Journal of Foot and Ankle Surgery

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2010-07-01

Human Subject Protection: Overkill?

Paul J. Kim — 2010-05-31

Conducting clinical research can be an arduous and complicated process. The investigator is under constraints of budget, time, and other pressures that can delay the process involved in its execution and completion. This is especially true in clinical trials owing to safety concerns regarding the use of human subjects. For example, it takes an estimated $1 billion and more than 7 years to bring a new drug to market . Human subject protection can play a major role in the increase in costs and delay in time in performing clinical research.

Commentary

D. Scot Malay — 2010-07-01

The difference between statistical and clinical significance is subtle but important. A result that we identify as statistically significant (usually defined at the 5% level, with P ≤ 0.05) may not be clinically significant (usually defined as an effect size, or difference between treatments, of ≥ 10%). The P-value, though readily attainable through any standard statistical software program, may not be very meaningful in real life. What we really want to know is the probability that an observed outcome is of clinical or practical significance. To this end, we have to use our experience and understanding of a clinical situation to define a threshold of clinical significance, which is often defined as a difference ≥ 10%. An alternative to the P-value is the confidence interval, which defines a range, in the same terms by which the data were measured, within which the true value probably (95% probability) resides. The confidence interval also provides information about statistical significance, the strength and direction of the effect, and enables us to consider the clinical relevance of the outcome. To make these points clear, authors and editors should make an effort to report confidence intervals about their point estimates. In the following editorial, Dr. Joseph explains the importance of reporting confidence intervals in the context of health care reform.

Health Care Reform, Statistical Significance, Effect Size, and the Future of the Profession

Robert M. Joseph — 2010-07-01

Health care reform is transforming the medical landscape for clinicians, patients, and administrators alike, with initiatives that strive to maximize health care access and quality while containing expense. The theme of “reform culture” is that of evolving processes of measurement, analysis, and change that are not unique to medicine but rather are a component of a new global economy. Research and analytics have never been so pervasive throughout industries ranging from communications and manufacturing to finance. Outside the health care sector, the vernacular of Six Sigma, Fair Market Valuation, and even Google Analytics are all hallmarks of a culture geared toward analytics. In health care, we have come to recognize this culture in the form of Pay for Performance, Physician Quality Reporting Initiative (PQRI), and Evidence-Based Medicine. No matter what the industry, society now expects greater clarity, transparency, justification, and accountability through analytics.

Surgical Treatment of Hallux Rigidus Using a Metatarsal Head Resurfacing Implant: Mid-term Follow-up

Brian Carpenter, Jason Smith, Travis Motley, Alan Garrett — 2010-07-01

Abstract: The treatment of advanced hallux rigidus remains controversial, with many authors discussing arthrodesis versus arthroplasty. The purpose of this study is to report mid-term outcomes after implantation of a motion-preserving metatarsal head–resurfacing prosthetic and to present our technical considerations and modifications to the published technique to further enhance the clinical benefit of the procedure. Thirty-two implantations were performed in 30 patients. Twenty-three patients were women, 9 men. The average age was 62.8 years (range, 39-86 years). Patients were graded at baseline according to Hattrup and Johnson and completed the American Orthopaedic Foot & Ankle Surgery metatarsophalangeal clinical rating system preoperatively and postoperatively and a patient satisfaction question at final follow-up. Seventy-two percent of implantations were grade III hallux rigidus and 28% were grade II. The average follow-up was 27.3 months (range, 12-43 months). The mean change score for the overall American Orthopaedic Foot & Ankle Surgery scale was 236.8% (SD = 146.62, confidence interval [CI] = 186-287.6). A similar result was achieved between grade II (250.9%, SD = 240.3, CI = 93.9-407.9) and grade III (231.3%, SD = 95.83, CI = 195.14-270.46). No implants were revised or removed, and all patients stated that they were happy with their outcome and would repeat the procedure again if needed. In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus. Salvage arthrodesis remains an option if future revisions are indicated.

Isolated Medial Incisional Approach to Subtalar and Talonavicular Arthrodesis

2010-07-01

Abstract: Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial–incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.

