Journal of Foot and Ankle Surgery

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2010-01-01

Successful Treatment Hinges on an Accurate Diagnosis

D. Scot Malay — 2010-01-01

All of us will agree that in most cases a careful historical interview and clinical examination will lead us to the correct diagnosis. But circumstances do not always fall neatly into place. Sometimes, historical information is inaccurate, clinical findings are obscured by concomitant physiological or pathological conditions, or technological limitations obscure the correct diagnosis. Misdiagnosis is also more likely in cases involving a rare disease or an unusual condition, one that doesn't fit established guidelines and previously understood standards. Sometimes the examining surgeon simply fails to pick up on an important clue. None of us is the perfect diagnostician all of the time, although we owe it to our patients to try to peg the diagnosis the first time, every time. Sometimes, moreover, we manage to successfully treat a patient even though our diagnosis may not be completely accurate. And, as described in the interesting case report dealing with a Maisonneuve fracture, by Charopoulos et al and published herein, the importance of reappraisal of the clinical situation, including taking a closer look at the radiographs, when clinical symptoms persist or change cannot be overstated. I think that we can all agree that if our patient is not progressing satisfactorily in a reasonable period of time, then either our treatment is inadequate or our diagnosis is wrong. In such cases, it usually pays to reassess the patient and, perhaps, to get another surgeon's opinion. We have all been in the clinical scenario where the precise diagnosis eludes us, and for this reason I hope that the Maisonneuve fracture case report that we publish in this issue piques our readers' interest.

A New Look for JFAS

D. Scot Malay — 2010-01-01

In this issue you will see that we have changed to a new print format in order to maximize page space, and to be as green as possible without going completely digital. You will also note that in our last print issue, we presented case reports as abstracts only, and referred our readers to the e-only digital version of JFAS for the complete text of the case reports. This was done in an effort to provide our readers with all of the valuable information in the articles, while taking advantage of every bit of print page space available. Since many of our readers around the world take advantage of JFAS online, and because we have enjoyed an increase in the number of publishable submissions, we decided to change the print layout and to publish some articles in the e-only format. We hope that you appreciate the new look and the rationale for these changes, and that you continue to use JFAS, in both its print and online formats, as a major resource for your foot and ankle surgical information.

Hallux Ulceration in Diabetic Patients

2010-01-01

Abstract: We undertook a prospective cohort study to assess risk factors associated with hallux ulceration, and to determine the incidence of healing or amputation, in consecutive patients with diabetes mellitus who were treated over the observation period extending from September 2004 to March 2005, at the Jabir Abu Eliz Diabetic Centre, Khartoum City, Sudan. There were 122 diabetic patients in the cohort (92 males and 30 females) with an overall mean age of 58 ± 9 years. Fifty-three percent of patients had complete healing within 8 weeks and 43% healed within 20 weeks. The overall mean time to healing was 16 ± 8 weeks. In 32 (26.2%) patients, osteomyelitic bone was removed, leaving a healed and boneless hallux. The hallux was amputated in 17 (13.9%) patients; in 2 (1.6%) patients it was followed by forefoot amputation and in 7 (5.7%) patients by below-the-knee amputation. In 90 (73.8%) patients the initial lesion was a blister. In conclusion, hallux ulceration is common in patients with diabetes mellitus and is usually preceded by a blister. Neuropathy, foot deformity, and wearing new shoes are common causative factors; and ischemia, osteomyelitis, any form of wound infection, and the size of the ulcer are main outcome determinants. Complete healing occurred in 103 (85%) of diabetic patients with a hallux ulcer. Vascular intervention is important relative to limb salvage when ischemia is the main cause of the ulcer.

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

2010-01-01

Abstract: We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.

