Tonya W. An

Millions of Americans wear ankle-foot orthotic devices for protection, pain relief, and deformity correction. Inquiries about off-the-shelf and custom devices are a common reason for evaluation with a foot and ankle surgeon or general orthopaedic surgeon. Despite limited high-quality evidence for their use, these devices can have a notable clinical impact on physical function. An up-to-date understanding of orthotic device options and their appropriate use in managing musculoskeletal pathologies applies to all orthopaedic providers. This review aims to categorize orthosis types and provide specific device recommendations for common adult conditions such as flatfoot, cavovarus foot, and ankle instability. Collaboration with a certified orthotist can help patients achieve functional and recreational goals with the use of appropriately designed and applied orthoses.

Category: Midfoot/Forefoot Introduction/Purpose: Cheilectomy with and without Moberg osteotomy is used to improve function and remove pain in early- moderate stage hallux rigidus. The rise of patient-reported outcome measurements allows greater precision in comparing treatments as value-driven paradigms become increasingly important in clinical decision-making. This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus. We compared one and two-year PROM scores between patients who underwent C and CM for hallux rigidus using PROMIS, a validated patient-reported outcomes measurement system, and compared rates of complications and subsequent operations between the two groups. We hypothesized that patients who underwent CM would experience better clinical outcomes and fewer returns to the operating room than patients undergoing cheilectomy alone. Methods: A single-center, retrospective registry search identified all patients with preoperative PROMIS scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. An a priori power analysis determined that 24 patients per cohort were needed to detect a previously published minimum clinically important difference of 5.8 points on the PROMIS Physical Function scale with alpha = .05 and 80% power. However, all C patients were included. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, one-year, and two-year PROMIS scores for Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression, as well as complication and revision data from chart review. Age, sex, BMI, preoperative radiographic hallux rigidus grade, and preoperative range of motion were compared between the two cohorts. Results: PROMIS outcome data is given in Table 1. Both groups demonstrated statistically significant improvements in PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health (P <.001 for all, both preoperative to one-year and preoperative to two-year), but not Global Mental Health or Depression. There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse Pain Interference scores preoperatively (58.1+- 5.9 vs. 52.4 +- 7.01, P < .001) and at one year (50.0 +- 9.3 vs. 45.1 +- 9.8, P = .01), while the C cohort reported worse Pain Intensity scores preoperatively (55.6 +- 7.3 vs. 49.6 +- 6.8, P < .001) and at one year (45.9 +- 8.0 vs. 39.9 +- 8.2, P < .001). These differences were no longer significant at two years postoperatively. There were no statistically significant differences between cohorts for additional PROMIS scores or complications data. Conclusion: The addition of a Moberg osteotomy does not appear to significantly change short-medium term outcomes of cheilectomy for hallux rigidus treatment. Our data contradicts the notion that addition of a Moberg osteotomy increases the likelihood of postoperative complications. The overall good results found for both procedures, as well as the general similarity between outcomes between them, suggest that external considerations like recovery time, comfort level with a more invasive osteotomy, and overall goals with surgery may be of greater importance than short-term clinical outcomes when deciding on the appropriate course of treatment for a given patient.

Background: The modified Lapidus procedure (first metatarso-cuneiform fusion) is a powerful technique for correcting triplanar deformity in hallux valgus. Although traditionally fixed with cross-screws (CS), growing awareness of intercuneiform stability and pronation deformity has led to fixation using a plate and first metatarsal–second cuneiform (1MT-2C) screw fixation (PS). We investigated Lapidus patient cohorts using CS vs PS fixation to understand patient-reported outcomes, angular and rotational correction, and complication rates. Methods: We retrospectively reviewed cases of modified Lapidus for hallux valgus by a single surgeon. Patients were divided into CS or PS groups according to fixation. All patients had preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores and minimum 12 months of follow-up. PROMIS scores in 6 key domains were compared within and between groups. Radiographic assessment of hallux valgus angle and intermetatarsal angle were performed on pre- and postoperative XR. Pronation of the first ray was measured on pre- and postoperative weightbearing computed tomography. Results: We compared 42 patients with PS fixation to 43 with CS fixation. Both groups had significant improvement in hallux valgus angle and intermetatarsal angle ( P < .001), with no difference between groups. PS patients experienced a greater correction of first metatarsal pronation, an average reduction of 11 degrees, compared to 8 degrees in the CS group ( P < .039). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity, and global physical function. There were no differences in PROMIS score improvements between the cohorts. The CS group started weightbearing at 6 weeks vs 3.6 weeks for the PS group. Complication and revision rates were similar. Conclusion: A plate and 1MT-2C screw fixation provides safe, robust fixation of Lapidus procedure and prevents instability through the intercuneiform joint. We observed similar improvement in PROMIS compared with patients treated with cross-screws. Complications did not increase despite the PS group weightbearing much earlier. PS patients achieved greater first ray rotational correction. Level of Evidence: Level III, retrospective cohort study.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease typically presents with hindfoot varus and forefoot valgus. This seemingly paradoxical relationship is poorly understood. Better insight into this complex three- dimensional alignment under physiologic load-bearing conditions is possible using weight-bearing computed tomography (WBCT). This is the first study to examine the extreme rotational deformity in the midfoot of CMT patients, and thereby provides a key to the successful operative correction of the CMT cavovarus foot. Methods: We retrospectively reviewed the WBCTs of patients with CMT who presented to a single surgeon. Those with history of bony surgical correction, severe degenerative joint disease, or open physes in the foot, were excluded. Scans were analyzed using three-dimensional analysis software (Disior Bonelogic) to generate axes of select bones and their relationship relative to the tibial plafond anterior-posterior axis in the axial plane. The coronal alignment of the foot involved angular measurements of the calcaneus, talar dome, midfoot and forefoot relative to the ground. We reported quantitative alignment parameters and compared the measurements to WBCT of 20 controls. Results: 17 WBCT scans from 15 CMT patients (average age 24 years) met criteria for inclusion. In the axial plane, external rotation of the distal tibia accounted for the varus heel position rather than subtalar malalignment. The greatest change in axial alignment occurred between the talar neck and navicular (26 degrees). The average talonavicular (TN) medial uncoverage angle was -15 degrees for CMT patients, indicating medial overcoverage, compared to +11 degrees for controls, (p<0.01). Coronal plane analysis revealed varus rotational deformity at the calcaneus (23 degrees), a peak of 61 degrees varus across the navicular and cuboid, then compensatory rotation of the cuneiforms and metatarsals to achieve a plantigrade forefoot (11 degrees varus). In comparison, controls averaged 9 degrees coronal valgus at the calcaneus and 34 degrees varus at the naviculo-cuboid level, (p<0.01). Figure 1 shows the WBCT scans of a representative CMT patient and control case. Conclusion: This three-dimensional WBCT analysis is the first to characterize and quantify the axial and coronal rotational deformity in CMT. Axial plane deformity had a center of rotational angulation at the talonavicular joint, associated with medial ’overcoverage’ of the talar head, likely from chronic tibialis posterior over-pull. The peak coronal deformity was localized at the navicular and cuboid, which measured nearly twice as much as controls. These observations suggest dorsiflexion osteotomy of the 1st metatarsal would fail to address the coronal rotation; releases through the talonavicular joint may be necessary to abduct and de-rotate the midfoot to achieve a plantigrade foot.

Background: The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease is often characterized by a paradoxical relationship of hindfoot varus and forefoot valgus. The configuration of the midfoot, which links these deformities, is poorly understood. Accurate assessment of 3-dimensional alignment under physiologic loadbearing conditions is possible using weightbearing computed tomography (WBCT). This is the first study to examine the rotational deformity in the midfoot of CMT patients and, thus, provide key insights to successful correction of CMT cavovarus foot. Methods: A total of 27 WBCT scans from 21 CMT patients were compared to control WBCTs from 20 healthy unmatched adults. CMT patients with a history of bony surgery, severe degenerative joint disease, or open physes in the foot were excluded. Scans were analyzed using 3-dimensional software. Anatomic alignment of the tarsal bones was calculated relative to the anterior-posterior axis of the tibial plafond in the axial plane, and weightbearing surface in the coronal plane. Results: Maximal rotational deformity in CMT patients occurred at the transverse tarsal joints, averaging 61 degrees of external rotation (supination), compared to 34 degrees among controls ( P < .01). The talonavicular joint was also the site of peak adduction deformity in the midfoot, with an average talonavicular coverage angle measuring 12 degrees compared with −11 degrees in controls ( P < .01). Conclusion: This 3-dimensional WBCT analysis is the first to isolate and quantify the multiplanar rotational deformity in the midfoot of CMT patients. Compared with healthy unmatched control cases, CMT patients demonstrated increased axial plane adduction and coronal plane rotation at the talonavicular (TN) joint. These findings support performing soft tissue release at the TN joint to abduct and derotate the midfoot as a first step for targeted deformity correction. Level of Evidence: Level III, retrospective case-control study.

Although long suspected, it has yet to be shown whether the foot and ankle deformities of Charcot-Marie-Tooth disease (CMT) are generally associated with abnormalities in osseous shape. Computed tomography (CT) was used to quantify morphologic differences of the calcaneus, talus, and navicular in CMT compared with healthy controls. Weightbearing CT scans of 21 patients (27 feet) with CMT were compared to those of 20 healthy controls. Calcaneal measurements included radius of curvature, sagittal posterior tuberosity-posterior facet angle, and tuberosity coronal rotation. Talar measurements included axial and sagittal body-neck declination angle, and coronal talar head rotation. Surface-mesh model analysis of the hindfoot was performed comparing the average of the CMT cohort to the controls using a CT analysis software (Disior Bonelogic 2.0). Means were compared with a t test (P < .05). CMT patients had significantly less talar sagittal declination vs controls (17.8 vs 25.1 degrees; P < .05). Similarly, CMT patients had less talar head coronal rotation vs controls (30.8 vs 42.5 degrees; P < .001). The calcaneal radius of curvature in CMT patients was significantly smaller than controls (822.8 vs 2143.5 mm; P < .05). CMT sagittal posterior tuberosity–posterior facet angle was also significantly different from that of controls (60.3 vs 67.9 degrees respectively; P < .001). Surface-mesh model analysis demonstrated the largest differences in morphology at the navicular tuberosity, medial talar head, sustentaculum tali, and anterior process of the calcaneus. This is the first study to quantify the morphologic differences in hindfoot osteology seen in CMT patients. Patients identified with osseous changes of the calcaneus, especially a smaller axial radius of curvature, may benefit from a 3-dimensional osteotomy for correction.

Background: Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. Methods: Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. Results: There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. Conclusion: This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. Level of Evidence: Level IV, case series.

Background: In response to COVID-19, American medical centers have enacted elective case restrictions, markedly affecting the training of orthopaedic residents. Residencies must develop new strategies to provide patient care while ensuring the health and continued education of trainees. We aimed to describe the evolving impact of COVID-19 on orthopaedic surgery residents. Methods: We surveyed five Accreditation Council for Graduate Medical Education-accredited orthopaedic residency programs within cities highly affected by the COVID-19 pandemic about clinical and curricular changes. An online questionnaire surveyed individual resident experiences related to COVID-19. Results: One hundred twenty-one resident survey responses were collected. Sixty-five percent of the respondents have cared for a COVID-19-positive patient. One in three reported being unable to obtain institutionally recommended personal protective equipment during routine clinical work. All programs have discontinued elective orthopaedic cases and restructured resident rotations. Most have shifted schedules to periods of active clinical duty followed by periods of remote work and self-isolation. Didactic education has continued via videoconferencing. Discussion: COVID-19 has caused unprecedented changes to orthopaedic training; however, residents remain on the front lines of inpatient care. Exposures to COVID-19 are prevalent and residents have fallen ill. Programs currently use a variety of strategies to provide essential orthopaedic care. We recommend continued prioritization of resident safety and necessary training accommodations.

Background: Charcot-Marie-Tooth (CMT) disease is a hereditary motor-sensory neuropathy that is often associated with a cavovarus foot deformity. Limited evidence exists for the orthopedic management of these patients. Our goal was to develop consensus guidelines based upon the clinical experiences and practices of an expert group of foot and ankle surgeons. Methods: Thirteen experienced, board-certified orthopedic foot and ankle surgeons and a neurologist specializing in CMT disease convened at a 1-day meeting. The group discussed clinical and surgical considerations based upon existing literature and individual experience. After extensive debate, conclusion statements were deemed “consensus” if 85% of the group were in agreement and “unanimous” if 100% were in support. Conclusions: The group defined consensus terminology, agreed upon standardized templates for history and physical examination, and recommended a comprehensive approach to surgery. Early in the course of the disease, an orthopedic foot and ankle surgeon should be part of the care team. This consensus statement by a team of experienced orthopedic foot and ankle surgeons provides a comprehensive approach to the management of CMT cavovarus deformity. Level of Evidence: Level V, expert opinion.

Background: In Charcot-Marie-Tooth (CMT) disease, selective weakness of the tibialis anterior muscle often leads to recruitment of the long toe extensors as secondary dorsiflexors, with subsequent clawing of the toes. Extensor hallucis longus (EHL) and extensor digitorum longus (EDL) tendon transfers offer the ability to augment ankle dorsiflexion and minimize claw toe deformity. The preferred site for tendon transfer remains unknown. Our goal was to quantify ankle dorsiflexion in the “intact” native tendon state, compared with tendon transfers to the metatarsal necks or the cuneiforms. We hypothesized that EHL and EDL transfers would improve ankle dorsiflexion as compared with the intact state and would produce similar motion when anchored at the metatarsal necks or cuneiforms. Methods: Eight fresh-frozen cadaveric specimens transected at the midtibia were mounted into a specialized jig with the ankle held in 20 degrees of plantarflexion. The EHL and EDL tendons were isolated and connected to linear actuators with suture. Diodes secured on the first metatarsal, fifth metatarsal, and tibia provided optical data for tibiopedal position in 3 dimensions. After preloading, the tendons were tested at 25%, 50%, 75%, and 100% of maximal physiologic force for the EHL and EDL muscles, individually and combined. Results: Transfers to metatarsal and cuneiform locations significantly improved ankle dorsiflexion compared with the intact state. No difference was observed between these transfer sites. Following transfer, only 25% of maximal force by combined EHL and EDL was required to achieve a neutral foot position. Conclusion: Transfer of the long toe extensors, into either the metatarsals or cuneiforms, significantly increased dorsiflexion of the ankle. Clinical Relevance: The transferred extensors can serve a primary role in treating foot drop in CMT disease, irrespective of the presence of clawed toes. This biomechanical study supports tendon transfers into the cuneiforms, which involves less time, fewer steps, and easier tendon balancing without compromising dorsiflexion power.