A Retrospective Cohort Study of the BioPro® Hemiarthroplasty Prosthesis

Christine C. Salonga, David C. Novicki, Martin M. Pressman, D. Scot Malay — 2010-04-26

Abstract: We reviewed the outcomes of 79 procedures in 76 patients who underwent first metatarsophalangeal joint hemiarthroplasty. The cohort included 23 men (2 bilateral cases) and 53 women (1 bilateral case), with a mean age of 59.6 ± 11.05 years and a mean follow-up of 2.91 years (range, 1.6-4.5 years). Hemiarthroplasty with the BioPro Hemi Implant (BioPro, Inc., Port Huron, MI) was undertaken in all cases, and 34 (43.04%) of the procedures involved long flexor transfer to the proximal phalanx. Mean first metatarsophalangeal joint dorsiflexion increased from 36.13° ± 17.89° to 56.92° ± 9.82° (P < .0001), plantarflexion increased from 2.71° ± 8.43° to 9.05° ± 4.52° (P < .0001), the first intermetatarsal angle decreased from 8.65° ± 1.17° to 8.41° ± 0.90° (P = .0009), and the prevalence of first-ray elevatus went from 52 (65.82%) to 44 (55.70%) (P = .0047). Postoperative prevalences included: antalgic gait, 11 (13.92%); normal hallux purchase, 74 (93.67%); satisfaction with the appearance of the great toe, 49 (62.03%); ability to wear conventional shoes, 42 (53.16%); freedom from pain, 45 (56.96%); and satisfaction or high level of satisfaction with the outcome, 68 (86.08%). The mean postoperative American College of Foot and Ankle Surgeons Universal Evaluation score was 94.00 (range, 44-100). Eight (10.13%) cases experienced complications: 2 severe pain (1 required implant removal), 1 sesamoiditis, 1 extensor hallucis longus contracture, 1 hallux subluxation and 1 dislocation, and 2 misaligned implants. Based on these results, use of the BioPro hemi-implant is a useful option for the treatment of first metatarsophalangeal joint degeneration.

Effectiveness of Instituting a Specific Bed Protocol in Reducing Complications Associated with Bed Rest

Monica H. Schweinberger, Thomas S. Roukis — 2010-04-05

Abstract: Pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia are well-known complications of bed rest. This retrospective, single-center, observational cohort study evaluated the effectiveness of instituting bed rest protocol that included specific positioning, continuous heel off-loading, recumbent upper and lower body bed exercises, scheduled incentive spirometry, frequent position changes, and thromboprophylaxis (chemical, mechanical, or both), in reducing the incidence of pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia in consecutive patients admitted for at least 7 days. A total of 29 patients (24 males, 5 females) were included in this study, with a mean age of 62.5 (median 63, range 17 to 84) years. The mean length of bed rest was 13.1 (median 10, range 7 to 31) days; and, the mean length of hospital stay was 21.1 (median 17, range 8 to 72) days. During hospitalization, 2 (6.9%) patients developed one or more of the complications measured, with 1 developing a posterior heel pressure ulcer that resolved with local care and another who developed deep venous thrombosis without pulmonary embolism, managed with therapeutic anticoagulation, and hospital-acquired pneumonia treated with antibiotic therapy. The results of this analysis were favorable in comparison with previously reported incidence rates for pressure ulcer, deep venous thrombosis, and hospital-acquired pulmonary complications in patients with similar risk factors, and suggested that a prescribed bed protocol reduces complications associated with bed rest.

Bacterial Skin Contamination Before and After Surgical Preparation of the Foot, Ankle, and Lower Leg in Patients with Diabetes and Intact Skin versus Patients with Diabetes and Ulceration: A Prospective Controlled Therapeutic Study

