Dr. Watson’s Published Articles
THE PROXIMAL OPENING WEDGE OSTEOTOMY: A REVIEW OF THE EVIDENCE AND TECHNIQUE
by Troy S. Watson, MD, Mark S. Hsiao, MD, Chris Harasym, DO, and John P. Walsh, DO
Abstract: The treatment of symptomatic, moderate-to-severe hallux valgus deformities offers numerous challenges to the foot and ankle surgeon. Many surgical procedures have been described for the correction of metatarsus primus varus with moderate-to-severe hallux valgus deformity. For the larger deformity, surgeons typically turn toward a shaft or basilar osteotomy or opt for a Lapidus-type procedure. The proximal opening wedge osteotomy has become popular with the recent development of specifically designed, low-profile, opening wedge, proximal metatarsal systems. Despite initial success and popularity, a reported 3% to 11% recurrence rate has been described in the literature. In this paper, we review the evidence, our indications, contraindications, technique, and pearls for success. We believe that the proximal opening wedge osteotomy technique provides excellent correction, is technically reproducible, easy to perform, and should be an option in every surgeon’s toolbox. As techniques continue to evolve, we have added a closing wedge or distal biplanar osteotomy in those cases presenting with an increased distal metatarsal articular angle, to better achieve an isometric correction of the first metatarsal and prevent a late recurrence.
TREATMENT OF SEVERE ANKLE AND HINDFOOT DEFORMITY: TECHNIQUE USING FEMORAL HEAD ALLOGRAFT FOR TIBIOTALOCALCANEAL FUSION USING A CUP-AND-CONE REAMER
by Victor Hoang, D.O., Taylor Anthony, B.S., Shivali Gupta, D.O., Ryan Chang, Holman Chan, M.D., Troy Watson, M.D.
Limb shortening due to structural bone loss in tibiotalocalcaneal arthrodesis is a concern that can negatively impact the patient’s gait and weight-bearing. To aid in preventing the risk of limb shortening, the use of a femoral head allograft and intramedullary nail in tibiotalocalcaneal arthrodesis has been shown to successfully preserve limb length in patients with structural bone deficits. We present our technique using a femoral head allograft with a cup-and-cone reamer for the treatment of severe ankle and hindfoot deformity.
Open modified Broström ankle reconstruction with internal brace augmentation: A novel approach
by Troy S. Watson, MD; Richard J. Lamour, MD
Chronic lateral ankle instability can cause debilitating ankle pain and dysfunction in athletes and active individuals. In the untreated patient, chronic lateral ankle instability can potentially lead to late sequelae, such as ankle arthritis and deformity.
For patients who have failed initial attempts at nonoperative treatment, i.e., physical therapy, bracing, etc., surgical management with an open modified Broström reconstruction is a wellaccepted technique with good to excellent outcomes. However, recurrent instability is reported after acute reinjury and chronic attritional wear of the repaired anterior talofibular ligament (ATFL) at rates as high as 16% in one longterm outcome study by Maffulli and colleagues. In addition, traditional rehabilitation after open modified Broström reconstruction is lengthy, which for competitive athletes, laborers or active individuals, can be costly with regard to time away from sport, work or a demanding lifestyle.
Correction of Moderate to Severe Hallux Valgus With Isometric First Metatarsal Double Osteotomy
by Werner Siekmann, MD, Troy S Watson, MD and Matthias Roggelin, MD
The operative treatment of moderate to severe hallux valgus presents various challenges for the surgeon. Despite the multitude of operative techniques and their combinations, the indications for single, double, or triple osteotomies remain muddled and treatment requires independent decisions for each foot. To correct a higher 1-2intermetatarsal angle (IMA), a more proximal metatarsal osteotomy is necessary. Biomechanical studies have identified the alignment of the first tarsometatarsal joint to be of high importance in the development of hallux valgus.
Therefore, while preserving the tarsometatarsal joint, the proximal procedure realigns the first ray to a greater extent than a distal procedure is capable of doing. According to biomechanical studies, the differences in stiffness and stability of various osteotomy types have led to the development of a medially placed low-profile plate for a proximal first metatarsal opening-wedge osteotomy. The plate should be thin enough to be self-bending while stabilizing the opening wedge osteotomy.
Dorsal Approach for Plantar Plate Repair With Weil Osteotomy: Operative Technique
by Troy S. Watson, MD1, Dorian Y. Reid, MD, MPH1, and Timothy L. Frerichs, MD2
In recent years, the role of the plantar plate in lesser metatarsophalangeal joint stability has increasingly been recognized. Tearing or attenuation of the plantar plate often will result in crossover or hammertoe deformity with hyperextension of the MTP joint. Some patients are able to have resolution of painful symptoms with conservative treatment but for those that fail these measures, surgical fixation of the plantar plate is indicated. While, there have been some described techniques for direct repair of the plantar plate, we present a surgical technique through a dorsal approach with a Weil osteotomy which accomplishes great clinical correction of the plantar plate tear and associated toe deformity as well as relief of patient’s pain. Additionally, we believe this technique is safe, efficient and reproducible. Level of Evidence: Level V, expert opinion.