Scarf-Akin Osteotomy Correction for Hallux Valgus: Short-term Results from a District General Hospital

Hui-Ling Kerr, Rosalyn Jackson, Paresh Kothari — 2010-01-01

Abstract: This study assessed the radiological measurements, American Orthopaedic Foot and Ankle Society (AOFAS) scores, and patient satisfaction associated with performance of the scarf osteotomy, combined with an Akin osteotomy, for the treatment of hallux valgus in patients at a general hospital. Thirty-five patients were assessed before surgery, and at 6 months following performance of the scarf first metatarsal osteotomy plus Akin osteotomy. The mean first intermetatarsal and hallux abductus angles reduced from 14.1° ± 3.5° to 10.0° ± 3.2° and 32.1° ± 9.9° to 16.4° ± 7.9°, respectively, and these differences were statistically significant (P < .001). The mean first to second metatarsal sagittal plane length ratio was unchanged by the osteotomy (P > .05). The mean global AOFAS Hallux Metatarsophalangeal-Interphalangeal score increased from 58.8 ± 11.6 to 86.4 ± 11.6, and this difference was statistically significant (P < .0001). Of the 35 patients (36 operated feet), 20 (57.1%) were extremely satisfied, 10 (28.6%) were satisfied, and 5 (14.3%) were unsatisfied with the results of the surgery. Based on these results, we concluded that the improved radiographic angles and AOFAS scores observed in this study were comparable to previously reported results, and our findings indicated that, in the setting of a general hospital, the scarf osteotomy combined with the Akin osteotomy is a safe, versatile and useful procedure for the treatment of hallux valgus.

Percutaneous Drilling for the Treatment of Atraumatic Osteonecrosis of the Ankle

2010-01-01

Abstract: Atraumatic osteonecrosis of the ankle can be severely debilitating and can lead to joint collapse. A relatively new technique of percutaneous drilling has previously been used to relieve the symptoms of osteonecrotic hips and knees. The purpose of the present study was to examine the results of this technique when used to treat osteonecrosis of the ankle. Between September 2002 and June 2005, the senior author (M.A.M.) treated and prospectively followed 44 symptomatic osteonecrotic ankles (31 patients) using this drilling technique. The series included 23 (74.2%) women and 8 (25.8%) men with a mean age of 43 ± 11 years. Arthrodesis had been recommended for 14 (45.2%) of these patients (20 [45.5%] ankles). At a mean follow-up duration of 45 ± 12 months, 40 (91%) ankles had achieved a successful clinical outcome. The mean American Orthopaedic Society of Foot and Ankle Society Ankle and Hindfoot score increased from 42 ± 5 points preoperatively to 88 ± 10 points postoperatively, and this difference was statistically significant (P < .0001). There were no perioperative complications, although 3 ankles subsequently collapsed and required arthrodesis. The percutaneous drilling technique appears to be a useful method for the relief of symptomatic ankle osteonecrosis.

Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients

Attilio Basile — 2010-01-01

Abstract: We compared the outcomes of displaced intra-articular calcaneal fractures in 33 patients aged 65 to 75 years, who were treated either operatively (n = 18) or nonsurgically (n = 15), between December 2001 and December 2005. The operative treatment group scored higher on the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and had less pain as measured with the 10-cm visual analog scale than did the nonsurgically treated group, with the differences being statistically significant (P ≤ .05), suggesting that results can be improved by operative treatment. Böhler's angle, the quality of operative reduction, subtalar joint motion, gender, and the Sanders type of fracture were also analyzed and compared between the treatment groups. The results confirmed that Böhler's angle, the quality of the reduction, and subtalar joint motion were important prognostic factors related to outcome, regardless of treatment; whereas gender and Sanders type had less influence on the results at the 2-year follow-up evaluation. The prevalence of complications observed in the surgically treated group was similar to that reported in prior publications, except for subtalar arthritis (38.9%), which may have been higher because of the age of our patients and the duration of follow-up.

Lower Extremity Complex Regional Pain Syndrome: Long-term Outcome after Surgical Treatment of Peripheral Pain Generators

Lee Dellon, Eugenia Andonian, Gedge D. Rosson — 2010-01-01

Abstract: We undertook a retrospective study to evaluate the hypothesis that complex regional pain syndrome (CRPS) I, known as the “new” reflex sympathetic dystrophy, persists because of undiagnosed injured joint afferents, cutaneous neuromas, or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II, which is known as the “new” causalgia. We used a research protocol, with institutional review board approval, to review medical records for the purpose of identifying 30 patients with lower extremity reflex sympathetic dystrophy, based on their history, physical examination, neurosensory testing, and response to peripheral nerve blocks, who were treated surgically at the level of the peripheral nerve. In this report, we describe long-term outcomes in 13 of these patients who were followed up for a minimum of 24 months (mean, 47.8 months; range, 25-90 months). Based primarily on the results of physical examination and the response to peripheral nerve blocks, surgery included a combination of joint denervation, neuroma resection plus muscle implantation, and neurolysis. Outcomes were measured in terms of decreased pain medication usage and recovery of function, and the results were excellent in 7 (55%), good in 4 (30%), and poor (failure) in 2 (15%) of the patients. Based on these results, we concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and chronic nerve compression, which is indistinguishable from CRPS II, and amenable to successful treatment by means of an appropriate peripheral nerve surgical strategy.

