Journal of Foot and Ankle Surgery - Articles in Press

Incidence and Risk Factors of Amputation in Foot and Ankle Trauma - Corrected Proof

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.

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

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.

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 - Corrected Proof

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.

Arthroscopy of the First Metatarsophalangeal Joint in 59 Consecutive Cases - Corrected Proof

Jae Hoon Ahn, Won-Sik Choy, Kwang-Won Lee — 2011-12-26

Abstract: The authors analyzed the results of 59 consecutive cases of the first metatarsophalangeal (MTP-I) joint arthroscopy to verify the efficacy and safety of the procedure. Fifty-nine patients were followed for >18 months after MTP-I joint arthroscopic procedures. The mean duration of follow-up was 25 months. Clinically, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the satisfaction of the patients were evaluated. Hallux valgus angle, the first intermetatarsal angle, and medial sesamoid position were analyzed in cases of hallux valgus. The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scale score was increased from 69 points preoperatively to 92 points postoperatively (p < .05). Radiologically, the mean hallux valgus angle was decreased from 29.2° preoperatively to 9.7° postoperatively (p < .05). The mean first intermetatarsal angle was decreased from 14.8° preoperatively to 7.7° postoperatively (p < .05). The medial sesamoid position was improved from 4.8 preoperatively to 2.0 postoperatively (p < .05). Ninety-five percent of the patients were satisfied with the procedures. There was 1 case of a wound problem and 1 case of temporary digital nerve injury as complications. Based on our experience, arthroscopy of MTP-I joint appears to be a safe and reproducible procedure for selected cases of MTP-I joint disorders.

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

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.

Failure after Soft-tissue Release with Tendon Transfer for Flexible Iatrogenic Hallux Varus: A Systematic Review - Corrected Proof

2011-12-26

Abstract: Hallux valgus is a common forefoot pathology often requiring surgical intervention for symptomatic relief. One complication of hallux valgus correction is flexible hallux varus. Iatrogenic flexible hallux varus often requires surgical repair; however, the most advantageous surgical procedure for repair of iatrogenic flexible hallux varus and their sustainability remains unclear. Therefore, we performed a systematic review to determine the sustainability of soft-tissue release with tendon transfer for the correction of iatrogenic flexible hallux varus. Studies were eligible for inclusion only if they involved failure of soft-tissue release with tendon transfer for flexible iatrogenic hallux varus. Eight studies met our inclusion criteria, seven of which were evidence-based medicine level IV studies and one was level V. A total of 52 patients, all female, involving 68 feet, were included. All studies included soft-tissue release of the first metatarsal-phalangeal joint capsule and 1 of the following procedures: Johnson transfer of the extensor hallucis longus tendon with arthrodesis of the hallux interphalangeal joint (41 feet); Hawkins transfer of the abductor hallucis tendon (9 feet); reverse Hawkins transfer (7 feet); Valtin transfer of the first dorsal interosseous tendon (7 feet); and Myerson transfer of the extensor hallucis brevis tendon (4 feet). The weighted mean age of the patients was 50.4 years, and the weighted mean follow-up was 30.2 months. A total of 11 complications (16.2%) occurred. Of note, only 3 cases (4.4%) of recurrent hallux varus deformity developed, all of which occurred after Johnson transfer of the extensor hallucis longus tendon, with arthrodesis of the hallux interphalangeal joint. Our results support that sustainable correction of iatrogenic flexible hallux varus can be achieved with soft-tissue release of the first metatarsal-phalangeal joint combined with a variety of tendon transfer procedures. However, given the limited data available, potential areas for additional prospective investigation remain.

Bilateral Talar Avulsion Fractures Secondary to Seizure: A Case Report - Corrected Proof

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 - Corrected Proof

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.

Average Depth of Tarsometatarsal Joint for Trephine Arthrodesis - Corrected Proof

