Foot & Ankle Specialist recent issues

Editor's Letter

Baravarian, B. — 2008-07-24

Retrograde Drilling of Osteochondral Lesions of the Talus

Hyer, C. F., Berlet, G. C., Philbin, T. M., Lee, T. H. — 2008-07-24

This study evaluates the use of retrograde drilling in medial osteochondral lesions of the talus (OLTs) with intact articular surfaces. During a 2-year period, 8 consecutive patients underwent surgical treatment for symptomatic posterior medial OLT. All patients underwent arthroscopy of the ankle followed by retrograde drilling of the talar lesion. A novel cannulated system was used to target the lesion, remove the necrotic segment, and then backfill using Grafton gel. The average age of the patients was 36 years old (range, 12-49 years). Follow-up ranged from 8 to 44 months (mean 24 months). One patient was lost to follow-up. Of the remaining 7, outcomes were assessed with a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle/ hindfoot scale and the SF-12 general health survey. Four patients had repeat magnetic resonance imaging scans at 1-year follow-up. The preoperative AOFAS scores from the modified hindfoot scale ranged from 0 to 41 (mean 22). Postoperative scores ranged from 52 to 68 (mean 56), with a mean improvement of 34 points. The SF-12 has 2 components: the physical component score (PCS) and the mental component score (MCS). Mean preoperative and latest follow-up SF-12 PCS scores were 35.8 and 44.0, respectively. Mean preoperative and latest follow-up SF-12 MCS scores were 40.7 and 52.8, respectively. In this limited series, this technique appears to give comparable short-term results to previously described techniques. Use of a cannulated system simplifies the surgical procedure. Overall, this procedure offers decreased operative time and maximizes safety and accuracy with retrograde talar drilling.

Salvage of the First Ray With External Fixation in the High-Risk Patient

Schweinberger, M. H., Roukis, T. S. — 2008-07-24

In diabetic patients, hallux and first-ray amputations significantly increase the risk of recurrent ulceration and more proximal amputation over time. This small, retrospective study demonstrates that salvage of the first ray can be reliably accomplished, even in high-risk patients, when basic principles of infection management are followed in conjunction with the appropriate use of external fixation. These techniques may help to improve the quality of life and reduce the overall medical resources required for the treatment of recurrent ulceration and amputation in this patient population.

Treatment of Painful Accessory Navicular: A Modification to Simple Excision

Micheli, L. J., Nielson, J. H., Ascani, C., Matanky, B. K., Gerbino, P. G. — 2008-07-24

An accessory tarsal navicular ossicle may produce pain and tenderness despite conservative treatment modalities. This condition causes pain along the medial arch and limitations of activities. This described modification of the Kidner procedure and simple excision technique keeps the tendon insertion intact while restoring some of the normal biomechanical relationships. In addition, this modification has the theoretical advantage of enhancing dynamic support of the longitudinal arch, and by maintaining the continuity of the posterior tibial tendon, a shorter period of immobilization is required. All patients at the most recent follow-up showed improvement, with 11 of 13 patients having excellent results with long-term follow-up.

The Effectiveness of Physician-Directed External Fixation Pin Site Care in Preventing Pin Site Infection in a High-Risk Patient Population

Schweinberger, M. H., Roukis, T. S. — 2008-07-24

Pin tract infection is one of the most frequently reported complications associated with the use of external fixation. Application of compression dressings to prevent motion at the pin-skin interface as well as periodic antiseptic cleansing of the pin sites has been advocated; however, no consensus has been reached on the most effective method of pin site care. This retrospective study was conducted to evaluate the effectiveness of a weekly, physician-directed pin site care protocol on reducing the rate of pin tract infections in a high-risk patient population.

Percutaneous Distal Soft Tissue Release-Akin Procedure, Clinical and Podobarometric Assessment With the BioFoot In-Shoe System: A Preliminary Report

