Foot and Ankle Surgery

Although functional and clinical outcomes after total ankle arthroplasty have been promising, a steep learning curve has been recognized. In addition, the performance of concomitant hindfoot realignment procedures is controversial. The purpose of this study was to report on a single surgeon's experience with the first 50 total ankle arthroplasty procedures. We wanted to define the characteristics of the learning curve and whether the rate of complications was increased in patients who required complex reconstruction for preexistent foot and ankle deformities. This was a retrospective study of 50 cases with an average follow-up of 24.2 months. The patient population consisted of 18 men and 30 women with an average age of 57.6 years. Twenty-six percent of the cases had concomitant bony realignment procedures, while 20% had prior history of major hindfoot corrective procedures. There were 19 cases with intraoperative malleolar fractures, 12 cases that exhibited some degree of malalignment, and 6 cases of syndesmotic nonunion, and 8 ankles required early component revision. Minor wound complications that resolved with local wound care occurred in 9 cases, while 1 patient had a major wound complication requiring flap coverage. Each of these complications, other than wound complications, decreased with the surgeon's experience. Our results also indicate that the performance of major realignment procedures at the same time of implant arthroplasty is not associated with an increased incidence of complications. The results of this study suggest that total ankle arthroplasty is associated with a learning curve. Perioperative complications may potentially decrease with surgeon experience.

Quantitative strength analysis of first metatarsophalangeal joint arthrodesis was performed using two fixation techniques: a small 6-hole plate with an interfragmentary screw or two crossed lag screws. Twelve matched-pair fresh-frozen cadaveric specimens (24 trials) were used for direct comparison of each of the two fixation techniques. All joint surfaces were prepared with power conical reamers utilizing a standard technique. The fixation construct was stressed to failure on each specimen using a computer-integrated materials tester. Fixation stiffness defined as force (load) over displacement and point of ultimate failure was evaluated. The six-hole plate and interfragmentary screw fixation method was a statistically stiff er form of fixation (p > .01) and displayed a greater point of ultimate failure (p > .002) under the laboratory conditions.

Introduction For the quantification of intra-articular fracture of the calcaneus, different types of angles have been mentioned in the literature. Of these, the Bohler's angle (BA) and the critical angle of Gissane (CAG) are used in common practice. However, there is a great paucity of literature conducted on the Indian populace to find out the normal range of BA and CAG. In this article, our objective is to homologate and confirm the normal range of BA and the CAG in the Indian population and compare their values to the published international reference values. Materials and methods It is an observational cross-sectional study done between 2017 and 2019. X-rays were anonymized by hiding the identification data. The BA and CAG were measured together and by two authors simultaneously. Each angle was measured two times. Two-sample T-test was chosen to compare the means of the values and the p value <0.05 was considered significant. Results Three hundred and eighty-four (n = 384...

A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adverse effects A B S T R A C T Aim: The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyal-uronic acid for mid-portion, non-insertional Achilles tendinopathy. Materials And Methods: A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed. Results: Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded. Conclusion: This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.

Self-administered questionnaires have become an important aspect for clinical outcome assessment of foot and ankle-related problems. The Foot and Ankle Ability Measure (FAAM) subjective form is a region-specific questionnaire that is widely used and has sufficient validity and reliability from previous studies. Translate the original English version of FAAM into a Thai version and evaluate the validity and reliability of Thai FAAM in patients with foot and ankle-related problems. The FAAM subjective form was translated into Thai using forward-backward translation protocol. Afterward, reliability and validity were tested. Following responses from 60 consecutive patients on two questionnaires, the Thai FAAM subjective form and the short form (SF)-36, were used. The validity was tested by correlating the scores from both questionnaires. The reliability was adopted by measuring the test-retest reliability and internal consistency. Thai FAAM score including activity of daily life (ADL) a...