Thomas S. Roukis — 2010-07-01

Abstract: Eradication of bacterial flora from the foot, especially the nailfolds and toe webspaces, through surgical preparation remains a challenge. All previous studies have involved healthy patients undergoing elective foot and ankle surgery or healthy volunteers. However, the patient with diabetes is considered an immunocompromised host with decreased ability to combat invasive bacterial infections. The use of an efficacious surgical preparation is therefore of paramount importance. The author conducted a prospective study involving patients with diabetes with and without ulceration who underwent the current “best evidence available” surgical preparation (i.e., chlorhexidine gluconate [4%] scrub followed by alcohol impregnated with iodine [1%] solution). Qualitative aerobic cultures before and after completion of this surgical preparation technique were obtained from the hallux nailfold; second, third, and fourth toe webspaces (as one culture); and distal anterior tibia. A total of 120 organisms were cultured before surgical preparation with 64 in the elective group and 56 in the ulcerated group. The most commonly isolated organism was methicillin-resistant Staphylococcus epidermidis, which was identified in 46 pre-preparation cultures (38.3%). This was followed by methicillin-sensitive S. epidermidis (16.7%) and “other” organisms (10.0%). There was a significant reduction for both numbers of organisms identified and positive cultures for the 3 most commonly isolated organisms after surgical preparation. Based on the results of this study, the surgical preparation used here appears to be an efficacious surgical preparation technique for eradicating aerobic bacterial pathogens from the foot in patients with diabetes both with and without ulceration. The high incidence of methicillin-sensitive and methicillin-resistant S. epidermidis found in this patient population is a cause for concern, especially when metallic fixation is intended to be implanted.

Early Weight Bearing After Modified Lapidus Arthodesis: A Multicenter Review of 80 Cases

2010-07-01

Abstract: The modified Lapidus arthrodesis involves fusion of the first tarsometatarsal, which typically takes about 6 weeks to consolidate. Postoperative protocols typically involve non-weight bearing until bone consolidation occurs, however, with a stable fixation construct, protected weight bearing can be initiated earlier than 6 weeks into the postoperative period. Studies specifically evaluating an early weight bearing protocol after lapidus arthrodesis do not exist; such a protocol is the focus of this investigation. A multicenter retrospective review of 80 feet in 76 patients who underwent a Lapidus arthrodesis by 2 different surgeons, involving a similar fixation technique and an early weight-bearing protocol, was performed. All patients were allowed protected weight bearing after the first postoperative visit, at approximately 2 weeks into the postoperative course. Patients began protected weight bearing at a mean 14.8 (95% CI 14.0, 15.6) days postoperative. All 80 feet proceeded to successful union (100% union), and the mean time to union was 44.5 days (95% CI 43.0, 46.0). No hardware was broken, and no complications requiring surgical revision were observed before solid boney fusion was achieved. Statistically significant (P < .001) improvements in the first intermetatarsal, hallux abductus, and lateral metatarsal angles were observed; and no cases of pathological first ray elevatus were encountered. The duration of time to bone healing in the cohort described in this article was similar to the rates described in previous reports describing Lapidus arthrodesis managed with a considerably longer duration of initial postoperative non–weight bearing. This study demonstrates that early weight bearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union. This is the first study that specifically evaluates the early weight bearing protocol after lapidus arthrodesis.

Characteristics of Adult Flatfoot in the United States

2010-05-31

Abstract: Many factors have been suggested to cause flatfoot deformity. The purpose of this study was to identify risk factors for flatfoot deformity, which itself can be a causative factor for other foot and ankle pathologies. The National Health Interview Survey (Podiatry Supplement) from 1990 was analyzed to determine associations of various demographic factors and other foot and ankle pathologies with self-reported flatfoot deformity. We found statistically significant (P ≤ .05) associations of flatfoot with age, male gender, BMI, white-collar occupation, veteran status, bunion, hammertoe, calluses, arthritis, and poor health. Treatment and prevention of flatfoot may have an effect on an individual's overall health and occurrence of other foot and ankle pathologies.

