DeOrio, James K.

Previous methods for determining limb length during hip arthroplasty have depended on physical examination and direct measurement techniques. A radiographic technique for assessing limb length intraoperatively with a single anteroposterior (AP) pelvis radiograph was studied in 46 consecutive hip arthroplasties in 41 patients (five with bilateral arthroplasties). Of the 41 patients, 97.6% had either an average postoperative limb length discrepancy of 2.9 mm (-1 mm to +7 mm), or the limb was lengthened no more than 7 mm. This radiographic method has led to one of the most successful results reported in the literature with regard to minimizing significant limb length discrepancy or limb lengthening (maximum of 7 mm) following total hip arthroplasty. The single AP radiograph made intraoperatively with the trial implant in place is a valuable aid in determining limb length in total hip arthroplasty.

We describe a technique of fixation for treatment of distal tibia periplafond fractures and nonunions that uses a modification of the principle of the fibula-pro-tibia procedure (fusing the tibia and fibula together to create a one-bone lower leg). The fibula is plated, and the screws are brought across to the medial tibial cortex. The procedure is accomplished with or without a tibial buttress plate and always includes iliac crest bone grafting of the nonunion site and synostosis. We have used this technique in five patients with satisfaction.

The distal chevron osteotomy is a well-established technique for correction of symptomatic mild to moderate metatarsus primus varus with hallux valgus deformity. Fixation of the osteotomy ranges from none to bone pegs, Kirschner wires, screws, or absorbable pins. We evaluated one surgeon's (J.K.D.) results of distal chevron osteotomy fixation with a single, nonpredrilled, 1.3-mm poly-p-dioxanone pin and analyzed any differences in patients with unilateral or bilateral symptomatic metatarsus primus varus with hallux valgus deformities. All osteotomies healed without evidence of infection, osteolysis, nonunion, or necrosis. Equal correction was achieved in unilateral and bilateral procedures. The technique is quick and easy, and adequate fixation is achieved.

Background: Digital workstations with high-resolution monitors are replacing standard radiographs for image evaluation and interpretation. Radiographic angles in the foot have been evaluated for interobserver and intraobserver reliability with plain films, but use of digital workstations has not been validated. Because the 1-2 intermetatarsal (IM) and hallux valgus (HV) angles help determine the most appropriate bunion procedure, the reliability of these measurements is important. Methods: The HV and 1-2 IM angles were evaluated on preoperative radiographs of 25 patients who subsequently underwent bunion procedures. A standardized technique using a film marker and goniometer on plain film was compared with use of a mouse and computerized angle measurement software at a digital workstation. Three foot and ankle surgeons conducted these measurements at various intervals. Completion of three readings of each radiograph in each format by each observer totaled 1,800 measurements. Results: Computerized measurement gave better overall reliability. For the HV angle, inter-observer agreement (measurements within 2 degrees) improved from 66% with plain films to 81% with the digital workstation (p < 0.001). Intraobserver agreement increased from 72% to 80%. The 1-2 IM angle was similarly reliable with both methods for inter- and intraobserver agreement. Conclusions: This study validates the use of computer-assisted angle measurement on digital radiographs for assessment of HV and 1-2 IM angles. Computerized measurement may result in more reliable readings because it eliminates the error inherent with use of a goniometer and facilitates adjustment of radiographic lines on the computer to ensure correct alignment.

Background: Substitutes for bone graft have been advocated to avoid the potential morbidity associated with harvest of autogenous iliac crest graft. However, no current commercially available graft equals autogenous bone's osteoinductive and osteoconductive qualities. We reviewed our patients' morbidity after harvest of anterior iliac crest bone grafts for procedures involving the foot and ankle. Methods: A computerized analysis of patient records was undertaken to identify all patients who had a harvest of unicortical iliac crest bone graft during a 12-year period. Patients were contacted either by telephone or by mailed questionnaire, inquiring about the postoperative morbidity of the procedure. Medical records were reviewed for any related complications. Results: Of the 169 patients identified, 134 could be contacted. Follow-up ranged from 1 to 13 years. Not all patients answered every question. At latest follow up, 120 (90%)-patients reported no pain at the bone graft site. Eleven patients complained of persistent residual numbness lateral to the harvest site on the pelvis. Of these 120 patients, 32 (27%) reported that pain at the graft site was greater than the pain at the operative site during the initial postoperative period. No patients had extra hospital days as a result of the bone graft harvest. No deep infections occurred, although 12 (6.7%) of 180 patients had a postoperative hematoma or seroma. Overall, 116 (90%) of 129 patients were satisfied or very satisfied with their bone graft harvest. Conclusions: Harvesting of autogenous iliac crest bone graft provides the optimal bone graft material, yields minimal morbidity, and is an acceptable choice in supplementing surgical procedures on the foot and ankle.

