Journal of Foot and Ankle Surgery

Cover 1

2012-01-01

Stand Up and Start Counting

Arnol Saxena — 2011-10-17

Everyone agrees that research is important. We use findings to shape how we practice. Patients use findings to see what treatment options appeal to them. Sometimes, practitioners and patients interpret studies differently, just as practitioners and patients may not agree on what constitutes a good outcome. An example is when a study shows statistical improvement between pre- and postoperative ACFAS or AOFAS scores and indicates to a practitioner that a procedure is worth using. A patient may disagree, however, as almost all studies fail to document activity level. A patient could have a 95+ AOFAS score after bunion or ankle surgery, but if that patient cannot run or perform daily activities without pain, the foot score is essentially meaningless.

An Analysis of Outcomes after Use of the Maxwell-Brancheau Arthroereisis Implant

Steven P. Brancheau, Kelly M. Walker, David R. Northcutt — 2012-01-01

Abstract: The authors present a retrospective study of 35 consecutive patients (60 feet) treated with the Maxwell-Brancheau Arthroereisis (MBA) implant. The mean age of the cohort at the time of surgery was 14.3 (range 5 to 46) years, and 22 (62.86%) men and 13 (37.14%) women were included. Preoperative and postoperative anteroposterior and lateral foot radiographs were compared at a mean of 36 (range 18 to 48) months postoperatively, and the following mean changes were reported: talocalcaneal angle 24.15° ± 7.97° to 18.53° ± 8.23°, calcaneocuboid angle 18.67° ± 8.72° to 11.76° ± 8.49°, first to second intermetatarsal angle 9.42° ± 2.67° to 7.61° ± 2.69°, calcaneal inclination angle 11.93° ± 6° to 14.93° ± 5.85°, and talar declination angle 34.0° ± 8.59° to 28.02° ± 6.85°; all of these differences were statistically significant (p < .0001). A subgroup of 24 (68.57%) patients also answered a subjective questionnaire at a mean of 33 (range 12 to 55) months postoperatively. The presenting chief complaints were resolved in 23 patients (95.83%) of the subgroup, and 21 patients (87.5%) returned postoperatively to either the same or a greater activity level in sports. Twenty-three (95.83% of the subgroup) patients said they were 75% to 100% satisfied with their surgical outcome, and that they would recommend the surgery to a friend or family member with the same condition, whereas 1 (4.17%) claimed 0% satisfaction after placement of inappropriately sized implants (which were later replaced to the patient’s clinical satisfaction) in both feet.

Infected Internal Fixation after Ankle Fractures—A Treatment Path

Yvonne Bernadette Maria Kollrack, Gunnar Moellenhoff — 2012-01-01

Abstract: In the emergency treatment of infected internal fixation after ankle fractures, the infection needs to be resolved quickly to protect the implants, bone, and tendons. Vacuum wound therapy (topical negative pressure therapy) has been used for more than 15 years to assist in closure and to accelerate healing of a wide range of wounds. In the present report, we describe the results of treatment of 7 angiopathic (dysvascular) patients who developed a deep wound infection after ankle osteosynthesis. Each patient was treated with initial surgical debridement, followed by vacuum wound therapy and meshed split-thickness skin graft transplantation. The mean inpatient length of vacuum wound therapy was 14.0 ± 4.31 days, and the mean total duration of vacuum treatment was 54.43 ± 7.74 days.

The Surgical Treatment of Peroneal Tendinopathy (Excluding Subluxations): A Series of 17 Patients

2011-11-24

Abstract: Peroneal tendon pathology is rare, but is probably underestimated because it is frequently undiagnosed. It should always be in the differential diagnosis of lateral ankle pain. Surgical treatment of peroneal tendinopathy is indicated after failure of conservative measures. The aim of this retrospective study is to evaluate the medium-term clinical results of 17 patients operated for peroneal tendinopathy without tendon subluxation. A series of 17 patients composed of 7 women and 10 men with a mean age of 53.6 ± 4.6 (range 45 to 60) years were reviewed. The mean preoperative Kitaoka score was 46.7 ± 17.1 (range 25 to 69) points. All patients had radiological evaluation, which demonstrated hindfoot varus in 6 of the 17. Surgical interventions comprised synovectomy, debridement, suture-tubularization, fibrous resection, or tenodesis depending on the preoperative findings and also a valgus osteotomy (Dwyer) in 6 cases and ankle ligament reconstruction (modified Blanchet) in 1 case. All patients were reviewed clinically with a mean follow-up of 4.3 ± 3.8 years (range 16 months to 14 years). Average time to return to sport was 8.5 ± 10.4 months (range 3 months to 3 years). The mean time to return to work was 2.5 ± 1.9 (range 0 to 6) months. The mean postoperative Kitaoka score was 90.1 ± 11 (range 64 to 100) points with a statistically significant improvement to the preoperative score (p < .0001). Sixteen patients were satisfied or very satisfied with their treatment (94.1%). Surgical treatment of peroneal tendinopathy after failed conservative treatment leads to significantly improved function. It is a simple treatment to undertake, which gives a good outcome for both the patient and surgeon.

