Journal of Foot and Ankle Surgery

Cover 1

2012-05-01

The Importance of N = 1

Luke D. Cicchinelli — 2012-05-01

Over the years, I've noticed that many busy surgeons and clinicians seem to shut down whenever the phrase evidence-based medicine is mentioned. I have seen this at seminars, during grand rounds, and even in the operating room. This reaction has been a source of disappointment to me, especially in situations in which I was the invited speaker talking about evidence-based medicine.

Complications Associated with Foot and Ankle Arthroscopy

2011-12-22

Abstract: Despite a late start within the realm of arthroscopy, foot and ankle arthroscopy proves to be an important diagnostic and treatment tool for the foot and ankle specialist. As indication for arthroscopy increases, complications associated with foot and ankle arthroscopy must be revisited. We reviewed 405 foot and ankle arthroscopic procedures performed on 390 patients in 4 different facilities over a 3-year period extending from January 2005 to August 2008. Two-hundred-sixty foot and ankle arthroscopic procedures on 251 patients met our inclusion criteria. A total of 246 ankle and 14 posterior subtalar arthroscopic procedures were performed with a mean follow-up of 10.7 ± 3.5 months. Patient demographics, preoperative findings, intraoperative technique, and postoperative course were reviewed. We failed to identify statistically significant predictive factors for complications. Arthroscopy performed in combination with adjunctive procedures showed a trend toward higher complication rate, although statistical significance was not noted. Overall, 20 cases (7.69%) experienced arthroscopy-related complications, and this finding was comparable with previously published results. The most common complication was cutaneous nerve injury, which involved 9 cases (3.46%), and localized superficial infection, which involved 8 cases (3.08%). Injury to the superficial peroneal nerve accounted for 5 of the cutaneous nerve injuries. There were no cases of arthroscopy-related vascular injury. All cases of superficial postoperative infection resolved with antibiotic therapy, and none of the cases required return to the operating room. These results were also similar to published data.

A Retrospective Comparison of Four Plate Constructs for First Metatarsophalangeal Joint Fusion: Static Plate, Static Plate with Lag Screw, Locked Plate, and Locked Plate with Lag Screw

Christopher F. Hyer, Ryan T. Scott, Michael Swiatek — 2012-03-29

Abstract: The primary treatment for progressive first metatarsophalangeal (MTP) joint arthritis is arthrodesis. Multiple fixation types have been used to accomplish fusion including plating. There have been no published articles reporting the outcomes of these 4 plate and/or screw constructs. We present our experience with 138 first MTP joint fusions using these constructs. A retrospective comparison and radiographic chart review of 132 patients (138 feet) was performed to compare different constructs in regards to successful union and time to fusion. All operations were performed by 4 fellowship-trained foot and ankle surgeons. The radiographs were independently read by 2 authors not involved in the index procedures. Radiographic fusion was determined by bridging cortices across the joint line. The mean time to union (in days) and rate of fusion were static plate: 59, 95%, static plate with lag screw: 56, 86%, locked plate: 66, 92%, and locked plate with lag screw: 53, 96%. There was not a statistically significant difference between the groups in regards to patient age, time to weight bearing, time to fusion, or rate of fusion. We report on the results of fusion comparing 4 different plate and/or screw constructs for first MTP joint fusion. The data reveal no significant difference in time to fusion or rate of fusion between static and locked plates, with or without a lag screw.

Usefulness of Oblique Axial Scan in Magnetic Resonance Imaging Evaluation of Anterior Talofibular Ligament in Ankle Sprain

2012-01-13

Abstract: The purpose of the present study was to clarify the usefulness of the oblique axial scan parallel to the course of the anterior talofibular ligament in magnetic resonance imaging of the anterior talofibular ligament in patients with chronic ankle instability. We evaluated this anterior talofibular ligament view and routine axial magnetic resonance imaging planes of 115 ankles. We diagnosed the grade of the anterior talofibular ligament injury and confirmed full-length views of the anterior talofibular ligament. Associated lesions were also checked. The subjective diagnostic convenience of associated problems was determined. The full-length view of the anterior talofibular ligament was checked in 85 (73.9%) patients in the routine axial view and 112 (97.4%) patients in the anterior talofibular ligament view. The grade of injury increased in the anterior talofibular ligament view in 26 (22.6%) patients compared with the routine axial view. There were 64 associated injuries. The anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and posterior tibialis tendinitis were more easily diagnosed on the routine axial view than on the anterior talofibular ligament view. An additional anterior talofibular ligament view is useful in the evaluation of the anterior talofibular ligament in patients with chronic ankle instability.

