Journal of Foot and Ankle Surgery - Articles in Press

Operative Treatment for Ganglion Cysts of the Foot and Ankle - Corrected Proof

Jae Hoon Ahn, Won-Sik Choy, Ha-Yong Kim — 2010-07-22

Abstract: The authors analyzed the clinical results of surgical excision for symptomatic or recurrent ganglion cysts of the foot and ankle, and tried to elucidate the prognostic factors. Fifty-three cases of ganglions in the foot and ankle were followed for more than 24 months after excision. The mean duration of follow-up was 3.7 years. As a preceding treatment, 17 cases received a mean of 1.3 aspirations, and 16 cases recurred after a mean of 1.7 operations. The cyst was most common in the dorsum of the foot and ankle, where 35 cases were found. Thirty cases originated from the tendon sheath, 19 cases from the joint, and 4 cases from others. Preoperative mean AOFAS foot scores were low in the cysts associated with the tarsal tunnel syndrome, and in the cysts of the plantar aspect of the first toe. Postoperative mean AOFAS foot scores were significantly increased in the preceding 2 groups. There were 3 (5.7%) cases of recurrence, all of which originated from the tendon sheath. In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence.

Immediate Weight Bearing Following Modified Lapidus Arthrodesis - Corrected Proof

Philip Basile, Emily A. Cook, Jeremy J. Cook — 2010-07-20

Abstract: First metatarsocuneiform arthrodesis (Lapidus procedure) can provide powerful correction of mild to moderate hypermobile or severe hallux valgus, although a period of non–weight bearing may be necessary. The purpose of this retrospective investigation was to compare patients who underwent a modified Lapidus arthrodesis with 2 screws plus an additional “neutralization” Kirschner-wire with immediate partial weight-bearing in a removable boot, with a control group without the Kirschner-wire who were non–weight bearing for 6 weeks in a short leg cast. A total of 41 consecutive patients from January 2004 to January 2007 were included in this comparative cohort study. There were no significant radiographic changes between immediate and final 6-month postoperative radiographs in regard to first intermetatarsal angle (°) and first ray elevation measurements (first to second metatarsal head elevation [mm] and Seiberg index [mm]) within groups (P = .49, .47, and .54, and 95% confidence intervals of [–2.1, 1.2], [–0.32, 2.03], and [–0.82, 0.44], respectively) or between groups (P = .259, .67, and .083, and 95% confidence intervals of [–4.2, 1.2], [–1.39, 0.91], and [–1.77, 0.12], respectively), as computed with paired 2-sample t tests. Stratified Mantel-Haenszel analyses revealed both groups to be comparable relative to severity of deformity, gender, age, smoking history, perioperative immunosuppressant use, and other comorbidities. No nonunions or malunions where observed in either group. The use of a temporary Kirschner-wire as a third point of fixation may enable immediate protected weight bearing, by minimizing load placed on the crossed lag screw construct, in patients undergoing modified Lapidus arthrodesis.

Radiographic Outcomes Following Primary Arthrodesis of the First Metatarsophalangeal Joint in Hallux Abductovalgus Deformity - Corrected Proof

Wenjay Sung, Andrew J. Kluesner, James Irrgang, Patrick Burns, Dane K. Wukich — 2010-07-20

Abstract: The purpose of this study was to evaluate the radiographic outcomes of primary metatarsophalangeal joint arthrodesis for hallux abductovalgus deformities. Between January 2004 and March 2009, 56 consecutive patients (58 feet) underwent primary arthrodesis of the metatarsophalangeal joint (MTPJ) for severe hallux abductovalgus deformity and or hallux rigidus. Results were assessed by primary radiographic outcome measurements (hallux valgus and first-second intermetatarsal angle). Overall, the mean hallux valgus (HA) angle improved significantly from 31.9° to 13.4° (P < .01). The mean first-second intermetatarsal (IM) angle correction was also signficantly reduced from 14.0° to 9.7° (P < .01). When separated by deformity group (mild, moderate, and severe), the mean hallux valgus and first-second intermetatarsal angles demonstrated statistically significant correction in all groups when comparing preoperative and postoperative values (P < .01). Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint. A separate proximal osteotomy for severe metatarsus primus varus correction may not be necessary because of the correction achieved at the metatarsophalangeal joint arthrodesis level. The results of this study demonstrate that as the severity of the preoperative deformity increases, the amount of postoperative radiographic (HA and IM angle measurement) correction after MTPJ arthrodesis will improve correspondingly.

