is known to Results from various studies have defined practice standards in treating the asymptomatic trauma patient. Cervical spine radiographs are not required in trauma patients without neck pain or tenderness who are awake, alert, not intoxicated, and have no distracting in- juries. This standard of care is supported by class I evi- dence from at least nine large prospective studies in- volving almost 40,000 patients. In contrast to the low incidence of spinal injury in as- ymptomatic patients, there is a 2% to 6% incidence of sig- nificant cervical spine injury requiring treatment in pa- tients who present with neck pain. It is generally agreed that symptomatic trauma patients with neck pain, tender- ness, neurologic deficit, altered mental status, or distract- ing injuries require radiographic evaluation of the cervi- cal spine before collar removal. Based on available class I evidence, a practice standard has also been suggested for 510 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 41 Adult Spine Trauma radiographic evaluation of the cervical spine in symptom- morphology and biomechanical characteristics. The third atic trauma patients. Specifically, a cervical spine series through sixth vertebrae (C3-C6) are considered typical consisting of AP and lateral views in addition to open- cervical vertebrae with small cylindrical bodies and mouth odontoid views is recommended. Supplemental CT short bifid spinous processes. The seventh cervical verte- examination is recommended to provide more detail of in- bra (C7) is a transitional vertebra between the cervical adequately visualized levels.The most common reason for and thoracic spinal regions and has a large nonbifid missing a significant injury appears to be inadequate vi- spinous process known as the vertebra prominens. sualization of the injured level, most frequently the occip- itoatlantoaxial region or cervicothoracic junction. How- The atlas is a ring containing two articular lateral ever, even with adequate plain radiographic visualization, masses with neither a body nor spinous process (Figure it has been estimated that this three-view series will miss 3). Incomplete formation of the posterior ring is rela- 15% to 17% of injuries. tively common as a developmental variation and does not represent a traumatic injury. The axis contains the Following initial plain radiographs and possibly a CT odontoid process or dens, which articulates with the an- scan, multiple options for determining safe collar re- terior arch of the axis against which it is stabilized by moval in symptomatic patients have been proposed. The the transverse ligament (Figure 4). negative predictive value of a three-view series and CT is greater than 99%, and in certain instances supplemen- Morphology of the subaxial cervical spine from C3 tal CT evaluation may be sufficient. However, despite to C6 is relatively consistent. The articular processes are the absence of apparent osseous injury, instability can located at the junction of the laminae and pedicles and exist from spinal soft-tissue disruption of ligaments, form pillars referred to as the lateral masses (Figure 5). facet capsules, and disk tissue. MRI is exquisitely sensi- The vertebral bodies are predominantly cancellous bone tive for acute soft-tissue injury and may be an option, surrounded by thin cortical bone. Superior end plates but the incidence of MRI abnormalities has been shown are concave in the coronal plane and convex in the sag- to be between 25% to 40%, suggesting that MRI may ittal plane, whereas the matching inferior end plates are be oversensitive. Moreover, MRI is only reliable for convex in the coronal plane and concave in the sagittal identifying soft-tissue injury within 48 hours of the trau- plane. The uncinate processes are osseous projections matic event. off the posterolateral surfaces of the superior end plates. Their articulation with the convex inferolateral Flexion-extension radiographs are frequently ob- surface of the more rostral vertebra comprises the joints tained to rule out significant instability. In awake and alert of Luschka. patients, active flexion-extension radiographs are safe, and no significant complications have been reported.The neg- The posterior facet joints caudal to C2 are encapsu- ative predictive value of plain films in conjunction with lated synovial joints with overlying hyaline cartilage and flexion-extension views is in excess of 99%. containing small menisci. The facet joint angle approxi- mates 45° in the sagittal plane. The transverse processes The most controversy surrounds cervical spine clear- of each cervical vertebra contain a vascular foramen. The ance in the obtunded patient. Again, MRI has been sug- vertebral artery typically passes anterior to the transverse gested as an adjunctive test but may be of limited