Jay D. Ryan, Eugene D. Timpano, Thomas A. Brosky — 2011-12-23

Abstract: The trephine arthrodesis technique has been shown to be an effective method for various foot and ankle fusion procedures, with acceptable rates of fusion reported. The tarsometatarsal joints are an excellent example for this procedure because of the joint shape and soft tissue stability. The success of this procedure depends on many factors, but a large consideration is adequate joint resection. A cadaveric study to examine the joint depth of the Lisfranc complex was undertaken, allowing for improved understanding of the resection needed to maintain a stable plantar cortex while removing all apposing joint surfaces. A statistical analysis was then performed to determine the significance of the joint depth to available demographic data. A total of 51 limbs were evaluated for the depth of the first, second, and third metatarsal-cuneiform joints. The average joint depth for the first through third metatarsal-cuneiform joints was 32.3, 26.9, and 23.6 mm, respectively. The plantar cortex depth was less than 2 mm for the first through third metatarsal-cuneiform joints. The correlation between the length of the foot and the joint depth was statistically significant. Subgroups stratified by shoe size were analyzed for differences in joint size and were also statistically significant. A better understanding of the tarsometatarsal joint anatomy would benefit the trephine technique for Lisfranc arthrodesis.

Incidence of Revision after Primary Implantation of the Agility™ Total Ankle Replacement System: A Systematic Review - Corrected Proof

Thomas S. Roukis — 2011-12-22

Abstract: Revision of failed total ankle replacement remains a challenge with limited information available to guide treatment options. I undertook a systematic review of electronic databases and other relevant sources to identify material relating to the incidence of revision after primary implantation of the Agility™ Total Ankle Replacement System. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved patients undergoing primary Agility™ Total Ankle Replacement; had evaluated patients at a mean follow-up of 12 months or longer; included details of the revision performed; and included revision etiologies of aseptic loosening, ballooning osteolysis, cystic changes, malalignment, or instability. A total of 14 studies involving 2312 ankles, with a weighted mean follow-up of 22.8 months, were included. Of the 2312 ankles, 224 (9.7%) underwent revision, of which 182 (81.3%) underwent implant component replacement, 34 (15.2%) underwent arthrodesis, and 8 (3.6%) underwent below-knee amputation. No significant effect from the surgeon’s learning curve on the incidence of revision or the type of revision surgery performed was identified. However, excluding the inventor increased the incidence of revision twofold, from 6.6% to 12.2%, and skewed the type of revision away from arthrodesis and toward implant component replacement or below-knee amputation. Regardless, the incidence of revision after primary implantation of the Agility™ Total Ankle Replacement System was less than historically reported and amenable to implant component revision more than 80% of the time. However, methodologically sound cohort studies are needed that include the outcomes after revision surgery, specifically focusing on what implant component replacement techniques are effective in enhancing survivorship of these revised implants and the role of custom-stemmed talar and tibial components have in revision of the Agility™ Total Ankle Replacement System. A direct comparison of the incidence of revision between the various contemporary total ankle replacement systems in common use is also warranted.

Significance of Sesamoid Ossification in Peroneus Longus Tendon Ruptures - Corrected Proof

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.

Complications Associated with Foot and Ankle Arthroscopy - Corrected Proof

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.

Arthrodesis of the First Metatarsophalangeal Joint: A Retrospective Analysis of Plate versus Screw Fixation - Corrected Proof

Jan Dening, Ruud H.G.P. van Erve — 2011-12-19

Abstract: Arthrodesis of the first metatarsophalangeal joint is a commonly accepted technique to treat various afflictions of the hallux. Many techniques have been described to fixate the arthrodesis. However, no superior fixation technique has been identified in regard to nonunion. We performed a retrospective analysis of first metatarsophalangeal joint arthrodeses in our clinic from January 2000 to April 2010, focusing on plate and screw fixation. Our aim was to identify the best fixation construct in regard to fusion rates and radiologic nonunion. We identified 72 arthrodeses performed using 1 oblique (n = 24) or 2 crossed (n = 21) lag screws or a plate (n = 13) or a plate augmented with plantar lag screw fixation (n = 14). Our analysis showed that plate fixation alone results in significantly fewer nonunions than single screw fixation. A comparison of the other fixation types showed no significant differences with regard to nonunion. Although our analysis showed that plate fixation alone is superior to single screw fixation, no definitive conclusion can be drawn owing to methodologic shortcomings. We believe a randomized controlled trial with larger sample sizes is necessary to find the clinically superior fixation technique.

An Adjunct to Percutaneous Plate Insertion to Obtain Optimal Sagittal Plane Alignment in the Treatment of Pilon Fractures - Corrected Proof

Frank A. Liporace, Richard S. Yoon — 2011-12-19

Abstract: Advances in the surgical technique and implant technology have offered significantly improved options for patients in the acute fracture setting. In particular, regarding extra- and intra-articular fractures of the distal tibia, percutaneous plating options have helped to minimize soft tissue stripping, maintain osseous vascularity, and increase the healing potential and fracture stabilization. However, even with the advent of new, minimally invasive technologies, misalignment after open reduction can still occur. In the present report, we present a simple, reproducible technique that we have used to consistently achieve optimal sagittal plane alignment of fixation during percutaneous plating of fractures of the distal tibia.