Bilateral Second Metatarsal Stress Fractures After Hallux Valgus Correction With the Use of a Tension Wire and Button Fixation System - Corrected Proof

David W. Mader, Nancy M. Han — 2010-07-16

Abstract: The pathomechanics and treatments of hallux valgus vary widely by deformity and surgeon, and are extensively described in the orthopedic and podiatric literature. With each newly described treatment, new complications can be encountered. In this report, we describe the case of a 22-year-old woman who underwent bilateral hallux valgus repair with a tension wire and button fixation system, and developed bilateral second metatarsal stress fracture at the point of fixation application during the postoperative period. Although this fixation system has been useful in our practice, like other surgical implants, it conveys a certain amount of risk that should be considered by surgeons using the device.

Erratum - Corrected Proof

2010-07-16

In the May/June 2010 issue (volume 49, number 3, pp 301-304) of the Journal of Foot & Ankle Surgery, the article “Reconstruction of Massive Midfoot Bone and Soft Tissue Loss as a Result of Blast Injury” was credited to by Rahul Banerjee, MD, FACS, Brian Waterman, MD, James Nelson, MD.

Tri-ligamentous Reconstruction of the Distal Tibiofibular Syndesmosis: A Minimally Invasive Approach - Corrected Proof

Tun Hing Lui — 2010-07-16

Abstract: The distal tibiofibular syndesmosis provides stability to the ankle mortise, and it is composed of the anterior inferior tibiofibular, posterior inferior tibiofibular, interosseous, and inferior transverse tibiofibular ligaments and the interosseous membrane. Subacute or chronic syndesmosis injuries can present after missed diagnosis in the acute period or after failed or inadequate nonoperative management. It can result in chronic ankle pain and progressive degeneration of the ankle. Reconstructive options for chronic syndesmosis disruption include arthroscopic debridement and screw fixation, arthrodesis of the syndesmosis, advancement of the anterior tibiofibular ligament, reconstruction of the interosseous and anterior inferior tibiofibular ligament, or tri-ligamentous reconstruction of the syndesmosis. We describe a minimally invasive technique of nearly anatomical reconstruction of the 3 syndesmotic ligaments. The syndesmosis is debrided and reduced under arthroscopic guidance and anatomical reduction of the syndesmosis can be achieved. Although we describe this technique for surgeons to consider, we recognize that a thorough clinical review of the method, complete with objective and subjective clinical outcome measurements, is warranted before widespread use of the technique.

Disseminated Intravascular Coagulation, Meningococcal Infection, and Ischemic Changes Affecting the Lower Extremities: A Case Study - Corrected Proof

Jessica L. Herzog, Kenneth P. Morgan, Matthew H. Paden, Paul A. Stone — 2010-07-12

Abstract: A middle-aged woman presented from an outside hospital with a diagnosis of Neisseria meningitidis and meningococcemia. A nonpalpable purpuric skin rash evolved into multiple wounds, with gradual necrosis of bilateral lower and upper extremities. Throughout the course of hospitalization, the patient developed ventricular tachycardia, normocytic anemia, thrombocytosis, Clostridium difficile infection, depression, and transient right eye blindness. The finding of decreased CH50 in the complement cascade was considered as the potential cause of the meningococcemia. The subsequent ischemia and necrosis of extremities were attributed to the systemic effect and trauma ensuing from N. meningitidis.