Moje First Metatarsophalangeal Replacement—A Case Series with Functional Outcomes Using the AOFAS-HMI Score

2010-01-01

Abstract: We report the functional results of a case series of Moje first metatarsophalangeal total joint replacements carried out between February 2001 and November 2006. All patients who underwent Moje arthroplasty under the care of a single surgeon were included; outcome scores and complications were recorded annually. A total of 32 joints in 29 consecutive patients were followed for a mean duration of 34 (range 6 to 74) months, and the mean patient age at the time of operation was 56 (range 38 to 79) years. Hallux rigidus was the primary diagnosis in 28 (87.5%) of the cases. The mean American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal score at final follow-up was 74/100 (range 9 to 100), with 13 (40.63%) joints rated good to excellent. Two (6.25%) joints were revised to arthrodesis at a mean of 52 (range 41 to 63) months following the arthroplasty procedure, and the overall prevalence of postoperative complications was 6 (18.75%). Based on these results, we concluded that first MTPJ total joint replacement with the Moje device remains promising, but still has room for improvement before the results match those obtained with larger joint (knee, hip) arthroplasty.

Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients

2010-01-01

Abstract: Limb- and life-threatening hand and foot infections in diabetic patients account for a large proportion of amputations and a substantial number of deaths. Between August 2006 and the end of July 2008, we conducted a prospective cohort study of consecutive diabetic patients with serious hand or foot infections, in an effort to identify clinical patterns and outcomes related to the treatment of these infections. Infections were categorized as dry, gas, and wet gangrene; necrotizing fasciitis or cellulitis; acute extensive osteomyelitis; and any of these infections involving the hand. All of the patients underwent a standard examination and treatment protocol, although none of the patients received vascular surgical care. End points included healing following debridement or minor amputation, major (transtibial or more proximal) amputation, or death. A total of 56 patients were included in the final analyses, and their mean age was 70 (range 51 to 86) years. Of the patients, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14) had diffuse hand infections. Five (8.93%) patients died (2 after prior amputation), 26 (46.43%) underwent debridement and/or minor amputation, and 27 (48.21%) required major amputations. Based on our findings, we concluded that 7 patterns of serious limb- or life-threatening infection were identified and, in the absence of vascular surgical intervention, mortality can be reduced at the expense of more amputations.

Short-term Financial Outcomes of Pilon Fractures

David Volgas, J. George DeVries, James P. Stannard — 2010-01-01

Abstract: Fractures of the distal tibia are potentially devastating injuries fraught with many complications and poor outcomes, including financial hardships. The purpose of this study was to examine the financial outcomes in the short term of pilon fractures. Sixty patients who sustained pilon fractures were prospectively assessed on financial criteria and injury characteristics. This included various scores and also introduced a financial data sheet and outcome form. Twenty-five patients met inclusion/exclusion criteria and were available for follow-up. The mean age was 46.3 ± 12.0 years (19–61 years), with a mean follow-up of 11.8 ± 4.8 months (6–20 months). Only 7 patients (29.2%) returned to work at latest follow-up. Seven of 19 patients (36.8%) reported selling possessions to meet financial obligations, and 8 of 19 patients (42.1%) used social assistance programs. All 4 white-collar workers returned to work whereas only 3 (14.3%) of 21 blue-collar workers had returned to work at last follow-up (P = .001). Five (62.5%) of 8 patients who had graduated from college returned to work, but only 2 (14.3%) of 14 patients who did not attend college returned to work (P = .01). Because there are no widely used measures of financial status change in the literature, we have introduced some in this article including preinjury financial preparedness and postinjury strategies to fulfill financial obligations. These may be useful in evaluating outcomes and counseling patients. In addition, we have again demonstrated that there is a significantly higher return to work outcome in white collar jobs and higher education.