The Proximal Opening Wedge Osteotomy for the Correction of Hallux Valgus Deformity
by Troy S. Watson, MD and Paul S. Shurnas, MD
Abstract: Many surgical procedures exist to correct metatarsus primus varus associated with hallux valgus deformity. Among these procedures are various first metatarsal osteotomies. Both distal and proximal osteotomies have been described to correct these deformities with the latter typically used for the more severe deformity. The goal of the operative procedure is correction of the intermetatarsal and hallux valgus angles with restoration of pain-free shoe wear. The complications associated with the various described proximal metatarsal osteotomies are many, and the techniques can be technically demanding, especially for the surgeon without assistance in the operating room. Although generally good results are observed with traditional osteotomies, the complication rate remains high, leading many surgeons to search for alternative means for correcting these deformities. In this paper, we review a novel technique with a proximal opening wedge osteotomy of the first metatarsal for the correction of moderate-to-severe hallux valgus deformity. Keywords: bunion, proximal osteotomy, hallux valgus, opening wedge osteotomy, metatarsal
The Adult Acquired Flatfoot Deformity: A Treatment Algorithm
by Troy Watson, MD
Abstract: The presentation of an adult with acquired flatfoot deformity is highly variable with a wide range of foot deformities. There remains much controversy in the treatment of the flexible deformities that are moderate to severe. If conservative treatment fails, surgery is often recommended to prevent progression of the deformity and continued pain. This article presents clinical and radiographic parameters in an algorithmic approach to the surgical management. Key Words: adult acquired flatfoot, posterior tibial tendon dysfunction, algorithm, flexible flatfootABSTRACT Background: Many surgical procedures have been described for the correction of metatarsus primus varus associated with hallux valgus deformity. The purpose of this study was to present the results of the proximal metatarsal opening wedge (PMOW) osteotomy using the Arthrex LPS first metatarsal system. Materials and Methods: Eighty-four patients (90 feet) underwent PMOW osteotomy with distal bunionectomy. There were 78 patients (93%) and 84 (93%) feet available for followup. Mean followup was 2.4 (range, 2.0 to 3.2) years from the time of the index surgery. Pre- and postoperative clinical examination, level of activity, patient derived subjective satisfaction score, radiographic measurements, and visual analogue scale (VAS) score for pain were obtained and evaluated retrospectively.
Treatment of Lisfranc Joint Injury: Current Concepts
by Troy S Watson, MD, the late Paul S. Shurnas, MD and Jacques Denker
Injuries to the tarsometatarsal joint complex, also known as theLisfranc joint, are relatively uncommon. However, the importance ofan accurate diagnosis cannot be overstated. These injuries,especially when missed, may result in considerable long-termdisability as the result of posttraumatic arthritis. A high level ofsuspicion, recognition of the clinical signs of injury, and appropriateradiographic studies are needed for correct diagnosis. Whensurgery is indicated, closed reduction with percutaneous screwfixation should be attempted. If reduction is questionable, openreduction should be performed. Screw fixation remains thetraditional fixation technique.
Proximal First Metatarsal Opening Wedge Osteotomy with a Low Profile Plate
by Paul S. Shurnas, MD; Troy S. Watson, MD; Timothy W. Crislip, DPM
ABSTRACT Background: Many surgical procedures have been described for the correction of metatarsus primus varus associated with hallux valgus deformity. The purpose of this study was to present the results of the proximal metatarsal opening wedge (PMOW) osteotomy using the Arthrex LPS first metatarsal system. Materials and Methods: Eighty-four patients (90 feet) underwent PMOW osteotomy with distal bunionectomy. There were 78 patients (93%) and 84 (93%) feet available for followup. Mean followup was 2.4 (range, 2.0 to 3.2) years from the time of the index surgery. Pre- and postoperative clinical examination, level of activity, patient derived subjective satisfaction score, radiographic measurements, and visual analogue scale (VAS) score for pain were obtained and evaluated retrospectively.
by Carroll P. Jones, MD & Troy S. Watson, MD
The current issue, in keeping with previous formats, combines a focused section with a collection of general foot and ankle techniques. The wide variety of surgical procedures presented, from calcanectomies to phalangeal osteotomies, reflects the diverse nature of our subspecialty and the reason many of us were drawn to this discipline. We are fortunate to have a growing number of innovative contributors. Dr Holmes presents his experience using the Mini TightRope for hallux valgus reconstruction. The opening-wedge osteotomy for bunion correction is growing in popularity, and Drs Shurnas and Watson present their technique, which has evolved over the last few years.