Do Weight-bearing Films Affect Decision Making in Hallux Valgus Surgery?

Alon Burg, Ori Hadash, Yehezkel Tytiun, Moshe Salai, Israel Dudkiewicz — 2011-12-26

Abstract: Hallux valgus is a complex deformity of the first ray and forefoot that can be surgically treated using different procedures and osteotomies. Preoperative planning includes anteroposterior and lateral plain films. The effect of weight-bearing on the results of the standardized measurements is still the subject of debate. We evaluated the effect of weight-bearing on the results of measurements and decision making by expert evaluators. A total of 21 foot and ankle surgeons were given weight-bearing and non–weight-bearing anteroposterior plain foot films of patients with hallux valgus. They were asked to measure 3 standard angles and then to select the most appropriate procedure from a short list. Using a paired Student's t test, no difference in the angles measured nor in the procedures chosen was detected between the weight-bearing and non–weight-bearing films. Although it is generally accepted that decisions regarding the treatment of hallux valgus should be based on plain weight-bearing films, in the present study, we established that non–weight-bearing films can reliably be used to choose the surgical procedure.

Anatomic Description of the Distal Tibia: Implications for Internal Fixation

2012-02-10

Abstract: Fracture fixation using minimally invasive plating techniques around the distal tibia are well described, although there are a number of potential hazards and complications. Our study provides an anatomical description of the distal tibia and its relations to surrounding structures. Twenty magnetic resonance imaging scans of the distal tibia were analyzed in the coronal, sagittal, and axial planes. Measurements were taken by 2 observers on 2 occasions of the distance of anterior structures from the tibial cortex as well as dimensional parameters. The mean dimensions of the distal tibia at the level of the plafond were 39 mm medial-lateral and 36 mm anteroposterior. The anterior neurovascular bundle was found to be a mean of 3 mm from the anterior tibial cortex with the anterior tendinous structures located <6 mm. The intraclass correlation coefficient for the first observer was 0.8 and for the second observer was 0.78 with an interclass correlation coefficient of 0.8. This demonstrated excellent interobserver and intraobserver reliability. This study presents the first magnetic resonance imaging–based anatomical description of the distal tibia. It showed that key anatomical structures are in very close proximity to the distal tibia, and this is important to consider when treating fractures in this region with internal fixation.

Open Reduction and Internal Fixation of OTA Type C2–C4 Fractures of the Calcaneus with a Triple-plate Technique

Alexander Brunner, Jochen Müller, Pietro Regazzoni, Reto Babst — 2012-02-17

Abstract: The purpose of this study was to present a surgical technique of open reduction and internal fixation of displaced intra-articular calcaneal fractures with 3 AO mini-fragment plates and to evaluate the clinical and radiological outcome of a consecutive group of patients after a mean follow-up of 41.7 months. A series of 54 patients (16 women and 38 men) with 62 calcaneal fractures were treated over a period of 6.5 years. Forty-five patients with 50 calcaneal fractures were completely clinically and radiologically followed up. Clinical follow-up included assessment of range of motion, pain according to a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score, and the short-form 36 health survey. Radiological follow-up included plain axial and lateral radiographs and measurement of the Böhler's angle and Gissane's angle. Independent Student's t test and paired Student's t test were used alongside the chi-square test to compare clinical and radiological data and score values between different groups of patients. Eleven patients showed breakage of the osteosynthesis material during the healing process and 2 patients sustained deep wound infection requiring revision surgery. At the final follow-up all fractures had healed. The average range of motion was supination 26.4° (range 0° to 50°; SD 11.6°), pronation 15.4° (range 0° to 30°; SD 6.4°), dorsal extension 14.3° (range –10° to 30°; SD 8.0°), and plantarflexion 39.6° (range 20° to 65°; SD 11.7°). Patients with OTA type C4 fractures achieved significantly lower supination (p < .01) and plantarflexion (p < .01) compared with other fracture types. The mean visual analog scale pain score was 3.6 (range 0 to 8; SD 2.3) points, average American Orthopaedic Foot and Ankle Society hindfoot score was 70.8 (range 33 to 100; SD 17.1) points, and the mean short-form 36 score was 60.98 (range 22.9 to 93.0; SD 18.4) points. The mean postoperative Böhler's angle was 28.9° (range 8° to 38°; SD 7.1°), which decreased to 23.6° (range 4° to 34°; SD 8.7°) at the final follow-up, and the mean postoperative Gissane's angle was 108.6° (range 80° to 140°; SD 11.8°), which finally decreased to 102.4° (range 72° to 126°; SD 12.7°). No statistically significant differences regarding Böhler's and Gissane's angles were found between different OTA fracture types. In conclusion, the presented surgical technique was found to provide comparable and adequate reduction of OTA type C2–C4 injuries based on statistically insignificant differences in radiographic measures of postoperative fracture reduction. Greater limitation in subtalar motion was observed in OTA type C4 fractures in comparison with less severe fractures (p < .01).

Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis for End-stage Hallux Rigidus with Crossed Titanium Flexible Intramedullary Nails and Dorsal Static Staple with Immediate Weight-bearing

Thomas S. Roukis, Tristan Meusnier, Marc Augoyard — 2012-01-09

Abstract: Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of the fixation type, nonunion of the arthrodesis site has been purported to be a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ for end-stage hallux rigidus with 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weight-bearing. The inclusion criteria were as follows: the exact internal fixation technique described was employed for end-stage hallux rigidus of the first MTPJ only; preoperative and at least 6 weeks of postoperative weight-bearing radiographs were available; weight-bearing was initiated on the operative foot immediately in a protective shoe; the patient was followed for at least 6 months postoperatively; any complication was documented; and bilateral surgery was not done in the same setting. A total of 42 female patients (51 feet) with a mean age ± SD of 69.4 ± 9.2 years met the inclusion criteria. Complications resulting from technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 3 feet (5.9%), but none led to nonunion or revision surgery. One delayed union (2%) occurred but it ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ consisting of 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple for end-stage hallux rigidus in an exclusively female population was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for end-stage hallux rigidus in both male and female patients are still needed, as are comparisons of the presented technique with other modern osteosynthesis techniques.

Pulsed Radiofrequency Electromagnetic Field Therapy: A Potential Novel Treatment of Plantar Fasciitis

Joel Brook, Damien M. Dauphinee, Jaryl Korpinen, Ian M. Rawe — 2012-02-10

Abstract: Plantar fasciitis is a common cause of heel pain, and although treatments are usually conservative, they can take up to 2 years to achieve resolution. A double-blind, multicenter, randomized, placebo-controlled study was used to evaluate a small, wearable, extended-use pulsed radiofrequency electromagnetic field (PRFE) device as a treatment of plantar fasciitis. A total of 70 subjects diagnosed with plantar fasciitis were enrolled in the present study. The subjects were randomly assigned a placebo or active PRFE device. The subjects were instructed to wear the PRFE device overnight, record their morning and evening pain using a 0- to 10-point visual analog scale (VAS), and log any medication use. The primary outcome measure for the present study was morning pain, a hallmark of plantar fasciitis. The study group using the active PRFE device showed progressive decline in morning pain. The day 7 AM-VAS score was 40% lower than the day 1 AM-VAS score. The control group, in comparison, showed a 7% decline. A significantly different decline was demonstrated between the 2 groups (p = .03). The PM-VAS scores declined by 30% in the study group and 19% in the control group, although the difference was not significant. Medication use in the study group also showed a trend downward, but the use in the control group remained consistent with the day 1 levels. PRFE therapy worn on a nightly basis appears to offer a simple, drug-free, noninvasive therapy to reduce the pain associated with plantar fasciitis.

