Journal of Foot and Ankle Surgery - Articles in Press

A Retrospective Comparative Analysis of Charcot Ankle Stabilization Using an Intramedullary Rod with or without Application of Circular External Fixator—Utilization of the Retrograde Arthrodesis Intramedullary Nail Database - Corrected Proof

J. George DeVries, Gregory C. Berlet, Christopher F. Hyer — 2012-05-14

Abstract: Brodsky type 3a Charcot destruction of the ankle is devastating to patients. The authors have surgically stabilized this deformity with the use of an intramedullary arthrodesis nail, and explore the usefulness of adjunctive application of a circular external fixator. Fifty-two patients were treated with retrograde intramedullary nail with and without circular external fixation. A comprehensive chart and radiographic review were pulled from the Retrograde Arthrodesis Intramedullary Nail database. Of these, 45 patients were treated with a nail alone (Nail group), and 7 were treated with a nail and circular external fixation augmentation (ExFix group). The primary end point was major amputation or braceable limb. The average age was 59.4 and 51.6 years in the Nail and ExFix groups, respectively (p = .0068). Chronic steroid use was statistically significantly different and was found in 3 (6.7%) and 4 (57.1%) patients in the Nail and ExFix groups, respectively (p = .0039). The rate of major amputation was 10/45 (22.2%) and 2/7 (28.6%) in the Nail and ExFix groups, respectively (p = .656), with an overall salvage rate of 40/52 limbs (75.6%). The addition of circular external fixation does not affect the overall salvage or complication rate. The authors feel that the added stability offered by external fixation may benefit patients who are at high risk for complications or require extended arthrodesis, but this was unable to be demonstrated statistically in this study. Patients with this difficult pathology can be successfully salvaged, but there is a high risk of complications.

Achilles Tendon Reattachment after Surgical Treatment of Insertional Tendinosis Using the Suture Bridge Technique: A Case Series - Corrected Proof

Bryan L. Witt, Christopher F. Hyer — 2012-05-14

Abstract: Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge® (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire® (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire® provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weight-bearing activities. The patients were followed up for approximately 2 years’ duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients’ average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0 to 10.71). The suture bridge technique is a viable option for Achilles tendon repair after surgical management of insertional Achilles tendinosis.

The Effect of Recombinant Bone Morphogenetic Protein-2 in Revision Tibiotalocalcaneal Arthrodesis: Utilization of the Retrograde Arthrodesis Intramedullary Nail Database - Corrected Proof

J. George DeVries, Minh Nguyen, Gregory C. Berlet, Christopher F. Hyer — 2012-05-11

Abstract: The use of bone morphogenetic protein-2 (BMP-2) has been recommended for high-risk fusions and nonunion. Patients undergoing revisional tibiotalocalcaneal (TTC) arthrodesis via a retrograde arthrodesis nail to evaluate the influence of BMP-2 on rate of fusion in this high-risk population are presented. A retrospective chart and radiographic review were performed on 23 patients with failed prior fusion attempts at the ankle treated with retrograde intramedullary nailing. Sixteen patients were treated without BMP-2 (None group) and 7 were treated with BMP-2 (BMP group). The primary and secondary end-points were successful fusion, and time to fusion, respectively, with a variety of variables evaluated for influence. Other than the use of BMP-2, there were no statistical differences in the patient population. Overall, 11 of 16 ankles (68.8%) in the None group and 5 of 7 ankles (71.4%) in the BMP group resulted in a stable, functional limb. Rate of complication was similar between the 2 groups (p > .05). Time to radiographic ankle union was 115.2 and 184.0 days in the None and BMP groups (p > .05). The effect of BMP-2 on revisional TTC fusions with retrograde nails is reported here. The overall result as a stable, functional limb was 69.6%, which suggests that revision surgery in this high-risk population is a reasonable consideration. Even though this study was unable to demonstrate statistically significant differences, biologic augmentation with BMP-2 did not increase the complication rate and showed a slightly enhanced salvage rate for revision TTC fusions with an intramedullary nail.

A Comparison of the Readability of Two Patient-reported Outcome Measures Used to Evaluate Foot Surgery - Corrected Proof

James Alvey, Simon Palmer, Simon Otter — 2012-05-03

Abstract: Measuring the outcome of surgical intervention is an integral part of modern-day healthcare provision. The increasing requirement to monitor patient-reported outcomes highlights the need for patients to be able to read and understand health outcomes questionnaires. The present study compared the readability of 2 commonly used, validated, foot surgery outcome questionnaires (the Foot Health Status Questionnaire and the Manchester-Oxford Foot Questionnaire) using the Flesch Reading Ease score and the Flesch-Kincaid grade level score. The Manchester-Oxford Foot Questionnaire had a significantly greater (p < .003) score for reading ease and a significantly lower reading grade score (p < .005) than the Foot Health Status Questionnaire. These findings suggest the Manchester-Oxford Foot Questionnaire is a more suitable instrument in terms of readability and comprehension for a greater proportion of the population undergoing hallux valgus surgery.