Pedal Occurrence of Nodular Fasciitis: A Case Report - Corrected Proof

2011-12-16

Abstract: Nodular fasciitis occurs primarily in the soft tissue structures of the upper extremities and, more rarely, in the lower extremities. This mass, although benign, can mimic certain sarcomas and is therefore important to differentiate from more serious conditions. We report a case of nodular fasciitis of the foot in a healthy 47-year-old male who presented with increasing pain and swelling in his right third digit of 3 months duration. Initial radiographs revealed an irregular contour to the proximal phalanx with increased soft tissue density. Magnetic resonance imaging and computed tomography scans were obtained that revealed a soft tissue mass with bone erosion and fracture. Histologic analysis from a specimen obtained after excision of the lesion confirmed the diagnosis of hyalinizing nodular fasciitis. Nodular fasciitis in the foot can appear malignant from the clinical and histopathologic findings but can be differentiated. A quick and accurate diagnosis of this benign process can prevent a treatment program unnecessarily dangerous to the patient.

Ankle Arthroscopy: Is Preoperative Marking of the Superficial Peroneal Nerve Important? - Corrected Proof

Mehdi Suzangar, Peter Rosenfeld — 2011-12-16

Abstract: The aim of this study was to see whether preoperative marking of the superficial peroneal nerve and its branches before anterior ankle arthroscopy reduced the incidence of nerve injury compared with the available evidence reported in the literature. We reviewed 100 consecutive cases of anterior ankle arthroscopy that had been performed between February 2005 and April 2009. The medical records for all of the patients were reviewed for any documented complications related to the arthroscopic procedure. The patients were interviewed by telephone to find out if they had experienced any temporary or long-term neurologic symptoms after the surgery, and any patient with symptoms suggestive of a neurologic complication was thereafter physically examined in the clinic. A total of 96 (96%) of the patients were followed up for a mean of 15.3 (range 1 to 39) months, and the incidence of post-arthroscopy injury to the superficial peroneal nerve or its branches was 1.04% (1 out of 96 cases). Based on our observations, we believe that marking the superficial peroneal nerve and its branches before anterior ankle arthroscopy is an important and effective way to decrease the risk of iatrogenic nerve injury.

Step-cut Medial Malleolar Osteotomy: Literature Review and Case Reports - Corrected Proof

S. Jeffrey Siegel, Alexander C. Mount — 2011-12-12

Abstract: Talar dome pathology involving the medial half of the talus is a common occurrence. Direct visualization of this region of the ankle joint can be challenging because of anatomical constraints. Many lesions can be seen arthroscopically and, with the aid of a distractor, can be successfully treated. However, because of adhesive capsulitis and/or the size and location of the lesion, an open arthrotomy or a transmedial malleolar osteotomy may be required. The purpose of this article is to review the literature on techniques developed for gaining access to this area of the ankle and to highlight the step-cut medial malleolar osteotomy (SCMMO) and modifications that can be made to it to facilitate joint access. Two case studies are used to exemplify the SCMMO and modifications used to increase talar dome access. Because of anatomic constraints, many foot and ankle surgeons recommend osteotomy of the medial malleolus to gain access to the posteromedial aspect of the ankle. The step-cut approach is technically simple to perform; it can be safely modified when treating central lesions, it has inherent osseous stability that minimizes risk of displacement during rehabilitation, and it has a broad cancellous surface area, which facilitates osseous union. The authors recommend this procedure when an osteotomy is needed to gain access to the posteromedial ankle joint.

Minimally Invasive Reduction Technique in Split Depression Type Tibial Pilon Fractures - Corrected Proof

2011-12-12

Abstract: Tibial pilon fractures usually result from high energy trauma and present as a challenge to the orthopedic surgeon. Accurate reduction of the joint with meticulous care for the surrounding soft tissues is mandatory. We present a case report in which an anterior cruciate ligament targeting device is used with a minimally invasive technique under arthroscopic and fluoroscopic guidance for Orthopaedic Trauma Association 43-B2.3 type pilon fracture treatment.