Incidence and Risk Factors for Amputation in Foot and Ankle Trauma

Daniel C. Jupiter, Naohiro Shibuya, Lacey D. Clawson, Matthew L. Davis — 2012-01-30

Abstract: Mobility, especially in elderly patients, is often a proxy for overall health. It is thus of interest to understand the rates of lower extremity amputation and the risk factors for these procedures in the trauma population. We compared the rates of lower extremity amputation in low- versus high-level trauma by analyzing the National Trauma Data Bank. We also attempted to identify the risk factors in the low-level trauma population with foot and ankle trauma that predispose to lower extremity amputation. The factors associated with lower extremity amputation in foot and ankle trauma differed slightly from those in other multi-trauma patients. The factors associated with lower extremity amputation in the low-level foot and ankle trauma population that were statistically and clinically significant in this study included male gender, confounding injury, other trauma type versus blunt trauma, penetrating versus blunt trauma, occurrence of fracture, and occurrence of crush injury or wound. Understanding these risk factors will assist in educating patients and their family about their prognosis. Also, understanding these risk factors will assist surgeons with patient selection when considering salvage procedures.

Incidence of Nonunion of the Unfixated, Isolated Evans Calcaneal Osteotomy: A Systematic Review

Mark A. Prissel, Thomas S. Roukis — 2012-02-10

Abstract: The Evans calcaneal osteotomy is frequently implemented in flatfoot reconstructive surgery for correction of planar deformity. Rigid fixation across an osteotomy is a documented, accepted technique to gain stability. However, since the original description of this osteotomy, which involved no internal fixation, debate has existed regarding the necessity of fixation. Conventional wisdom suggests that the nonunion rate would increase with an unfixated osteotomy. Thus, in an effort to determine the incidence of nonunion of the unfixated, isolated Evans calcaneal osteotomy, we conducted a systematic review. Studies were eligible for inclusion only if they included the following: the nonunion rate for unfixated, isolated Evans calcaneal osteotomy, follow-up of at least 1 year and a sample size of at least 5 feet. After considering all potentially eligible studies, 2 evidence-based medicine level 2 and 3 evidence-based medicine level 3 studies met our inclusion criteria. A total of 73 feet, with a weighted mean age of 22.6 years, were included. The weighted mean follow-up of the included studies was 3.6 years. A total of 1 nonunion (1.4%) was reported. The results of our systematic review revealed an acceptably low rate of nonunion for the unfixated, isolated Evans calcaneal osteotomy. However, considering the limited data available, additional prospective investigations are warranted to further validate the nonunion rate with this technique.

Entire Posterior Process Talus Fracture: A Report of Two Cases

2012-03-12

Abstract: The complex anatomy of the posterior process of the talus includes the medial and lateral tubercles extending from the talar body. Review of the current literature indicates that fracture of the entire posterior process of the talus is a rare injury. Two patients presented to our emergency department after motor vehicle accidents, and both were diagnosed with entire posterior process talus fractures. After evaluation of each patient, treatment of each was undertaken by means of open reduction and internal fixation via the posteromedial approach to fracture. Headless screws were used to fixate the reduced posterior tubercle in each case. Based on our experience with the patients described in this report, open reduction and internal fixation appear to be suitable methods of treatment for complete posterior process fractures of the talus.

Modified Tension Band Wiring Fixation for Avulsion Fractures of the Calcaneus in Osteoporotic Bone: A Review of Three Patients

2011-12-12

Abstract: Calcaneal avulsion fractures are not uncommon, and they are probably more likely in patients with osteoporosis. Closed manipulation for this type of fracture often fails to achieve acceptable reduction, and open reduction and internal fixation are usually required. However, open reduction and internal fixation with either a lag screw or Steinmann pins do not provide satisfactory fixation in patients with diabetes and elderly patients because of the presence of porotic bone. Levi described a tension band fixation system used to treat a calcaneal avulsion fracture using a simple technique performed with a transverse Kirschner wire through the os calcaneus, securing a figure-of-8 metal tension band wiring to the fragment. We report the successful treatment of 3 patients with calcaneal avulsion fractures using a modified tension band wiring technique, resulting in satisfactory recovery. Re-displacement of the fragment during the initial follow-up period was not reported, and bony union was achieved in all patients. We believe this technique is a useful surgical option for the treatment of calcaneal avulsion fractures.

