Foot & Ankle Specialist recent issues

Primum Non Nocere (First, or Above All, Do No Harm)

Berlet, G. C. — Thu, 08 Oct 2009 12:00:09 PDT

Positional Effects of the Knee and Ankle on the Ends of Acute Achilles Tendon Ruptures

Wray, W. H., Regan, C., Patel, S., May, R., Parekh, S. G. — Thu, 08 Oct 2009 12:00:09 PDT

Conservative management of acute Achilles tendon ruptures in a plantarflexed short leg cast or functional brace is a viable alternative to surgery. The ideal plantarflexion angle to allow the free ends of the tendon to oppose one another has not been clearly defined. The purpose of this cadaveric study was to define a plantarflexion angle where the free Achilles tendon ends reliably oppose one another. Ten cadaveric legs amputated at the distal femur were obtained. A laceration of the Achilles tendon was made 4 cm above the calcaneal insertion. A joint-spanning external fixator was placed across the knee. With differing degrees of knee flexion (0, 45, and 90 degrees), the diastasis between the free ends of the Achilles tendon was measured as the ankle was moved from 20 degrees of dorsiflexion to 30 degrees of plantarflexion (—20, —10, neutral, 10, 20, and 30 degrees). Regardless of knee flexion angle, the ankle plantarflexion angle where the free ends of the Achilles tendon opposed one another was 28.0 (95% confidence interval: 25.0-33.6) degrees. The ideal ankle angle in which to immobilize patients appears tightly clustered around 28 degrees of plantarflexion.

Recovery of Calf Muscle Strength Following Acute Achilles Tendon Rupture Treatment: A Comparison Between Minimally Invasive Surgery and Conservative Treatment

Thu, 08 Oct 2009 12:00:09 PDT

The aim of this study was to measure the effect of treatment of acute Achilles tendon ruptures on calf muscle strength recovery. Eighty-three patients with acute Achilles tendon rupture were randomly allocated to either minimally invasive surgery with functional after-treatment or conservative treatment by functional bracing. Calf muscle strength using isokinetic testing was evaluated at 3 months and after 6 or more months posttreatment. To exclusively investigate the effect of treatment on outcome, the authors excluded patients with major complications from the analysis. In 31 of 39 patients in the surgical treatment group and 25 of 34 patients in the conservative treatment group, isokinetic strength tests were performed. In the analysis of differences in mean peak torque, no statistically significant differences were found between surgery and conservative treatment, except for plantar flexion strength at 90 degrees per second at the second measurement, favoring conservative treatment. After 8 to 10 months follow- up, loss of plantar flexion strength was still present in the injured leg in both treatment groups. In conclusion, isokinetic muscle strength testing did not detect a statistically significant difference between minimally invasive surgical treatment with functional after-treatment and conservative treatment by functional bracing of acute Achilles tendon ruptures.

Results of Lapidus Arthrodesis and Locked Plating With Early Weight Bearing

Sorensen, M. D., Hyer, C. F., Berlet, G. C. — Thu, 08 Oct 2009 12:00:09 PDT

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Special Segment: Soft Tissue Matrices--David G. Armstrong, DPM, PhD

Thu, 08 Oct 2009 12:00:09 PDT

Special Segment: Soft Tissue Matrices--One Form of Acellular Human Dermis for Use in Tendon and Ligament Repairs in the Foot and Ankle

Blum, B. E., Burgess, A. V. — Thu, 08 Oct 2009 12:00:09 PDT

Trauma to tendons and ligaments represents a significant part of orthopaedic and podiatric injuries. To improve the outcome of repair, complex or chronic injuries may require reinforcement of the primary repair with a graft. Biologic grafts currently available provide different handling, strength, and biological responses. One of the currently available grafts, an acellular human dermal membrane with specific properties, has been successfully used in the augmentation of tendon and ligament repairs for more than 6 years.

