Journal of Foot and Ankle Surgery - Articles in Press

Gastrocnemius Recession as an Alternative to TendoAchillis Lengthening for Relief of Forefoot Pressure in a Patient with Peripheral Neuropathy: A Case Report and Description of a Technical Modification - Corrected Proof

2010-02-05

Abstract: The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.

Safety of Local Anesthesia Combined with Monitored Intravenous Sedation for American Society of Anesthesiologists 3 and 4 Patients Undergoing Lower Limb–Preservation Procedures - Corrected Proof

2010-02-05

Abstract: The aim of this retrospective study is to evaluate the prognostic value of American Society of Anesthesiologists (ASA) classification with regard to perioperative variables of cardiac complications, pulmonary complications, and mortality in patients undergoing limb salvage procedures with monitored intravenous sedation and foot and ankle blocks. None of the ASA 3 or 4 patients experienced any pulmonary or cardiac complication; no patient required invasive monitoring or postoperative cardiac care unit admission. We suggest that the performance of peripheral foot and ankle blocks with monitored intravenous sedation appears to be a safe and useful option for ASA 3 and 4 patients undergoing limb-preservation surgery.

Functional Outcome and Patient Satisfaction after Flexor Tenotomy for Plantar Ulcers of the Toes - Corrected Proof

Tim Schepers, Heleen A. Berendsen, I. Hok Oei, Jan Koning — 2010-02-05

Abstract: Ulcers of the toes may cause a severe physical burden, especially in patients with diabetes, in whom they occur most frequently. Several treatments have been proposed for the underlying anatomical abnormalities, but they vary in effectiveness. We evaluated our results in using flexor tenotomy to treat ulcers with underlying flexible clawing of the toes. For 42 toes from 23 patients, 15 of whom were diabetic, all ulcers healed. The mean healing time was 4 weeks (range, 1-8 weeks), the mean follow-up was 11 months (range, 1-27 months), and one recurrence and one complication occurred. Postoperative American Orthopaedic Foot Ankle Society Midfoot scores were available for 15 patients: the mean was 77 (range, 43-100). The mean visual analogue scale (VAS) for patient satisfaction increased from 3.9 points (range, 0-10 points) preoperatively to 7.7 (range, 5-10 points) postoperatively. Flexor tenotomy is a simple treatment with low complications and recurrence rates and provides good-to-excellent functional outcomes in treating flexible clawing of the toes and the associated ulceration.

Comparison of Achilles Tendon Repair Techniques in a Sheep Model Using a Cross-linked Acellular Porcine Dermal Patch and Platelet-rich Plasma Fibrin Matrix for Augmentation - Corrected Proof

2010-02-05

Abstract: The primary goal of this study was to evaluate a cross-linked acellular porcine dermal patch (APD), as well as platelet-rich plasma fibrin matrix (PRPFM), for repair of acute Achilles tendon rupture in a sheep model. The 2 surgically transected tendon ends were reapproximated in groups 1 and 2, whereas a gap was left between the tendon ends in group 3. APD was used to reinforce the repair in group 2, and autologous PRPFM was used to fill the gap, which was also reinforced with APD, in group 3. All sheep were humanely euthanized at 24 weeks after the repair, and biomechanical and histological testing were performed. Tensile strength testing showed a statistically significant difference in elongation between the operated limb and the unoperated contralateral limb in groups 1 and 3, but not in group 2. All operated tendons appeared healed with no apparent fibrosis under light and polarized microscopy. In group 1, all surgical separation sites were identifiable, and healing occurred via increasing tendon thickness. In group 2, healing occurred with new tendon fibers across the separation, without increasing tendon thickness in 2 out of 6 animals. Group 3 showed complete bridging of the gap, with no change in tendon thickness in 2 out of 6 animals. In groups 2 and 3, peripheral integration of the APD to tendon fibers was observed. These findings support the use of APD, alone or with PRPFM, to augment Achilles tendon repair in a sheep model.