use- processes of C7 before entering the spine at the C6 vas- fulness because of the lack of correlation between MRI cular foramen. An accessory vertebral vein typically oc- findings and clinically significant injury. Passive flexion- cupies the C7 foramen. At C1, the vertebral arteries pass extension manipulation of the cervical spine under fluo- through a foramen, and then turn posteromedially around roscopy has been advocated by several investigators. the superior articular process before entering the foramen However, there is a theoretic risk of causing iatrogenic magnum and joining to form the basilar artery. An anom- spinal cord injury to these patients because of unrecog- alous course for the vertebral artery is present 3% of the nized disk herniation. It has been suggested that many time and most commonly involves medial deviation to- obtunded patients are at low risk for any significant in- ward the vertebral body at its midpoint. The incidence of jury and can be cleared on the basis of plain radio- unilateral absence or hypoplasia of the vertebral artery is graphs and CT. Proposed high-risk criteria indicating 5% to 10%. Arterial supply of the anterior two thirds of the need for further evaluation include high-velocity the cervical spinal cord derives from a single anterior spi- motor vehicle accidents (> 35 mph), any fall from a nal artery, which is fed by segmental arteries derived from height of more than 10 feet, closed-head injuries, neuro- the vertebral arteries. Paired posterior spinal arteries de- logic deficits referable to the cervical spine, and pelvis rived from either the vertebral arteries or the posterior in- or extremity fractures. ferior cerebellar artery supply the posterior one third of the cord. Branches of the vertebral arteries provide a ro- Anatomy of the Cervical Spine bust blood supply for individual vertebra. Odontoid non- unions were previously attributed to inadequate arterial The cervical spine includes seven vertebrae. The rostral perfusion; however, recent anatomic studies have revealed two vertebrae, the atlas (C1) and axis (C2), have distinct an extensive arterial arcade surrounding the odontoid American Academy of Orthopaedic Surgeons 511

Adult Spine Trauma Orthopaedic Knowledge Update 8 Figure 3 Illustrations of the osseous anatomy of the first cervical vertebra (C1; atlas). A, Cranial view of the atlas. B, Caudal view of the atlas. (Reproduced with permission from Heller JG, Pedlow FX Jr: Anatomy of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.) Figure 4 Illustration of the ligamentous stabilizers of the atlantoaxial segment show- The central opening in each cervical vertebra is ing the relationship among the transverse (TR), alar (AL), and atlantodens (AD) liga- known as the vertebral canal, which in continuity with ments. (Reproduced with permission from Heller JG, Pedlow FX Jr: Anatomy of the the vertebral canal of adjacent vertebrae constitutes the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott- spinal canal containing the spinal cord. The average Raven, 1998, pp 3-36.) sagittal diameter of the spinal canal averages 23 mm at C1 and decreases progressively to 15 mm at C7. Nerve process supplied by anterior and posterior ascending root pairs exit the canal at each level through the inter- branches of the vertebral arteries and pharyngeal vertebral foramen formed by notches on the inferior branches from the external carotid arteries.Venous drain- and superior aspects of adjacent pedicles. The anterior age from the cervical spine occurs through pairs of exter- border of the foramen is formed by the posterolateral nal veins traveling with these major supplying arteries as uncovertebral joint and intervertebral disk, whereas the well as through an internal epidural plexus of valveless si- posterior border is formed by the caudal superior artic- nuses, both of which drain into the superior vena cava and ular facet. Each nerve root normally occupies one third azygos vein. of the cross-sectional area of the foramen. The C3 through C8 nerve roots exit anterior to the facet joints in contrast to the C2 nerve roots, which exit posterior to the C1-2 facet joint. The spinal nerves pass posterior to the vertebral artery at approximately the middle of the corresponding lateral mass. Ventral rami of C1 to C4 make up the cervical plexus and provide innervation to the cervical strap muscles and the diaphragm. Ventral rami of C5 to C8 along with T1 make up the brachial plexus. The sympathetic chain lies bilaterally in proxim- ity to the carotid sheath between the longus capitis and longus colli muscles. Stability of the cervical spine is highly dependent on the integrity of the intervertebral ligaments and disks. The osseous anatomy of the occipitocervical junction provides little inherent stability. Instead, the anterior