Atraumatic, Symptomatic Ankle Plica Successfully Treated by Arthroscopic Debridement: A Case Report - Corrected Proof

Alan James Highcock, Daniel Cohen, Simon Platt — 2012-04-27

Abstract: Synovial plicae, both symptomatic and asymptomatic, are increasingly being diagnosed with the expansion of arthroscopic procedures in synovial joints. Ankle plicae, however, remain an uncommon diagnosis and have previously only been reported as symptomatic in the post-traumatic ankle. Here the authors present a case report of an atraumatic, symptomatic ankle plica successfully treated with arthroscopic debridement.

Scarf Versus Chevron Osteotomy for the Correction of 1–2 Intermetatarsal Angle in Hallux Valgus: A Systematic Review and Meta-analysis - Corrected Proof

Simon E. Smith, Karl B. Landorf, Paul A. Butterworth, Hylton B. Menz — 2012-04-09

Abstract: The chevron and scarf osteotomies are commonly used for the surgical management of hallux valgus (HV). However, there is debate as to whether one osteotomy provides more 1–2 intermetatarsal (1–2 IMA) correction than the other. The objective of this systematic review and meta-analysis was to compare the effectiveness of 3 types of first metatarsal osteotomy for reducing the 1–2 IMA in HV correction: the chevron osteotomy, the long plantar arm (modified) chevron osteotomy, and the scarf osteotomy. A systematic search for eligible studies was performed of the following databases: Medline, Embase (Ovid), CINAHL (EBSCO Host), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials. Only English-language studies previous to May 2010 were included in the review. Additional hand and electronic content searches of relevant foot and orthopaedic journals were performed. Criteria for inclusion in this analysis included systematic reviews of randomized controlled trials, prospective and retrospective cohort studies, and case-control studies, as well as case-series studies involving the chevron, scarf, or long plantar arm chevron osteotomy of >20 participants with a minimum of 80% follow-up. Quality of evidence of the included studies was assessed with the Grading of Recommendations Assessment, Development and Evaluation system. All pooled analyses were based on a fixed effects model. There was a total of 1351 participants who underwent either a chevron (n = 1028), scarf (n = 300), or long plantar arm chevron osteotomy (n = 23). Only one study for the long plantar arm chevron group fitted the eligibility criteria for this review; however, it was not amenable to meta-analysis. The chevron osteotomy was associated with a mean reduction of 1–2 IMA from preoperative to postoperative of 5.33° (95% confidence interval, 5.12 to 5.54, p < .001), and the scarf osteotomy was associated with a mean reduction of 6.21° (95% confidence interval, 5.70 to 6.72, p < .001). There was a statistically significant 0.88° increase in the correction of the 1–2 IMA in favor of the scarf osteotomy compared with the chevron osteotomy. The studies included in this review were of very low- to low-quality evidence. Our findings indicate that the scarf osteotomy provides greater correction of the 1–2 IMA when used for HV correction. However, only a weak recommendation in favor of the scarf osteotomy can be made based on the low quality of evidence of the studies included in this analysis.

Pain Management in Patients with Plantar Fasciitis: The Emerging Role of Radial Extracorporeal Shockwave Therapy - Corrected Proof

Shailendra Kapoor — 2012-04-01

I read with great interest the article by Brook et al in a recent issue of your esteemed journal . The article is highly thought provoking. Interestingly, the past few years have seen the emergence of novel strategies besides electromagnetic field therapy in the management of pain in patients with plantar fasciitis. One such rapidly emerging therapeutic alternative is radial extracorporeal shockwave therapy (rESWT).

Limb Salvage: Revision of Failed Intramedullary Nail in Hindfoot and Ankle Surgery in the Diabetic Neuropathic Patient - Corrected Proof

Lawrence A. DiDomenico, Damieon Brown — 2012-03-26

Abstract: Herein, we illustrate an operative technique to attain limb salvage after a failed intramedullary nail in the diabetic Charcot neuropathic patient. The use of the blade plate, or T-plate, in combination with external fixation, fastened into the body of the calcaneus allows for greater bone capture. Our experience has shown that this provides for a stable, long-lasting construct.

Under the Microscope: Foot and Ankle Fellowships - Corrected Proof

Jeffrey E. McAlister — 2012-03-22

Foot and ankle fellowships have been in existence for decades and have, within the past 5 years, surged in popularity among recent graduates. Advanced training is available in a wide array of subspecialties, including diabetic limb salvage and wound care, foot and ankle trauma, foot and ankle reconstructive surgery, sports medicine, and patient-oriented research. The American College of Foot and Ankle Surgeons (ACFAS) promotes 18 recognized fellowship training programs: 14 reconstructive, 2 sports medicine, and 2 diabetic limb salvage . The Council on Podiatric Medical Education (CPME) of the American Podiatric Medical Association (APMA) accredits 12 different surgical and nonsurgical fellowships; many are located in private practice settings, whereas others are based in arenas of higher learning and universities .

