Volume 23-4, Winter 2014

Tears of the Achilles tendon in professional athletes are an infrequent yet devastating injury. Historical studies have demonstrated not only a poor rate of return to competitive play but have also noted significant declines in performance for those able to return. While classic treatment of these injuries in the competitive athlete has been an open, locked suture repair, this article reports on a consecutive series of professional football athletes who underwent mini-open repair. All athletes returned to professional football, with seven out of nine (78%) returning to National Football League (NFL) competition. Average return to play was 273 days (8.9 months), with one athlete returning at 166 days (5.4 months). There have been no reruptures and no sural nerve or wound healing complications. Although limited in number currently, mini-open repair in NFL athletes has allowed successful return to competitive play with no reruptures and a trend toward faster return to play compared with historical open repair outcomes. (Journal of Surgical Orthopaedic Advances 23(4):179–183, 2014) Key words: Achilles, mini-open, National Football League, NFL

Transfer of the flexor digitorum longus (FDL) is indicated to compensate for the loss of posterior tibial tendon (PTT) function in the treatment of adult acquired flatfoot deformity (AAFD). The aim of this study was to determine the effect of PTT resection on pain relief following surgical treatment of stage II AAFD. A retrospective review of patients who underwent surgical treatment for stage II AAFD was performed. Patients were divided into two groups based on whether the degenerated PTT was resected or left in situ. A visual analog scale (VAS) score for pain was recorded for each patient preoperatively. Concomitant surgical procedures and the incidence of postoperative pain were also reported for each group. Deformity correction was assessed with standard weight-bearing radiographs. Thirty-four patients with a mean follow-up of 14 months were included in the study. There was no difference in preoperative VAS pain scores, and patients in both groups demonstrated excellent pain relief postoperatively. Five patients in the PTT resection group and one patient in the PTT in situ group reported lateral-sided foot pain postoperatively. Resection of the PTT did not significantly affect postoperative pain relief. Future prospective studies are needed to determine whether resection of the degenerated PTT is necessary at the time of surgery for stage II AAFD. (Journal of Surgical Orthopaedic Advances 23(4):184–188, 2014) Key words: flatfoot, posterior tibial tendon insufficiency, posterior tibial tendon resection, postoperative pain

The purpose of this study was to compare the biomechanical properties of two common forms of prophylactic fixation of the medial malleolus during total ankle arthroplasty (TAA). Ten matched pairs of cadaveric lower extremities were fixed with a single cannulated cortical screw or a one-third tubular plate after preparation for TAA. Ten unmatched single cadaver lower extremities were used as the control. A transverse load was applied to the medial malleolus. Bone mineral density, peak loads at fracture, and fracture pattern were noted. There was no statistically significant difference in peak load to failure between either fixation cohorts or between the fixation cohort and the control cohort. There was a moderate positive correlation between bone mineral density and peak load for all three experimental groups. The peak load was significantly (p D .035) increased in male cadavers. Fractures occurred almost exclusively at the apex of the tibial and malleolar cuts with a vertical fracture pattern. (Journal of Surgical Orthopaedic Advances 23(4):189–192, 2014) Key words: ankle, arthroplasty, fixation, malleolus, medial, prophylactic

Total ankle arthroplasty is a procedure that has been shown to greatly improve patient quality of life. However, it is associated with moderate to severe postoperative pain. Commonly used strategies for pain control include opioids, multimodal analgesia with nonsteroidal anti-inflammatory drugs, acetaminophen and gabapentinoids, and regional anesthetic techniques such as peripheral nerve blocks. Nerve blocks in particular afford high-quality relief from pain while avoiding many of the side effects of traditional systemic therapies. This review highlights the state-of-the-art practice for providing postoperative analgesia following total ankle arthroplasty. (Journal of Surgical Orthopaedic Advances 23(4):193–197, 2014) Key words: ankle arthroplasty, nerve blocks, perioperative pain, total ankle

The objective of this study was to review the use of liposomal bupivacaine as a multimodal pain management adjunct following hallux valgus surgery. The study was a prospective review of a consecutive series of patients who underwent hallux valgus surgery and received liposomal bupivacaine.
From postoperative day (POD) 1 to 4, pain scores, number of narcotic rescue pills used, and adverse events were recorded. Wound complications, narcotic refills, and unscheduled clinic and emergency room (ER) visits or hospital admissions for pain were also recorded. The average pain rating was <3.4 (š2.4) during POD 1 to 4. Four patients (28.6%) reported never experiencing pain (Numeric Rating Scale 1). Seventy-one percent used narcotic rescue pills on POD 1. There were no unscheduled office or ER visits or hospital admissions. One adverse event and one wound complication occurred. Liposomal bupivacaine may be a safe and useful adjunct in a multimodal pain regimen for patients undergoing hallux valgus surgery. More rigorous studies are needed to determine its efficacy, safety profile, and cost-effectiveness compared to placebo. (Journal of Surgical Orthopaedic Advances 23(4):198–202, 2014) Key words: hallux valgus surgery,liposomal bupivacaine, multimodal pain management, postoperative pain

Little is known about the clinical significance of heterotopic ossification after total ankle replacement and the factors contributing to its occurrence. This study documented the incidence of heterotopic ossification in a large ankle arthroplasty series; identified potentially related patient, implant, and operative factors; and determined the strength of association of those factors with the clinical outcome. Ninety ankles in 88 primary ankle arthroplasty patients were followed for an average of 32.4 months. Scandinavian Total Ankle Replacement, Salto-Talaris, and INBONE ankle implants were used at the surgeon’s discretion. Heterotopic ossification was measured and classified using methods previously described for total hip arthroplasty. Incidence, location, severity, predisposing factors, and outcomes were documented, and correlation between ossification severity and each examined factor was determined. Eighty percent and 95.6% of ankles showed heterotopic ossification on anteroposterior and lateral views, respectively, and 97.8% showed evidence on either anteroposterior or lateral views. Ossification grades 4 and 3 were most common, predominantly located at themedial gutter and posterior to the tibial component. No preoperative variables were associated with heterotopic ossification, but its presence on lateral radiographs correlated with insufficient coverage of the tibial or talar component. Only three ankles required heterotopic ossification resection because of recalcitrant pain. The incidence of heterotopic ossification following primary total ankle arthroplasty was higher in this series than previously reported. (Journal of Surgical Orthopaedic Advances 23(4):203–213, 2014) Key words: ankle, arthroplasty, heterotopic, ossification

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data. (Journal of Surgical Orthopaedic Advances 23(4):214–223, 2014) Key words: clinical history, diagnose, lesser toe deformities, metatarsophalangeal joint, MTP instability, MTP plantar plate lesions, physical examination

Within the past two decades, magnetic resonance imaging (MRI) has evolved into an integral part of noninvasive diagnostic testing for evaluation of musculoskeletal disorders. With the advancements in imaging and coil technology, assessment of small and spatially complex structures, such as the acetabular labrum, became possible. Labral tears are being diagnosed with increasing frequency with MRI. However, themedical literature reveals erratic sensitivity and specificity values of MRI, includingMR arthrography, in identifying labral tears. This finding could be partly attributable to false-positive results caused by normal anatomic variants of the acetabular labrum. Additional challenges are introduced by the lack of consensus on the existence and the distributions of the normal anatomic variants of the labrum in MRI and orthopedic literature. In this article, the spectrum and incidence of these variations are discussed with emphasis on MRI features of the variant anatomy and the labral tears. (Journal of Surgical Orthopaedic Advances 23(4):224–228, 2014) Key words: acetabular labrum, anatomic variants of labrum, labral cleft, labral tears, MRI, perilabral recess, sublabral sulcus

Liposomal bupivacaine, a slow-releasing form of bupivacaine, is proving to be effective and safe for postsurgical pain management. It can provide great benefit and patient satisfaction because of its long-duration local analgesia by a single infiltration for up to 72 hours. A technical tip and application considerations of liposomal bupivacaine in total ankle arthroplasties are described. (Journal of Surgical Orthopaedic Advances 23(4):229–232, 2014) Key words: liposomal bupivacaine, postsurgical pain management, total ankle arthroplasty

the metatarsals are displaced relative to the midfoot. The injury pattern that is described in this article is one of a longitudinal force through the first ray and cuneiform. A reliable measure to recognize the longitudinal Lisfranc variant injury has been the height difference between the distal articular surfaces of the first and second cuneiform bones in an anteroposterior (AP) weight-bearing radiograph. This measure helps identify subtle injuries in which there is a proximal and medial subluxation of the first cuneiform-metatarsal complex. Delayed diagnosis and treatment have been associated with poorer results and significant functional consequences. This article describes a simple radiographic measurement to recognize the longitudinal injury pattern and to aid in determining whether operative intervention is required. (Journal of Surgical Orthopaedic Advances 23(4):233–236, 2014) Key words: Lisfranc classification, longitudinal Lisfranc variant injury, midfoot radiographic evaluation, midfoot sprain