An Invitation to Authors to Submit Video Footage with Manuscripts - Corrected Proof

D. Scot Malay — 2010-02-05

In an effort to further enhance the teaching value and interest in the manuscripts that we publish, authors are encouraged to include video clips along with their figures and tables. Video can be used to depict complicated surgical maneuvers and clinical examinations as a supplement to the text of an article. To view an example, visit our web site, http://www.jfas.org, where you can find the add-on that accompanies The Journal of Foot & Ankle Surgery Instructional Course entitled “Closed Reduction of the Supination-Eversion Stage IV (Weber Type B) Ankle Fracture,” by D'Angelantonio et al, Volume 48, Issue 3, pp. 283–418, May–June 2009 (http://www.jfas.org/article/S1067-2516%2809%2900055-6/addOns). This particular video clip shows a complex closed reduction maneuver that brings the words on the written page to life. Video imagery activates our sensory system and transcends language, and most readers simply enjoy watching an interesting or unusual diagnostic examination, fracture reduction, tendon transfer, arthroscopic manipulation, or other therapeutic intervention. Readers can also view the video as often as they desire, and even stop the action to study a particular aspect of the footage. At The Journal of Foot & Ankle Surgery, we accept the most commonly used audiovisual formats, such as .avi, .gif, and .mov; however, we prefer .mpg (MPEG-1 or MPEG-2) and .mp4. Each of these formats is capable of containing a number of data streams, and we prefer that they be limited to one stream each for video, audio, and titles to minimize the file size. Currently, we do not accept Flash video files, although we should have the capacity to handle the Flash format in the near future. Video is a powerful tool for teaching and learning and an asset to any publication, and we encourage our authors to take advantage of this medium to enhance their manuscripts.

Precise Intraoperative 60° Skin Z-plasty - Corrected Proof

Samantha E. Bark, L. Marie Keplinger, Andrew J. Meyr — 2010-02-01

Abstract: The primary objective of this tip is to assist foot and ankle surgeons in performing a precise 60° lengthening Z-plasty in the operating room without the use of a template or protractor. A ruler and basic trigonometric principles are applied to the line of contracture to obtain consistent and reliable results.

The Extended Knee Hemilithotomy Position for Gastrocnemius Recession - Corrected Proof

Paul Dayton, Jeffrey Wienke — 2010-02-01

Abstract: The focus of this communication is to share an alternative positioning method that we have used over the past 3 years for gastrocnemius recession with the patient supine on the operating table. The technique uses a candy-cane leg holding system to situate the patient in the extended knee hemilithotomy position. We have found that this position provides excellent visualization of the surgical site, furnishes the anesthesiologist with optimal access to the patient, negates the need to turn the patient from prone to supine when adjunct procedures are to be undertaken, and allows the involved extremity to remain sterile throughout the operation, without an increase in complications or cost.

Efficacy of Power-Pulsed Lavage in Lower Extremity Wound Infections: A Prospective Observational Study - Corrected Proof

Gregory A. Mote, D. Scot Malay — 2010-01-13

Abstract: Power-pulsed lavage is a common adjunct to surgical wound debridement, although few studies have examined the effect of this technique in lower extremity wounds. Fifty-five consecutively enrolled patients underwent 73 surgical debridements with power-pulsed lavage, and specimens were obtained for Gram stain and culture and sensitivity analyses before and after lavage. A number of risk factors were analyzed in regard to a successful outcome, which was defined as the absence of any organisms observed on the immediate postlavage culture. The incidence of a successful outcome was 69.86%, and debridement plus power-pulsed lavage statistically significantly decreased bacteria between the immediate prelavage and immediate postlavage specimens, for Gram stain (P = .0004) and culture (P = .005) analyses. Generalized estimation equations provided fully adjusted effect estimates that revealed a decreased likelihood of observing success if the patient's age was 85 years or older, or if rare or many organisms, or gram-negative rods, were present on the immediate prelavage Gram stain; whereas an increased likelihood of success was observed if the patient's body mass index was indicative of normal weight, and if few bacteria were noted on the immediate prelavage culture specimen. Based on these results, we concluded that power-pulsed lavage can be effective in decreasing the presence of bacteria in lower extremity wounds, and an awareness of the patient characteristics and microbiological factors associated with the persistence of bacteria may be helpful to surgeons treating such wounds.

The Porcine Small Intestinal Submucosa (SIS) Patch in Foot and Ankle Reconstruction - Corrected Proof

Christopher Bibbo — 2009-12-21

Abstract: We undertook a retrospective cohort study of 54 patients who underwent foot and ankle soft tissue reconstructive surgery augmented with a porcine small intestinal submucosal (SIS) patch. The mean patient age was 44 (range 17 to 68) years, there were 21 (38.89%) males in the cohort, and the mean follow-up duration was 1080 (range 365 to 1943) days. Clinical outcomes were considered excellent in 46 (85.19%) patients, good/fair in 3 (5.56%) patients, and poor in 5 (9.26%) patients; and no adverse events attributable to the xenograft were observed. Direct SIS patch failure, resulting in stretching of the repair, re-tear, or tendon stenosis, occurred in 3 (5.56%) patients, and delayed incision healing occurred in 6 (11.11%) patients. Based on our observations, we concluded that the porcine SIS xenograft, when used to augment cellular and vascular in-growth, is a viable adjunct to musculoskeletal reconstructions of the foot and ankle.