Distraction Arthrodesis of the Subtalar Joint Using Allogeneic Bone Graft: A Review of 15 Cases

Michael S. Lee, Valerie Tallerico — 2010-05-12

Abstract: Distraction arthrodesis of the subtalar joint is often used for the correction of neglected calcaneal fractures. Although different techniques have been advocated, there remains some debate as to the optimal type of bone graft for this purpose. This study retrospectively reviewed one surgeon's results for distraction arthrodesis of the talocalcaneal joint for 15 consecutive feet in 15 patients using 12 frozen femoral head and 3 freeze-dried iliac crest allografts. Indications for distraction arthrodesis in this series included neglected calcaneal fracture (n = 10), failed open reduction with internal fixation (n = 3), malunion after ankle fusion (n = 1), and subtalar joint arthritis with deformity (n = 1). The mean patient age was 47.5 (range 29 to 66) years, and the mean duration of follow-up was 20.6 (range 13 to 31) months. Complete union was achieved in 14 (93.33%) feet. Orthobiological agents were used in every case, including 7 (46.67%) platelet-rich plasma, 5 (33.33%) demineralized bone matrix combined with platelet-rich plasma, 2 (13.33%) platelet-rich plasma combined with an implantable electrical bone growth stimulator, and 1 (6.67%) demineralized bone matrix only. One (6.67%) patient developed a nonunion with collapse of the allogeneic graft, requiring revision with autogenous iliac crest bone graft. There were 8 (53.33%) minor complications, including 4 (26.66%) cases with inferior heel irritation, 2 (13.33%) with sural nerve paresthesia, and 2 (13.33%) with wound dehiscence. In conclusion, the use of allograft for subtalar joint distraction arthrodesis results in similar union rates as autogenous iliac crest grafting previously reported in the literature.

A Retrospective Analysis of Anterior Calcaneal Osteotomy with Allogenic Bone Graft

2010-04-12

Abstract: Anterior calcaneal osteotomy (ACO) with extension bone graft is commonly employed in the treatment of symptomatic supple, hypermobile flatfoot in adolescent as well as adult (≥ 18 years of age) patients. Although autogenous bone graft has been considered the gold standard, allogenic bone is widely used for this procedure because it is readily available, requires no additional procedure for procurement and has incorporation rates similar to autogenous bone graft. There is increasing agreement among surgeons that the union rates with allograft bone are comparable with that observed with autograft bone when used in the ACO. We reviewed the medical records of 51 consecutive patients who had undergone 53 ACO with allogenic bone graft for the repair of flatfoot deformity in an effort to further evaluate outcomes associated with the use of allogenic bone graft. All of the patients had at least 12 months of follow-up. The mean time to graft incorporation was 9.10 ± 1.54 weeks for adolescents and 9.81 ± 2.13 weeks for adults (P = .0149), The incidence of graft incorporation (bone union) was 100% and 90% (P = .1391) in the adolescent and adult groups, respectively. Complications included lateral column pain, sinus tarsitis, nonunion, calcaneocuboid capsulitis, complex regional pain syndrome, incisional dehiscence, and sural neuritis; and all of the complications occurred in the adult group. The results support the understanding that ACO with allogenic bone graft is a reasonable alternative to autograft bone graft in the treatment of flexible flatfoot in adolescent and adult patients.

Lateral Column Lengthening for Acquired Adult Flatfoot Deformity Caused by Posterior Tibial Tendon Dysfunction Stage II: A Retrospective Comparison of Calcaneus Osteotomy with Calcaneocuboid Distraction Arthrodesis

Guus A. Haeseker, Marc A. Mureau, Frank W.M. Faber — 2010-07-01

Abstract: In this study, clinical and radiological results after lateral column lengthening by calcaneocuboid distraction arthrodesis and calcaneus osteotomy were compared. Thirty-three patients (35 feet) treated with lateral column lengthening by distraction arthrodesis (14 patients, 16 feet; group I) or by calcaneus osteotomy (19 patients, 19 feet; group II) for adult-acquired flatfoot deformity caused by stage II posterior tibial tendon dysfunction were compared retrospectively. Mean follow-up was 42.4 months (range, 6-78 months) for group I and 15.8 months (range, 6-32 months) for group II (P < .001). The American Orthopaedic Foot & Ankle Society ankle-hindfoot score was determined, 4 variables were measured on preoperative and postoperative weight-bearing radiographs, and a number of independent and outcome variables, including patient satisfaction, were recorded. Group 2 had a significantly higher American Orthopaedic Foot & Ankle Society score compared with group I (mean, 85 vs. 72, respectively; P < .02) at time of last follow-up, and there were no dissatisfied patients in group I, whereas 2 patients in group II were dissatisfied with the result of the operation. All radiological results were significantly better at time of follow-up in both groups (except for talocalcaneal angle in group I), although no significant differences were noted in the amount of change in radiographic measurements between the groups. No significant correlation was found between follow-up time and radiographic improvement, indicating stable radiographic measurements over time. In group II, 13 mild calcaneocuboid subluxations were observed. In both groups, 1 nonunion and 1 wound complication occurred. Based on our experience with the patients described in this report, we recommend lateral column lengthening by means of calcaneus osteotomy rather than distraction arthrodesis of the calcaneocuboid joint, for correction of stage II posterior tibial tendon dysfunction.