and posterior atlanto-occipital membranes and the artic- ular capsules provide most of the stability to the cranio- cervical junction (Figure 6). The atlantoaxial joint pro- vides 50% of overall cervical rotation, with stability 512 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 41 Adult Spine Trauma Figure 5 Cranial (A) and lateral (B) illustrations of the osseous anatomy of the subaxial cervical spine. (Reproduced with permission from Heller JG, Pedlow FX Jr: Anatomy of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.) again provided largely by specific ligamentous struc- Figure 6 Illustration of the local anatomy of the occipitocervical junction. (Repro- tures. In the horizontal plane, the transverse ligament is duced with permission from Heller JG, Pedlow FX Jr: Anatomy of the cervical spine, in the primary stabilizer, whereas the apical ligament and Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp the paired alar ligaments constitute secondary stabiliz- 3-36.) ers (Figure 4). In the subaxial spine, the anterior and posterior longitudinal ligaments and intervertebral disk spinal trauma care. The classic definition by White and provide significant resistance to shear forces. Posteriorly, Panjabi describes instability as the loss of ability of the the ligamentum nuchae, interspinous ligaments, and lig- spine under physiologic loads to maintain its pattern of amentum flavum comprise the posterior ligamentous displacement so that there is no initial or additional complex and provide primary resistance against flexion neurologic deficit, no major deformity, and no incapaci- distraction forces. tating pain. This definition is elegant, but unfortunately The cervical spinal cord is ovoid in shape. It is nar- rower in the sagittal plane and has an expansion be- tween C3 and C6 to provide innervation to the upper extremities. The white matter of the spinal cord exists in the periphery and contains bundles of myelinated ax- onal tracts that are divided into three discernable col- umns (Figure 7). The posterior columns conduct ascend- ing proprioceptive, vibratory, and tactile signals from the ipsilateral side of the body. The lateral columns contain the lateral spinothalamic tracts, which conduct ascend- ing pain and thermal signals for the contralateral side, as well as the lateral corticospinal tracts, which conduct 85% of descending voluntary motor signals for the ipsi- lateral side of the body. The anterior columns contain the anterior spinothalamic tracts, which conduct ascend- ing light touch signals from the contralateral side, as well as the anterior corticospinal tracts, which conduct descending signals underlying fine motor control. Re- cent evidence suggests that the previously reported highly organized laminar structure of the white matter tracts probably does not exist. Cervical Spinal Instability The concept of spinal instability is vague and controver- sial but remains central to clinical decision making in American Academy of Orthopaedic Surgeons 513

Adult Spine Trauma Orthopaedic Knowledge Update 8 Figure 7 Illustrations of the cross-sectional anatomy of the cervical spinal cord. A, S = sacral; L = lumbar; T = thoracic; C = cervical. B, 1 = fasciculus gracilis; 2 = fasciculus cuneatus; 3 = dorsal spinocerebellar tract; 4 = ventral spinocerebellar tract; 5 = lateral spinothalamic tract; 6 = spinoolivary tract; 7 = ventral corticospinal tract; 8 = tectospinal tract; 9 = vestibulospinal tract; 10 = olivospinal tract; 11 = propriospinal tract; 12 = lateral corticospinal tract. (Reproduced with permission from Heller JG, Pedlow FX Jr: Anatomy of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.) Table 1 | Criteria for Identifying Instability at the Occipito- Table 2 | Checklist for the Diagnosis of Clinical Instability cervical Junction in the Middle and Lower Cervical Spine > 8° Axial rotation C0-C1 to one side Element Point Value > 1 mm C0-C1 translation > 7 mm Overhang C1-C2 (total right and left) Anterior elements destroyed or unable to function 2 > 45° Axial rotation C1-C2 to one side 2 > 4 mm C1-C2 translation Posterior elements destroyed or unable to function 2 < 13 mm Posterior body C2 to posterior ring C1 4 Avulsed transverse ligament Positive stretch test 1 (Adapted with permission from White AA, Panjabi MM: Clinical Biomechanics of the Spine, Radiographic criteria 1 ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 1990.) A. Flexion/extension radiographs 2 it is difficult to translate directly into clinical practice. a. Sagittal plane translation > 3.5 mm or 20% 1 Based predominantly on data from cadaveric studies, (2 points) 1 more specific criteria have been suggested for identify- ing instability at the occipitocervical junction (Table 1) b. Sagittal plane rotation > 20° (2 points) and in the subaxial cervical spine (Table 2). or B. Resting radiographs Occipital Condyle Fracture a. Sagittal plane displacement > 3.5 mm or Diagnosis of occipital condyle fractures has increased in 20% (2 points) frequency because of greater use of CT evaluation of the cervical spine in trauma patients. Sensitivity of plain b. Relative sagittal plane angulation > 11° radiography for diagnosis is as low as 3%. Occipital (2 points) condyle fractures should be considered a marker for po- tentially lethal trauma, with an 11% mortality rate from Abnormal disk narrowing associated injuries. The rate of associated cervical spine injury at an additional level is 31%. According to the Developmentally narrow spinal canal most commonly used classification system for occipital 1. Sagittal diameter < 13 mm condyle fractures developed by Anderson and Monte- or sano, type I fractures (3% of fractures) are comminuted 2. Pavlov’s ratio < 0.8 mm fractures resulting from axial load, type II fractures (22%) involve extension of a basilar skull fracture into Spinal cord damage the condyle, and type III fractures (75%) are avulsion Nerve root damage Dangerous loading anticipated Total (5 points or more = unstable) (Adapted with permission from White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 1990.) fractures and should raise clinical suspicion for an un- derlying occipitocervical dissociation. Cranial nerve pal- sies may develop days to weeks after injury and most frequently affect cranial nerves IX, X, and XI or result in visual disturbance. Treatment of occipital condyle 514 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 41 Adult Spine Trauma fractures requires ruling out occipitocervical dissocia- ing of the transverse ligament. Because data from ca- tion, particularly in patients with type III fractures, fol- daveric studies indicate that a combined lateral mass lowed by external immobilization in a cervical orthosis. displacement in excess of 7 mm strongly suggests liga- ment disruption, an 18% radiographic magnification Occipitocervical Dissociation factor has been incorporated, resulting in an increase in the measurement to 8.1 mm. However, with improve- Most instances of traumatic occipitocervical dissociation ments in MRI technology, it has become a more sensi- are lethal, with approximately 100 cases having been re- tive means of detecting a ligamentous injury than plain ported in the literature. Survivors may demonstrate a radiographs. Two types of transverse ligament injury wide range of neurologic injuries ranging from complete have been described. Midsubstance ruptures (type I in- spinal cord lesions to isolated cranial nerve palsies juries) are least likely to heal, and early surgical treat- (most commonly affecting cranial nerves VI, X, and ment with C1-2 fusion may be necessary. Type II injuries XII). Occipitocervical dissociation injuries have been involve an avulsion fracture of the ligamentous inser- classified as anterior type I, longitudinal type II, or pos- tion. Because of higher rates of healing, an initial at- terior type III. tempt at external immobilization using a halo vest is a reasonable treatment option in these patients. Diagnosis of this condition can be challenging be- cause of the poorly visualized osseous detail on plain ra- In general, most isolated anterior or posterior arch diographs of this region. The most frequently described fractures and lateral mass and transverse process frac- measurement is the Powers ratio, which divides the ba- tures of the atlas can be treated conservatively with 6 to sion to posterior arch distance by the anterior arch to 12 weeks of external immobilization. Burst fractures in- opisthion distance. A ratio greater than 1 suggests possi- volving both anterior and posterior arches with an intact ble anterior dissociation. Other measurements consid- transverse ligament are considered stable injuries that ered suggestive of injury include a basion to odontoid should also be treated with external immobilization. distance greater than 10 mm, posterior mandible to an- Disruption of the transverse ligament introduces the op- terior atlas distance greater than 13 mm, and posterior tion of early surgical fusion, typically involving a poste- mandible to odontoid distance greater than 20 mm. The rior C1-2 fusion. Multiple procedures have been de- Harris basion-axial interval–basion-dental interval scribed, including various wiring techniques and screw- method measures distance from the basion to a line rod constructs. C1-2 transarticular screw placement is drawn tangentially to the posterior border of C2 (a dis- the most stable form of fixation currently in general use tance greater than 12 mm or less than 4 mm is abnor- and obviates the need for postoperative halo immobili- mal) as well as the distance from the basion to the od- zation required with