Extensive tissue resection often mandates unique approaches to complete a functional reconstruction.
While there are numerous options for selecting a donor site for a skin or soft tissue flap, available options
for securing a local flap following midfoot amputation are quite limited. Adequate flap fixation is
essential to maintain its viability, yet this may be challenging to achieve when there is a substantial
residual post debridement requiring coverage and only limited remaining viable surrounding soft tissue
available for anchoring. Over thinning the flap may compromise vital circulation to it from plantar (or
other pertinent) artery perforators. In our experience, the adjunctive use of Kirschner wire(s) to support
external soft-tissue fixation in conjunction with traditional methods has been successful in securing
such tenuous fasciocutaneous flaps. To our knowledge, few alternative techniques have been described
to fasten flaps in instances of compromised surrounding skin and soft tissue integrity in high-risk
patients. This technique offers the surgeon a strong, inexpensive, and versatile solution for soft tissue
anchoring. It allows for mechanical creep and ultimately stress relaxation at a potential wound closure
site. This manuscript reviews several cases, each using this simple, novel approach to fixate an unsecured
flap during the closure of an open amputation.

A retrospective evaluation of 64 randomly selected patients with 100 nonfixated Austin bunionectomy procedures was performed. A radiographic and a clinical evaluation were performed, including an analysis of preoperative and postoperative angles as well as postoperative complications. This study demonstrates a similar complication rate for nonfixated Austin bunionectomies as compared with previous studies with internal fixation. Removal of the fibular sesamoid was performed in 90% of the cases and did not increase the incidence of hallux varus. The nonfixated Austin bunionectomy is an acceptable alternative to the correction of hallux valgus. If internal fixation is utilized, the most cost-effective device should be used.

Although replant of the extruded talus would be preferable at the time of initial management, some patients present with a talus that had not been recovered. A series of 3 cases of the extruded talus that were reconstructed with large allograft interfaces are presented. Two of the cases had femoral head allografts and the other used morcellized cancellous allograft. Several orthobiologic substances were used in various proportions for each case. All 3 resulted in a solid union with minimal shortening of the extremity. 4.

Abstract:
Plantar foot ulcerations in the diabetic population are a significant source of morbidity, mortality, and cost to the healthcare system globally1. The lifetime risk of a patient with diabetic neuropathy developing a foot ulcer is as high as 25%, with rates increasing annually2. It has been previously reported that over 50% of these ulcerations will become infected, with 20-30% of them resulting in lower extremity amputation, likely a transmetatarsal amputation (TMA) or higher3,4. 

The panmetatarsal head resection (PMHR) as originally described by Hoffman in 1911 is a proven alternative to the TMA in the treatment of painful forefoot Rheumatoid Arthritis5. Modifications by Jacobs in 1982 brought the procedure to diabetic feet with chronic neuropathic ulcerations6. Continued improvements, including arthrodesis of the first metatarsophalangeal joint (MTPJ) to the original technique have improved patient outcomes, namely by increasing stability and intrinsic forefoot propulsion capacity5. Additionally, maintenance of the distal toes may allow a patient to wear ‘off the shelf’ extra depth or accommodative athletic shoes, rather than becoming solely dependent on costly, custom-molded shoes7.

Given that multiple isolated metatarsal resections often lead to transfer lesions requiring multiple revisional surgeries in the operating theatre8, the pan-metatarsal head resection may be an excellent alternative for the diabetic patient seeking ulcer prevention following the failure of conservative care. When used in tandem with adequate postoperative offloading, it is our belief that this concept may prevent the need for more proximal amputation such as a TMA.

References:
1. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-228.
2. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-1724.
3. Lipsky BA, Weigelt JA, Sun X, Johannes RS, Derby KG, Tabak YP. Developing and validating a risk score for lower-extremity amputation in patients hospitalized for a diabetic foot infection. Diabetes Care. 2011;34(8):1695-1700.
4. Lavery LA, Peters EJG, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009;83(3):347-352.
5. Institute TP, Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Wolters Kluwer Health; 2012.
6. Giurini JM, Basile P, Chrzan JS, Habershaw GM, Rosenblum BI. Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc. 1993;83(2):101-107.
7. Armstrong DG, Fiorito JL, Leykum BJ, Mills JL. Clinical efficacy of the pan metatarsal head resection as a curative procedure in patients with diabetes mellitus and neuropathic forefoot wounds. Foot Ankle Spec. 2012;5(4):235-240.
8. Zgonis T. Surgical Reconstruction of the Diabetic Foot and Ankle. Lippincott Williams & Wilkins; 2009.