Minimum-incision Metatarsal Ray Resection: An Observational Case Series

Thomas S. Roukis — 2010-01-01

Abstract: This report describes the results of 17 metatarsal ray resections performed through a minimal incision in 13 consecutive patients. Each patient underwent minimum-incision metatarsal ray resection for either definitive treatment or as the index incision and drainage procedure followed by transmetatarsal amputation. There were 10 male and 3 female patients with a mean age of 68.8 ± 8.5 years (range, 59-83 years). Twelve patients had diabetes mellitus and 7 had critical limb ischemia. There were 11 right feet and 6 left feet involved, and 3 second, 3 third, 3 fourth, and 8 fifth minimum-incision metatarsal ray resections performed. Direct primary-incision closure was performed 7 times (1 with adjacent percutaneous metatarsal osteotomy), delayed primary closure was performed 4 times (1 with external fixation), and conversion to a transmetatarsal amputation was performed 2 times. Fourteen of 17 minimum-incision metatarsal ray resections were deemed successful. Two failures occurred when skin necrosis developed from excessive tension along the incision line requiring conversion to a transmetatarsal amputation, and the other occurred in a patient with unreconstructed critical limb ischemia who underwent multiple repeated incision and drainage procedures and vascular bypass with ultimate healing via secondary intent. When properly performed in patients with adequate vascular inflow, minimum-incision metatarsal ray resection as the definitive procedure or in conjunction with an incision and drainage for unsalvageable toe infection or gangrene represents a safe, simple, useful technique.

The Role of Polymethylmethacrylate Antibiotic–loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

Valerie L. Schade, Thomas S. Roukis — 2010-01-01

Abstract: Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections. The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention. A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009. There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years). A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3). All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion. A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (90.4%) and 7 positive for bacterial growth (9.6%). Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively. When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.

The Multiplanar Effect of First Metatarsal Osteotomy on Sesamoid Position

Roland Ramdass, Andrew J. Meyr — 2010-01-01

Abstract: The standard classification system used to measure the sesamoids in the evaluation of hallux abductovalgus is a uniplanar description of a multiplanar deformity. Additionally, it cannot accurately describe a true measure of sesamoid positional change in the perioperative period because the first metatarsal is laterally transposed during corrective surgery. The intended emphasis of this investigation is to evaluate the sesamoid position in multiple planes relative to a stationary anatomical landmark following first metatarsal osteotomy for the surgical correction of hallux abductovalgus deformity. A retrospective radiographic review of 46 feet in 38 patients demonstrated statistically significant (P < .001) differences between preoperative and postoperative values for the first intermetatarsal angle, hallux abductus angle, sesamoid rotation angle, tibial sesamoid position, and tibial sesamoid grade. However, there was no significant difference in the sesamoid position in both the transverse (P = .07) and frontal (P = .29) planes when measured relative to the stationary second metatarsal. Based on the preceding results, the appropriate expected surgical outcome of hallux abductovalgus correction may be to relocate the first metatarsal on top of the relatively immobile sesamoids.

Complications Associated with Uni-portal Endoscopic Gastrocnemius Recession in a Diabetic Patient Population: An Observational Case Series

Thomas S. Roukis, Monica H. Schweinberger — 2010-01-01

Abstract: The purpose of this article was to report the complications associated with uni-portal endoscopic gastrocnemius recession for surgical treatment of pathologic soft tissue ankle equinus contracture in diabetic patients. This is an observational case series involving a retrospective review of prospectively collected data of 23 uni-portal endoscopic gastrocnemius recessions used to treat pathologic soft tissue ankle equinus contracture in 18 consecutive diabetic patients between November 2006 and January 2009. Each patient underwent uni-portal endoscopic gastrocnemius recession under general or spinal anesthesia with thigh tourniquet control in combination with soft tissue and/or osseous reconstructive foot and/or ankle surgery. Patients were kept non–weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 9 male and 9 female patients with a mean age ± SD of 69.0 ± 7.4-years (range: 47.0 to 71.0 years). There were 11 right and 12 left lower limbs involved, with 5 procedures performed bilateral. Complications included 3 conversions to an open incision secondary to difficulty dissecting through excessive adipose tissue, delayed healing of 3 incision sites in patients with uncontrolled diabetes mellitus at the time of surgery, and 3 undercorrections in patients with spastic contractures. The remainder of the procedures were deemed successful with no saphenous nerve, sural nerve, or lesser saphenous vein related injuries occurring. When properly performed, uni-portal endoscopic gastrocnemius recession represents a safe, reliable, and minimally invasive technique useful for correcting pathologic soft tissue ankle equinus contracture in patients with diabetes. A percutaneous tendo-Achilles lengthening should be performed in patients who have marginal arterial inflow that precludes tourniquet use or have a spastic contracture. An open rather than endoscopic gastrocnemius recession should be performed in patients with excessive adipose tissue. Before surgery, the risk of delayed wound healing should be discussed with patients who have uncontrolled diabetes mellitus and in-patient management with tight glycemic control considered.

