University Foot & Ankle Institute

Modern advancements in total ankle arthroplasty techniques and implants have increased their popularity as treatment for ankle osteoarthritis. The preeminent approach for ankle replacement involves an anterior incision. However, wound complications with this approach provide a persistent challenge to surgeons. The present study was conducted to synthesize current data on ankle replacement wound complications via an anterior approach. A systematic review was completed including studies published from 1993 to present that employed an anterior approach and had precise criteria for wound healing and revisions. Twenty-nine studies, with level 3 to 4 evidence and moderate to serious bias, were included for a total of 6,986 ankle arthroplasties. The rate of wound healing without any complication was 90.38 %. Minor dehiscence occurred in 6.00 % of cases, while major wounds or infections occurred in 3.62 %. Across 2,966 implants, the rate of major wounds or infections decreased from 7.03 % before 2013 to 4.75 % after 2013 (p = 0.034). Limited comparisons involving simple suture closure to various adjunct wound management techniques including negative pressure wound therapy, 2-octyl cyanoacrylate, platelet-rich plasma, dehydrated human amniotic membrane allograft, non-invasive skin expansion strips, compression wound dressings, tranexamic acid, surgical helmets, tourniquets, ankle arthrodesis, and lateral approach ankle arthroplasty, yielded non-significant differences (p > 0.18). Therefore, contemporary techniques, patient selection, and current implants may be leading to better soft tissue healing. As ankle replacement continues to surge in popularity, further research is needed to evaluate causative factors in successful anterior incision healing. Level of Clinical Evidence3

Herein, we present a case series of tibiotalocalcaneal arthrodesis (TTCA) with a distal femoral locking plate and describe the short-term clinical and radiographic results of the procedure. We performed a case review of four patients with hindfoot and ankle pathology who had been treated with a TTCA using a distal femoral locking plate (Depuy Synthes, Zimmer Biomet) by a single surgeon (H.A.H.) from January 2018 to December 2020. At final follow-up, there was a 75% complication rate (3/4) with two developing a nonunion of the ankle joint and one developing a postoperative wound and surgical site infection. Lateral locking plate fixation with a distal femoral locking plate system may be an alternative fixation option for tibiotalocalcaneal fusions in complex patients. However, a larger sample size with longer term follow-up is needed to make any significant recommendations on the use of this plating system.

Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration. A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations. Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations. Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.

Background:Intense therapeutic ultrasound (ITU) is an innovative ultrasound-based therapy where sound waves are concentrated into select musculoskeletal tissue. These focused waves generate thermal coagula at a controlled depth and space while preserving surrounding tissues. A multicenter study was conducted evaluating the efficiency, safety, and patient tolerance of ITU for the treatment of chronic plantar fasciitis (CPF) pain.Methods:Seventy-four CPF patients, having failed conservative and/or minimally invasive treatment, participated in the study. Randomized participants either received 2 ITU treatments or 2 sham ITU treatments in addition to standard-of-care therapy. Plantar fascia pain was assessed pretreatment and at 4, 8, 12, and 26 weeks after treatment. Diagnostic ultrasonographic images were analyzed to examine hypoechoic, perifascial lesions whose volumes were calculated until week 12. Function and patient satisfaction were measured using self-reported outcome measures.Results:The treated group reported significant average pain reduction (–26%, –33%, –43%) and hypoechoic lesion volume (–33%, –53%, –68%) at weeks 4, 8, and 12 compared to baseline. Although the control/sham group reported insignificant pain changes at the same time points (–5%, +8%, and +2%) and increased hypoechoic lesion volume (+15%, +28%, +58%). Treated patients reported a significant increase in daily living activities (+28%, +42%, +47%, +40%) compared to the sham/control group (+0.12%, +12%, +3%, +21%). Patient satisfaction remained more than 80% at weeks 8, 12, and 26 for all treatment groups.Conclusion:ITU is an effective pain relief treatment for CPF, which is refractory to either conservative measures or minimally invasive treatments.Level of Evidence:Level II.

Purpose: Anterior drawer and varus stress radiographs are commonly to diagnose chronic lateral ankle instability. We compared the preoperative stress radiographs with the intraoperative radiographs under anesthesia to determine the accuracy and efficacy of stress radiographs in an outpatient clinical environment. Materials and Methods: Data was collected from patients who underwent a modified Broström operation for painful chronic unilateral lateral ankle instability between January 2014 and June 2016. Subjects were divided into three groups—complete tear, partial tear, and instability without rupture—according to the status of preoperative MRI findings of the anterior talofibular ligament. The anterior drawer and varus stress radiographs were taken preoperatively and intraoperatively under anesthesia. Results: Ninety-six patients, with a mean age of 29.63 years, were enrolled. There were 39, 46, and 11 patients in the complete tear, partial tear, and instability without rupture groups, respectively. On the anterior drawer and varus stress radiographs of the affected limb, talar anterior translation and varus tilting were significantly increased by 2.56 mm and 2.0°. The gaps between the unaffected limbs were also increased by 2.47 mm and 1.32° after anesthesia. Although the stress radiographs were taken under anesthesia, the results were often smaller than the diagnostic value. Conclusion: Stress radiographs for painful chronic lateral ankle instability taken at the outpatient clinic might be inaccurate for diagnosis.