Hallux Saltans due to Flexor Hallucis Longus Entrapment at a Previously Unreported Site in an Unskilled Manual Laborer: A Case Report

Rajesh Purushothaman, Raju Karuppal, Jojo Inassi, Rejith Valsalan — 2012-03-29

Abstract: Triggering of the big toe, or hallux saltans, is commonly due to stenosing tenosynovitis of the flexor hallucis longus at the fibro-osseous tunnel below the sustentaculum tali. It is a rare condition described mainly in female ballet dancers. This is hypothesized to be due to the en pointe position used in ballet, which puts enormous supraphysiologic loads on the flexor hallucis longus, predisposing it to injury. Trigger hallux is extremely uncommon in the general population. We are reporting a case of hallux saltans in an unskilled manual laborer, with the site of tendon entrapment just proximal to the medial malleolus in the distal leg, a hitherto unreported location of stenosis.

Subungual Melanoma of the Great Toe in a Hispanic Male with Down Syndrome: A Case Report and Review of the Literature

2012-03-29

Abstract: Solid mass tumors are not as common as leukemia in individuals with Down syndrome. In this report, we describe the rare case of an adult Hispanic male with Down syndrome who developed advanced subungual melanoma in the hallux. We also describe the course of treatment, which involved hallux amputation along with metastatic work-up and sentinel lymph node biopsy with eventual resection.

Fibroma of the Flexor Hallucis Longus Tendon Sheath

Sang Wha Kim, So Young Lee, Sung-No Jung, Won Il Sohn, Ho Kwon — 2012-03-01

Abstract: Fibroma of tendon sheath is a rare benign tumor that usually occurs in upper extremities. It is mostly asymptomatic and grows slowly within the tendons or tendon sheaths. Histopathologic findings show well-demarcated nodules consisting of haphazardly arranged fibroblast-like spindle cells, which are embedded in a dense, collagenous matrix. We present a patient with fibroma of the tendon sheath on the flexor hallucis longus tendon, which was in an unusual location and has never been reported. The lesion was completely excised and showed no evidence of recurrence after 2 years of follow-up.

Metastatic Adenosquamous Carcinoma of the Foot: A Case Report

Jennifer Trinidad, David Kaplansky, Vincent Nerone, Kevin Springer — 2012-02-10

Abstract: Metastasis of carcinoma to the bones of the foot is rare and carries with it a very poor prognosis for patients. Acrometastasis can be the initial manifestation of an occult cancer or widespread metastasis of a previously diagnosed cancer. A high level of suspicion and timely diagnosis are essential to the timely diagnosis and treatment of this condition. In this report, a case of metastatic non–small cell lung carcinoma to the first metatarsal, intially diagnosed as acute gout, is presented.

Significance of Sesamoid Ossification in Peroneus Longus Tendon Ruptures

Mark Maurer, Jeffrey Lehrman — 2011-12-22

Abstract: Ruptures of the peroneus longus tendon are uncommon, with a small number of case reports found in published studies. The presence of an os peroneum can predispose the peroneus longus tendon to rupture at the cuboid level with or without concomitant fracture, or fracture through a partite os peroneum. Whether the os peroneum can be represented by various stages of ossification is still a matter of debate. We present 2 cases of acute peroneus longus tendon rupture at the cuboid notch in the presence of an intact os peroneum in the ossified and nonossified form. We treated patients with excision of the os peroneum and tenodesis of the peroneus longus to the peroneus brevis tendon.

Chondroblastoma in a Metatarsal Treated with Autogenous Fibular Graft: A Case Report

Sarvdeep S. Dhatt, Kishan R. Bhagwat, Vishal Kumar, Mandeep Singh Dhillon — 2012-02-10

Abstract: Chondroblastoma is a relatively rare tumor that mimics giant cell tumor and displays a predilection for long bones. In the present report, we describe the case of a benign chondroblastoma localized to the second metatarsal in a 20-year-old male who presented with a 2-year history of painless left foot swelling. Treatment of the tumor involved excision of the second metatarsal with use of an autologous structural fibular bone graft to stabilize the metatarsus and second toe. After 27 months of follow-up, the patient was ambulating well in regular shoes, with no clinical or radiographic evidence of tumor recurrence.