Radiofrequency Thermoneurolysis for the Treatment of Morton’s Neuroma

Joshua L. Moore, Ritchard Rosen, Jeffrey Cohen, Brad Rosen — 2011-11-07

Abstract: Pedal neuroma is a common disorder. The authors undertook a review of 32 feet in 29 patients with a symptomatic neuroma treated between January 2007 and January 2010 to evaluate the effectiveness of radiofrequency thermoneurolysis therapy in alleviating symptoms. Overall relief of symptoms was rated as complete by 24 (83%) patients, with 5 patients experiencing minimal to no relief. Two patients were lost to follow-up after 1 month, 2 patients opted for no further intervention, and 1 patient went to open resection of the neuroma. Average follow-up was 13 months and total recovery time was 2 days. Complications included 1 foot with cellulitis treated by a course of oral antibiotics. The results of this retrospective study indicate radiofrequency thermoneurolysis therapy is a safe, effective, and minimally invasive alternative treatment for symptomatic neuromas of the foot.

Extraosseous Talotarsal Stabilization Using HyProCure® in Adults: A 5-year Retrospective Follow-up

Michael E. Graham, Nikhil T. Jawrani, Avanthi Chikka — 2012-01-01

Abstract: The purpose of this retrospective study was to determine long-term functional outcomes and device tolerance achieved in adult patients who chose to undergo an extraosseous talotarsal stabilization procedure HyProCure® for the treatment of flexible talotarsal joint deformity. Eighty-three adult patients participated in this study. Postoperative subjective assessment of device performance was evaluated using Maryland Foot Scores, which were collected at a mean follow-up period of 51 months. The mean postoperative Maryland Foot Score was 88 out of 100; postoperatively, 52% of cases reported complete alleviation of foot pain, 69% of cases had no limitations on their foot functional abilities, and 80% of cases reported complete satisfaction with the appearance of their feet. The implant was removed in 7 out of 117 cases (removal rate: 6%) due to prolonged pain of the anterior talofibular ligament (4 cases), psychogenic reaction (2 cases), and postoperative infection (1 case). The long-term positive subjective outcomes and excellent patient satisfaction obtained in this study may imply that extraosseous talotarsal stabilization was effective in stabilizing the talotarsal joint complex and eliminating excessive abnormal pronation, thus reducing pain and improving quality of life of the patients; it represents a possible treatment option for partial talotarsal dislocation in cases with flexible and reducible deformity.

Incorporation of Bovine-based Structural Bone Grafts Used in Reconstructive Foot Surgery

Naohiro Shibuya, Daniel C. Jupiter, Lacey D. Clawson, Javier La Fontaine — 2011-10-31

Abstract: Timely incorporation of bone grafts is essential to the structural rigidity in most foot and ankle surgeries. Although bovine-based xenografts possess some of the key features necessary for foot and ankle surgery, the studies evaluating the efficacy of these grafts are limited. The aim of the present study was to determine the incorporation rate of bovine-based bone grafts in foot surgery. A total of 22 patients who had undergone reconstructive foot surgery using 31 bovine-based xenografts were identified, and the rate of radiographic incorporation of the grafts was evaluated. A survival analysis was used to show the trend of the incorporation of the xenografts over time. Of the 21 grafts observed for at least 12 weeks, none showed radiographic graft incorporation by 12 weeks. The analogous numbers for 24, 36, and 48 weeks were 3 (20%) of 15, 4 (31%) of 13, and 3 (27%) of 11 grafts. A total of 19 (61.29%) of the 31 grafts studied were never observed to have incorporated radiographically, for the entire observation period. A Kaplan-Meier estimate revealed the median interval to graft incorporation was 56 weeks. Compared with previous studies, which investigated the incorporation of other types of grafts, such as autograft and allografts, we believe that xenografts incorporate more slowly. For this reason, such grafts might not be ideal for use in reconstructive foot surgery.

Prognostic Difference Between Soft Tissue Abscess and Osteomyelitis of the Foot in Patients with Diabetes: Data from a Consecutive Series of 452 Hospitalized Patients