C1-2 wiring techniques. ontoid (greater than 12 mm is abnormal) and is considered by some to be the most sensitive measure- Axis Fractures ment. Overall, the sensitivity of plain radiographs for occipitocervical dissociation is approximately 57%. The Odontoid fractures are the most common type of axis sensitivity of CT and MRI has been estimated to be fracture and have been classified by Anderson and 84% and 86%, respectively, and one or both of these ad- D’Alonzo as type I avulsion fractures of the tip, type II junctive studies is recommended for patients with sus- fractures through the waist of the odontoid process, or pected occipitocervical dissociation injuries. type III fractures extending into the C2 vertebral body. Nearly all odontoid fractures will require some form of Use of traction is associated with a 10% rate of neu- treatment. rologic deterioration and should be avoided in patients with these injuries. In patients with survivable injuries, Type I fractures can be treated with an external an instrumented occipitocervical fusion is recom- orthosis once the possibility of an associated occipito- mended. Different techniques of fixation have been de- cervical dissociation has been excluded. Type III frac- scribed, including occipital and cervical wiring, wire tures have been reported to have a sufficiently high mesh and methylmethacrylate, and occipitocervical plat- healing rate with rigid external immobilization in a halo ing. More recently, modular occipital plates have been vest. Treatment of type II fractures is controversial and developed that can be rigidly locked to longitudinal depends largely on specific patient and fracture charac- rods placed across the subaxial cervical spine (Figure 8). teristics. Elderly patients tolerate halo vest immobiliza- tion poorly, demonstrate decreased healing rates, and Atlas Fractures should be considered for early C1-2 surgical fusion. Eld- erly debilitated patients who are at increased risk of Fractures of the atlas constitute approximately 7% of medical complications from surgical treatment can be cervical spine fractures. Jefferson fractures are bilateral treated with an external orthosis for 6 to 12 weeks with fractures of the anterior and posterior arches resulting the understanding that successful fusion is unlikely to from an axial load (Figure 9). Long-term stability de- occur. In most patients, a fibrous nonunion develops pends on the mechanism of injury and subsequent heal- American Academy of Orthopaedic Surgeons 515

Adult Spine Trauma Orthopaedic Knowledge Update 8 Figure 8 Lateral (A) and AP (B) radiographs of occipitocervical segmental fixation implants (DePuy AcroMed Summit system, Raynham, MA). that provides sufficient stability for routine daily activi- complishing a posterior C1-2 fusion. Traditional sublam- ties. Nevertheless, these patients should be informed inar wiring techniques (Gallie and Brooks fusions) are that they remain at risk for spinal cord injury in the being supplemented or replaced by more rigid fixation event of a fall or motor vehicle accident. methods such as C1-2 transarticular screws and C1 lat- eral mass and C2 pedicle screw-rod constructs (Figure In younger, healthy patients with a type II fracture, 11). These more rigid fixation techniques provide the specific fracture characteristics assume increased signifi- surgeon with the opportunity to avoid postoperative cance. Nondisplaced fractures diagnosed early should be halo vest immobilization. treated with halo vest immobilization for 6 to 12 weeks. Risk factors for nonunion include fracture comminu- Traumatic Spondylolisthesis of the Axis tion, displacement of more than 6 mm, posterior dis- placement, delay in diagnosis, and patient age greater This injury is characterized by bilateral fractures of the than 50 years. Early surgical treatment is an option for pars interarticularis and is also known as a hangman’s patients with any of these risk factors. Surgical treat- fracture, although recent efforts have been made to re- ment should also be considered for fractures in which place this term with traumatic spondylolisthesis of the reduction cannot be achieved or maintained. axis. Most injuries of this type that occur in the United States are the result of motor vehicle accidents, and the Anterior odontoid screw osteosynthesis using a sin- forces involved are likely a combination of hyperexten- gle screw placed with lag technique is an option for sion, compression, and rebound flexion. The currently treating both type II and type III noncomminuted frac- popular classification scheme is Levine and Edwards’ tures. For the best results using this technique, the frac- modification of previous systems described by Effendi ture should be diagnosed early, reduction must be possi- and Francis and is based on mechanism of injury (Fig- ble, and patient body habitus must allow achievement of ure 12). Type I fractures result from axial compression proper intraoperative screw trajectory (Figure 10). In and hyperextension and demonstrate less than 3 mm addition, odontoid fracture obliquity should run from displacement and no angulation. Type II fractures result anterosuperior to posteroinferior. Otherwise, surgical treatment may involve any of several methods for ac- 516 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 41 Adult Spine Trauma Figure 9 Illustrations of common atlas frac- ture patterns. A, posterior arch fracture. B, Lateral mass fracture. C, Classic burst (Jeffer- son fracture). D, Unilateral anterior arch frac- ture. E, Transverse process fracture. F, Anterior arch avulsion fracture. (Reproduced with per- mission from Klein GR, Vaccaro AR: Cervical spine trauma: Upper and lower, in Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. Philadelphia, PA, Mosby, 2003, pp 441-462.) from hyperextension and axial load followed by re- up to 5 mm of displacement can occur without disruption bound flexion and demonstrate translation of greater of posterior ligaments or the C2-3 disk. Suggested indica- than 3 mm as well as angulation. Type IIA fractures are tions for surgical treatment include type II fractures with characterized by angulation without significant transla- severe angulation, type III fractures with disruption of the tion and result from a flexion-distraction injury. Identifi- C2-3 disk, or inability to achieve or maintain fracture re- cation of this fracture type is important because applica- duction. All type III fractures associated with facet dislo- tion of traction may cause further fracture displacement cation require open reduction and fusion. Surgical options and should be avoided. Type III fractures are essentially include anterior C2-3 interbody fusion, posterior C1-3 fu- type I pars fractures associated with injury to the C2-3 sion, or bilateral C2 pars screw osteosynthesis. facet joints, most commonly bilateral facet dislocation. These fractures are thought to result from flexion- Fractures and Dislocations of the Subaxial Spine distraction followed by hyperextension. A type IA frac- ture pattern was recently added to this classification sys- The most commonly used classification system for sub- tem to describe asymmetric fracture lines with minimal axial spine injuries is the system developed by Allen and translation and no angulation. This fracture is thought to associates. Six distinct phylogenies were described based result from hyperextension with a component of lateral on mechanism of injury, with each phylogeny being sub- bending forces. divided into stages of progressive severity. The three commonly observed categories are compressive flexion, Most patients with traumatic spondylolisthesis of the distractive flexion, and compressive extension. Vertical axis can be successfully treated with 6 to 12 weeks of ex- compression is observed less commonly, and the two ternal immobilization in a cervical orthosis or halo vest. least common categories are distractive extension and Data from a recent cadaveric study have suggested that lateral flexion. American Academy of Orthopaedic Surgeons 517

Adult Spine Trauma Orthopaedic Knowledge Update 8 of disrupted posterior elements. In patients with this type of injury, supplemental posterior instrumented fu- sion should be considered. Figure 10 Odontoid radiograph of anterior odontoid screw fixation. (Reproduced with Facet Dislocations permission from Klein GR, Vaccaro AR: Cervical spine trauma: Upper and lower, in Patients with cervical facet dislocations should undergo Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. timely reduction of their injuries upon diagnosis. Classi- Philadelphia, PA, Mosby, 2003, pp 441-462.) cally, plain radiographic evidence of vertebral body sub- luxation of 25% has been reported to suggest a uni- Compression and Burst Fractures lateral facet dislocation, whereas vertebral body Compression fractures are defined by compressive fail- subluxation of 50% has been reported to suggest a bilat- ure of the anterior half of the vertebral body (anterior eral dislocation (Figure 13). Unilateral facet dislocations column) without disruption of the posterior body cortex are commonly associated with a monoradiculopathy and without retropulsion into the spinal canal. Patients that improves following application of traction. Bilateral are typically neurologically intact, and in the absence of facet dislocations are often associated with significant significant deformity or instability, most fractures can be spinal cord injuries. Awake and alert patients can safely treated with external immobilization for 6 to 12 weeks. undergo closed reduction with progressive application of axial traction forces. It