Irreducible Tibial Pilon Fracture Caused by Incarceration of the Fibula in the Tibial Medullary Canal

Prasad Ellanti, Yassir Hammad, Damir Kosutic, Philip P. Grieve — 2011-12-09

Abstract: Fractures can be irreducible for several reasons, including soft tissue or bone fragment interposition. We report an unusual fracture configuration of a comminuted tibial pilon fracture in which the distal fibular shaft fragment was occupying the medullary canal of the proximal tibial shaft fragment and inhibiting reduction and fixation. To the best of our knowledge, this has not been previously reported in a published study.

Pedal Presentation of Kaposi's Sarcoma in a Non-HIV Hispanic Female: A Case Report and Literature Review

2012-02-20

Abstract: Kaposi's sarcoma is divided into 5 subtypes primarily differentiated by clinical presentation and typical at-risk population. We report the unique case of a 74-year-old Latin American woman who presented with a violaceous lesion on the dorsum of her right second digit, which was diagnosed as Kaposi's sarcoma but was not easily placed into a discrete subtype. We discuss the factors that usually predispose people to this infection and the lack of those factors in our patient, as well as the subsequent treatment of our patient. The patient remained in complete remission at 4 years follow-up.

Digital Ray Transposition for Correction of Late-stage Post Toe-to-Hand Transfer Forefoot Deformity

Tun Hing Lui — 2011-12-12

Abstract: A patient with a painful, severe crossover third toe presented approximately 30 years after a second toe-to-hand transfer. He was successfully treated with multiple digital ray transposition. This procedure can realign the lesser toe, close the toe web, and eliminate the need for lifelong use of a toe filler.

Bilateral Talar Avulsion Fractures Secondary to Seizure: A Case Report

M. Argyropoulos, D. Clark, P. Harvie — 2011-12-26

Abstract: Musculoskeletal injury as a result of seizure activity is not uncommon, posterior shoulder dislocation being a well-described example. In this report, we describe what we believe to be the first published case of bilateral talar avulsion fractures secondary to seizure.

Reduction Calcaneoplasty and Local Muscle Rotation Flap as a Salvage Option for Calcaneal Osteomyelitis with Soft Tissue Defect

Christopher Bibbo, James D. Stough — 2011-12-26

Abstract: Plantar heel wounds with infection remain a surgical challenge. Reduction calcaneoplasty combined with local muscle flap is an alternative technique to achieve limb salvage when standard wound therapy fails to resolve complex wounds of the plantar heel complicated by osteomyelitis of the calcaneus.

Intramedullary Fixation of the Medial Column of the Foot with a Solid Bolt in Charcot Midfoot Arthropathy: A Case Report

Martin Wiewiorski, Victor Valderrabano — 2012-03-05

Abstract: Medial column fixation for rocker-bottom deformity in Charcot arthropathy is commonly performed. However, implant failure is commonly encountered because of uncontrolled weight bearing by the patient. The aim of this case report is to describe the use of a large solid bolt for fusion of the medial column of the foot in a patient with collapse of the midfoot due to diabetic neuroarthropathy.

Arthroscopic Management of C3 Tibial Plafond Fractures: A Technical Guide

Allan W. Hammond, Brett D. Crist — 2012-03-23

Abstract: Tibial plafond fractures are technically challenging and have the potential for serious complications. Minimizing soft tissue trauma can compromise visualization of articular reduction. There has been recent interest in the use of arthroscopy to improve visualization of plafond fractures while preserving the soft tissue envelope. Here the authors offer some technical points in order to simplify a technically demanding procedure.

A Novel Combination of Printed 3-Dimensional Anatomic Templates and Computer-assisted Surgical Simulation for Virtual Preoperative Planning in Charcot Foot Reconstruction

2012-02-27

Abstract: Charcot foot syndrome (Charcot neuroarthropathy affecting the foot), particularly in its latter stages, may pose a significant technical challenge to the surgeon. Because of the lack of anatomic consistency, preoperative planning with virtual and physical models of the foot could improve the chances of achieving a predictable intraoperative result. In this report, we describe the use of a novel, inexpensive, 3-dimensional template printing technique that can provide, with just a normal printer, multiple “copies” of the foot to be repaired. Although we depict this method as it pertains to repair of the Charcot foot, it could also be used to plan and practice, or revise, 3-dimensional surgical manipulations of other complex foot deformities.