2012-01-01

Abstract: From January 2008 to December 2010, 452 patients with diabetes were admitted to our diabetic foot unit because of deep soft tissue abscess (group A: n = 210) or chronic osteomyelitis (group B: n = 242). Patients from group A underwent emergency debridement in the operating room. Patients from group B underwent elective surgery. Twenty-six (5.8%) major amputations were performed: of these, 18 (8.57%) were performed in patients from group A and 8 (3.31%) were performed in patients from group B (p = .024). Multivariate analysis showed the independent role on amputation outcome of the abscess (odds ratio, 2.64; p = .029; confidence interval [CI] 1.11 to 6.28), dialysis treatment (odds ratio, 3.17; p = .039, CI 1.06-9.51), and C-reactive protein > 0.5 mg/dL (odds ratio, 3.75; p = .022, CI 1.21-11.64). In group A, 43 (22.6%) patients healed only with drainage, and 147 (70.0%) minor amputations were performed: 53 (36.1%) at the level of the forefoot and 94 (63.9%) at the level of the midfoot. In group B, 234 (96.7%) minor amputations were performed, 208 (88.9%) at the forefoot and 26 (11.1%) at the midfoot level (p < .001). Fourteen postoperative complications occurred in patients from group A and 2 in patients from group B (p < .001). In group A, 3 patients died during hospitalization, 1 from septic shock and 2 from sudden death. None of the group B patients died. This study demonstrates that the severity of a foot soft tissue abscess is not comparable with that of a chronic osteomyelitis not only because of a higher rate of major amputation, but also because of a much more proximal level of minor amputation.

Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing

2012-01-01

Abstract: Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.

Publication Rates of Poster Presentations at the American College of Foot and Ankle Surgeons Annual Scientific Conference Between 1999 and 2008

2012-01-01

Abstract: Publication is the desired end point of scientific research. Ultimately, it is desired that research presented in poster format at a scientific conference will be developed into a report and become published in a peer-reviewed scientific journal. Moreover, poster presentations of research studies are often referenced and, as a result, influence treatment care plans. No data exist for the actual publication rate of podiatric foot and ankle surgery poster presentations. Therefore, the objective of the present study was to determine the actual publication rates of poster presentations at the American College of Foot and Ankle Surgeons (ACFAS) annual scientific conference (ASC) during a 10-year period. Print or electronic media for the ACFAS ASC official program from 1999 to 2008 were obtained. Each year's official program was manually searched for any poster presentation and, when identified, the authors and title were individually searched using Internet-based search engines to determine whether a poster presentation had been followed by publication. Of the 825 posters, 198 (24%) poster presentations were ultimately published in 1 of 32 medical journals within a weighted mean of 17.6 months. Of the 32 journals, 25 (78.1%) represented peer-reviewed journals. The publication rate of poster presentations at the ACFAS ASC was less than that of oral manuscripts presented at the same meeting during the same period and was also less than the orthopedic subspecialty poster presentation publication rates. Therefore, attendees of the ACFAS ASC should be aware that only a few of the posters presented at the ACFAS ASC will be valid because they will not survive the rigors of publication 76% of the time. Additionally, more stringent selection criteria should be used so that the selected poster presentations can ultimately withstand the publication process.

A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant, and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus

2011-10-03

Abstract: This is a retrospective, multicenter study examining the long-term results for the treatment of end-stage hallux rigidus using 3 different surgical procedures. A total of 158 subjects (105 females and 53 males) were included in the present study. They had undergone 1 of the following surgical procedures: arthrodesis, hemi-implant, or resectional arthroplasty. The long-term results for the subjective assessment of pain, function, and alignment, as well as objective radiographic and physical findings, were examined. The median interval to postoperative follow-up for the 3 procedure groups was 159 weeks. No statistically significant difference was found in age or the number of subjects included in the 3 treatment groups (p = .11 and p = .16, respectively). The body mass index was significantly different statistically among the 3 treatment groups, with the hemi-implant group representing a smaller body mass index compared with the other procedures (p = .007). No statistically significant difference was found in the subjective outcomes among the 3 treatment groups using the American College of Foot and Ankle Surgeons' First Metatarsophalangeal Joint and First Ray Scoring Scale (patient questionnaire) or the modified Hallux Metatarsophalangeal-Interphalangeal Scale of the American Orthopedic Foot and Ankle Society (p = .64 and p = .14, respectively). Furthermore, the correlation coefficient between the 2 subjective scoring scales was 0.78, statistically significant and reflecting a moderate to high correlation (p < .001). The results of the radiographic and clinical evaluation revealed that metatarsalgia was the most common finding for the arthrodesis group (9.8%), bony overgrowth into the joint for the hemi-implant group (28.3%), and floating hallux for the resectional arthroplasty group (30.9%). The results of our study suggest that all 3 surgical procedures are viable options for the treatment of end-stage hallux rigidus.

A Retrospective Analysis of Lesser Metatarsophalangeal Joint Fusion as a Treatment Option for Hammertoe Pathology Associated with Metatarsophalangeal Joint Instability