Radiographic Analysis of the Canale View for Displaced Talar Neck Fractures - Corrected Proof

James L. Thomas, Brandon M. Boyce — 2011-12-12

Abstract: Fractures of the talar neck comprise almost 50% of fractures of the talus and may result in significant long-term morbidity. It is of paramount importance to ensure anatomic reduction of the fracture not only for fracture healing but also for minimizing future posttraumatic arthritic sequelae. In addition to conventional radiographs and computed tomography scans, the Canale view has proven to be beneficial, especially when evaluating for varus displacement. This study investigated whether the original method of performing the Canale view could be modified for improved evaluation for varus displacement. Simulated talar neck fractures were created in 6 cadaveric specimens. These were placed into varying amounts of varus displacement; the Canale view was performed with progressive degrees of eversion, from 0° to 25°, resulting in 108 total views. Blinded evaluation was performed, and a ranking system was used to determine the most beneficial degree(s) of eversion for evaluating varus malalignment. Multiple statistical analyses were performed. A significant difference was seen between the high and low range of values of eversion. A significantly lower ranking was achieved with 10° of eversion. As opposed to a single view taken at 15° of eversion, a range of angles may be most beneficial in evaluating varus displacement in talar neck fractures.

Periprosthetic Fracture after Femoral Intramedullary Nail Use in Two Cases of Tibiotalocalcaneal Arthrodesis - Corrected Proof

Jason B. Woods, Andrew B. Shinabarger, Patrick R. Burns — 2011-12-12

Abstract: Tibiotalocalcaneal arthrodesis using intramedullary nail fixation is a technically demanding procedure. Periprosthetic fracture in association with tibiotalocalcaneal arthrodesis is a rare occurrence, with relatively few instances reported. The present report describes 2 such instances that occurred after tibiotalocalcaneal arthrodesis using retrograde femoral intramedullary nail fixation. Studies have suggested that a longer nail might decrease the incidence of periprosthetic fracture. Other factors could also have an influence, including the proximal screw orientation and the presence of medical comorbidities, such as osteopenia.

Brodie’s Abscess of the Cuboid in a Pediatric Male - Corrected Proof

Sharat Agarwal, Mohammad Nasim Akhtar, Jerryson Bareh — 2011-12-12

Abstract: Brodie’s abscess of the tarsal cuboid is a rare presentation of a common disease. In the present report, we describe the case of Brodie’s abscess of the tarsal cuboid after a thorn prick in the foot of a 10-year-old boy. The patient was asymptomatic in the acute phase of the injury, and on presentation, no evidence was found of an open cutaneous wound. The foot radiographs showed a cavitary osteolytic lesion in the cuboid bone. Magnetic resonance imaging revealed a classic penumbra sign and an abscess in the plantar intrinsic musculature. The patient was treated with curettage and debridement combined with broad-spectrum antibiotics, which resulted in complete resolution of the symptoms by 6 weeks postoperatively. Although microbiologic analysis of the surgical specimen failed to reveal a causative microorganism, histopathologic inspection showed chronic inflammation, consistent with Brodie’s abscess.

Hindfoot Plantarflexion: A Radiographic Aid to the Diagnosis of Achilles Tendon Rupture - Corrected Proof

Simon Pearce, Chinmay Gupte, Sam Singh, Mark Prince, Sarah Elsabagh — 2011-12-12

Abstract: Although tendo Achilles (TA) rupture is a clinical diagnosis, radiographs are sometimes taken to exclude bony injury. In equivocal clinical examination findings, an ultrasound examination is often performed. We investigated whether any radiographic signs of TA rupture existed that could help diagnose TA rupture in equivocal cases. We examined the case notes of 25 consecutive patients who had undergone repair for complete TA rupture. Their lateral radiographs were reviewed and the following angles were measured: calcaneal pitch, lateral talocalcaneal, and tibiocalcaneal. These were compared with a control group of patients who had undergone radiographic examination for ankle injuries resulting in a diagnosis of ankle sprain. The results were compared using an unpaired Student's t test. The mean tibiocalcaneal angle of the patients with complete TA rupture was 87.0 compared with 69.4 for the control group (p < .05). No significant difference was found with the other angles measured. The tibiocalcaneal angle can be a useful adjunct to the clinical examination in the diagnosis of TA rupture. It might also have a role in the evaluation of serial cast application after TA repair.

