February 2013

When it comes to ankle arthrodesis, can a less invasive approach be more effective? A recent study in the Journal of Bone and Joint Surgery concludes that arthroscopic ankle arthrodesis is a more viable alternative to open ankle arthrodesis in patients with end-stage ankle arthritis.

   In this comparative case series, researchers assessed the improvements of 30 patients who received open ankle arthrodesis and 30 patients who had arthroscopic ankle arthrodesis. According to study authors, both groups of patients showed substantial improvements in both the Ankle Osteoarthritis Scale score and the Short Form-36 physical component score after one and two years. However, patients in the arthroscopic group had significantly greater improvements in the Ankle Osteoarthritis Scale score and also experienced shorter hospital stays.

   Patrick DeHeer, DPM, FACFAS, is skeptical on the study’s advantageous outcomes with arthroscopic ankle arthrodesis. He agrees that a less invasive approach would provide less soft tissue damage but notes that once bone healing occurs, the approach used is insignificant. Dr. DeHeer says he generally uses a mini-arthrotomy approach, a combination of the two procedures as described by Myerson.

   “I find arthroscopic ankle arthrodesis to be a bit tedious and only use an open approach when there is a deformity that would make the mini-arthrotomy approach not viable,” explains Dr. DeHeer, who is in private practice in Indianapolis.

   Dr. DeHeer maintains that one must keep in mind certain anatomical deformities when choosing the best procedure. Specifically, he notes that severe degenerative changes with joint space narrowing would make arthroscopic arthrodesis difficult. In addition, any type of angular deformity, such as ankle varus or valgus, requires an open approach, according to Dr. DeHeer.

   He doubts that this study will have a great impact overall for podiatric surgeons treating patients with ankle osteoarthritis.

   “I do think the significant improvement in Ankle Osteoarthritis Scale score could be a factor for surgical approval from an insurance standpoint,” adds Dr. DeHeer.

Which Fixation Method Is Strongest For Tailor’s Bunion Osteotomies?

By Brian McCurdy, Senior Editor

A recent study in the Journal of Foot and Ankle Surgery compares fixation methods for tailor’s bunions and finds the Chevron osteotomy is superior in strength.

   Researchers tested osteotomies to failure with a sample size of 10 for each construct. They tested the distal reverse Chevron (Kirschner wire fixation), the long plantar reverse Chevron osteotomy (two screws), a mid-diaphyseal sagittal plane osteotomy (two screws), the mid-diaphyseal sagittal plane osteotomy (two screws), and an additional cerclage wire and a transverse closing wedge osteotomy (box wire fixation technique). The authors note the Chevron was statistically the strongest construct at 130 N with the second strongest being the long plantar osteotomy at 78 N.

   Study co-author Todd Haddon, DPM, feels the Chevron is the easiest osteotomy to perform but is still challenging to fixate. The fact that the Chevron typically offers only one point of fixation is the primary reason he switched to the long plantar arm osteotomy, which allows two screws from dorsal to plantar. Dr. Haddon adds that if a surgeon has difficulty with the cuts becoming too long, he or she can make a small plantar exit to the osteotomy with a back cut of the plantar arm, making it into a small scarf osteotomy.

   Although he notes that the Chevron has worked well for patients in the long term, Dr. Haddon cites a primary issue of a limited amount of bone in the typical fifth metatarsal head. He also prefers the long plantar arm procedure since it allows the capital fragment to be rotated medially, reducing complete reliance on translocation for correction.

   “It becomes very challenging to try to shift adequately such a small piece of bone and fixate it with a single pin or screw,” says Dr. Haddon, who is in private practice in Mesa, Ariz.

   Study co-author Stephan J. LaPointe, DPM, PhD, prefers two-screw fixation for fifth metatarsal osteotomies. He cites the Acutrak cannulated screw (Acumed), saying its guide pins function as temporary fixation and the guide for the screws.

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