Robert Joseph, Kevin Schroeder, Marc Greenberg — 2011-11-07

Abstract: Complex hammer digit deformity is commonly associated with instability of the metatarsophalangeal joint. Restoring joint stability is critical for digit alignment and function and can be challenging and unpredictable. Lesser metatarsophalangeal joint fusion might be an alternative treatment to the current soft tissue balancing, repair, and extra-articular osseous procedures used to treat joint instability. The present study was a retrospective chart and radiographic review of the pooled outcomes of 31 consecutive lesser metatarsophalangeal joint fusion procedures performed by 3 independent surgeons from May 2004 to September 2009. The clinical and radiographic outcomes were analyzed with descriptive and inferential statistics. The overall interval to radiographic union was 8.69 ± 1.7 weeks (range 6 to 12 and 95% confidence interval 7.9 to 9.4). The overall period to clinical union was 10.25 ± 4.5 weeks (range 4 to 22 and 95% confidence interval 8.5 to 11.9). The mean duration of non–weight-bearing was 4.71 ± 1.74 weeks, followed by 5.09 ± 2.8 weeks of guarded weight-bearing with a brace. Complications included nonunion in 4 (12.90%), hardware breakage in 2 (6.45%), and soft tissue infection in 1 (3.23%). Patients demonstrated a statistically significant reduction in pain (p = .035) and improved digit alignment after the procedure that enabled full return to unrestricted weight-bearing activities without limitations or the need for orthoses. These findings support metatarsophalangeal joint fusion as an alternative treatment of lesser digit metatarsophalangeal joint instability associated with hammer digit deformities that obviate the need for concomitant soft tissue procedures such as plantar plate repair or tendon balancing procedures.

Incidence of Acute Deep Vein Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma: Analysis of the National Trauma Data Bank

2012-01-01

Abstract: The incidence of deep vein thrombosis (DVT) after foot and ankle surgery is generally believed to be low. However, little information is available regarding DVT as it specifically relates to foot and ankle trauma. The National Trauma Data Bank data set (2007 to 2009) was used to evaluate the incidence of thromboembolism in foot and ankle trauma. Also, the risk factors associated with the thromboembolic events were identified. Data regarding the demographics, comorbidities, procedures, trauma types, and complications, including DVT and pulmonary embolism (PE), were collected from the data set for analysis. The incidence of DVT and PE was 0.28% and 0.21%, respectively. The risk factors statistically significantly associated and clinically relevant for both DVT and PE in foot and ankle trauma were older age (DVT, odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01 to 1.03; PE, OR 1.02, 95% CI 1.01 to 1.03), obesity (DVT, OR 2.35, 95% CI 1.33 to 4.14; PE, OR 3.06, 95% CI 1.68 to 5.59), and higher injury severity score (DVT, OR 1.22, 95% CI 1.16 to 1.28; PE, OR 1.21, 95% CI 1.14 to 1.29). Owing to the low incidence, routine pharmacologic thromboprophylaxis might be contraindicated in foot and ankle trauma. Instead, careful, individualized assessment of the risk factors associated with DVT/PE is important.

Surgical Intervention for Congenital Nail Fold Hypertrophy

Rebecca Exton, Gill Smith — 2012-01-01

Abstract: Congenital nail fold hypertrophy of the hallux is an uncommon abnormality affecting the periungual soft tissue of the great toe. It is usually identified at birth or shortly thereafter, and is known to spontaneously resolve in most cases. In this report, we describe the case of a 14-month-old boy presenting with nail fold hypertrophy of both great toes. The completely united skin bridge covering the nail on the right was excised and the nail folds recreated, with debulking of the left hypertrophic nail fold. We propose that management should be conservative in the first instance and that surgery should be reserved for cases in which 1) inflammation is unresponsive to conservative measures, 2) there is a dense condensation of tissue crossing the nail surface, or 3) there is significant hypertrophy persisting past 1 year of age with no signs of resolution.

Function after Total Calcanectomy for Malignant Tumor in a Child: Is Complex Reconstruction Necessary?

V. Madhuri, B. Balakumar, N.M. Walter, H. Prakash, V. Dutt, L. Chowdhurie — 2011-11-15

Abstract: Complex reconstruction after calcaneal excision for aggressive or malignant tumors has been advocated. In this report we describe a 7-year-old child who underwent chemotherapy followed by total calcanectomy for a primitive neuroectodermal tumor of the calcaneum. The near-normal function achieved after the operation leads us to believe that complex reconstruction after calcaneal excision is not warranted in every pediatric case. This report also highlights the benefits of the Cincinnati incision for calcanectomy, and describes the gait abnormalities after the operation. To the best of our knowledge, a description of the gait abnormality observed after calcanectomy for tumor resection in a pediatric patient has not been reported up to now.

Myxoid Liposarcoma of the Ankle: A Case Report

2011-10-24

Abstract: Myxoid liposarcoma occurs predominantly in the deep soft tissues of the extremities, and tends to metastasize to a wide range of soft tissue or bone locations. We report a case of myxoid liposarcoma arising in the ankle of a 19-year-old man. A diagnosis of myxoid liposarcoma was made by open biopsy, and a wide resection requiring plastic surgical reconstruction was performed. Cytogenetic analysis of the resected tumor exhibited a reciprocal translocation t(12;16)(q13;p11) as the sole anomaly, which is found in more than 90% of myxoid liposarcoma cases. The patient had no evidence of local recurrence or metastasis within 7 years of follow-up. Although myxoid liposarcoma is rare in the ankle, it should be considered in the differential diagnosis of a painless soft tissue mass in this region.