V-Y Fasciocutaneous Advancement Flap Coverage of Soft Tissue Defects of the Foot in the Patient at High Risk

Thomas S. Roukis, Monica H. Schweinberger, Valerie L. Schade — 2009-07-01

Abstract: This single-center, observational case series involved a review of prospectively collected data pertaining to 16 V-Y fasciocutaneous advancement flaps performed on 16 consecutive patients between August 2006 and December 2008. Each patient underwent primary excision of a foot ulcer with debridement of soft tissue and bone, insertion of polymethylmethacrylate antibiotic–loaded bone cement, and immobilization. At an average of 3 days after the index procedure, soft tissue and osseous deformities were corrected in 13 of the 16 patients, and a V-Y fasciocutaneous advancement flap was used for coverage of the soft tissue defect in all patients. Patients were kept nonweightbearing and were followed up until clinical healing occurred or failure was declared. There were 12 male and 4 female patients with a mean age of 64.0 ± 7.4 years (range, 48–75 years). Fifteen patients had diabetes mellitus with a mean of 5.1 ± 1.8 (range, 3–8) medical comorbidities. There were 10 medial forefoot, 3 central forefoot, 2 lateral forefoot, and 1 dorsal midfoot full-thickness soft tissue defects that displayed a mean diameter of 2.3 ± 1.4 cm (range, 1.0–3.5 cm). All but 4 flaps healed primarily, with each developing marginal dehiscence that healed with local wound care measures. Two deep infections occurred despite healing of the flap, which necessitated transmetatarsal amputation with split-thickness skin graft coverage. When properly performed and after complete resolution of infection, V-Y fasciocutaneous advancement flap coverage of complex foot ulcerations represents a useful and reliable technique even in patients with multiple medical comorbidities.

Malignant Transformation of a Chronic Venous Stasis Ulcer to Basal Cell Carcinoma in a Diabetic Patient: Case Study and Review of the Pathophysiology

Molly Schnirring-Judge, Drew Belpedio — 2010-01-01

Abstract: The degeneration of chronic wounds into basal cell carcinoma is rare. We present an atypical case of basal cell carcinoma diagnosed by soft tissue biopsy in a long-standing wound that had been treated for 3 years as a chronic venous stasis ulcer. In addition to the case report, we review the biomedical literature describing malignant transformation of long-standing wounds. Foot and ankle specialists should be on the lookout for changes that signal malignant transformation in long-standing ulcers.

Melorheostosis: A Literature Review and Case Report with Surgical Considerations

Gabrielle Gellman Gagliardi, Kieran T. Mahan — 2010-01-01

Abstract: Melorheostosis is a rare disorder marked by increased bony sclerosis on radiographs. In addition to bone changes, the skin and soft tissues overlying affected bone often demonstrate increased fibrosis, which can create joint contracture. These can all affect surgical planning for a patient with melorheostosis. This article reviews the literature and describes the surgical intervention and 4-year follow-up of a 10-year-old boy with melorheostosis.

Myxoinflammatory Fibroblastic Sarcoma: A Case Report and Review of the Literature

Erik Monson, Robert Vancourt, John Dawson — 2010-01-01

Abstract: The majority of soft tissue masses seen in the lower extremity are benign tumors caused by degenerative, reactive, or inflammatory processes. Sarcomas are relatively uncommon entities but need to be diagnosed and treated appropriately. We present a case of a myxoinflammatory fibroblastic sarcoma of the leg and review the literature on this topic. This is a rare tumor that predominately involves the distal extremities. It often presents as a painless mass within the subcutaneous tissue and can easily be confused with benign lesions. A high rate of local recurrence means patients must be followed up closely after resection of the tumor.

Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

Uel Hansen, Melinda Moniz, Joseph Zubak, Jacinto Zambrano, Russell Bear — 2010-01-01

Abstract: Addressing segmental loss of the Achilles tendon with overlying soft tissue loss is a serious challenge. We present a case of Achilles tendon reconstruction in a patient who had significant soft tissue loss as well as segmental loss of the tendon involving the calcaneal insertion. The staged reconstruction was undertaken with a combination of a sural fasciocutaneous flap and an Achilles tendon allograft with an attached calcaneal bone block.

Maisonneuve Fracture without Deltoid Ligament Disruption: A Rare Pattern of Injury

2010-01-01

Abstract: The Maisonneuve fracture is considered by many to be one of the most unstable ankle injuries. We report a rare injury involving fracture of the proximal fibula in association with a posterior malleolar fracture and disruption of the anterior-inferior tibiofibular ligament, without disruption of the deltoid ligament or fracture of the medial malleolus. This report of a diagnostically challenging case highlights the importance of timely clinical and radiographic reassessment of a patient who fails to improve with initial therapy, and describes the clinical and diagnostic imaging findings of an unusual ankle injury.

Closed Tibial Fracture Associated with Laceration of Tibialis Anterior Tendon

Firooz Vazirzadeh Ebrahimi, Mehdi Tofighi, Hossein Khatibi — 2009-11-11

Abstract: Traumatic laceration of the tibialis anterior tendon is a rare finding. To the best of our knowledge, 4 such cases have been reported in the surgical literature, and 3 of these were missed upon initial clinical examination. We present the case of a 26-year-old male motorcyclist who sustained an acute laceration of the tibialis anterior tendon in association with closed fractures of the tibia and fibula. The laceration was initially not included in the diagnosis, because weak ankle dorsiflexion was attributed to antalgic guarding. The primary aim of this report is to emphasize the possibility of tibialis anterior tendon laceration in association with closed fracture of the tibia, and to encourage surgeons to maintain a high index of suspicion for this particular defect. Furthermore, we encourage surgeons to undertake a meticulous physical examination and, if warranted, obtain ancillary diagnostic images, such as magnetic resonance images, in order to accurately diagnose and determine the optimal course of treatment.

Prevention and Management of Complications Arising from External Fixation Pin Sites

Christopher Bibbo, Jon Brueggeman — 2010-01-01

Abstract: The use of external fixation devices to assist in the management of lower extremity trauma and reconstruction continues to rise. Despite the distinct advantages of external fixation, complications from external fixators continue to exist. The complicated external fixator–associated pin site may be a potential source of significant morbidity, especially in the at-risk patient, which may lead to soft tissue healing problems and infections, as well as osteomyelitis. This article describes both simple as well as more complex techniques that the authors use in the prevention and management of complications arising from external fixator pin sites, and solutions to the difficult task of incorporating external fixator wires into negative-pressure dressings.

Treatment of a Unicameral Bone Cyst of Calcaneus with Endoscopic Curettage and Percutaneous Filling with Corticocancellous Allograft

2010-01-01

Abstract: The surgical procedures for unicameral solitary calcaneal bone cysts have ranged from simple curettage and grafting to subperiosteal resection with internal fixation and grafting. In this article, an endoscopically assisted technique is proposed for the curettage of a simple calcaneal cyst that takes advantage of direct visualization of the cyst wall and contents and permits accurate assessment of the extent of the lesion. After curettage, percutaneous filling of the defect with corticocancellous allograft makes the technique a complete, minimally invasive surgical approach for this condition. The technique uses 2 lateral portals, one for viewing and the other for manipulation, both of which are created under fluoroscopic control. Once the cyst has been located, the 30° arthroscope is used to evacuate fluid, after which more solid cyst contents are fragmented and removed. Thereafter, curettage of the inner surface of the cavernous cyst wall is performed. Finally, complete packing of the previously cystic cavity with crushed corticocancellous allograft is performed under endoscopic visualization and confirmed radiographically.