Missing the Lisfranc Fracture: A Case Report and Review of the Literature - Corrected Proof

2011-12-12

Abstract: Injuries to the tarsometatarsal joint are infrequent and the presentation varies. The radiologic evaluation can be difficult, and injuries are missed initially in up to one third of cases. A 60-year-old female sports instructor presented to the emergency department with a Lisfranc fracture dislocation of the foot as result of an indirect trauma. The patient attended to a hospital the day she sustained the injury, where the Lisfranc fracture was missed. At our hospital, the patient underwent immediate restoration of the dislocation. Because of swelling, internal fixation was applied 2 weeks later. Postoperatively, the patient was mobilized in a non–weight-bearing plaster cast for 6 weeks, continued by progressive weight-bearing in a walker. The fixation screws were removed 3 months after surgery. Lisfranc fractures are rare injuries and can be missed at first sight. Careful clinical examination and radiographs in 3 different planes are required to identify the injury. Computed tomography might be helpful when the findings from the above-mentioned examinations are inconclusive. Operative treatment, including anatomic reduction and fixation, is required in almost all cases to achieve the best satisfactory result. Long-term complications include secondary arthritis and foot deformities, which can be treated by foot ortheses or arthrodesis.

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

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.

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

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.

Case of Juxta-Articular Osteoid Osteoma of Calcaneus Mimicking Arthritis - Corrected Proof

2011-12-09

Abstract: Juxta-articular osteoid osteoma is a rare disorder that is difficult to correctly diagnose at an early stage. We report a case of osteoid osteoma in the calcaneus that arose near to the talocalcaneal joint. An 18-year-old female presented with symptoms of joint swelling and effusion similar to those of monoarthritis. Conservative treatment proved ineffective in achieving pain relief, and she underwent surgery 6 months later. The lesion was diagnosed by histologic examination, and it resolved after resection of the tumor.

Subjective Results after Surgical Treatment for Displaced Intra-articular Calcaneal Fractures - Corrected Proof

Attilio Basile — 2011-12-09

Abstract: We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.

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

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.

Subcutaneous Rupture of the Flexor Hallucis Longus Tendon: A Case Report - Corrected Proof

Daisuke Noda, Ichiro Yoshimura, Kazuki Kanazawa, Tomonobu Hagio, Masatoshi Naito — 2011-12-08

Abstract: It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.

Metastatic Esophageal Adenocarcinoma of the Great Toe: A Case Report - Corrected Proof

Said Atway, Robert Vancourt — 2011-12-08

Abstract: Owing to the rarity of metastatic disease to the bones of the foot, the guidelines for the proper care and workup of such conditions are inconsistent. The present case illustrates the evaluation of a patient with established esophageal adenocarcinoma that metastasized to involve the hallux, which had not been confirmed by previous imaging scans. The purpose of reporting the present case was to aid in establishing a protocol for a multidisciplinary approach to patient care and evaluating the entire body when performing metastatic disease treatment. As the present case has shown, evaluation of various abnormalities such as chronic paronychia could mask additional underlying conditions related to the patient’s primary cancer.

Complete Open Dislocation of the Navicular—A Case Report - Corrected Proof

Harish Rao — 2011-12-08

Abstract: Complete dislocation of the navicular is rare, and open dislocation even more so. We report a case of a 85-year-old female patient who experienced complete open dislocation of navicular, successfully treated by open reduction and arthrodesis of the naviculocuneiform and calcaneocuboid joints. At 2 years after treatment, the patient was symptom free and had nearly normal foot function.

Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis with Crossed Titanium Flexible Intramedullary Nails and a Dorsal Static Staple with Immediate Weightbearing - Corrected Proof