Adolescent Hallux Valgus Deformity with Bilateral Absence of the Hallucal Sesamoids: A Case Report

Sattar Alshryda, Thai Lou, Edwin R. Faulconer, Akinwande O. Adedapo — 2011-10-28

Abstract: The absence of the hallucal sesamoid is a rare condition. Rarer still is the presentation of adolescent hallux valgus with the absence of both hallucal sesamoid. Seven cases of absence of the tibial sesamoid bone and 3 cases of absence of the fibular sesamoid bone have been found in the literature, and only a single case of bilateral absence of both sesamoid bones with hallux varus has been reported. We would like to present a unique case of bilateral absence of the hallucal sesamoid in an 18-year-old woman with severe adolescent hallux valgus but no other apparent congenital deformity.

Use of Allograft Cellular Bone Matrix in Multistage Talectomy with Tibiocalcaneal Arthrodesis: A Case Report

J. Randolph Clements — 2011-10-21

Abstract: Surgical treatment for traumatic dislocation of the talus is a challenging procedure that is often associated with complications. Application of allograft cellular bone matrix with viable mesenchymal stem and osteoprogenitor cells can eliminate the need for autograft and may increase fusion rates in procedures such as tibiocalcaneal arthrodesis. This report describes the treatment of an adult man who presented with a right ankle fracture and subtalar joint dislocation after a motor vehicle accident. After initial treatment with open reduction and internal fixation, the patient developed avascular necrosis of the talus and septic arthritis of the tibiotalar and subtalar joints. After treatment of the infection, the patient was ultimately treated with multistage talectomy and tibiocalcaneal arthrodesis augmented with a cellular bone allograft. Approximately 3 months after the final operation, plain radiographs and computed tomography confirmed solid fusion at the arthrodesis interface. The patient’s recovery was uneventful thereafter, and amputation was avoided. This case, which presented additional challenges because of the large defect created by the infection, suggests that use of an allograft cellular bone matrix has the potential to replicate the bone-healing properties of autograft without the constraints and morbidity associated with autograft harvesting.

Matrix-associated Autologous Chondrocyte Transplantation Combined with Iliac Crest Bone Graft for Reconstruction of Talus Necrosis due to Villonodular Synovitis

Jörg Dickschas, Götz Welsch, Wolf Strecker, Volker Schöffl — 2011-11-21

Abstract: We report the case of a 24-year-old driving instructor with osteonecrosis of the talus and a large articular cartilage and osseous defect. The cystic lesion was caused by villonodular synovitis. After magnetic resonance imaging detection and arthoscopic analysis, the defect was filled with a bone graft, followed by matrix-associated autologous chondrocyte transplantation (MACT) combined with a total synovectomy. In general, lesions similar to the one described in this case are treated using osteochondral autografts, but in our case the osseous defect was too large to perform an osteochondral autograft. Our choice of treatment with an iliac crest bone graft combined with a MACT simultaneously has not yet been published, as far as we know. The patient returned to his former activities of daily living and sport activities, without restrictions or complaints, and with only a slight deficit in range of motion. Morphological and biochemical magnetic resonance imaging 12 months after surgery showed excellent bone healing with no intraosseous edema. The MACT resulted in a good clinical outcome, with 100% defect filling and excellent integration and surface and signal intensity of the cartilage repair tissue, and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score increased from 47 to 79 points.

Fracture of the Talus as a Complication of Subtalar Arthroereisis

Michael Corpuz, David Shofler, Jonathan Labovitz, Lawrence Hodor, Kelly Yu — 2011-09-29

Abstract: Subtalar joint arthroereisis remains a popular procedure for a flexible flatfoot deformity. Potential complications of the procedure have been discussed in published reports and are often believed to have resulted from shortcomings related to the mechanical properties of the biomaterial, implant size, and/or implant placement. In the present report, we describe the case of a talar neck fracture with migration of the implant after subtalar joint arthroereisis performed 10 years earlier. The 19-year-old patient was treated with implant removal and open reduction internal fixation and bone void filler and recovered unremarkably thereafter.

A Case of “Fresh Rupture” after Open Repair of a Ruptured Achilles Tendon

Paul R.P. Rushton, Alok K. Singh, Rajiv G. Deshmukh — 2011-11-07

Abstract: We present the case of Achilles tendon rupture in a 54-year-old man while rehabilitating after end-to-end open repair of an acute Achilles tendon rupture. Re-rupture after surgical repair of Achilles tendon is well known. The present case, however, is atypical, because the second rupture occurred significantly proximal to the first rupture. To our knowledge, this is the first time this has been described in English language studies. We have termed this incident a fresh rupture. A gastrocnemius turndown flap was used to repair the fresh rupture, which led to a satisfactory recovery. This case report serves to inform surgeons of the existence of this type of Achilles tendon rupture, while considering the possible etiologies and suggesting a technique that has been shown to be successful in the present case.