Sterile Cast Padding as an Alternative to Commercially Available Cotton Balls for Split-thickness Skin Graft Bolster Dressing

Valerie L. Schade, Thomas S. Roukis — 2009-07-01

Abstract: The use of a bolster dressing to secure a split-thickness skin graft to the underlying wound bed is essential for successful healing. Sterile medical grade commercially available cotton balls are commonly used; however, they are relatively expensive and frequently not readily available in sufficient quantities. In this techniques report, the authors describe the use of handmade cotton balls from sterile cotton cast padding, which are inexpensive and simple to fabricate from a readily available source.

Preoperative Doppler Assessment for Transmetatarsal Amputation

Christopher E. Attinger, Andrew J. Meyr, Sarah Fitzgerald, John S. Steinberg — 2010-01-01

Abstract: A thorough preoperative vascular evaluation should be performed before the initiation of any lower extremity surgical intervention, but particularly in situations of diabetic foot reconstruction with compromised blood flow. The intended emphasis of this brief report is to provide the foot and ankle surgeon with an appreciation for the clinical vascular anatomy of the transmetatarsal amputation through a handheld Doppler examination.

Diabetic Limb Preservation: Defining Terms and Goals

Charles A. Andersen — 2010-01-01

Editor's note: Although many of us undertake, on an almost daily basis, surgical procedures that are directed at limb salvage, it is interesting to consider that the definition of limb salvage may vary from surgeon to surgeon and, more importantly, from patient to patient. As a general rule, I think that most foot and ankle surgeons focus their efforts on optimizing patient function while trying to maximize tissue preservation. In the following commentary, Dr. Andersen addresses the concept of limb salvage and offers his view of 'functional limb preservation.

Surgical Reconstruction of the Diabetic Foot and Ankle

Thomas S. Roukis — 2009-11-16

One editor and 52 very experienced surgeons have produced this magnificent textbook on surgical techniques related to foot and ankle reconstruction of the patient with diabetes. The color photographs total more than 800 and are simply beautiful. These photographs are very informative and show, in step-by-step fashion, the individual chapter author's surgical technique for performing the procedures currently used for surgical reconstruction of the foot and ankle in patients with diabetes.

Masthead

2010-01-01

Editorial Board

2010-01-01

Journal of Foot and Ankle Surgery

Cover 1

Successful Treatment Hinges on an Accurate Diagnosis

A New Look for JFAS

Hallux Ulceration in Diabetic Patients

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

Scarf-Akin Osteotomy Correction for Hallux Valgus: Short-term Results from a District General Hospital

Percutaneous Drilling for the Treatment of Atraumatic Osteonecrosis of the Ankle

Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients

Lower Extremity Complex Regional Pain Syndrome: Long-term Outcome after Surgical Treatment of Peripheral Pain Generators

Moje First Metatarsophalangeal Replacement—A Case Series with Functional Outcomes Using the AOFAS-HMI Score

Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients

Short-term Financial Outcomes of Pilon Fractures

Minimum-incision Metatarsal Ray Resection: An Observational Case Series

The Role of Polymethylmethacrylate Antibiotic–loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

The Multiplanar Effect of First Metatarsal Osteotomy on Sesamoid Position

Complications Associated with Uni-portal Endoscopic Gastrocnemius Recession in a Diabetic Patient Population: An Observational Case Series

V-Y Fasciocutaneous Advancement Flap Coverage of Soft Tissue Defects of the Foot in the Patient at High Risk

Malignant Transformation of a Chronic Venous Stasis Ulcer to Basal Cell Carcinoma in a Diabetic Patient: Case Study and Review of the Pathophysiology

Melorheostosis: A Literature Review and Case Report with Surgical Considerations

Myxoinflammatory Fibroblastic Sarcoma: A Case Report and Review of the Literature

Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

Maisonneuve Fracture without Deltoid Ligament Disruption: A Rare Pattern of Injury

Closed Tibial Fracture Associated with Laceration of Tibialis Anterior Tendon

Prevention and Management of Complications Arising from External Fixation Pin Sites

Treatment of a Unicameral Bone Cyst of Calcaneus with Endoscopic Curettage and Percutaneous Filling with Corticocancellous Allograft

Sterile Cast Padding as an Alternative to Commercially Available Cotton Balls for Split-thickness Skin Graft Bolster Dressing

Preoperative Doppler Assessment for Transmetatarsal Amputation

Diabetic Limb Preservation: Defining Terms and Goals

Surgical Reconstruction of the Diabetic Foot and Ankle

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