Correction of Varus Heel Pad in Patients with Syme’s Amputations

2012-02-27

Abstract: Syme's amputations can provide a reliable alternative to more proximal amputations, but they are not without their occasional complication. Varus heel pad migration has been well documented as a complication following Syme's amputations. We describe a technique of resection of soft tissue and bone combined with anchoring of the lateral band of the plantar fascia in order to treat patients with the complication of varus heel pad migration.

The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results

Troy J. Boffeli, Matthew C. Peterson — 2012-03-26

Abstract: Surgical treatment of Haglund's deformity typically involves either bump removal or a closing wedge calcaneal osteotomy. Although bump removal may initially seem easier to perform and quicker to heal, there are advantages to avoiding bone resection adjacent to the Achilles tendon. Healing of the wedge osteotomy can be faster and more predicable than tendon healing at the Achilles insertion, which is beneficial to the young and active population that tends to have this condition. This article describes a reproducible Keck and Kelly closing wedge osteotomy technique that effectively decompresses the posterior/superior aspect of the calcaneus without need for dissection around the Achilles insertion. Our technique allows for consistent correction of Haglund's deformity, reliable symptom relief, and minimal opportunity for intraoperative or postoperative complications. Technique pearls include patient selection criteria for bump removal versus wedge osteotomy and a preoperative template protocol.

The Role of the DPM, PhD in Advancing Foot and Ankle Surgery

Robert M. Joseph — 2012-02-17

Those of us who evaluate and treat patients daily appreciate the difficulties related to trying to accumulate unbiased data that could lead to a better understanding of a clinical condition. We also appreciate the fact that meaningful clinical questions arise from interactions between clinicians and patients both when we are trying to make an accurate diagnosis and when we are deciding upon a course of treatment. Furthermore, it is well known that what pleases clinicians and surgeons is not always what pleases patients, even though pain relief and improved function are usually acceptable to both. Still further, clinicians usually do not have the time or the skills to design a clinical investigation that is likely to yield meaningful results. Finally, biostatisticians do not always understand the concerns of patients and clinicians or surgeons and usually find it difficult to understand the clinician's research aims unless they are clearly explained. As such, clinicians with scientific training, particularly those trained in clinical epidemiology and patient-oriented research, are uniquely qualified to fill an important role in medicine, whether they be DPMs, MDs, or DOs, or whether they have other degrees with clinical training. The decision to pursue such training can be difficult to make, especially for a busy clinician already in practice, and the following comments by Dr. Joseph present an interesting and informative account of 1 surgeon's experience in this regard.

Letter to the Editor

Peter J. Bregman — 2012-02-17

In the article “Radiofrequency thermoneurolysis for the treatment of Morton's neuroma” by Moore et al [Moore JL, Rosen R, Cohen J, Rosen B. J Foot Ankle Surg 51(1):20–22, 2012], the authors discussed treatment of primary nerve entrapment with the use of radiofrequency (RF) treatment. One of the flaws of this article is that the follow-up was only 6 months out. Treatment by RF does not, necessarily, provide a permanent resolution of symptoms. As current President of the Association of Extremity Nerve Surgeons (AENS), I feel that as foot and ankle physicians and surgeons we need to stop referring to nerve entrapments as neuromas. Specifically, calling an intermetatarsal nerve entrapment a Morton's neuroma is scientifically and physiologically incorrect. Morton did not understand that this was an entrapment problem; therefore, I do not think we should even use his name for this diagnosis. A true neuroma is when there is physical damage caused by an injury or a tumor. The typical presentation of a nerve entrapment, which is often misnamed Morton's neuroma, is almost always secondary to impingement by the deep transverse intermetatarsal ligament or, at the very least, diminished volume in the intermetatarsal space. I proffer using intermetatarsal nerve entrapment of second or third interspace.