Painless Giant Angioleiomyoma in the Subfascia of the Lower Leg

Koichi Ogura, Takahiro Goto, Tetsuo Nemoto — 2011-09-26

Abstract: Angioleiomyoma is rare, benign vascular smooth muscle tumor originating from the tunica media of the veins and arteries. It usually presents as a slow-growing, small, and painful mass arising from the cutaneous or subcutaneous tissue. We report an unusual case of angioleiomyoma that was located in the subfascia of the lower leg and had grown to massive size (≤5 cm in diameter) during a 3-year period without pain. A 57-year-old female presented with a 3-year history of a slowly growing pain-free mass on the anterior portion of her right lower leg, just above the ankle joint. Magnetic resonance imaging revealed a well-demarcated lesion, measuring approximately 5 × 4 cm, located deep to the fascia of the anterior compartment of the lower leg and adjacent to the tibia, fibula, and interosseous membrane. The mass was isointense to skeletal muscle on T1-weighted images, hyperintense and heterogeneous on T2-weighted images, and enhanced intensely and heterogeneously after the intravenous administration of contrast medium. We performed an excision, and histologic analysis revealed smooth muscle cells surrounding blood vessels of various sizes. From these histologic findings, the tumor was diagnosed as a solid form of angioleiomyoma. The present case was unique in that the tumor grew to a massive size without pain and was located deep to the fascia.

Removal of Osteoid Osteoma of the Tibia Using Two-portal Posterior Ankle Arthroscopy

Ivan Bojanić, Srđan Rogošić, Alan Mahnik, Tomislav Smoljanović — 2011-11-14

Abstract: The case of a 30-year-old male with a history of pain in his left ankle is presented. The pain was described as predominantly nocturnal and frequently relieved by the use of nonsteroidal anti-inflammatory drugs. Computed tomography indicated a diagnosis of an osteoid osteoma in the posteromedial portion of the tibia. The patient underwent excision of the tumor using 2-portal posterior ankle arthroscopy. A clearly visualized nidus was removed using a combination of a cochlea and shaver. Histopathologic analysis of the resected tissue confirmed the diagnosis of an osteoid osteoma. The patient reported immediate relief of the pain and was rapidly allowed to bear weight on the foot. During regular follow-up, he had no pain recurrence and his joint mobility was normal. To our knowledge, this is the first report of the removal of an osteoid osteoma of the ankle using 2-portal posterior ankle arthroscopy.

Lateral Supramalleolar Flap for Coverage of Ankle and Foot Defects in Children

Med Faouzi Hamdi, Anis Khlifi — 2012-01-01

Abstract: The lower part of the leg, the ankle and the foot, is a difficult region to cover especially with exposure of bones or tendons. There are many options for covering soft tissue defect in these areas. The supramalleolar flap is an interesting procedure. The lateral supramalleolar flap was used in 8 cases for the reconstruction of skin defects of the ankle, heel, and foot that compromised the Achilles tendon and the osteoarticular system. Of the 8 patients, 5 were males and 3 were females, with an average age of 6.4 (range 2 to 10) years. The skin defect was secondary to trauma in all cases. The mean follow-up period was 31 (range 19 to 47) months; at the last follow-up visit, the region had been successfully covered in all cases. No necrosis of the flap was reported. The donor site morbidity was minimal. The lateral supramalleolar flap is an interesting surgical technique to salvage the lower extremity in children because this flap has a large skin paddle and a wide rotation arc and is based on a secondary vascular axis.

Deep Soft Tissue Leiomyoma Mimicking Fibromatosis in a 5-year-old Male

2011-11-14

Abstract: Leiomyomas of the deep soft tissue in the extremities of children are very rare. These benign soft tissue tumors occur more frequently in adults between the fourth and sixth decades of age. Women are more commonly affected than men, with the uterus the most common location. We present a rare case of deep soft tissue leiomyoma in the foot of a 5-year-old male. The tumor was misdiagnosed as a desmoid-type fibromatosis from the findings of both magnetic resonance imaging and needle biopsy. The unusual age of presentation, atypical location, and failure of magnetic resonance imaging and ultrasound-guided needle biopsy in diagnosing the lesion make the case interesting. The case also highlights the importance of treating such patients at specialist tertiary centers with a multidisciplinary setting.

Arthroereisis of the Subtalar Joint: An Uncommon Complication and Literature Review

Bas van Ooij, C.J. (Stan) Vos, Rachid Saouti — 2011-09-28

Abstract: Arthroereisis is an operation to prevent abnormal pronation in the subtalar joint in children and adults with symptomatic flexible flatfeet. In the present report, we describe an uncommon late complication of a former variation of this procedure, namely the case of an adult male who experienced migration of a xenogeneic bone graft that had been implanted 55 years earlier. A thorough review of the existing data was also undertaken to better understand the complications of this procedure.