Thomas S. Roukis, Tristan Meusnier, Marc Augoyard — 2011-12-08

Abstract: Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ with crossed flexible titanium intramedullary nails and a dorsal static staple followed by immediate protected weight bearing. The subjects were included if they had undergone the exact internal fixation technique described; surgery had been performed only by 1 of us; and they had not undergone bilateral surgery in the same setting. Also, the indication for surgery was required to be pathology of the first MTPJ other than rheumatoid arthritis. Weight bearing preoperative radiographs and weight bearing radiographs at least 6 weeks postoperatively were required. Also, the patients had to have initiated weight bearing on the operative foot immediately postoperatively in a protective shoe. Finally, documentation of any complications was required. A total of 83 patients (95 feet) met the inclusion criteria and were included. Of the 83 patients, 77 (92.7%) were female and 6 (7.3%) were male. Their mean age ± standard deviation was 69.7 ± 16.7 years. Of the 95 feet, 55 (57.9%) were right and 40 (42.1%) were left feet. The indications included 61 (64.2%) with severe hallux valgus deformity, 24 (25.3%) with hallux rigidus, and 10 (9.5%) with failed first MTPJ surgery. Complications related to technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 16 feet (16.8%) but none led to nonunion or revision surgery. A total of 3 asymptomatic nonunions (3.2%) occurred, all in female patients with severe hallux valgus that did not require revision surgery. The incidence of nonunion after arthrodesis of the first MTPJ consisting of crossed flexible titanium intramedullary nails and a dorsal static staple for predominantly severe hallux valgus and hallux rigidus was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies are still needed that focus on the use of isolated arthrodesis of the first MTPJ for purely severe hallux valgus or hallux rigidus and a comparison of the technique we have presented with other modern osteosynthesis techniques.

Results of Accelerated Postoperative Rehabilitation Using Novel “Suture Frame” Repair of Achilles Tendon Rupture - Corrected Proof

2011-12-08

Abstract: The management of Achilles tendon rupture is a much-debated subject. In recent years, there has been much interest in early postoperative mobilization. We present the results of our Achilles tendon repair technique and accelerated rehabilitation program. The technique we propose uses the strength of a 1-loop polydioxanone “suture frame” to enable restoration of the tendon length, immediate positioning of the foot in a near-plantigrade position, and an accelerated rehabilitation program. We followed up 15 cases of Achilles tendon rupture treated with this technique. The initial follow-up was a review of case notes and a telephone questionnaire. All patients were subsequently invited for a clinical follow-up visit, and 11 patients (68.75%) attended. No cases of infection or repeat rupture occurred. The return to work (mean 5.6 weeks) and return to sport (mean 4.8 months) were relatively rapid. Regarding overall satisfaction on a scale of 0 to 10, the median was 9 (range 8 to 10). Of the 11 patients who attended the clinical follow-up visit, the mean American Orthopaedic Foot and Ankle Surgery ankle-hindfoot score was 94.5 points (range 83 to 100). The Achilles rupture repair scores (including isokinetic muscle strength) were good or excellent in all but 1 patient, whose result was fair. Of the 11 patients, 10 reported complete satisfaction with their outcome. Our technique with accelerated rehabilitation is safe and effective in the management of acute Achilles tendon rupture. It facilitates an early return to work and recreational sports, with excellent overall patient satisfaction.

Arthroscopic De Novo NT® Juvenile Allograft Cartilage Implantation in the Talus: A Case Presentation - Corrected Proof

Dustin L. Kruse, Alan Ng, Matthew Paden, Paul A. Stone — 2011-12-05

Abstract: Osteochondral defects of the talus are a challenging subject facing foot and ankle surgeons. The available treatment options have relatively good subjective outcomes; however, they are limited by the ability to reproduce hyaline cartilage, the need for multiple surgeries, and high morbidity. We present a new technique using DeNovo NT® juvenile allograft cartilage implantation introduced into a talar lesion arthroscopically in a single procedure to repair a posteriomedial talar osteochondral defects in a healthy, active 30-year-old female. The patient tolerated the procedure well. At the 6-month follow-up visit, the patient had returned to full activity, and at 24 months, she remained completely pain free.

Multiple Tenotomies after Ponseti Method for Management of Severe Rigid Clubfoot - Corrected Proof