2008-07-24

Hallux valgus (HV) is a common, complex, and progressive deformity of the first ray, leading to biomechanical changes. The purpose of this study is to describe the midterm outcomes of the percutaneous distal soft tissue release–Akin procedure for mild hallux valgus on plantar pressures distribution, clinical outcome, and radiographic parameters. Twenty-six patients (30 feet) who had undergone this procedure were evaluated prospectively. The BioFoot in-shoe system was used for an objective functional evaluation of dynamic plantar pressures in the heel, midfoot, first through fifth metatarsal heads, hallux, and lesser toes. The clinical outcome measurements included preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score. The radiological parameters measured were hallux abductus angle (HAA) and first intermetatarsal angle in weight-bearing radiographs. The average follow-up was 12.1 months. There were improvements in the AOFAS rating scale score from 68.7 to 88.1, in HAA from 25.4° to 11.4°, and in the first intermetatarsal angle from 12.0° to 9.2°. The pedobarographic analysis showed a statistically significant decrease (P < .001) in the maximum peak pressure (from 1037 to 498 kPa) and mean pressure (from 487 to 159 kPa) under the hallux. The percutaneous distal soft tissue release–Akin procedure improved the patients' clinical status and reduced the plantar pressures beneath the hallux. This improvement could be attributable to the removal of the medial eminence, which avoids pain around the first metatarsophalangeal joint, and to the Akin procedure, which provides a more physiological postoperative position of the hallux.

The Use of Low-Energy Radial Shockwave in the Treatment of Entrapment Neuropathy of the Medial Calcaneal Nerve: A Pilot Study

Barrett, S. L., Reese, M. M., Tassone, J., Buitrago, M. — 2008-07-24

Medial calcaneal nerve entrapment is a well-recognized cause of heel pain. In addition, the development of an amputation neuroma of the medial calcaneal nerve from prior heel surgery via an open incision on the medial aspect of the heel is a serious common postoperative complication and can be extremely difficult to treat. This preliminary pilot study demonstrates that the use of low-energy extracorporeal shockwave is safe and efficacious in the treatment of this disorder without the morbidity associated with denervation surgery, which would be one of the most common methods to treat this complicated situation. Four patients, 2 with bilateral affectation, for a total of 6 medial calcaneal nerves, had a series of treatments with low-energy radial shockwave with the Swiss DolorClast machine. All 4 patients had improvement in their pain scores, to the point that none elected surgical treatment, and there were no complications.

Charcot Neuroarthropathy

Giza, E., Hyer, C. F., Sella, E. J., Zgonis, T. — 2008-07-24

Rigid Equinovarus Deformity Corrected With a Multiplanar External Fixator

Philbin, T. — 2008-07-24

Operative Techniques for Osteochondral Lesions of the Talus

Giza, E. — 2008-07-24

Advanced Reconstruction: Foot and Ankle: JA Nunley, GB Pfeffer, RW Sanders, E Trepman * American Academy of Orthopaedic Surgeons * 2004 * ISBN: 0-89203-314-2

2008-07-24

2008 Conferences

2008-07-24

The Diabetic Foot: A Truly Multidisciplinary Effort

Baravarian, B. — 2008-06-02

Use of a Surgical Preparation and Sterile Dressing Change During Office Visit Treatment of Chronic Foot and Ankle Wounds Decreases the Incidence of Infection and Treatment Costs

Schade, V. L., Roukis, T. S. — 2008-06-02

Foot and ankle surgeons work with a patient population burdened by multiple factors that adversely affect wound healing and the ability to combat infection. As a result, many of these patients are seen for treatment of chronic ulcerations on their lower extremities that are highly susceptible to colonization and possible progression to a limb- and/or life-threatening infection. The Limb Preservation Service at the Madigan Army Medical Center hypothesized that implementation of a standardized protocol involving a formal physician-directed surgical preparation of the affected lower extremity and a physician-applied sterile dressing at each outpatient clinic appointment would reduce the incidence of infection, use of systemic antibiosis, and thus the requirement for frequent follow-up office appointments. Initiation of this protocol resulted in the reduction of infection to the extent that antibiotic need was eliminated. The frequency of office visits required for follow-up was also significantly reduced. This is key in treating a patient population in which the financial burden to treat chronic wounds and associated infections represents a large portion of the health care money spent for their medical care.

Use of Platelet-Rich Plasma With Split-Thickness Skin Grafts in the High-Risk Patient

Schade, V. L., Roukis, T. S. — 2008-06-02

Split-thickness skin grafting (STSG) is commonly employed for soft-tissue coverage because of its broad application for use, ease of harvest, and universal equipment. STSG healing proceeds through 3 stages: (1) anchorage, (2) inosculation, and (3) maturation. The success of the first 2 stages is critical to the overall success. Bolster dressings of various types are universally applied to create apposition of the skin graft with the granular bed, thereby preventing shearing forces and fluid accumulation until vascular ingrowth can occur. The application of autologous platelet-rich plasma (PRP) to STSG application sites has been recently described and theorized to provide immediate skin graft anchorage as well as inosculation of the STSG with nutrient-rich blood media. This study was performed to report the time to ≥90% primary healing of STSGs augmented with application of PRP in a high-risk patient population. The mean time to ≥90% STSG recipient site healing was 16 ± 4.2 days, as determined by retrospective chart review and digital photograph analysis. The addition of PRP to STSG recipient sites seems to enhance primary healing and reduce healing time, likely as a result of shearing force reduction and enhancement of the wound environment with growth factors.

