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Achilles Tendon Reconstruction With Flexor Hallucis Longus Transfer Augmentation

Indications Symptomatic Achilles tendon disease (signal change on magnetic resonance imaging [MRI] within the tendon) or Achilles rupture in older individuals in whom end-to-end repair would lead to excessive tightness Treatment Options Achilles ruptures Nonoperative treatment can be done, but especially in older patients with degenerative tendons, the rerupture rate is higher and the incidence of continued pain is higher. Options include a weight-bearing cast or…

Posterior Tibial Tendon Transfer for Footdrop

Indications Flaccid footdrop following traumatic injury to the common peroneal nerve or peroneal division of the sciatic nerve Spastic footdrop seen in cerebral palsy Other indications may include footdrop associated with poliomyelitis, cerebrovascular accident, Charcot-Marie-Tooth disease, or leprosy Indications Pitfalls Transfer of the posterior tibial tendon contraindicated if there is a high likelihood of neurologic recovery (i.e., incomplete injury) Weakness of the gastrocnemius-soleus complex Insufficient vascularity…

Malunion of Fibula Fractures

Technique #1: Distal Fibular Osteotomy Through Fracture Site Indications This should be utilized for a fracture below the level of the syndesmosis, usually with a stable syndesmosis that can be preserved Fibular shortening Fibular malrotation Syndesmosis malreduction Indications Pitfalls Fibular malunion leads to abnormal mortise and ankle mechanics that can contribute to the development of posttraumatic arthritis. Fibular malunion is poorly tolerated and therefore often necessitates…

Arthroscopic Fracture Reduction With Fibular Nail

Indications Patients with potential wound healing issues such as diabetes, soft tissue trauma, or older age Weber C fractures in younger patients to avoid extensive dissection Patients with medial and posterior malleolar fractures that are amenable to percutaneous reduction and fixation Indications Pitfalls A fibula too tight to accept the nail Patients with involvement of the tibial plateau Failure to recognize poorly controlled diabetes, Charcot arthropathy,…

Calcaneoplasty for Insertional Tendinopathy of Achilles Tendon

Indications Haglund Syndrome refractory to conservative measures Bony prominence Posterior-superior-lateral Retrocalcaneal bursitis Insertional Achilles tendinopathy Partial rupture Often associated with bony prominence Recurrent tendinopathy after failed surgery Indications Pitfalls Local infection Peripheral vascular disease Indications Controversies Severe pes cavovarus with steep heel pitch Previous cortisone injection Examination/Imaging Physical Examination Painful thickening of the soft tissues at the Achilles tendon insertion – the so-called pump pump Prominent…

Ligament Reconstruction for Chronic Medial Ankle Instability

Indications Chronic medial ankle instability based on patient’s feeling of “giving-way,” especially toward medial, when walking on even ground, downhill, or downstairs Pain at the anteromedial aspect of the ankle, and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot Progressive pronation deformity Secondary tendinosis of posterior tibial (PT) tendon Treatment Options Footwear modifications and orthotics with medial arch support Physical therapy to…

Chronic Peroneal Tendon Subluxation-Dislocation

Indications Symptomatic chronic peroneal tendon subluxation-dislocation Indications Pitfalls Check for concomitant varus hindfoot alignment and lateral ankle instability that needs to be addressed during surgery. Treatment Options Nonsurgical treatment is an option for acute dislocation of the peroneal tendons, but it has a success rate of only 50% ( ). Other techniques exist for operative treatment in addition to the groove deepening with periosteal flap procedure…

Peroneal Tendinopathy With Allograft

Indications Chronic, irreparable tears (tears >50% of the cross sectional area) of either the peroneus longus, brevis, or both Indications Pitfalls One must make certain that the tendon cannot be repaired primarily after the débridement of the tendon and that an intercalary segment defect exists. One must make sure that a preoperative magnetic resonance imaging (MRI) demonstrates a viable proximal muscle belly. If there is fibrofatty…

Peroneal Tendon Tears: Débridement and Repair

Indications Typically presents with pain and swelling posterior to the distal fibula, or, at the level of the peroneal tubercle of the calcaneus. There is often a history of an ankle sprain or repeated ankle sprains that never fully resolved. Activity modification, bracing, nonsteroidal antiinflammatory drugs, ice physical therapy, and possible a 4–6 week trial of immobilization in a cast or controlled ankle movement (CAM) walker…

Salvage of a Failed Lateral Ligament Repair

Indications Persistent symptomatic lateral ankle laxity following a lateral ligament procedure Failure of a physical therapy program that emphasizes peroneal strength, proprioception, and range of motion Inability to return to sports, even with the use of a brace Indications Pitfalls Heel varus and forefoot valgus of more than 10° should be corrected at the same surgery. In a patient with a high cavus foot, consider an…