The Use of Autologous Platelet Gel in Toenail Surgery: A Within-Patient Clinical Trial

Antonio Córdoba-Fernández, Rafael Rayo-Rosado, José María Juárez-Jiménez — 2010-06-04

Abstract: A number of studies have stressed the importance of platelets in acute and chronic wound healing, although their clinical utility remains controversial. To analyze the use of autologous platelet gel in the surgical treatment of ingrown toenails, a within-patient clinical trial was conducted. Thirty-five healthy volunteers (70 feet) underwent surgical treatment for bilateral ingrown hallux nails. Recovery time (days), postoperative pain (analog chromatic scale), and inflammation (digital circumference) at 48 hours postoperative were the outcomes of interest. Recovery time and postoperative pain were less in the experimental group, although the differences of means were not statistically significant. Based on these results, we suggest that local application of APG in surgical ingrown toenail wounds may produce a slight increase in acute inflammatory phase dermal wound healing, but it does not cause a statistically significant reduction in recovery times or postoperative pain.

Scarf and Weil Metatarsal Osteotomies of the Lateral Rays for Correction of Rheumatoid Forefoot Deformities: A Systematic Review

Thomas S. Roukis — 2010-04-26

Abstract: Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays has recently been proposed for the treatment of global rheumatoid forefoot deformities because of the perceived benefit of sparing the metatarsal-phalangeal joints. Furthermore, it has been proposed that undergoing this form of global forefoot reconstruction is reliable based on specific preoperative and intraoperative techniques used to realign the individual rays. Finally, it has been proposed that performing global forefoot reconstruction in the rheumatoid patient population can be safely performed and does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities. Information from peer-reviewed journals, as well as from non–peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved patients undergoing Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays, evaluated patients at mean follow-up of 12-months or longer duration, commented on the reliability of metatarsal realignment, and included details of complications, as well as the incidence and severity of wound-healing complications. Two studies were identified that met the inclusion criteria involving only 8 patients (8 feet) with 1 patient undergoing surgical revision in the form of arthrodesis secondary to development of a septic first metatarsal–phalangeal joint. Partial incision dehiscence developed in 2 patients, 1 healed with local wound care and the other led to the septic first metatarsal–phalangeal joint mentioned previously. Finally, stress fracture of the third metatarsal and fourth metatarsals developed that healed without problems in one other patient. Rather than providing strong evidence for or against the use of Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities, the results of this systematic review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.

Comparison Between Ponseti's and Kite's Clubfoot Treatment Methods: a Meta-analysis

Marcos Almeida Matos, Luiz Antonio Alcântara de Oliveira — 2010-07-01

Abstract: The objective of our study was to compare both Kite's and Ponseti's methods to evidence which one is the most efficient technique in the treatment of congenital idiopathic clubfoot, based on a meta-analysis of current scientific literature. We performed a search of the past 20 years of literature (1986 to 2006) on MEDLINE, LILACS, and EMBASE databases for clinical trials that compared both Kite's and Ponseti's methods. The search in the literature provided 4 selected papers for the meta-analysis. There was a significant difference between the groups, in which the Ponseti's group was more effective in treating congenital clubfoot, considering both primary correction (P = .001) and uncorrected plus relapsed feet (P = .014). In conclusion, our meta-analysis indicates that Ponseti's group in the clubfoot treatment was superior to Kite's group; however, the available studies have some methodological limitations such as small sample sizes and historical control.

