Background: Many physicians continue to fear iatrogenic complications of the total contact cast, and use of this modality has remained restricted to a segment of the orthopaedic and podiatric communities. I examined the actual rate of complications and the factors associated with them in a large consecutive series of total contact casts drawn from the practice of a single surgeon to determine whether this modality is safe for multiple conditions in the neuropathic foot and ankle. Method: A consecutive series of 398 total contact casts spanning a 28-month period from the practice of a single physician were analyzed. All casts were placed by the same team of orthotists. This study comprised 70 patients with severe peripheral neuropathy; an average of 5.69 sequential casts per patient were placed. Three-hundred and sixty-seven casts were placed in diabetic patients, and 31 in patients with idiopathic peripheral neuropathy. By protocol, the initial cast was changed at an interval of no more than 1 week. On occasion, subsequent casts were left on longer, but on average casts were left in place for 7.69 days. Logistic regression analysis was used to analyze the contribution of patient factors to the chance of ulceration. Results: Complications occurred in 22 casts, including six new pretibial ulcers, six new midfoot ulcers, four forefoot or toe ulcers, five hindfoot ulcers, and one malleolar ulcer. In no case was a preexisting ulcer made worse. This corresponds to an overall complication rate of 5.52% per cast. Overall, 30% of patients suffered one complication during the course of their treatment. With one exception, all new ulcers healed with simple modalities within 3 weeks, often with continued total contact casting. A single cast led to a proximal interphalangeal ulceration that exposed the joint and eventually required toe amputation. The rate of permanent sequelae from cast-related injuries was therefore 0.25%. In no case were the resultant odds ratios statistically different from 1.0, but several trends were observed. Charcot arthropathy represented the highest risk (odds ratio 1.46), while the presence of neuropathic ulceration was surprisingly benign (odds ratio 0.69). The presence of diabetes as opposed to other causes of neuropathy was associated with increased risk (odds ratio 1.34). The use of a cast after deformity-correcting surgery in a neuropathic patient was remarkably safe (odds ratio 0.44), as were casts in which the patient was instructed to remain nonweightbearing (odds ratio 0.27). Patient age was not a factor (odds ratio 1.03). The length of time the cast was left on was not statistically important (odds ratio 0.99), although strict protocols for cast changing likely altered this data. Conclusion: A frequently changed total contact cast is a safe modality for the offloading and immobilization of the neuropathic foot, albeit with an expected constant rate of minor, reversible complications. Patients should be informed of these complications and risks before cast application.

Background: A new transfibular total ankle arthroplasty (TAA) system has not been assessed for potential early complications. Methods: We retrospectively assessed prospectively collected data on the initial cohort of patients undergoing TAA with this implant. We evaluated visual analog scale (VAS) pain and function, range of motion, and early radiographic outcomes. Results: Twenty consecutive TAAs (19 patients) were treated with the implant from January 2013 through June 2014. Average patient age was 63.7 (range, 41-80) years, with an average follow-up of 18 (range, 12-27) months. No fibular nonunion or implant failure was found at 12 months postoperatively. One patient had asymptomatic mild tibial lucency. Four of 20 TAAs underwent additional surgery for anterior impingement (1 ankle), deep infection and symptomatic fibular hardware (1 ankle), and symptomatic fibular hardware (2 ankles). Conclusion: Of 20 ankles treated with a new transfibular arthroplasty system, no fibular nonunion, delayed union, or implant failure was noted at 12 months postoperatively. Two complications were resolved with secondary treatment, and 2 other ankles underwent secondary surgery for symptomatic fibular hardware with good outcome. The findings suggest that this total ankle system is safe and effective at short-term follow-up. Level of Evidence: Level IV, retrospective case series.

Secutive older, sedentary patients with insertional or midsubstance Achilles tendinosis were enrolled prospectively and underwent the procedure. Ten patients were lost to follow-up, leaving forty-eight limbs in forty-six patients available for evaluation after twenty-four months. Results: The forty-six patients who were included in the study had an average age of 54 ± 10 years with an average body mass index of 33.8 ± 6.8 kg/m2. Significant improvement was observed between baseline and twenty-four months in terms of the visual analog scale for overall pain intensity (6.7 ± 2.3 versus 0.8 ± 2.0; p < 0.001), the Short Form-36 physical score (34.3 ± 8.0 versus 49.0 ± 9.3; p < 0.001), the Ankle Osteoarthritis Scale pain (54.4 ± 19.2 versus 1.9 ± 2.7; p < 0.001) and dysfunction (62.6 ± 21.4 versus 11.0 ± 24.2; p < 0.001) subscale scores, and performance of a single-leg heel rise (1.9 ± 3.0 versus 7.3 ± 2.7 cm; p < 0.001). Significant improvement compared with baseline was observed at three or six months except in the single-leg heel rise. Improvements in terms of pain and function occurred over twenty-four months, with the most improvement occurring in the first twelve months. At twenty-four months, maximum gastrocnemius circumference was significantly less in the involved compared with the uninvolved leg (40.2 ± 5.1 versus 41.2 ± 4.8 cm; p < 0.001). The mean passive range of motion of the first metatarsophalangeal joint decreased from 85.1° ± 25.3° preoperatively to 68.1° ± 36.7° (a 20% change) at six months (p = 0.03). Most patients reported no hallux weakness (57%; twenty-six of forty-six patients) and no loss of balance due to hallux weakness (76%; thirty-five of forty-six patients). Postoperative peroneal tendinitis was observed in seven patients. Complications included deep-vein thrombosis (two patients), superficial infection or delayed wound-healing (six), scar pain (four), and early disruption of the reconstruction due to a fall (one). Conclusions: Surgical debridement of the Achilles tendon with flexor hallucis longus tendon transfer was associated with significant improvement in terms of Achilles tendon function, physical function, and pain intensity in a group of relatively inactive, older, overweight patients. When present, hallux weakness had minimal functional sequelae. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence....