Aggressive Management of Necrotizing Fasciitis Through a Multidisciplinary Approach Using Minimal Surgical Procedures: A Case Report

2008-06-02

Necrotizing fasciitis is an aggressive, destructive infection of the soft tissue and fascia and is a life-threatening surgical emergency. A case study is presented of necrotizing fasciitis in the right lower extremity of a 53-year-old male resident of a long-term skilled nursing facility. Limb salvage was achieved through a multidisciplinary approach with early surgical management and aggressive postoperative management. Through 3 surgical procedures, the combined efforts of podiatric surgery, orthopaedic surgery, general/trauma surgery, and infectious disease provided early wound closure and limb salvage. An aggressive multidisciplinary approach to the management of necrotizing fasciitis in the lower extremity is necessary for limb salvage. Use of this multidisciplinary approach will minimize the number of surgical procedures and decrease the potential morbidity and mortality seen in patients with this infection.

Approach to the Management of Soft Tissue Tumors of the Foot and Ankle

DeGroot, H. — 2008-06-02

To properly treat soft tissue tumors, the foot and ankle surgeon must start with an adequate fund of knowledge and follow a systematic approach. Some malignant soft tumors have a predilection for the foot and ankle, and they may mimic common musculoskeletal conditions, leading to a trap for the unwary clinician. This review will familiarize the practitioner with the common soft tissue tumors that occur in the foot and ankle along with their presentations. A systematic approach to the workup is outlined, which is designed to establish the diagnosis with a significant degree of certainty before the surgical treatment of the tumor is planned. A practical and reliable method of distinguishing benign tumors from those that are potentially malignant is presented. Finally, the techniques for surgical management of the common soft tissue tumors are summarized.

Wound Care

Armstrong, D. G., Bluman, E. M., Gould, L., Zgonis, T. — 2008-06-02

Rethinking the Hallux Valgus Correction

DiDomenico, L. A. — 2008-06-02

The Triumph of Technology Over Reason

Bluman, E. M. — 2008-06-02

Letter to the Editor

Garcia-Campos, J., Ortega-Diaz, E. — 2008-06-02

Reconstructive Foot and Ankle Surgery * Mark S. Myerson * Elsevier * 2005 * ISBN: 978-1-4160-2358-6

2008-06-02

2008 Conferences

2008-06-02

Editor's Letter

Berlet, G. C. — 2008-04-02

Clinical Research: Modification of Lesser Metatarsophalangeal Joint Arthroplasty Using Flexor Digitorum Longus Transfer

Lee, E. J., Wong, Y.-S. — 2008-04-02

The authors present a modification of an interposition arthroplasty using the flexor digitorum longus for degeneration of the metatarsophalangeal joint with an associated hammer toe deformity. This procedure is simple to perform and allows for relief of pain and stiffness associated with metatarsophalangeal joint arthrosis.

Clinical Research: Etoricoxib, Paracetamol, and Dextropropoxyphene for Postoperative Pain Management: A Questionnaire Survey of Consumption of Take-Home Medication After Elective Hallux Valgus Surgery

Turan, I., Assareh, H., Rolf, C., Jakobsson, J. G. — 2008-04-02

In this study, patients were presented with a questionnaire-based survey about the consumption of analgesics and pain ratings up to the third postoperative day following elective hallux valgus surgery. The aim was to study the consumption of analgesics and to look for factors influencing the need for rescue analgesia. All patients were provided with take-home oral medication, with etoricoxib 120 mg once daily, paracetamol 1 to 4 g daily, and dextropropoxyphene 100 mg provided as add-on rescue analgesics in a stepwise fashion. Thirty-five of the 102 patients responding (response rate 91%) did not take any further analgesics during the entire 4-day follow-up period than the recommended coxib, 67 patients took at least 1 tablet of rescue analgesic, 41 took only paracetamol, and 26 patients (25%) took paracetamol plus at least 1 dextropropoxyphene. There was a significant association between the subjective experience of pain and consumption of analgesics. Female gender and low age were significantly associated with the consumption of analgesics. A stepwise approach based on etoricoxib, paracetamol, and a small number of opioid tablets seems to be a rational approach for take-home medication following a standardized hallux valgus surgery. Female gender and lower age comprise a group that warrants special atten group that warrants special attention.