Percutaneous Distraction Osteogenesis for Treatment of Brachymetatarsia - Corrected Proof

Bradley M. Lamm — 2009-12-21

Abstract: Brachymetatarsia is not an unusual deformity and is often associated with functional and cosmetic issues that warrant surgical reconstruction. Lengthening of the affected metatarsal can be undertaken on an acute basis in a single operative procedure that involves the use of a bone graft or by means of gradual callus distraction. Because of the risk of metatarsophalangeal joint malalignment, it is important for the surgeon to take steps to stabilize the joint during the lengthening process. In this report, a percutaneous method of callus distraction for repair of brachymetatarsia and maintenance of metatarsophalangeal joint alignment is presented.

Inflammatory Reaction to Implanted Equine Pericardium Xenograft - Corrected Proof

Bryan M. Feldner, William T. DeCarbo, Christopher F. Hyer — 2009-12-21

Abstract: Equine pericardium xenograft is now widely used to augment Achilles tendon repair. In this article, we describe the case of a postoperative complication in a healthy 37-year-old male who underwent primary repair, augmented with equine pericardium, of his acutely ruptured Achilles tendon. At 4 months postoperative, an indurated and fluctuant subcutaneous soft tissue reaction was noted at the repair site. Further questioning led the patient to recall having an allergy to horses, although it had been a very long time since he had experienced any symptoms related to the allergy and, as such, he failed to mention this important fact at the time of his initial examination. At 11 months postoperative, the xenograft was removed and, thereafter, the wound healed uneventfully. At 6 months following removal of the xenograft, the patient displayed no evidence of allergy or Achilles tendon dysfunction.

Irreducible Fracture Dislocation of the Ankle Caused by Tibialis Posterior Tendon Interposition - Corrected Proof

2009-12-21

ABSTRACT: A patient with severe irreducible open fracture dislocation of the ankle was admitted to our emergency department. After wound irrigation and debridement, skeletal traction was applied to the calcaneus to minimize soft tissue injury and swelling. The patient was followed in traction for 1 week, after which reduction and fixation of the fibula was attempted but not achieved. We extended the incision distally, visualized the ankle, and located the tibialis posterior tendon between the distal tibia and fibula, thereby inhibiting the reduction. The tendon coursed into the tibiotalar joint anteriorly and pushed the talus anterolaterally. After manipulation of the tendon to its anatomically correct location, the ankle was easily reduced. The wound at the medial side was closed with a fasciocutaneous rotational flap. The ankle was then immobilized for 6 weeks postoperatively. The patient regained her full range of motion, and there were no problems with the tibialis posterior tendon, such as rupture or insufficiency. Isolated tibialis posterior tendon interposition between the distal tibiofibular and tibiotalar joints has rarely been reported, and can inhibit anatomical reduction of the fractured ankle.

Treatment of Metastatic Prostate Adenocarcinoma to the Calcaneus - Corrected Proof

Christopher Bibbo, Shawn P. Hatfield, Justin T. Albright — 2009-12-16

Abstract: Metastatic skeletal adenocarcinoma is an all too common and unfortunate complication of advanced oncologic states. Mortality rates are usually elevated when bony metastasis are evident, as this signifies advanced disease. The foot and ankle are uncommon sites for metastatic deposits, but may occur. As such, the foot and ankle surgeon must be aware of the potential for such disease, and be able to proceed with an imaging and medical work-up of the patient with foot and ankle skeletal metastasis. The goal of treatment is pain relief and the preservation of functional ambulation, which may greatly enhance the quality of remaining life for patients. A team approach is mandatory to manage the patients with metastatic disease. We present a case of an elderly male with a known history of prostate cancer, who presented with unrelenting heel pain, which upon diagnostic work-up, proved to be progressive calcaneal as well as axial metastasis after a brief period of clinical remission. Operative management coupled with palliative radiation and bisphosphonate therapy provided symptomatic pain relief and maintenance of functional ambulation.