Special Segment: Soft Tissue Matrices--Soft-Tissue Augmentation of the Foot and Ankle Using an Acellular Regenerative Tissue Scaffold

Brigido, S. A. — Thu, 08 Oct 2009 12:00:09 PDT

Surgical treatment of damaged soft-tissue structures in the young and physically active patient requires keen understanding of biomechanical forces that are placed on the repair during rehabilitation. Over the years, several materials have been evaluated to mechanically augment suture repair. Autograft tissues such as the gastrocnemius fascia, flexor hallicus longus, peroneus brevis, fascia lata, and plantaris have been implemented successfully. Concerns over donor site morbidity have limited the use of these autologous tissues. Allografts such as fascia lata and tendon have been used successfully but are plagued with practical issues such as inflammatory reaction and suture retention weakness. Acellular regenerative tissue scaffolds have gained in popularity in recent years because of the limited host inflammatory response, ease of use, and high tensile strength.

Imaging of the Foot

Baker, J. R., Landsman, A., Liddell, R. M., Sella, E. J. — Thu, 08 Oct 2009 12:00:09 PDT

Lisfranc Tightrope

Baravarian, B., Geffen, D. — Thu, 08 Oct 2009 12:00:09 PDT

Surgical Reconstruction of the Diabetic Foot and Ankle * Thomas Zgonis * Lippincott Williams & Wilkins * 2009 * ISBN: 0781784581

Thu, 08 Oct 2009 12:00:09 PDT

2009-2010 Conferences

Thu, 08 Oct 2009 12:00:09 PDT

On the Other Side

Baravarian, B. — Thu, 20 Aug 2009 12:20:29 PDT

The Impact of the Spartathlon Ultramarathon Race on Athletes' Plantar Pressure Patterns

Karagounis, P., Prionas, G., Armenis, E., Tsiganos, G., Baltopoulos, P. — Thu, 20 Aug 2009 12:20:29 PDT

More than 90% of injuries in runners are recorded in the lower extremity, equally affecting the regions of the knee, shank, and foot. Stress fractures are responsible for numerous running-related injuries. In the current study, the plantar pressure patterns of prerace, immediately postrace, and 24 hours after long-distance running in the Spartathlon were analyzed to compare foot loading in the respective conditions. Forty-six male participants of the Spartathlon ultramarathon were examined before, immediately after completion of the race, and 24 hours later with plantar pressure measurements during barefoot walking on a capacitive platform. The results revealed a significant increase in the peak pressure and impulse values in the forefoot areas and a decrease under the toes before and immediately after the race. On the contrary, no significant differences were found between the prerace and the 24-hour postrace values. The present findings indicate that the Spartathlon race leads to significant variations in foot-loading characteristics, especially in the peak pressure and impulse values under the forefoot and toe regions. Twenty-four-hour postrace data measurements reveal insignificant differences from the prerace statement, probably because of the restoration of local muscular activity.

Cartilage Repair: Current and Emerging Options in Treatment

Clair, B. L., Johnson, A. R., Howard, T. — Thu, 20 Aug 2009 12:20:29 PDT

Currently, there are many options in cartilage repair. These cartilage repair techniques can generally be categorized into 3 groups: marrow stimulation—based techniques, osteochondral transfer techniques, and cell-based cartilage repair techniques. This review article presents an overview of these techniques, indications for usage, advantages and disadvantages of each, and a current review of applications in foot and ankle surgery.

Systemic Inflammatory Disease in the Foot

Bibbo, C., Delmi, M., Hyer, C. F., Jacobs, A. M., Roukis, T. S. — Thu, 20 Aug 2009 12:20:29 PDT

Double-Calcaneal Osteotomy With a Unilateral Rail External Fixator for Correction of Pes Planus: A Case Report

Penney, N. T., Viselli, S. J., Holmes, T. R., Weiner, R. D. — Thu, 20 Aug 2009 12:20:29 PDT