Background: We aimed to define reference lines on standard lateral ankle radiographs that could be used intraoperatively to minimize iatrogenic nerve injury risk in medial displacement calcaneal osteotomy. Methods: Forty cadaveric specimens were used. In 20 specimens, the sural, medial plantar (MP), and lateral plantar (LP) nerves were sutured to radiopaque wire, and a lateral ankle radiograph was obtained. On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the “landmark line.” A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique. Dissection was performed to assess for laceration of the sural, MP, LP, medial calcaneal (MC), or lateral calcaneal (LC) nerves. Results: The safe zone was determined to be within the area 11.2 ± 2.7 mm anterior to the landmark line. After open osteotomy, lacerations were found in 3 of 10 MC nerves and 3 of 10 LC nerves. After percutaneous osteotomy, lacerations were found in 2 of 10 MC nerves and 1 of 10 LC nerves. No lacerations of the sural, MP, or LP nerves were found with either osteotomy. Conclusions: The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line. The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy. Clinical Relevance: Nerve injury to both major and minor sensory nerves is likely underrecognized as a source of morbidity after calcaneal osteotomy. The current study provides a ready intraoperative guideline for minimizing this risk.

Sessed the accuracy of the radiologists' and orthopaedic surgeon's reading of preoperative MRI for diagnosing ankle lesions in patients with ankle instability warranting surgery. Patients and Methods We retrospectively reviewed 133 patients who underwent 135 surgeries for lateral ankle ligament reconstruction with concomitant ankle arthroscopy and who had preoperative MRI. Results We found 72 associated lesions in 66 of the 135 surgeries, including 38 chondral injuries, 18 peroneus brevis tears, seven loose bodies, and nine other miscellaneous abnormalities. Eliminating eight lesions for which the decision to operate was not based on operative findings, there were 127 surgeries with 64 associated lesions that required intraoperative confirmation or were detected intraoperatively. In the original reports, the radiologists identified 39% (15) of the chondral injuries, 56% (10) of the peroneal tears, and 57% (four) of the loose bodies. Radiologists' MRI sensitivity for detecting lesions was 45%. The attending surgeon identified 47% (18) of the chondral injuries, 89% (16) of the loose bodies, 71% (five) of the peroneus brevis tears, and the posterior talus process lesion, with a sensitivity of 63%. Conclusions Our data suggest orthopaedic surgeons should review preoperative MRIs and also suggest the sensitivity of MRI may not be adequate to detect lesions in these patients before surgery. Level of Evidence Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence....

Background: A subacromial balloon spacer is an option to treat irreparable rotator cuff tears. We hypothesized that the balloon would restore glenohumeral contact pressure, the acromion-humeral interval, and deltoid load to intact values after a simulated irreparable supraspinatus tear in a cadaveric model. Methods: Fourteen cadaveric shoulders (mean age at the time of death, 67.9 years) were tested using a custom test frame. In this frame, glenohumeral contact pressure, the acromion-humeral interval, and deltoid load were measured using a digital sensor, a MicroScribe, and a spring scale, respectively. Test conditions included the intact shoulder, a small supraspinatus tear, supraspinatus repair, repair plus balloon, an irreparable supraspinatus tear (rotator cable-insufficient), and an irreparable tear plus balloon. Load was applied in a simulated neutral arm position (balanced) and active shoulder abduction (unbalanced). Results: When the balloon was inflated over the irreparable supraspinatus tear in the balanced condition, glenohumeral contact pressure increased by 122% (p = 0.006) compared with that for the irreparable tear at 0° of abduction and by 94% (p = 0.046) at 60°. In the unbalanced condition, pressure decreased in the irreparable tear condition after the balloon was inflated, restoring pressure to close to that in the intact state. The balloon did not restore glenohumeral contact area to that in the intact shoulder in either the balanced or the unbalanced condition. The irreparable tear displaced the humeral head superiorly in the unbalanced condition, decreasing the acromion-humeral interval. The balloon moved the head inferiorly by a mean (and standard error of the mean) of 6.2 ± 1.3 mm (p < 0.001) at 0° of abduction, 4.4 ± 1.3 mm (p < 0.001) at 30°, and 3.0 ± 0.8 mm (p < 0.001) at 60°. The balloon increased the deltoid load after an irreparable tear by 8.2% (p = 0.022) at 0°, 12.6% (p = 0.002) at 30°, and 11.1% (p = 0.008) at 60°. Conclusions: In a cadaveric model of an irreparable supraspinatus tear, a balloon spacer restored intact-state glenohumeral contact pressures at most abduction angles, lowered the humeral head, and increased deltoid load at postoperative time 0. Clinical Relevance: This study supports further investigation of the balloon spacer in comparative clinical studies of surgical options for irreparable rotator cuff tears, with clinically relevant evaluation measures and observation periods.