A Review of 51 Talonavicular Joint Arthrodeses for Flexible Pes Valgus Deformity - Corrected Proof

Craig A. Camasta, Christopher R.D. Menke, Patrick B. Hall — 2009-12-16

Abstract: The purpose of this study was to evaluate the radiographic and clinical outcomes of isolated talonavicular arthrodesis in the treatment of the flexible pes valgus foot type. Retrospectively, 51 consecutive isolated talonavicular arthrodeses in 41 patients were evaluated. The mean patient age was 47 (range 9 to 72) years, and the mean follow-up duration was 43.3 (range 11 to 113) months. The mean 10-cm categorical pain score before the surgery was 7.60 ± 2.37, and this improved to 1.90 ± 2.38 postoperatively, and this difference was statistically significant (P < .001). We also measured the preoperative and postoperative percent of talar uncovering, calcaneocuboid angle, Kite's angle, talar dome height, calcaneal inclination angle, and Meary's angle, and observed statistically significant (P < .001) improvements in all of these. Fifty-one (100%) of the cases progressed to radiographic osseous union, although 2 (3.92%) of the cases were considered delayed unions. Moreover, 4 (7.84%) of the cases displayed juxta-articular arthrosis postoperatively, and 2 (3.9%) cases developed transfer pain to the lateral column. The authors concluded that isolated talonavicular arthrodesis is a safe and effective procedure for the treatment of painful pes valgus deformity.

Reimplantation of a Totally Extruded Talus: A Case Report - Corrected Proof

2009-12-16

Abstract: Total extrusion of the talus is an unusual injury, and the obvious risks of reimplantation of the extruded bone include infection and avascular necrosis. In this article, the authors present the case of a 34-year-old man who sustained an open ankle injury with complete extrusion of the talus. The talus was recovered at the scene of the accident, and subsequently reimplanted along with ankle stabilization with pins and an external fixator. At 6 weeks following the osseous surgery, final soft tissue reconstruction with a suralis flap was performed. At 3 years after the injury, radiographs revealed spontaneous fusion of the tibiotalar and subtalar joints, and the clinical examination and history indicated satisfactory weight-bearing function of the involved foot and ankle. The definitive treatment of this serious lower extremity injury remains controversial, and the use of large allogeneic bone grafts, vascularized bone grafts, and tibiocalcaneal fusion, as well as reimplantation of the extruded talus have been recommended.

Use of the Taylor Spatial Frame in Compression Arthrodesis of the Ankle: A Study of 10 Cases - Corrected Proof

Wasiq A. Thiryayi, Zafar Naqui, Sohail A. Khan — 2009-12-04

Abstract: Ankle fusion is a well established way of managing a variety of recalcitrant ankle pathologies including severe osteoarthritis and infected malunion of ankle fractures. Compression arthrodesis has been a widely accepted surgical means of achieving ankle fusion. The authors describe compression arthrodesis of the tibiotalar joint in 10 cases using the Taylor-Spatial Frame (TSF). From 2003 to 2005, 10 patients (9 male and 1 female) aged between 48 and 71 years (median age 61 years) underwent application of the TSF to achieve compression arthrodesis of 10 ankle joints. The TSF is an external fixator system supported by a computer program. After input of the radiological deformities referenced to one of the rings, the computer provides the detailed strut adjustments necessary to bring about gradual correction. The underlying pathology was severe posttraumatic arthritis (2 cases), malunion (1 case), nonunion of pilon fracture (1 case), and infected ankle (1 case). Five cases presented with previous failed surgical arthrodesis. Clinical, subjective, objective, and radiological analyses were performed regularly and at the end of an average follow-up of 16.7 months (range 12–26 months). Solid fusion in anatomical alignment with return to a fully functional status was obtained in 10 out of 10 ankles. The TSF has shown encouraging results as a simple, effective and versatile means of achieving compression arthrodesis of the ankle joint.

Digital Fracture After a Flexor Tendon Transfer for Hammertoe Repair: A Case Report - Corrected Proof

William D. Fishco, Bryan J. Roth — 2009-12-04

Abstract: The authors present a case report of a complication of a complete phalangeal fracture after flexor digitorum longus tendon transfer used for the surgical correction of a hammertoe deformity.