A combination of the medial displacement calcaneal osteotomy with the Evans lateral column-lengthening osteotomy has been suggested when hindfoot valgus, forefoot abduction, and midtarsal joint instability are significant. However, the deforming forces must be flexible. The goal of this procedure is to restore alignment, stabilize the foot, and improve overall function. This double-calcaneal osteotomy addresses all components of the pes planus deformity. This article reports the use of a unilateral external fixator to callus distract the Evans calcaneal osteotomy while compressing the posterior medial calcaneal displacement osteotomy, which to the authors' knowledge has not been performed or reported in the literature. At the final post-operative visit of this clinical patient, the foot was rectus, and X-rays demonstrated an increased calcaneal inclination angle from 10° preoperatively to 15° postoperatively, a decreased talar declination angle from 39° preoperatively to 26° postoperatively, and the cuboid abduction angle decreased from 32° preoperatively to 9° postoperatively. The patient was pain free and extremely satisfied with the surgery, especially with the use of the external fixator.

McGlamry's Comprehensive Textbook of Foot and Ankle Surgery (2-Volume Set) * Alan S. Banks, Micheal S. Downey, Dennis E. Martin, Stephen J. Miller * Lippincott Williams & Wilkins * 2001 * ISBN-10: 0683304712 * ISBN-13: 978-0683304718

Thu, 20 Aug 2009 12:20:29 PDT

2009 Conferences

Thu, 20 Aug 2009 12:20:29 PDT

Coming of Age

Baravarian, B. — Fri, 29 May 2009 13:52:05 PDT

Unilateral Versus Bilateral First Ray Surgery: A Prospective Study of 186 Consecutive Cases-Patient Satisfaction, Cost to Society, and Complications

Fridman, R., Cain, J. D., Weil, L., Weil, L. S., Ray, T. B. — Fri, 29 May 2009 13:52:05 PDT

Many studies have evaluated bilateral versus unilateral surgery in large joints, but limited research is available to compare outcomes of bilateral staged foot surgeries versus synchronous bilateral foot surgery. In total, 186 consecutive cases of first metatarsal-phalangeal (MTP) joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged bilateral operations, and 66 were synchronous bilateral operations. Patients were evaluated at 6 and 12 weeks for specific early complications and surveyed about their return to work, activities of daily living, shoe gear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. In addition, a cost analysis was performed on all surgical scenarios. Student t test showed no statistical significance between groups in all clinical settings to a 95% confidence level. Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first MTP joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.

A 1-Piece Shape-Metal Nitinol Intramedullary Internal Fixation Device for Arthrodesis of the Proximal Interphalangeal Joint in Neuropathic Patients With Diabetes

Roukis, T. S. — Fri, 29 May 2009 13:52:05 PDT

A common complication associated with diabetes is the development of a rigid structural lesser toe contracture, which, when combined with peripheral sensory neuropathy, can lead to ulceration, infection, and amputation. Surgical correction of lesser toe contractures in persons with diabetes has been advocated to decrease the potential for ulceration and amputation. Lesser toe proximal interphalangeal joint arthrodesis employing myriad joint preparation and fixation methods is commonly performed to correct a rigid structural toe contracture. The author performed a retrospective, observational, cohort study involving 10 patients (30 toes) with diabetes, dense peripheral neuropathy, and rigid structural toe contracture treated with a 1-piece shape-memory Nitinol intramedullary internal fixation device for arthrodesis of the proximal interphalangeal joint. Successful fusion was achieved in 28 of 30 toes (93%), with a stable nonunion achieved in the remainder. Complications that arose occurred early in the author's experience with this implant and consisted of secondary contracture of the distal interphalangeal joint (23%), displaced fixation (13%), and malunion (7%). No patient developed ulceration, and no additional surgery has been required to date. When properly performed, the use of this implant for arthrodesis of the proximal interphalangeal joint in neuropathic patients with diabetes appears safe and reliable.