Synovial Sarcoma Involving the Calcaneus and Plantar Compartment of the Foot: A Case Report

2010-05-31

Abstract: Synovial sarcoma arising in the foot is a rare finding. We report a 64-year-old female with synovial sarcoma involving the calcaneus and central plantar compartment. The patient presented with a 2-year history of painful heel with soft tissue mass presentation 21 months after initial pain. We performed an incisional biopsy with frozen section; histopathology was consistent with synovial sarcoma.

Missed Posterior Deep, Inferior Subcompartment Syndrome in a Patient with an Ankle Fracture: A Case Report

Kalman John Piper, Jessica Chua Yen-yi, Mark Horsley — 2010-05-31

Abstract: Deep posterior compartment syndrome is an extremely rare complication of ankle fracture and the few reported cases in the literature show that it is usually diagnosed late. Anterior and deep posterior compartment syndromes have been described with variable manifestations according to the compartment affected. We present a case of deep posterior compartment syndrome isolated to the disputed distal “subcompartment” of the leg, which had a very subtle and late presentation and was missed. The diagnosis of compartment syndrome was confirmed on MRI scan. Subsequently the patient developed a flexor hallucis longus muscle contracture that was managed nonoperatively.

Angioleiomyoma in the Ankle Mimicking Tarsal Tunnel Syndrome: A Case Report and Review of the Literature

2010-06-04

Abstract: We present the case of a 64-year-old woman with a subcutaneous vascular leiomyoma in the tarsal tunnel in the ankle. The patient presented with pain of several years' duration in the medial aspect of the ankle in the retromalleolar region corresponding to the tarsal tunnel and associated with a subcutaneous mass. We report the clinical manifestation, the imaging and histopathologic features, and a review of the literature. Vascular leiomyomas are part of the differential diagnosis of painful subcutaneous masses in the lower extremity.

Arthroscopic Removal of an Intraarticular Osteoid Osteoma of the Distal Tibia

Giacomo Rizzello, Umile Giuseppe Longo, Nicola Maffulli, Vincenzo Denaro — 2010-05-21

Abstract: Intraarticular osteoid osteomas can simulate several other traumatic or degenerative pathologies of the joint with delay in diagnosis. We report the clinical features, radiographic and histopathological findings, the technical aspects of arthroscopic excision, and results of surgery in a 28-year-old woman who had an intraarticular osteoid osteoma of her left ankle, in whom the initial diagnosis was erroneous and delayed 1 year. Arthroscopy allowed minimally invasive complete excision of the osteoid osteoma, with a short postoperative rehabilitation and excellent functional results.

Multicentric GCT of Tarsal Bones in an Immature Skeleton: A Case Report with Review of Literature

Atul Varshney, Harish Rao, Raghvendra Sadh — 2010-05-31

Abstract: Multicentric giant cell tumor of the foot is rare. Multicentric giant cell tumor of the tarsal bones in an immature skeleton is unheard of. We report a case of synchronous multicentric giant cell tumor involving the talus and calcaneum in a 14-year-old boy with open epiphyseal plate for its rarity and successful treatment by curettage and synthetic bone graft.

Irreducible Salter Harris Type II Distal Tibial Physeal Fracture Secondary to Interposition of the Posterior Tibial Tendon: A Case Report

Robert Soulier, Lawrence Fallat — 2010-07-01

Abstract: Pediatric distal tibial fractures generally occur without significant long-term sequelae, and patients are commonly able to return to their preinjury activities after proper management. The literature reports excellent outcomes after anatomical reduction of distal tibial and ankle physeal fractures with closed or open treatment. Treatment options include simple immobilization of nondisplaced fractures, and closed or open reduction for restoration of anatomic alignment of displaced fractures. Soft tissue interposition within the fracture can threaten successful closed reduction, and may warrant open management if closed reduction fails to produce a satisfactory result. Despite the documented possibility of soft tissue interposition preventing closed reduction of pediatric ankle fractures, there is a paucity of literature reporting this complication. We report a unique case of an irreducible Salter-Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon.