Lateral Ankle Ligament Reconstruction Using Plantaris Autograft

Indications Symptomatic chronic lateral ankle instability with insufficient local tissue (ligament remnants, extensor retinaculum) Failed primary lateral ankle ligament repair Indications Pitfalls Heel varus, tibial varus misalignment, and muscular disbalance (e.g., peroneus brevis incompetence, posterior tibial contracture) must be addressed at the time of surgery. Indications Controversies Stress radiographs do not correlate with symptomatic lateral ankle instability ( ). A medial ankle instability may result in…

Modified Brostrom Procedure for Lateral Ankle Laxity, With and Without an Internal Brace

Indications Symptomatic chronic laxity of the lateral ankle with repeated sprains Limitation of activity Failure of an appropriate rehabilitation program Indications Pearls The anterior drawer test rotates the talus forward around the intact medial axis of the deltoid ligament complex (except on very rare occasions when the deltoid is also lax). This rotation is most easily appreciated if the examiner, seated in front of the patient…

Percutaneous Lateral Ligament Reconstruction

Indications Chronic lateral ankle instability with complaints of pain or functional problems Indications Pitfalls Patients with os subfibulare, osteochondral lesion, or any intraarticular pathology should be treated at same time by arthroscopic or open procedure. Indications Controversies Patients with insufficient ligament, high body mass index, failed previous lateral ligament repair surgery, or general laxity should be treated not by repair but by a reconstruction procedure. Open…

Charcot Ankle Fractures

Indications Open reduction internal fixation is indicated for unstable neuropathic ankle fractures in patients with a suitable soft tissue envelope. Closed, neuropathic ankle fractures commonly present in three ways: Acutely after a traumatic incident, these are often missed since the patient may be weight bearing on the fractured limb. Subacutely, with a history of a minor injury and a longer period of sustained swelling, erythema, and…

Salvage of Ankle Large Bony Defect With Spinal Cage

Indications Maintenance of limb length and stability in patients requiring hindfoot arthrodesis with large bone loss Hindfoot fusion after failed total ankle arthroplasty (TAA) Hindfoot fusion for treatment of talar body osseous necrosis Hindfoot fusion for traumatic talectomy Indications Pitfalls Nonunion Meticulous attention to positioning is paramount to avoid malposition of foot Indications Controversies Benefits of spinal cage Maintain limb length Interference fit stabilizing the construct…

Ankle Arthrodesis for Salvage of the Failed Total Ankle Arthroplasty

Indications Failed total ankle arthroplasty (TAA) where the option for revision of the implants is contraindicated or not selected, including Aseptic loosening of any one or all of the components Pain without radiographic evidence of loosening Infection Examination/Imaging A careful history and physical examination remain critical for the clinician to begin planning intervention in this situation. Any history of trauma, infection, or pattern of discomfort can…

Salvage of Failed Total Ankle Arthroplasty

Indications Failed arthroplasty of the ankle due to Primary loosening of component Late loosening of component Progressive nonmanageable malalignment Nonmanageable instability Avascular necrosis of underlying bone Deep infection Periprosthetic fracture Breakdown of soft tissues Chronic pain syndrome Others (e.g., metal allergy or intolerance, dysfunction) Indications Pitfalls Active infection Neuroarthropathy (Charcot arthropathy) Indications Controversies Controversy about appropriate salvage procedure Revision arthroplasty Tibiotalar arthrodesis Tibiocalcaneal arthrodesis Treatment Options…

Total Ankle Arthroplasty Through a Lateral Approach (Zimmer Prosthesis)

Indications Symptomatic arthritis of the ankle Patients with compromised anterior tissue Prior lateral scar from fracture fixation, lateral ligament reconstruction, or peroneal tendon surgery Contralateral ankle fusion Symptomatic arthritis of the ankle with adjacent joint arthritis Ankle deformity that involves a malunion or deformity of the fibula Sagittal plane deformity (anterior or posterior translation) of the ankle Valgus deformity with shortened or valgus fibula Varus deformity…

Total Ankle Arthroplasty With a Current Three-Component Design (HINTEGRA Prosthesis)

Indications Primary osteoarthritis (e.g., degenerative disease) Systemic arthritis (e.g., rheumatoid arthritis) Posttraumatic osteoarthritis (if instability and malalignment are manageable) Secondary osteoarthritis (e.g., infection, avascular necrosis; if at least two thirds of the talar surface is preserved) Salvage for failed total ankle replacement or for nonunion and malunion of ankle fusion (if bone stock is sufficient) Low demands for physical activities (e.g., hiking, swimming, biking, golfing) Relative…

Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary Nail

Indications Posttraumatic/degenerative/primary/secondary arthritis of tibiotalar and subtalar joints Rheumatoid arthritis of tibiotalar and subtalar joints Significant osteonecrosis of the talus Diabetic patients with unstable Charcot neuroarthropathy or peripheral neuropathy Failed ankle arthrodesis Failed total ankle replacement Skeletal defects after tumor resection or trauma Severe malalignment or deformities associated with neuromuscular disease or clubfoot Indications Pitfalls Contraindications for this procedure Acute or chronic infections with/without osteitis/osteomyelitis Severely…