Clinical Implications of Peroneal Artery Variation

Kishman, L., Malin, D., Nerone, V., Siesel, K. — Fri, 29 May 2009 13:52:05 PDT

Vascular anatomy has a strong influence on the choice of surgical approach. Anomalies of vascular patterns may explain uncharacteristic physical or clinical findings. We present a case of an anomalous peroneal artery not previously described. The anomalous anatomic pattern is the peroneal artery replacing the posterior tibial artery in the medial ankle and providing the primary blood supply to the plantar foot.

Acrometastasis to the Foot: Three Case Reports With Primary Colon Cancer

Ellington, K., Kneisl, J. S. — Fri, 29 May 2009 13:52:05 PDT

Acrometastasis (metastasis to the hand or foot) is a rare occurrence; however, bone is a common site of metastatic disease, which occurs in up to 30% of patients with malignancy. Although acrometastasis is rare, a high clinical suspicion must exist, especially in evaluating a patient with a known history of cancer. The diagnosis may be difficult and prolonged, which may ultimately affect the patient's outcome. Misdiagnosis of acrometastasis seems to be a common problem. Early diagnosis and treatment is important for improving quality of life in these patients. The authors report 3 cases of acrometastasis from a rare source, the colon.

Wound Care and Diabetic Foot

Landsman, A., Zgonis, T., Neufeld, S., Sella, E. J. — Fri, 29 May 2009 13:52:05 PDT

Mastering the Scarf Procedure for Hallux Valgus Correction

Weil, L. — Fri, 29 May 2009 13:52:05 PDT

Orthopaedic Surgery Essentials: Foot and Ankle * David B. Thordarson, ed. * Lippincott Williams * 2004 * ISBN-13: 9780781744379

Fri, 29 May 2009 13:52:05 PDT

American College of Foot and Ankle Surgeons (ACFAS) 2009 Annual Scientific Meeting

Hyer, C. F. — Fri, 29 May 2009 13:52:05 PDT

2009 Conferences

Fri, 29 May 2009 13:52:05 PDT

Burden of Proof

Berlet, G. C. — Fri, 27 Mar 2009 09:18:22 PDT

Use of an Acellular Flowable Dermal Replacement Scaffold on Lower Extremity Sinus Tract Wounds: A Retrospective Series

Brigido, S. A., Schwartz, E., McCarroll, R., Hardin-Young, J. — Fri, 27 Mar 2009 09:18:22 PDT

A novel injectable human dermal matrix has been developed for the treatment of complex diabetic sinus tract wounds. Bioengineered grafts are commercially available that have been somewhat effective in treating chronic wounds such as diabetic foot ulcers; however, these bioengineered grafts are only available in sheet form. These therapies are less effective in treating complex or irregularly shaped wounds that demonstrate tunnels or extensions into deep soft tissue. One acellular graft (GRAFTJACKET, Matrix, Wright Medical Technology, Arlington, Tennessee) that has been shown to effectively treat open wounds is also available in a micronized form (GRAFTJACKET Xpress Scaffold, Wright Medical Technology). This human dermal graft forms a flowable soft tissue scaffold that can be delivered via syringe into tunneling wounds. In this retrospective series, 12 patients with deep tunneling wounds were treated with GRAFTJACKET Xpress Scaffold and followed for 12 weeks. Complete wound healing was achieved in 10 of 12 patients within the 12-week evaluation. The average time to complete healing was 8.5 weeks, whereas the average time to depth healing was 7.8 weeks. The data from the study suggest that this injectable human dermal matrix has unique properties that allow it to facilitate healing of complex tunneling diabetic foot ulcers. The material is easy to prepare and inject into the wound, thereby preventing the necessity of extensive surgical exposure. The matrix supports neo-subcutaneous tissue formation and allows the body to rapidly repair these wounds.