Massive Bilateral Tarsal Ankylosis and Surgical Correction: A Case Report

Saqib Noor, Paul Rollinson — 2010-05-24

Abstract: Tarsal ankylosis is described as a feature of advanced juvenile or rheumatoid arthritis. Ankylosis involving more then one tarsal segment is uncommon. Incidental reports of massive tarsal ankylosis have been described in a case of juvenile spondyloarthropathy, a case of familial tarsal ankylosis, and, more recently, it was discovered in a prehistoric skeleton dating back to the Iron Age. We describe a rare case of bilateral massive tarsal ankylosis, and the surgical intervention used to treat the condition, in a 21-year-old female with no other features of any known forms of arthritis and no family history of the condition.

High-pressure Water Injection of the Foot with Associated Subcutaneous Emphysema: A Case Report

Bradly Bussewitz, Scott Littrell, Karl Fulkert, Robert VanCourt — 2010-05-21

Abstract: A review of the literature yields few reported cases of industrial-strength high-pressure water injection injuries involving the foot, and sources of information for industrial-strength high-pressure water injection injuries reside primarily in the hand surgical literature. Toxic materials, such as grease, paint, and diesel oil, are relatively common agents involved in injection injuries, and these substances are associated with increased morbidity in comparison with injection of water or air. Treatment of high-pressure injection of a toxic substance is a surgical emergency requiring irrigation, debridement, antibiotic administration, and monitoring for signs and symptoms of compartment syndrome. There are, however, documented cases where less extreme treatment regimens have met with success. We report a successful limb salvage case, and review of the literature, related to a high-pressure water injury involving the foot with associated extensive subcutaneous emphysema.

Intraneural Ganglion of the Superficial Peroneal Nerve: A Case Report

Emmanouil D. Stamatis, Nikolaos E. Manidakis, Paraskevas P. Patouras — 2010-05-31

Abstract: Ganglia affecting the peripheral nerves of the foot and ankle are rare. The most frequent location of occurrence is the common peroneal nerve at the level of the fibular neck. We report the case of an intraneural ganglion of the superficial peroneal nerve and its branches. Although there have been many previous reports of intraneural ganglion involvement with the common peroneal nerve, deep peroneal nerve, sural nerve, and the posterior tibial nerve, to our knowledge, this is the first reported occurrence of an intraneural ganglion distinctly localized to the superficial peroneal nerve and its branches. The presumptive diagnosis was made preoperatively using magnetic resonance imaging, and then confirmed postoperatively by pathologic examination. Despite the use of operative magnification, it was impossible to remove all of the cyst elements within the nerve trunk, because the nerve fascicles were intimately intertwined. Therefore, complete resection of the common trunk of the superficial peroneal nerve and its terminal branches was performed, and the proximal stump was buried in a hole in the distal fibula. Two years after the surgery, the patient was pain free and asymptomatic except for cutaneous anesthesia in the distribution of the superficial peroneal nerve.

Low-grade Fibromyxoid Sarcoma of the Talus: A Case Report

2010-05-31

Abstract: Low-grade fibromyxoid sarcoma is a rare tumor, which most commonly arises from the deep soft tissues of the lower extremities in young men. Diagnosis of this tumor can be difficult because of its deceptively benign histopathologic appearance. Specifically, the lesion is characterized by alternating fibrous and myxoid areas with variable cellularity and a whorled growth pattern. Like many soft tissue tumors, low-grade fibromyxoid sarcoma is also characterized by strong immunoreactivity to the human proto-oncogene BCL-2. Cytogenetically, the lesion has also been associated with the t (7,16) (q33;p11) translocation, with the characteristic resultant FUS and CREB3L2 fusion gene. In this report, we describe the rare case of a low-grade fibromyxoid sarcoma that appeared to develop as a primary malignancy in the neck of the talus of a young man who presented with recurrent ankle pain after a previous surgery for a cystic lesion at the same site.

Evans Calcaneal Osteotomy Using an Anterior Lumbar Distractor-Inserter

Naohiro Shibuya, Monica R. Agarwal — 2010-05-21

Abstract: Although it is a relatively simple procedure for an experienced foot and ankle surgeon, Evans calcaneal opening wedge osteotomy requires 2 separate steps: 1) distraction of the osteotomy, and 2) insertion of a bone graft, and each of these maneuvers can be difficult without the use of appropriate instrumentation. In this report, a simplified method of executing this procedure with an anterior lumbar distractor-inserter is introduced. With the use of this particular instrument, a surgeon can avoid excessive distraction of the osteotomy while positioning a large bone graft in the distracted osteotomy without fracturing the anterior calcaneal fragment. The device also allows the surgeon to fine tune the correction of deformity by controlling the depth of bone graft insertion. The instrument provides all of these benefits without a high learning curve or additional cost to the procedure.