A 5-year Review of Statistical Methods Presented in The Journal of Foot & Ankle Surgery® - Corrected Proof

Andrew J. Meyr — 2010-07-12

Abstract: This article presents a review of the statistical analyses used by authors and published in The Journal of Foot & Ankle Surgery® from January 2004 to December 2008. Of the 215 articles reviewed, descriptive statistics were used in 84% and comparative statistics in 68%. The most commonly used comparative statistical tests were Student t test (30%), analysis of variance (14%), the Mann Whitney U test (Wilcoxon rank sum) test (13%), chi-squared analyses (11%), and Fisher's exact test (10%). The aim of this investigation was to review the prevalences of various statistical methods used by foot and ankle surgeons, as reported in The Journal of Foot & Ankle Surgery®, and to serve as a primer of the most common methods used in the analysis of surgical data and the development of a scientific basis for the practice of foot and ankle surgery.

Outcomes after Cheilectomy with Phalangeal Dorsiflexory Osteotomy for Hallux Rigidus: A Systematic Review - Corrected Proof

Thomas S. Roukis — 2010-07-12

Abstract: Cheilectomy with phalangeal dorsiflexory osteotomy has been proposed for treatment of hallux rigidus because of its perceived safety and efficacy and because it does not prevent the ability to perform revision surgery. The author undertook a systematic review to identify material relating to the clinical outcomes after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Studies were considered only if they involved consecutively enrolled patients undergoing cheilectomy with phalangeal dorsiflexory osteotomy, evaluated patients at mean follow-up ≥ 12 months' duration, included some form of objective and subjective data analysis, and included details of complications requiring surgical intervention. Eleven studies involving a total of 374 procedures were identified that met the inclusion criteria. Pain was relieved or improved in 149/167 (89.2%) procedures, and 139/217 (77%) patients related being satisfied or very satisfied with their outcomes. A total of 18 (4.8%) procedures underwent surgical revision. Six studies involving 177 procedures specified the grade of hallux rigidus as follows: grade I, 10.2% (n = 18); grade II, 72.3% (n = 128); and grade III, 17.5% (n = 31). The results of this systematic review make clear the general improvement in objective and subjective data as well as the low incidence of revision surgery required after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Therefore, cheilectomy with phalangeal dorsiflexory osteotomy should be considered a first-line surgical treatment for hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of this procedure for specific grades of hallux rigidus and compare the subjective and objective outcomes as well as the need for surgical revision with other procedures.

Late Hematogenous Infection of First Metatarsophalangeal Joint Replacement: A Case Presentation - Corrected Proof

Paul A. Stone, Esther S. Barnes, Thomas Savage, Matthew Paden — 2010-06-30

Abstract: Late hematogenous infection of previously asymptomatic orthopedic implants is extremely rare and usually associated with total joint replacements, such as those of the hip or knee. We present the case of an otherwise healthy female who developed a deep space infection 18 months after a first metatarsophalangeal joint implant arthroplasty. The patient presented with pain and swelling at the site, and over the course of several days developed fever and tachycardia and leukocytosis. Cultures of the surrounding soft tissues and the implant grew Streptococcus pneumoniae. The patient reported a 1- to 2-week history of symptoms consistent with an upper respiratory tract infection and it is believed that this distant focus of infection was the probable source of late hematogenous seeding of the first metatarsophalangeal joint implant.

The Variability of the Achilles Tendon Insertion: A Cadaveric Examination - Corrected Proof

Paul J. Kim, Johanna-Marie Richey, Lance R. Wissman, John S. Steinberg — 2010-06-25

Abstract: Pathology associated with the Achilles tendon is a common problem, particularly at the site of insertion. A better understanding of the anatomy in this area would assist in developing and fine-tuning treatment options. A cadaveric examination was conducted using 60 human lower extremities (40 cadavers) to determine the location for the terminal insertion site of the Achilles tendon on the posterior aspect of the calcaneus. The average age of the specimens was 67.8 years (range, 43-98 years). Three different investigators examined each specimen, and a consensus as to the site of termination of the Achilles tendon was made. Upon inspection, 55% (22/40) of the limbs had the Achilles tendon inserting on the superior 1/3 aspect of the calcaneus, 40% (16/40) of the limbs inserted on the middle 1/3, and 5% (2/40) of the limbs inserted on the inferior 1/3. The distribution of the insertion was statistically different from random (P = .000371). Further, 8% (3/40) of the specimens revealed a partially contiguous relationship between the Achilles tendon and the plantar fascia. This correlated with the younger specimens (P < .0001). This study provides a better understanding of the anatomical relationship between the Achilles tendon, the calcaneus, and the plantar fascia.