is crucial that these patients Burst fractures are characterized by compressive be closely monitored with serial neurologic examina- failure of the vertebral body with fracture extension tions and plain radiographic assessment following the through the posterior body cortex and some degree of placement of each additional weight. Development of bone retropulsion into the spinal canal. Burst fractures new or worsening neurologic deficits is an indication to have a significantly higher rate of instability when com- cease attempts at closed reduction, and an MRI scan pared with compression fractures and are frequently as- should be obtained to rule out herniated disk material. sociated with spinal cord injury. A burst fracture in the Overall, as many as 26% of patients with cervical facet presence of either complete or incomplete spinal cord dislocations will fail attempted closed reduction, with injury will typically require surgical decompression and higher failure rates observed for patients with unilateral stabilization. In most patients with burst fractures, surgi- facet dislocations. Although 50% of patients with facet cal decompression can be best achieved through an an- dislocations will demonstrate signs of disk disruption on terior approach with corpectomy of the involved lev- MRI, most of these signs are of uncertain clinical signif- el(s). Interbody fusion with anterior plate fixation may icance. be insufficient to stabilize these fractures in the setting Following successful closed reduction, surgical stabi- lization of these injuries is typically necessary. In the ab- sence of a traumatic disk herniation, posterior instru- mented fusion is recommended. However, various treatment options are available for associated disk her- niation. After successful closed reduction, an MRI scan of the cervical spine should be obtained to rule out the presence of associated disk herniation. Anterior diskec- tomy and fusion with anterior plating has been reported to be successful, although associated with kyphotic de- formity in some instances. For this reason, patients with persistent kyphosis following closed reduction who have anterior compression from disk material may require anterior decompression and grafting with a concomitant posterior stabilization. Failure of closed reduction mandates open reduction and instrumented cervical fusion. A preoperative MRI scan is required to rule out the presence of a herniated disk, which, if present, indicates the need for anterior diskectomy and fusion. A unilateral facet dislocation can often be reduced anteriorly using vertebral body Caspar pins. This technique involves maintaining dis- traction across these pins followed by rotation of the proximal pin toward the side of the dislocated facet joint. Alternatively, for unilateral or bilateral disloca- 518 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 41 Adult Spine Trauma Figure 11 Lateral (A) and AP (B) radiographs showing C1-2 transarticular screw fixation. Figure 12 Illustrations of types of traumatic spondylolisthesis of the axis using the Levine and Edwards modification of the Effendi classification system. A, Type I. B, Type II. C, Type IIA. D, Type III. (Reproduced with permission from Klein GR, Vaccaro AR: Cervical spine trauma: Upper and lower, in Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. Philadelphia, PA, Mosby, 2003, pp 441-462.) tions associated with a significant disk herniation, an cant kyphosis or subluxations can be considered for anti-kickout plate can be used to avoid the need for a nonsurgical treatment with 6 to 12 weeks of external im- second anterior stage of the surgery. Following anterior mobilization in a halo vest or cervical orthosis. Kyphotic diskectomy and placement of an interbody graft, the deformity, significant subluxations, or radiculopathy plate is fixed only to the superior body. Open reduction should be considered for open reduction and posterior can then be performed posteriorly with the plate main- instrumented stabilization. Bilateral facet fractures and taining position of the graft. lateral mass dissociations are typically unstable injuries and may be treated with anterior or posterior instru- Unilateral facet fractures are the most frequently mented fusion. missed significant cervical spine injuries on plain radio- graphs. These injuries may reduce in the supine position Thoracic Spine Trauma during initial trauma evaluation. Subtle subluxations or rotational malalignment visualized on plain radiographs Thoracic spine fractures represent approximately 16% should prompt further study with CT. The superior facet of fractures involving the thoracic and lumbar spine. is more frequently fractured. Fractures without signifi- These injuries typically result from high-energy blunt American Academy of Orthopaedic Surgeons 519