Management of Combined Soft Tissue and Osseous Defect of the Midfoot with a Free Osteocutaneous Radial Forearm Flap: A Case Report

J. Randolph Clements, Cay Mierisch, Cesar J. Bravo — 2011-11-15

Abstract: Extensive soft tissue and osseous defects of the foot are difficult to manage and often result in amputation. Most of these wounds are created by trauma, but other causes, such as infection and malignancy, can create similar defects. A variety of wound management options exist for the treatment of these challenging wounds, including negative pressure wound therapy, autogenous skin grafting, and the use of skin substitutes, as well as internal and external fixation methods. In the present report, we describe the use of a free osteocutaneous radial forearm flap to manage a 10-cm × 5-cm dorsal soft tissue defect and a 2.5-cm second metatarsal diaphyseal defect in an adult male.

Double Row Anchor Fixation: A Novel Technique for a Diabetic Calanceal Insufficiency Avulsion Fracture

Robert M. Greenhagen, Peter D. Highlander, Patrick R. Burns — 2011-11-07

Abstract: Avulsion fractures of the calcaneal tuberosity represent only 1.3% to 2.7% of calcaneal fractures. These fractures are common pathologically in nature and attributed to decreased bone mineral density. Calcaneal insufficiency avulsion (CIA) fracture in patients with diabetes mellitus is most likely due to Charcot neuroarthropathy (CN) as described by the Brodsky classification (Brodsky 3B). Traditional open reduction and internal fixation is difficult in all calcaneal avulsion fractures because of poor bone quality. The authors report the first known description of the use of fracture fragment excision and double row anchor fixation.A 39-year-old woman with type I diabetes mellitus and a history of CN presented with an avulsion fracture of the calcaneal tuberosity. Excision of the fracture fragment and a gastrocnemius recession and reattachment of the Achilles tendon with double row anchor fixation to the calcaneus were performed. At 1 year, the patient’s American Orthopaedic Foot & Ankle Society rearfoot score improved from 27/100 to 88/100. CIA fractures are an infrequently described injury. Because diabetes mellitus is frequently associated with this disease, it most likely represents a CN event. Traditionally, CIA fractures have been operatively treated with open reduction internal fixation. Previous authors have described difficulty with fixation because of poor quality. In the current report, the authors describe a novel operative approach to CIA fractures through the use of double row anchor fixation and excision of the fracture fragments. The authors feel that this previously undescribed treatment is superior to traditional methods and may serve as a new treatment option for all patients who have sustained this unusual pathology regardless of the underlying cause. The current authors provide a novel operative technique that provides inherent advantages to the traditional repair of CIA fractures. We believe CIA fractures represent a CN-type event and care should be taken when evaluating and treating these patients to prevent further sequelae.

Tibiotalocalcaneal Arthrodesis Using a Femoral Locking Plate

Lawrence A. DiDomenico, Mari Wargo-Dorsey — 2011-09-26

Abstract: The goal of a tibiotalocalcaneal arthrodesis is to create a pain-free, stable hindfoot and ankle. Although a reserved procedure, it is useful when simultaneous ankle and subtalar joint pathology exists. Numerous complications have been reported after tibiotalocalcaneal arthrodesis, most importantly nonunion. Locking plates have proved to be a more stable construct than alternative forms of arthrodesis. In the inverted positions, the hybrid plating of the femoral locking plate structurally aligns with the anatomy of the hindfoot. This provides an anatomically sound construct, while allowing for both locking and lag screw insertion. We describe a new technique using a 4.5-mm condylar plate for tibiotalocalcaneal arthrodesis.

Transverse Incision for Calcaneal Tuberosity Avulsion Fractures

Abdullah Eren, Hakan Cift, Korhan Özkan, Salih Söylemez — 2011-11-24

Abstract: A number of incision options are available to surgeons approaching the posterior aspect of the calcaneus for repair of fractures of the posterosuperior aspect of the body of the calcaneus. In this brief communication, we depict our preference for the use of a transverse posterior calcaneal incision for reduction and fixation of avulsion fractures of the calcaneus. The advantages of this particular incisional approach include adequate exposure to the underlying target structures, orientation of the scar in line with relaxed skin tension lines, which minimizes scar formation, and avoidance of dissection of the Achilles tendon.

Surgical Technique for Combined Dwyer Calcaneal Osteotomy and Peroneal Tendon Repair for Correction of Peroneal Tendon Pathology Associated with Cavus Foot Deformity

Troy J. Boffeli, Rachel C. Collier — 2011-11-07

Abstract: Peroneal tendon pathology is commonly seen in patients with underlying pes cavus. The Dwyer calcaneal osteotomy is a useful adjunctive procedure to address the heel varus component of the cavus foot deformity, especially in the presence of concomitant peroneal tendon pathology. The lateralizing heel osteotomy using a wedge resection can effectively reduce future stress on the repaired peroneal tendons, although technical challenges arise when attempting to perform both tendon repair and heel osteotomy through the same incision. Specific principles must be followed to achieve adequate exposure of the desired structures, obtain desired correction of the deformity, and avoid complications such as sural neuritis. In the present report, the surgical principles and technical pearls are highlighted in a pictorial demonstration of preoperative planning for calcaneal wedge resection, incision placement, osteotomy guide pin technique, fixation pearls, and peroneal tendon repair and transfer.