Clinical Research: A New Concept in the Topical Treatment of Onychomycosis With Cyanoacrylate, Undecylenic Acid, and Hydroquinone

Rehder, P., Nguyen, T. T. — 2008-04-02

The authors report a pilot study of a new approach for the topical treatment of onychomycosis using physiologic principles of fungal growth and serial debridement. In total, 154 patients were studied for 1 year with mild, moderate, and severe nail disease. Negative mycologic cultures in these 3 groups were 100%, 65%, and 35%, respectively. All patients reported subjective improvement in the first 3 months.

Review: Innovative Techniques in Preventing and Salvaging Neurovascular Pedicle Flaps in Reconstructive Foot and Ankle Surgery

Zgonis, T., Stapleton, J. J. — 2008-04-02

Pedicle flaps to cover soft tissue defects of the foot, ankle, and lower extremity are invaluable. However, venous congestion and flap necrosis, a common complication, poses greater morbidity to the patient as few remaining options for attempted limb salvage remain. The authors discuss how to prevent flap failure by allowing close observation and strict offloading of the pedicle flap through current external fixation designs. This article also discusses the role of medicinal leeches in reestablishing blood flow through the pedicle flap to prevent tissue necrosis. In addition, the use of hydrosurgery as an innovative technique offers the surgeon another option if faced with pedicle flap necrosis.

Review: Prevention and Management of Complications of the Ilizarov Treatment Method

Sella, E. J. — 2008-04-02

Serious orthopaedic conditions such as nonunions and pilon, calcaneal, and Lisfranc fractures, as well as leg lengthening, correction of angular deformities, resection of osteomyelitis, and bone transfer, can be treated successfully with the Ilizarov system. However, complications such as contractures, loss of range of motion, neurologic deficits, articular damage, contractures, and pin track infections can occur. This article describes the costs of limb salvage with the Ilizarov system compared with amputation as well as possible complications and their prevention; it also provides a treatment protocol.

Roundtable Discussion: Ankle Arthritis

Berlet, G. C., DiDomenico, L. A., Panchbhavi, V. K., Steck, J. K. — 2008-04-02

Master Surgeon: Endoscopic Calcaneo-Bursectomy

Giza, E., Sullivan, M. — 2008-04-02

Technology: Noninvasive Assessment of Lower Extremity Healing Potential

Gould, L. J. — 2008-04-02

Book Review: Surgery of the Foot and Ankle

2008-04-02

Industry News

2008-04-02

Foot & Ankle 2008 Conferences

2008-04-02

Editors' Letter

Baravarian, B., Berlet, G. C. — 2008-02-01

A New Minimally Invasive Technique for Treating Plantar Fasciosis Using Bipolar Radiofrequency: A Prospective Analysis

Weil, L., Glover, J. P., Weil, L. S. — 2008-02-01

The purpose of this study was to evaluate the effectiveness of a new minimally invasive technique using bipolar radiofrequency in the treatment of plantar fasciosis. A prospective study was performed on 10 patients with recalcitrant plantar fasciosis that failed conservative care. A percutaneous microtenotomy was performed unilaterally with a Topaz microdebrider. Outcome measures included visual analog scale, American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot and Midfoot Scale, and patient satisfaction assessment. All patients had statistical improvement in outcome measures at 6 months and 1 year. One patient developed recurrent heel pain at the 1-year mark. There were no postoperative complications. This minimally invasive technique is a viable surgical treatment option in patients with plantar fasciosis that failed conservative care.

Anatomy of the Lisfranc Ligament

Johnson, A., Hill, K., Ward, J., Ficke, J. — 2008-02-01

Most authors agree that anatomic reduction is the key to optimal results in treatment of injuries of the Lisfranc joint; a few controversies remain. One controversy is the identification of the strongest ligament of the second metatarsal-medial cuneiform articulation—the critical ligament of the Lisfranc joint. The purpose of this study is to objectively quantify the cross-sectional area of each ligament of this crucial joint. Twenty cadaveric feet were dissected to isolate the second metatarsal-medial cuneiform articulation. The point of maximum thickness, height, and width of the dorsal, plantar, and interosseous ligaments were measured using handheld calipers at the second metatarsal attachment. The distribution failed to pass Mauchly's test of sphericity, so the Greenhouse-Geisser method was used to assess differences in the height and width to a P ≤ .05 level of significance. There was a significant difference in the height, width, and area between all ligaments (P < .001). The interosseous ligament was the largest, with the greatest height, width, and cross-sectional area (P < .001). The dorsal ligament was the smallest, with the least height, width, and cross-sectional area (P < .001). