Completed Research by Dr. W. Bret Smith:
A proposed treatment algorithm for midfoot charcot arthropathy
Source: Smith WB, Moore CA. Moore Orthopaedics, Columbia, South Carolina (WBS).
Charcot arthropathy (CA) is an insidious, destructive, and disabling pathology of the foot and ankle. Efficient and effective treatment is therefore required to improve clinical outcomes and to reduce overall mortality risk. The purpose of this case series report is to propose a treatment algorithm for correcting deformity and restoring a plantigrade, shoeable foot in patients with midfoot CA. While there is no clear evidence in the literature favoring either internal or external fixation methods, it may be appropriate to use both techniques during most deformity correction cases. Depending on the presence of ulceration, single-stage and multi-stage reconstruction with either biplanar or aggressive resection can effectively address the presentation of nonviable tissue and a wide degree of variable deformity. Following midfoot reduction, medial column plating and circular external frame can be used together to effectively stabilize and protect the correction and construct. In all cases, the aim is to immediately place the patient into a Charcot Restraint Orthotic Walker boot, with the ultimate goal of transitioning to diabetic shoeing as quickly as possible.
Single-screw fixation for subtalar joint fusion does not increase nonunion rate
Source: DeCarbo WT, Berlet GC, Hyer CF, Smith WB. Orthopedic Foot & Ankle Center, Westerville, Ohio, USA.
A philosophical shift toward more joint-sparing procedures has led to increased use of isolated subtalar joint (STJ) versus triple arthrodesis. Union rates for STJ fusion range from 47% to 100%, leading to controversy regarding the optimal type, orientation, and amount of internal fixation. The purpose of this study was to determine if single-screw fixation is a predisposing factor to nonunion. Single-screw fixation is parallel to the STJ axis and may result in motion. It is hypothesized that higher nonunion rates will be observed in single-screw versus 2-screw fusions. Isolated STJ arthrodeses performed in 113 patients were retrospectively reviewed. Single screws were used in 89 (78.8%) fusions; 2 screws were used in 24 (21.2%) fusions. The mean follow-up was 11 months (range, 9-17 months). Nonunion occurred in 13 (14.6%) single-screw and 6 (25.0%) 2-screw fusions. Twenty (22.5%) single-screw and 3 (12.5%) 2-screw fusions required hardware removal. Revision surgery was performed in 6 (6.7%) single-screw and 3 (12.5%) 2-screw fusions. No significant differences in demographics were calculated between single and 2-screw fusions. Furthermore, no significant differences were observed in nonunion rate, postoperative complication incidence, or subsequent surgeries. The results from this study do not support the contention that single-screw fixation predisposes STJ fusions to nonunion. Comparable nonunion and complication incidences were observed between single and 2-screw fusions. These data suggest that the motion occurring from single-screw fixation may not be significant enough to directly affect the rate of union.
Opening wedge osteotomies for correction of hallux valgus: a review of wedge plate fixation
Source: Smith WB, Hyer CF, DeCarbo WT, Berlet GC, Lee TH. Moore Orthopaedics
Osteotomy of the proximal metatarsal for the correction of moderate to severe hallux valgus deformity is commonly performed. The purpose of this study is to review the early results of a technique for the correction of hallux valgus, an opening wedge osteotomy of the proximal first metatarsal with opening wedge plate fixation. A review was performed of the results of 47 patients (49 feet) who underwent correction of hallux valgus with proximal metatarsal opening wedge osteotomy. All osteotomies were secured with plate fixation on the medial side. Evaluation consisted of preoperative and postoperative radiographic as well as clinical evaluations. Mean corrections of 7 degrees were achieved for the 1-2 intermetatarsal angles. Fourteen complications occurred, 6 of which involved mild hardware irritation and did not affect outcome. Four nonunions or delayed unions were identified. The authors find the opening wedge osteotomy of the proximal first metatarsal to be a technically straightforward procedure for correcting moderate to severe hallux valgus. The correction obtained is comparable to other described techniques.
Peroneal Tendon Injuries
Terrence M. Philbin, DO, Geoffrey S. Landis, DO and Bret Smith, DO (Moore Orthopaedics)
Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain. Ankle sprains are common, and up to 40% of affected individuals experience subsequent chronic ankle pain. Identifying the source of chronic ankle pain can be difficult because of the large number of possible causes. The peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilizers. A careful physical examination, along with a thorough patient history and imaging studies, are critical in arriving at an accurate diagnosis. Understanding the anatomy of the peroneal tendons and knowledge of current treatment approaches for peroneal tendon tears, subluxation and dislocation of the tendons, and peroneal tenosynovitis are of great importance in achieving a favorable outcome. Low-demand patients do well with a nonsurgical approach; high-demand patients may benefit from surgery.
Posterior Ankle Impingement: The Role of Posterior Ankle Arthroscopy
Smith, William Bret MS, DO; Berlet, Gregory C. MD
Posterior ankle arthroscopy is a useful tool for evaluating and treating the pathologic posterior aspect of the ankle joint and related structures. Increased awareness and understanding of the issues in the posterior aspect of the ankle joint have led to the development of newer techniques for treatment of this pathologic condition. In this paper, we review the current understanding of pathologic posterior ankle and the application of posterior ankle arthroscopy as a treatment option.
New Intramedullary Implant for Proximal Interphalangeal Joint Arthrodesis
Cuttica, Daniel J. DO; DeCarbo, William DPM; Smith, W. Bret DO; Berlet, Gregory C. MD
Hammertoe deformity of the lesser toes is one of the most common conditions the foot and ankle surgeon will treat. Proximal interphalangeal (PIP) joint arthrodesis is a reliable method of treatment for this deformity. There are multiple techniques that may be used, some using internal fixation. Internal fixation is particularly useful for revision cases, significant spasticity, or rigidity. The ideal PIP implant will be easy to install and provide predictable correction, with little risk of disengagement or pullout failure. The Smart Toe implant was developed specifically for PIP joint arthrodesis, and its one-piece design offers several advantages over other methods of fixation. With proper patient selection and correct surgical technique, the Smart Toe implant can prove to be a reliable method of fixation in PIP joint arthrodesis for the treatment of hammertoe deformity.
Osteochondral Lesions of the Talus: Predictors of Clinical Outcome
Daniel J. Cuttica, DO; W. Bret Smith, DO; Christopher F. Hyer, DPM, MS, FACFAS; Terrence M.
Published in Foot & Ankle International
November 2011 (Vol. 32 #11) November 1, 2011
Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. Methods: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. Results: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 ± 13.7 (range, 12 to 73) years. The average followup was 37.2 ± 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 ± 0.67 cm2. There were 20 lesions larger than 1.5 cm2 and 110 lesions smaller than 1.5 cm2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm2 and uncontained lesions were associated with a poor clinical outcome. Conclusions: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions are often associated with inferior functional outcomes and may require a more extensive initial procedure. Level of Evidence: IV, Retrospective Case Series