Background: Screws have been recommended for fixation of the site of the metatarsal osteotomy. Methods: A report is presented on one surgeon's experience with a temporary, single Kirschner wire instead of screws for fixation of metatarsal neck osteotomies combined with proximal interphalangeal (PIP) joint resection arthroplasty in patients with dislocated metatarsophalangeal (MTP) joints and severe hammertoe deformities. Eleven consecutive patients (13 toes) were treated between January 1999 and January 2002 (mean age, 69 years; range, 44–81 years; seven women, four men) at a tertiary care foot and ankle center. Records and radiographs were reviewed retrospectively, and all patients were examined at follow-up by one of the authors (mean follow-up, 13 months; range, 6–32 months). Results: All 13 metatarsal neck osteotomies had clinical and radiographic union by 6 weeks, with no evidence of nonunion, malunion, avascular necrosis of the metatarsal head, deep wound infection, pin-tract infection, broken pins, or other serious complications. Two metatarsals (18%) had minor residual plantar calluses beneath the metatarsal head. The mean postoperative American Orthopaedic Foot and Ankle Society score was 76 of 95 points possible. All patients were satisfied with the procedure and would do it again. Conclusion: The use of a single, temporary K-wire provides adequate fixation for combined PIP joint resection arthroplasty and metatarsal neck osteotomy in patients with central metatarsalgia and severe hammertoe deformity.

Between January 1997 and July 2000, 10 patients with symptomatic bunionette deformity underwent 12 distal fifth metatarsal chevron osteotomies in which an absorbable poly- p-dioxanone suture (PDS) pin was used for fixation. Of the 10 patients, nine were female. Average age at operation was 41 years (range, 23–70). Mean duration of follow-up was 48 months (range, 6–81). All patients obtained clinical and radiographic union by 6 weeks, and there was no radiographic evidence of osteolysis, displacement, or avascular necrosis of the metatarsal head at final follow-up. There were no serious complications. The average postoperative AOFAS score was 93 of 100 possible. All patients were satisfied with the procedure and would have it again. Distal chevron osteotomy with a single, nonpredrilled PDS absorbable pin for the correction of symptomatic bunionette deformity is a reliable and effective technique that provides adequate fixation without complications.

Twenty-three patients with clinical signs of adjacent intermetatarsal nerve irritation who underwent adjacent nerve release with single-nerve excision through one incision were studied. Mean follow-up was 11 months. Of 21 patients interviewed, 19 (90%) had resolution of all or most of their pain, 20 (95%) had no or only minimal activity limitation, and 20 (95%) were completely satisfied with their outcome. Of 19 patients examined, none had pain with compression of the interspace of the excised nerve, although two (11%) had discomfort with compression of the interspace of the nerve that was only released. Protective sensation was present postoperatively in all patients except one who had preoperative neuropathy.

To investigate the usefulness of a standard surgical preparation in prevention of surgical site contamination, 49 consecutive patients undergoing foot or ankle surgery were randomly assigned to standard preparation with chlorhexidine gluconate home scrubs and preoperative povidone-iodine or to standard preparation plus preoperative preparation with 70% alcohol. Results were available for all 49 patients. Cultures were positive for normal aerobic bacteria from the toes of nine of 26 patients (35%) receiving standard surgical preparation and from the toes of 13 of 23 patients (57%) receiving standard preparation plus alcohol (P=0.12). No patient had a positive culture for anaerobic organisms or clinical evidence of infection or wound problems. Standard surgical preparation did not provide a completely sterile field, and the inclusion of alcohol added no benefit.

Background: Posterior tibial tendon dysfunction (PTTD) is a common malady leading to acquired flatfoot, which frequently causes foot and ankle pain and swelling. We hypothesized that patients with PTTD and pitting edema along the course of the posterior tibial tendon (PTT) would have evidence of fluid within the tendon sheath on MRI. We introduce and validate a novel, yet simple physical examination finding, the posterior tibial edema (PTE) sign, to help distinguish PTTD from other causes of foot and ankle pain and swelling. Patients and Methods: To determine an association between the PTE sign and changes to the PTT evident on MRI, we reviewed the medical records of patients with PTTD who underwent magnetic resonance imaging (MRI). Results: Of 186 patients identified with PTTD, 49 underwent MRI, and 42 (86%) demonstrated imaging characteristics consistent with tendonitis, tendinosis, or tenosynovitis. Presence or absence of increased posterior malleolar pitting edema agreed with presence or absence of these MRI findings in 43 patients (88%), making the clinical examination finding significantly predictive of MRI results ( p = 0.01). The sensitivity of the test for PTE was 86%, with specificity of 100%. Conclusion: The PTE sign refers to pitting edema along the course of the PTT, not associated with acute trauma and not accompanied by other areas of edema. Physical examination signs that are highly sensitive and specific to the condition may help lower the cost of diagnosis by eliminating the need for expensive tests that are not always necessary.