Scarfette Osteotomy for Surgical Treatment of Bunionette Deformity

Glover, J. P., Weil, L., Weil, L. S. — Fri, 27 Mar 2009 09:18:22 PDT

Numerous procedures have been described for a bunionette deformity. Choosing a specific osteotomy depends largely on the degree of the deformity and surgeon preference. The Scarfette osteotomy is a versatile procedure that addresses specific etiologic factors associated with bunionette deformities. The primary aim of this study is to show the versatility of the Scarfette osteotomy in varying degrees of bunionette deformities. A retrospective review of 50 cases was performed with a follow-up of 12 months. Objective information was obtained by measuring specific radiographic variables on preoperative and postoperative weight-bearing radiographs. Mean radiographic results are presented for the intermetatarsal 4-5 angle, lateral deviation angle, and fifth metatarsophalangeal angles postoperatively. The authors report short-term results of the Scarfette osteotomy in the correction of bunionette deformities. The Scarfette is a predictable and versatile osteotomy to correct varying degrees of bunionette deformities. The Scarfette is not technically demanding and allows early postoperative ambulation.

Stress Fracture of the Fifth Metatarsal Base Caused by Tension Band Wiring: An Isolated Case Report

Mofidi, A., Hamer, P., Thomas, R. H., Hemmadi, S. S. — Fri, 27 Mar 2009 09:18:22 PDT

Tension band technique has been described as a successful method of treatment for the fractures of the proximal part of the fifth metatarsal bone. A high rate of union and a low rate of complications have made this mode of treatment popular, especially in patients with nonunion and high-level athletes with stress fracture of the proximal fifth metatarsal bone. The authors report a case of an avulsion fracture of the base of the fifth metatarsal bone treated with tension band wiring fixation, which resulted in a stress fracture 1 year after the tension band wiring. The authors recommend a K-wire perforation and tension band drill hole distal to the watershed area of the fifth metatarsal bone and removal of metalwork 6 to 12 months after fracture union to avoid this complication.

Hindfoot Charcot

Landsman, A., Zgonis, T., Neufeld, S., Sella, E. J. — Fri, 27 Mar 2009 09:18:22 PDT

Concept and Use of the Scandinavian Total Ankle Replacement

Kofoed, H. — Fri, 27 Mar 2009 09:18:22 PDT

Neurometer Diagnostic Sensory Evaluation

Cione, J. A., Cozzarelli, J. — Fri, 27 Mar 2009 09:18:22 PDT

Percutaneous Reduction and Injection of Norian Bone Cement for the Treatment of Displaced Intra-articular Calcaneal Fractures

Wee, A. T. H., Yue Shuen Wong, — Fri, 27 Mar 2009 09:18:22 PDT

The treatment of intra-articular calcaneal fractures remains controversial. Although open reduction and fixation are favored by many authors, increased risk of soft tissue complications makes this method of treatment a challenge. Conversely, conservative treatment frequently leads to severe functional impairment and disability. Percutaneous surgical techniques have been employed to reduce the incidence of soft tissue complications but carry the risk of inadequate reduction and fracture stabilization. Norian SRS bone cement is an injectable calcium phosphate cement. Recent clinical studies have demonstrated the safe use of Norian SRS bone cement to augment standard plate fixation of calcaneal fractures. The authors describe their method of combining a percutaneous technique of fracture reduction with stabilization using Norian SRS bone cement. A total of 10 patients with 12 displaced intra-articular calcaneal fractures underwent this method of treatment. All 12 cases achieved adequate reduction on postoperative radiographs. Full weight bearing was started at 1 month postoperation, and none of the cases demonstrated loss of reduction on serial postoperative radiographs. No wound complications or cement-related soft tissue reactions were encountered. A 6-month assessment using the visual analog scale, the Maryland Foot Score, and the Short Form 36 general health survey showed encouraging results. Early results of treating displaced intra-articular calcaneal fractures using this method of a percutaneous technique of fracture reduction combined with Norian SRS bone cement stabilization are encouraging and promising.

Baxter's The Foot and Ankle in Sport

Fri, 27 Mar 2009 09:18:22 PDT

American Academy of Orthopaedic Surgeons 2OO9 Annual Meeting

Fri, 27 Mar 2009 09:18:22 PDT

2009 Conferences

Fri, 27 Mar 2009 09:18:22 PDT