Soft Tissue Complications Following Calcaneal Fractures
by Troy S. Watson, MD
Since the 1990s, the orthopaedic surgeon’s ability to manage calcaneal fractures has improved, increasing the popularity of open reduction and internal fixation. Calcaneal fractures account for most tarsal bone fractures and 2% of all fractures. Clinical studies have examined the effectiveness of operative versus nonoperative treatment of these fractures and the use of computed tomography (CT) has improved the ability to classify a fracture for more accurate comparisons. Howard and colleagues  found that significant complications following intra-articular fractures occurred whether treated operatively or nonoperatively and despite management by experienced
surgeons. Most of these studies have not focused on soft tissue complications associated with calcaneal fractures.
Plantar Approach for Isolated Fibular Hallux Sesamoidectomy
by Marc J. Milia, MD, Bruce E. Cohen, MD & Robert B. Anderson, MD
Fibular hallux sesamoidectomy via a plantar approach provides excellent pain relief and return to function. The surgical incision allows for direct visualization of the sesamoid and surrounding soft tissue structures, minimizes the violation of normal anatomic structures, and provides for repair of the flexor hallucis brevis tendon following sesamoid excision. Painful scar, hallux varus, and neuromas do not appear to be common clinically. Persistent pain is an uncommon complication. Keywords: sesamoidectomy, plantar approach, hallux, metatarophalangeal joint
Distal Tarsal Tunnel Release With Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis
by Troy S. Watson, M.D.>; Robert B. Anderson, M.D.; W. Hodges Davis, MD.; Gary M. Kiebzak, PhD.+
This study evaluated the effectiveness of distal tarsal tunnel release with a partial plantar fasciotomy for chronic subcalcaneal pain syndrome in patients who failed nonoperative management through a retrospective review of all patients undergoing this procedure between 1994 and 1999. Distal tarsal tunnel release and a partial plantar fasciotomy were offered only to those patients with disabling heel pain and were performed under general anesthesia or ankle block. Seventy-five patients (80 heels), averaging 20 months of nonoperative treatment, were identified (group I). Postoperative outcome questionnaires (SF-36 and Foot Function Index [FFI]) were sent to these patients and 44 (46 heels) responded (group II).
Outpatient Management of Low-Velocity Gunshot-Induced Fractures
by Troy S Watson, MD, Kyke Dickson, MD , Mitch Harris, MD, Charles Haddad, BS and Joel Jenne, BS
This prospective study evaluated the efficacy of an out-patient management protocol for patients with gunshot-induced fracture with a stable, nonoperative configuration. Forty-one patients (44 fractures) with a grade I or II open, nonoperative fracture secondary to a low-velocity missile comprised the study population. Patients were treated by a standard protocol, which included 1 g of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. Follow-up visits were performed until complete wound and fracture healing achieved.
Thirty-two (78%) of 41 patients underwent full follow-up. Average follow-up was 5.2 months. One (2.8%) fracture (distal fibula) developed a superficial infection, which responded to an additional week of oral antibiotics, and no patient with painful retained shrapnel. These results demonstrate that patients with stable, low-velocity, gunshot-induced fractures can be managed effectively and safely on an outpatient basis using this protocol.
Pulsed Ho:YAG Laser Meniscectomy: Effect of Pulsewidth on Tissue Penetration Rate and Lateral Thermal Damage
by C. Thomas Vangsness, Jr., MD, Troy Watson, MS, BS,
Vahid Saadatmanesh, MS, and Kevin Moran, MD
Background and Objective: Studies need to define the optimal parameters under which the holmium laser should operate for arthroscopic meniscectomy. This study was designed to analyze the effect of various Holmium wavelength pulsewidths on human meniscal tissue penetration rates and lateral thermal injury. Study DesignlMaterials and Methods: Using a pulsed Holmium: YAG laser at a wavelength of 2.1 pm, the effect of various pulsewidths on tissue penetration rates as well as the degree of accompanying thermal damage in human meniscal tissue was evaluated in a specially designed jig. Holding the energy constant at 500 mJ per pulse, the pulsewidth was varied between 100 and 600 microseconds. Results: Fiber penetration of meniscal tissue was found to be fastest at a pulsewidth of 250 microseconds. As the pulsewidth was increased or decreased around this number, the observed penetration time decreased, although no statistical difference was found. The size of the hole created was inversely related to the penetration time. Microscopic examination revealed zones of lateral thermal effect extending 800 pm from the ablation site. Conclusion: No relationship between the pulsewidth and the lateral thermal effect could be found.
THE ORIGIN OF THE LONG HEAD OF THE BICEPS FROM THE SCAPULA AND GLENOID LABRUM
by C. THOMAS VANGSNESS JR, SAMUEL S. JORGENSON, TROY WATSON, DARREN L. JOHNSON
We dissected 105 cadavenc shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid.
In all specimens approximately 50% ofthe biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posteriorlabrum, we distinguished four types of origin.
These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both.