Retained Hawthorn Fragment in a Child's Foot Complicated by Infection: Diagnosis and Excision Aided by Localization with Ultrasound - Corrected Proof

Edwin J. Harris — 2009-12-04

Abstract: Puncture wounds in children are very common and often result in foreign body retention. Organic materials in the form of plant thorns present problems in identification and localization because they are not visualized with plain radiographs. A case of a 10-year-old girl with a small piece of retained hawthorn is presented. Correct diagnosis and treatment were delayed because of misinterpretation of magnetic resonance image studies. Ultrasound ultimately located the foreign body, and assisted in its excision. Plant thorns may be toxic and produce an intense local inflammatory response. In the case described in this article, deep infection caused by Enterobacter cloacae and Pantoea agglomerans was associated with the retained thorn. The small size of the foreign body, misinterpretation of diagnostic images, and the deep infection highlight the challenges that can be encountered by physicians managing puncture wounds in children.

Clostridium septicum Necrotizing Fasciitis of the Forefoot Secondary to Adenocarcinoma of the Colon: Case Report and Review of the Literature - Corrected Proof

Valerie L. Schade, Thomas S. Roukis, MAJ Mohamad Haque — 2009-11-30

Abstract: Clostridium septicum accounts for 1% of all reported clostridial infections. C septicum infections are most often nontraumatic in nature and associated with either an occult colonic or hematologic malignancy. The initial presentation of a C septicum infection can be relatively benign with rapid progression to fatality without emergent treatment. Presented is a case of necrotizing fasciitis of the forefoot caused by C septicum associated with an occult adenocarcinoma of the colon in a patient with uncontrolled diabetes. The process we used to achieve successful functional limb preservation based on rapid surgical intervention and use of a multidisciplinary approach to medical and surgical management of this patient is discussed in detail, as well as a through review of the literature regarding the association between malignancies and C septicum infections.

Application of an Endobutton and Suture Device for Hallux Valgus Correction: A Review of Outcomes in a Small Series - Corrected Proof

Priya Ponnapula, Richard Wittock — 2009-11-11

Abstract: A relatively new method to treat a bunion deformity by means of positional correction rather than structural realignment via osteotomy has been used in a series of 5 patients. This approach to first ray correction entails the use of an endobutton and suture device that is positioned under tension between the first and second metatarsals, thereby reducing the first intermetatarsal angle. The median age of the group of patients was 51 years (range, 16-71 years), and the median follow-up duration was 20 months (range, 8-64 months). Statistically significant reductions in the first intermetatarsal and hallux abductus angles were observed between the preoperative and immediate postoperative measurements (P = .0006 and P = .0044, respectively) and between the preoperative and long-term postoperative measurements (P = .0189 and P = .0305, respectively), and, although loss of correction was observed between the immediate and long-term postoperative first intermetatarsal and hallux abductus angles, these changes were not statistically significant (P = .1369 and P = .1193, respectively). In 3 (60%) of the cases, complications developed that required revisional surgery and removal of the device. In the other 2 (40%) cases, the surgical procedure was modified and satisfactory outcomes were obtained, although minor complications occurred in both. Based on our experience with these patients, the modified surgical procedure shows some effectiveness in treating hallux abductovalgus, although further evaluation of the technique is warranted.

Concomitant Rupture of Achilles Tendon and Superior Peroneal Retinaculum: A Case Report - Corrected Proof

Jake Lee, John M. Schuberth — 2009-11-11

Abstract: A case of a concomitant rupture of the Achilles tendon and superior peroneal retinaculum is presented. This combination of injuries has only been reported once in the available literature. The intraoperative findings revealed a mid-substance failure of the superficial peroneal retinaculum, which is also a rare finding. It is suggested that mid-substance failure of this structure be included within the existing classification scheme for superficial peroneal retinacular tears. The authors also discuss the probable pathoanatomical features of these combined injuries and a proposed mechanism of injury.

The Use of a Femoral Distractor to Aid Distal Tibial Resection During Total Ankle Arthroplasty - Corrected Proof

Michael Whitehouse, Simon Thompson, Paul Halliwell, Matthew Solan — 2009-07-03

Distal tibial resection during total ankle arthroplasty can be time consuming and presents a technical challenge. We recommend the use of a femoral distractor to assist with this specific part of the operation. We describe the technique below and have now adopted it as a commonplace stage in our ankle replacements.

Stenosing Tenosynovitis of the Peroneus Brevis Tendon Associated with Hypertrophy of the Peroneal Tubercle - Corrected Proof

Hakan Boya, Halit Pinar — 2009-05-11

Stenosing peroneal tenosynovitis is not an uncommon ailment. It has a number of different causes, one of which is hypertrophy of the peroneal tubercle. In this report, we present a case of stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle without involvement of the peroneus longus tendon. The condition was fully resolved by means of operative treatment. Level of Clinical Evidence: 4