VERSAJETtm Hydrosurgery Technique for the Preparation of Full Thickness Skin Grafts and the Creation of Retrograde Split Thickness Skin Grafts

Christopher Bibbo — 2010-06-04

Abstract: Full- and split-thickness skin grafts continue to serve a vital role in lower extremity wound coverage, and meticulous preparation of the recipient site is vital to incorporation of the transplanted skin. A technique for the rapid, controlled preparation of full-thickness skin grafts and creation of thick-split thickness skin grafts from full-thickness donor tissue, using a high-pressure stream of saline solution, is described.

Masthead

2010-07-01

Editorial Board

2010-07-01

Journal of Foot and Ankle Surgery

Cover 1

Human Subject Protection: Overkill?

Commentary

Health Care Reform, Statistical Significance, Effect Size, and the Future of the Profession

Surgical Treatment of Hallux Rigidus Using a Metatarsal Head Resurfacing Implant: Mid-term Follow-up

Isolated Medial Incisional Approach to Subtalar and Talonavicular Arthrodesis

A Retrospective Cohort Study of the BioPro® Hemiarthroplasty Prosthesis

Effectiveness of Instituting a Specific Bed Protocol in Reducing Complications Associated with Bed Rest

Bacterial Skin Contamination Before and After Surgical Preparation of the Foot, Ankle, and Lower Leg in Patients with Diabetes and Intact Skin versus Patients with Diabetes and Ulceration: A Prospective Controlled Therapeutic Study

Early Weight Bearing After Modified Lapidus Arthodesis: A Multicenter Review of 80 Cases

Characteristics of Adult Flatfoot in the United States

Distraction Arthrodesis of the Subtalar Joint Using Allogeneic Bone Graft: A Review of 15 Cases

A Retrospective Analysis of Anterior Calcaneal Osteotomy with Allogenic Bone Graft

Lateral Column Lengthening for Acquired Adult Flatfoot Deformity Caused by Posterior Tibial Tendon Dysfunction Stage II: A Retrospective Comparison of Calcaneus Osteotomy with Calcaneocuboid Distraction Arthrodesis

The Use of Autologous Platelet Gel in Toenail Surgery: A Within-Patient Clinical Trial

Scarf and Weil Metatarsal Osteotomies of the Lateral Rays for Correction of Rheumatoid Forefoot Deformities: A Systematic Review

Comparison Between Ponseti's and Kite's Clubfoot Treatment Methods: a Meta-analysis

Synovial Sarcoma Involving the Calcaneus and Plantar Compartment of the Foot: A Case Report

Missed Posterior Deep, Inferior Subcompartment Syndrome in a Patient with an Ankle Fracture: A Case Report

Angioleiomyoma in the Ankle Mimicking Tarsal Tunnel Syndrome: A Case Report and Review of the Literature

Arthroscopic Removal of an Intraarticular Osteoid Osteoma of the Distal Tibia

Multicentric GCT of Tarsal Bones in an Immature Skeleton: A Case Report with Review of Literature

Irreducible Salter Harris Type II Distal Tibial Physeal Fracture Secondary to Interposition of the Posterior Tibial Tendon: A Case Report

Massive Bilateral Tarsal Ankylosis and Surgical Correction: A Case Report

High-pressure Water Injection of the Foot with Associated Subcutaneous Emphysema: A Case Report

Intraneural Ganglion of the Superficial Peroneal Nerve: A Case Report

Low-grade Fibromyxoid Sarcoma of the Talus: A Case Report

Evans Calcaneal Osteotomy Using an Anterior Lumbar Distractor-Inserter

VERSAJETtm Hydrosurgery Technique for the Preparation of Full Thickness Skin Grafts and the Creation of Retrograde Split Thickness Skin Grafts

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