Hazem M. ElTayeby — 2011-11-24

Abstract: The purpose of the present study was to evaluate the efficacy of multiple tenotomies performed after application of the Ponseti method in reducing the tendency for recurrence in the severe rigid idiopathic clubfoot and limiting the need for application of the hyperabduction brace in the prewalking age. From November 2002 to December 2004, 30 severe (Pirani >5), rigid (nonresilient), idiopathic clubfeet in newly born infants aged 2 to 24 days were treated by the Ponseti method of weekly manipulations and castings until achieving full correction, apart from equinus. With the patient under general anesthesia, through 2 small incisions (2 cm), tenotomy of the Achilles tendon, tibialis posterior, and flexor digitorum longus was performed, together with posterior capsulotomy of the ankle to achieve >30° dorsiflexion in 26 feet. An above the knee plaster cast in extreme dorsiflexion and 70° hyperabduction was applied for 6 to 8 weeks. This was followed by a hyperabduction brace on a full-time basis (23 hours daily) for an additional 6 months. A satisfactory result was achieved after a follow-up period of 2 to 5 (mean 3.8) years. The Pirani score on initial presentation was 5 to 6 and on the final visit was 0 to 0.25, with 10° to 20° passive dorsiflexion of the ankle in those who underwent posterior capsulotomy compared with 5° to 10° in the 4 patients who had not. The number of manipulations needed before tenotomy was 5 to 7 (mean 5.9), reflecting the rigidity of the studied feet. Active plantarflexion to almost normal power was regained at 18 to 30 months of age. A relapse developed in only 1 foot that failed to respond to manipulation and casting. It required posteromedial release and tibialis anterior transfer at 2 years of age. The proposed minimally invasive procedure of open multiple tenotomies and posterior capsulotomy of the ankle is safe and effective. If performed in newly born infants with severe rigid clubfeet followed by strict application of the hyperabduction brace on a full time basis for 6 months, it will ensure full correction of the deformity. Thus, the brace can be discarded before the infant reaches walking age, with no tendency for relapse.

Diabetic Heel Ulcer in the Sudan: Determinants of Outcome - Corrected Proof

2011-11-14

Abstract: Heel ulceration, on average, costs 1.5 times more than metatarsal ulceration. The aim of this study was to analyze the determinant factors of healing in diabetic patients with heel ulcers and the late outcomes at Jabir Abu Eliz Diabetic Centre Khartoum, Khartoum, Sudan. Data were collected prospectively for 96 of 100 diabetic patients presenting with heel ulcers at the Jabir Abu Eliz Diabetic Centre Khartoum from May 2003 to January 2005. Late outcome was assessed 3 years later (February 2008). Heeling was achieved in one half of the patients (n = 48). In the remaining 48 patients, 22 ended with major lower extremity amputation and 22 were still receiving wound care. A total of 8 patients died, 4 in each group, the healed and unhealed. The most significant determinants of healing using a logistic multivariate regression model, 95% confidence intervals, and odds ratios included a shorter duration of diabetes (p < .009), adequate lower limb perfusion (p < .043), and a superficial foot ulcer (p < .012). Three years later, of the 88 patients who could be traced, 78 were alive and 59 had healed ulcers (7 had died of unrelated causes and 3 of diabetic-related complications), and no additional lower extremity amputation was recorded. Mortality in the series was 18 patients, of whom 14 had undergone a previous lower extremity amputation. Superficial heel ulcers in diabetic patients with a short history of diabetes and with good limb circulation are more likely to heal within an average duration of 25 weeks. At 3 years of follow-up, 75% showed a favorable outcome for ulcer healing, and 22 patients underwent lower extremity amputation (25%), of whom 14 were dead within 3 years.

Use of Custom-made Stockings to Control Postoperative Leg and Foot Edema Following Free Tissue Transfer and External Fixation of Fractures - Corrected Proof

Cigdem Unal, Huseyin Gercek — 2011-11-11

Abstract: Patients with lower extremity trauma treated with free tissue transfer and external fixation of fractures almost always have postoperative edema of the foot and leg. Although compressive elastic stockings have been advised to be worn by patients with venous or lymphatic insufficiency, no such stocking has been described for postoperative use by patients with external fixators. The aim of the present report was to describe a custom-made elastic compression stocking for patients who have undergone soft tissue reconstruction and fracture fixation with external fixators. These custom-made stockings can help to decrease postoperative edema during the nonambulatory and nonweight-bearing ambulatory period. They are easy to apply, affordable, and can be tailored from regular compression stockings according to the needs of the patients.

Fungal Osteomyelitis of Calcaneus due to Candida albicans: A Case Report - Corrected Proof

Lee Fleming, Alan Ng, Matthew Paden, Paul Stone, Dustin Kruse — 2011-11-07

Abstract: Osteomyelitis can be a challenging entity to treat. Because of the emergence of risk factors, including broad-spectrum antibiotics, intravenous drug abuse, immunocompromised hosts, and other factors, opportunistic pathogens have increased in prevalence in bone infections. A review of the published data revealed few reported cases of fungal osteomyelitis localized to the foot. In the present report, we describe a rare case of fungal osteomyelitis localized to the calcaneus in an elderly female patient who was successfully treated with surgical debridement and a 6-week course of oral fluconazole.

Chondroblastoma of the Talus: A Case Report and Literature Review - Corrected Proof

Kairui Zhang, Yuan Gao, Haifei Dai, Sheng Zhang, Gong Li, Bin Yu — 2011-11-07

Abstract: Chondroblastoma is a rare, benign cartilaginous neoplasm that accounts for approximately 1% of all bone tumors, and approximately 4% of all chondroblastomas arise in the talus. Here we report a case of chondroblastoma in the left talus. The 22-year-old male patient presented with a 16-month history of ankle pain. Based on radiological and pathological examination, we diagnosed the patient with chondroblastoma. A posterolateral approach was used to allow access to the lesion. After curettage, the allogenic bone chips were packed into the talar body defect. After 2 years’ follow-up, we found no recurrence or metastasis of chondroblastoma, suggesting our surgery procedure was effective.

Use of Intramedullary Nonvascularized Fibular Graft with External Fixation for Revisional Charcot Ankle Fusion: A Case Report - Corrected Proof

Soon-Taek Jeong, Hyung-Bin Park, Sun-Chul Hwang, Dong-Hee Kim, Dae-Cheol Nam — 2011-11-07

Abstract: We describe a case of Charcot ankle arthropathy in a 43-year-old male patient who underwent revision surgery for tibiotalocalcaneal arthrodesis with a retrograde intramedullary nonvascularized fibular graft. After 3 months of postoperative stabilization with a ring external fixator, successful radiographic union was identified. The findings obtained at 33 months postoperatively showed maintenance of solid fusion and restoration of hindfoot alignment without any complications.

Allograft Cellular Bone Matrix as an Alternative to Autograft in Hindfoot and Ankle Fusion Procedures - Corrected Proof

Shane M. Hollawell — 2011-10-31

Abstract: This report summarizes the radiographic results of Osteocel Plus in 20 hindfoot and ankle fusions at a single center. The patient population was 40% female with an average age of 57.9 ± 16.1 years. Average body mass index was 33.8 ± 9.1. Risk factors included 3 smokers and 6 patients with diabetes. Primary surgical indications included trauma (50%), Charcot arthropathy (15%), foot drop with osteoarthritis (20%), primary osteoarthritis (10%), and total talar extrusion (5%). Nine patients had a history of prior hindfoot surgery in the same foot; however, only 2 of the cases reported in this series were revisions due to a failed prior surgery; the remaining 7 were treated for correction of a traumatic deformity (n = 5) or diagnosis at a new site in the same foot (n = 2). Treatment included subtalar joint arthrodesis (50%), ankle arthrodesis (40%), triple fusion (5%), and tibial-calcaneal-calcaneal-cuboid arthrodesis (5%). Solid fusion was observed in 100% of patients by the 6-month evaluation. Average time to fusion was 13.5 weeks. Although patients with a prior surgery trended toward a longer time to fusion than patients who underwent their first hindfoot and ankle procedure (14.4 ± 5.3 vs. 12.6 ± 5.7 weeks), the difference was not statistically significant (p = .47). There was no evidence of graft rejection or failure. This series demonstrates that mesenchymal stem cell–based bone allograft is a safe and effective bone-healing material with a high radiographic success rate in foot and ankle arthrodeses with successful and timely fusion rates.

Reconstruction of Large Defect of Foot with Extensive Bone Loss Exclusively Using a Latissimus Dorsi Muscle Free Flap: A Potential New Indication for This Flap - Corrected Proof

Manuel Macemino Gomez, Diogo Casal — 2011-09-26

Abstract: In cases of extensive damage to the foot, with significant bone loss, it is generally accepted that reconstruction must include bone flaps or grafts either in the emergency setting or subsequently. In this report, we describe the case of an 18-year-old student with an avulsion injury of the dorsum of his right foot. Consequently, he lost most of the soft tissue over the dorsum of the foot and the cuboid, navicular, and cuneiform bones. A latissimus dorsi free flap was used to reconstruct the defect. A functional pseudoarthrosis developed between the remaining bones of the foot, and the patient experienced satisfactory foot function after rehabilitation. For this reason, no additional reconstructive procedure was undertaken. This case suggests that it might be adequate to use the latissimus dorsi muscle flap more liberally than previously reported in the reconstruction of extensive defects of the dorsum of the foot, including cases with significant bone loss. This option could avoid the morbidity and inconvenience of a second surgery and the need to harvest a bone flap or graft.