Letter to the Editor

Eric W. Nelson, George Rivello — 2011-10-19

In a recent article [Tosun B, Al F, Tosun A. Spontaneous osteonecrosis of the tarsal navicular in an adult: Mueller-Weiss syndrome. J Foot Ankle Surg 50(2):221–224, 2011], the authors presented a case of Müller-Weiss disease of the tarsal navicular in a 43-year-old male. Although this is a well-written article, we have questions about how the author arrived at the conclusion that the case presented was, indeed, Müller-Weiss disease.

Reply

Bilgehan Tosun — 2011-10-17

We thank Dr. Nelson and Mr. Rivello for their comments regarding our article. As they point out, Maceira et al developed a five-stage system using lateral weight-bearing radiographs and compression and splitting of the tarsal navicular in classifying and describing the disease .

Thanks to Our Peer Reviewers

2012-01-01

Once again, we would like to thank all of the individuals who served as peer reviewers for the manuscripts submitted to The Journal of Foot & Ankle Surgery®. Peer review is the foundation upon which the articles published in The Journal of Foot & Ankle Surgery® are refined and considered for publication. From October 1, 2010, to November 1, 2011, the following individuals provided commentary that our editors used to decide which manuscripts would be published, revised, or rejected, and we appreciate the efforts of every peer reviewer.

Editorial Board

2012-01-01

Journal of Foot and Ankle Surgery

Cover 1

Stand Up and Start Counting

An Analysis of Outcomes after Use of the Maxwell-Brancheau Arthroereisis Implant

Infected Internal Fixation after Ankle Fractures—A Treatment Path

The Surgical Treatment of Peroneal Tendinopathy (Excluding Subluxations): A Series of 17 Patients

Radiofrequency Thermoneurolysis for the Treatment of Morton’s Neuroma

Extraosseous Talotarsal Stabilization Using HyProCure® in Adults: A 5-year Retrospective Follow-up

Incorporation of Bovine-based Structural Bone Grafts Used in Reconstructive Foot Surgery

Prognostic Difference Between Soft Tissue Abscess and Osteomyelitis of the Foot in Patients with Diabetes: Data from a Consecutive Series of 452 Hospitalized Patients

Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing

Publication Rates of Poster Presentations at the American College of Foot and Ankle Surgeons Annual Scientific Conference Between 1999 and 2008

A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant, and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus

A Retrospective Analysis of Lesser Metatarsophalangeal Joint Fusion as a Treatment Option for Hammertoe Pathology Associated with Metatarsophalangeal Joint Instability

Incidence of Acute Deep Vein Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma: Analysis of the National Trauma Data Bank

Surgical Intervention for Congenital Nail Fold Hypertrophy

Function after Total Calcanectomy for Malignant Tumor in a Child: Is Complex Reconstruction Necessary?

Myxoid Liposarcoma of the Ankle: A Case Report

Adolescent Hallux Valgus Deformity with Bilateral Absence of the Hallucal Sesamoids: A Case Report

Use of Allograft Cellular Bone Matrix in Multistage Talectomy with Tibiocalcaneal Arthrodesis: A Case Report

Matrix-associated Autologous Chondrocyte Transplantation Combined with Iliac Crest Bone Graft for Reconstruction of Talus Necrosis due to Villonodular Synovitis

Fracture of the Talus as a Complication of Subtalar Arthroereisis

A Case of “Fresh Rupture” after Open Repair of a Ruptured Achilles Tendon

Painless Giant Angioleiomyoma in the Subfascia of the Lower Leg

Removal of Osteoid Osteoma of the Tibia Using Two-portal Posterior Ankle Arthroscopy

Lateral Supramalleolar Flap for Coverage of Ankle and Foot Defects in Children

Deep Soft Tissue Leiomyoma Mimicking Fibromatosis in a 5-year-old Male

Arthroereisis of the Subtalar Joint: An Uncommon Complication and Literature Review

Management of Combined Soft Tissue and Osseous Defect of the Midfoot with a Free Osteocutaneous Radial Forearm Flap: A Case Report

Double Row Anchor Fixation: A Novel Technique for a Diabetic Calanceal Insufficiency Avulsion Fracture

Tibiotalocalcaneal Arthrodesis Using a Femoral Locking Plate

Transverse Incision for Calcaneal Tuberosity Avulsion Fractures

Surgical Technique for Combined Dwyer Calcaneal Osteotomy and Peroneal Tendon Repair for Correction of Peroneal Tendon Pathology Associated with Cavus Foot Deformity

Letter to the Editor

Reply

Thanks to Our Peer Reviewers

Editorial Board

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