Letter to the Editor

Joshua L. Moore — 2012-02-17

Thank you, Dr Bregman, for your comments concerning our recent article, “Radiofrequency thermoneurolysis for the treatment of Morton's neuroma.” Numerous descriptions for Morton's neuroma can be identified in the literature. Definitions range from a benign growth of the sheath of a nerve that courses between the toes, as was written by Jonathan Cluett, MD, to the Mayo Clinic's definition of it as a thickening of the tissue around one of the nerves leading to the toes. In our opinion, the symptoms of a neuroma are not caused by entrapment but instead are caused by swelling, which led us to investigate whether or not radiofrequency (RF) would be an adjunct procedure for the treatment of neuroma. As surgeons who classically trained in podiatric surgery, the definitive treatment of neuromas is surgical excision of the benign growth on the nerve sheath. Due to the growth, the compression, as you mention, may be causing the symptom; however, the compression is not the etiology of the pain. We question whether we are encountering neuromatous symptoms due to tight transverse ligaments or truly due to an enlargement of the nerve.

Information for Subscribers

2012-05-01

Editorial Board

2012-05-01

Invitation to Authors to Submit Video Footage with Manuscripts

2012-05-01

Journal of Foot and Ankle Surgery

Cover 1

The Importance of N = 1

Complications Associated with Foot and Ankle Arthroscopy

A Retrospective Comparison of Four Plate Constructs for First Metatarsophalangeal Joint Fusion: Static Plate, Static Plate with Lag Screw, Locked Plate, and Locked Plate with Lag Screw

Usefulness of Oblique Axial Scan in Magnetic Resonance Imaging Evaluation of Anterior Talofibular Ligament in Ankle Sprain

Do Weight-bearing Films Affect Decision Making in Hallux Valgus Surgery?

Anatomic Description of the Distal Tibia: Implications for Internal Fixation

Open Reduction and Internal Fixation of OTA Type C2–C4 Fractures of the Calcaneus with a Triple-plate Technique

Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis for End-stage Hallux Rigidus with Crossed Titanium Flexible Intramedullary Nails and Dorsal Static Staple with Immediate Weight-bearing

Pulsed Radiofrequency Electromagnetic Field Therapy: A Potential Novel Treatment of Plantar Fasciitis

Incidence and Risk Factors for Amputation in Foot and Ankle Trauma

Incidence of Nonunion of the Unfixated, Isolated Evans Calcaneal Osteotomy: A Systematic Review

Entire Posterior Process Talus Fracture: A Report of Two Cases

Modified Tension Band Wiring Fixation for Avulsion Fractures of the Calcaneus in Osteoporotic Bone: A Review of Three Patients

Hallux Saltans due to Flexor Hallucis Longus Entrapment at a Previously Unreported Site in an Unskilled Manual Laborer: A Case Report

Subungual Melanoma of the Great Toe in a Hispanic Male with Down Syndrome: A Case Report and Review of the Literature

Fibroma of the Flexor Hallucis Longus Tendon Sheath

Metastatic Adenosquamous Carcinoma of the Foot: A Case Report

Significance of Sesamoid Ossification in Peroneus Longus Tendon Ruptures

Chondroblastoma in a Metatarsal Treated with Autogenous Fibular Graft: A Case Report

Irreducible Tibial Pilon Fracture Caused by Incarceration of the Fibula in the Tibial Medullary Canal

Pedal Presentation of Kaposi's Sarcoma in a Non-HIV Hispanic Female: A Case Report and Literature Review

Digital Ray Transposition for Correction of Late-stage Post Toe-to-Hand Transfer Forefoot Deformity

Bilateral Talar Avulsion Fractures Secondary to Seizure: A Case Report

Reduction Calcaneoplasty and Local Muscle Rotation Flap as a Salvage Option for Calcaneal Osteomyelitis with Soft Tissue Defect

Intramedullary Fixation of the Medial Column of the Foot with a Solid Bolt in Charcot Midfoot Arthropathy: A Case Report

Arthroscopic Management of C3 Tibial Plafond Fractures: A Technical Guide

A Novel Combination of Printed 3-Dimensional Anatomic Templates and Computer-assisted Surgical Simulation for Virtual Preoperative Planning in Charcot Foot Reconstruction

Correction of Varus Heel Pad in Patients with Syme’s Amputations

The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results

The Role of the DPM, PhD in Advancing Foot and Ankle Surgery

Letter to the Editor

Letter to the Editor

Information for Subscribers

Editorial Board

Invitation to Authors to Submit Video Footage with Manuscripts

Table of Contents