A Preliminary Review of the Use of Deep Peroneal Neurectomy for the Treatment of Painful Midtarsal and Tarsometatarsal Arthritis - Corrected Proof

Douglas K. Blacklidge, Suhail B. Masadeh, Michael C. Lyons, J. Michael Miller — 2012-03-19

Abstract: This report describes a retrospective analysis of chart and radiographic data pertaining to 10 consecutive cases performed over a 30-month period, undertaken in an effort to evaluate the preliminary efficacy of denervation for pain relief in high-risk surgical candidates with midfoot and tarsometatarsal joint arthritis. Ten patients (13 feet) were treated, and objective and subjective assessments were obtained using an index of subjective patient satisfaction. Results revealed 9 (69.2%) feet from 7 (70%) patients had greater than 75% relief. Two (15.4%) feet from 2 (20%) patients had at least 50% improvement and 2 (15.4%) feet from 1 (10%) patient claimed no relief. Our results indicate that this method of treatment can be an effective way to relieve pain associated with arthrosis involving the midfoot and tarsometatarsal joints.

Incidence of Nonunion of First Metatarsophalangeal Joint Arthrodesis for Severe Hallux Valgus Using Crossed, Flexible Titanium Intramedullary Nails and a Dorsal Static Staple with Immediate Weightbearing in Female Patients - Corrected Proof

Thomas S. Roukis, Tristan Meusnier, Marc Augoyard — 2012-03-15

Abstract: Myriad forms of fixation have been proposed for arthrodesis of the first metatarsophalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. The authors performed a retrospective analysis of all patients undergoing arthrodesis of the first MTPJ for severe hallux valgus with 2 crossed, flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weightbearing. Patients were included if they had: surgery for severe hallux valgus of the first MTPJ; undergone the exact internal fixation technique described; not undergone bilateral surgery in the same setting; weightbearing preoperative radiographs; at least 6-week postoperative weightbearing radiographs; initiated weightbearing on the operative foot immediately postoperative in a protective shoe; been followed up clinically for at least 6 months' time postoperatively; and documentation of any complications. One hundred fifty-six female patients (195 feet) with a mean age of 67 ± 9.3 years met the inclusion criteria. Complications due to technical error during insertion of the crossed, flexibe titanium intramedullary nails occurred in 22 (11.3%) feet, but none led to revision surgery. There were 5 (2.6%) asymptomatic nonunions and 1 (0.5%) delayed union, but this ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ using the specific internal fixation construct presented here for severe hallux valgus is lower than the historic mean for most other fixation techniques. However, there is still a need for methodologically sound prospective cohort studies that compare the technique presented here with other modern osteosynthesis techniques.

An Alternative Technique for Transosseous Calcaneal Pinning in External Fixation - Corrected Proof

Lawrence A. DiDomenico, Albert Giagnacova, Davina J. Cross, Bruce H. Ziran — 2012-03-05

Abstract: The authors describe a technique in which two 5.5-mm pins are inserted from the posterior aspect of the calcaneus and advanced anteriorly on a slightly convergent vector. The 2 points of fixation, with a 5/8 ring, provide a “steering wheel” effect allowing for leverage and control of the hindfoot and ankle. The construct also allows for offloading of the posterior calcaneus.

Common Peroneal Nerve Palsy Secondary to Peroneus Longus Abscess: Case Report - Corrected Proof

Mayank Agrawal, Vikas Bhardwaj, Tsering Wangchuk, Sumit Sural, Anil Dhal — 2012-02-20

Abstract: Muscle abscess presenting as nerve palsy is rare and has not been previously reported in the common peroneal nerve (CPN). The objective of this case report is to describe the diagnosis and treatment of an uncommon presentation of peroneal abscess in the leg of an otherwise healthy man. We present a case of CPN palsy in a 50-year-old immunocompetent man with no other comorbid medical condition secondary to peroneus longus abscess. The diagnosis was suggested by magnetic resonance imaging examination and confirmed by intraoperative findings. After surgical drainage of the abscess, the patient made a complete recovery. A review of the literature confirms that peroneus longus abscess giving rise to CPN palsy has not been described. Early diagnosis and surgical drainage of the compressing abscess can produce a favorable outcome.

An Unusual Case of Fibular (Postaxial) Polydactyly: Extrametatarsal Head with Fused Duplication of the Proximal Phalanx - Corrected Proof

Emeka Oragui, Nnaemeka Eli, Semiu Folaranmi, Subramaniyan Soosainathan — 2012-02-10

Abstract: Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. A number of morphologically and anatomically based classifications exist. We present an unusual case of fibular (postaxial) polydactyly characterized by an extrametatarsal head with fused duplication of the proximal phalanx. We describe the method of surgical correction and emphasize the need for careful preoperative planning to achieve a good functional and cosmetic outcome.