Periosteal Chondrosarcoma of the Foot: A Case Report - Corrected Proof

Nuray Haliloglu, Gulden Sahin, Cemil Ekinci — 2010-06-24

Abstract: A 19-year-old girl presented with painless swelling of the first left toe of 6 years' duration. Magnetic resonance imaging (MRI) of the lesion demonstrated a soft tissue mass adjacent to the surface of the bone with slight erosion of the underlying cortex. Surgical excision was performed and the histopathological diagnosis was low-grade periosteal chondrosarcoma, which is quite uncommon in this location.

Hourglass Ganglion Cyst of the Foot: A Case Report - Corrected Proof

Gautam D. Talawadekar, Puthur Damodaran, Sharat A. Jain — 2010-06-24

Abstract: Ganglion cyst, a common benign soft tissue lesion, is not uncommon in the foot, with the most common location being the dorsal aspect. We describe a case where the ganglion had an unusual radiographic appearance in the form of an hourglass, extending from dorsum into the planter compartments of the foot. A 74-year-old woman presented with longstanding pain in her midfoot. Clinical examination revealed a soft tissue swelling with minimal tenderness in the first webspace of the right foot. The initial radiograph was normal. Ultrasound examination revealed a cystic swelling filled with hemorrhagic fluid with an hourglass appearance. Magnetic resonance imaging examination confirmed the cystic nature of the swelling and depicted the hourglass-shaped ganglion extending from the dorsal to plantar aspect of foot. Complete excision was possible with a combined dorsal and plantar approach. Ganglion cyst can present in the foot in locations other than the dorsum and could have extensions into the plantar aspect. This variation needs to be considered when planning surgical excision, which could be aided by preoperative magnetic resonance imaging.

Delayed Rupture of the Extensor Hallucis Longus and Extensor Digitorum Communis Tendons After Breaching the Anterior Capsule with a Radiofrequency Probe During Ankle Arthroscopy: A Case Report - Corrected Proof

Serdar Tuncer, Neslihan Aksu, Ugur Isıklar — 2010-06-24

Abstract: A 40-year-old man with early arthritis, loose bodies, and anterolateral joint impingement symptoms in his left ankle, which was refractory to noninvasive therapeutic modalities for 1 year, underwent ankle arthroscopy and radiofrequency thermal ablation. The anterior capsule of the ankle joint was breached by the radiofrequency probe while the loose bodies were removed from the anterior recess, exposing the extensor tendons and resulting in a delayed spontaneous rupture of the extensor hallucis longus tendon and extensor tendons to the second and third toes. The extensor hallucis longus tendon was repaired with a semitendinosus tendon graft, and extensor digitorum tendons underwent primary repair. The patient regained full function and was symptom free 1 year after surgery.

Multifocal Cementoplasty and Internal Fixation as a Palliative Procedure for Skeletal Metastases in the Foot: A Case Report - Corrected Proof

David Mark Gibbs, Claire P. Esler, Robert U. Ashford, Alistair Best — 2010-04-26

Abstract: Cementoplasty is a well-established intervention for symptomatic control of localized skeletal metastases; however, its use has never been reported for metastases in the foot. We report on a patient with symptomatic skeletal metastases throughout the foot in which cementoplasty, in conjunction with internal fixation, was used to alleviate pain and enable comfortable ambulation.

Outcome Following Autogenous Soft Tissue Interpositional Arthroplasty for End-Stage Hallux Rigidus: A Systematic Review - Corrected Proof

Thomas S. Roukis — 2010-03-29

Abstract: Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non–peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7° preoperatively rising to 51.1° postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus.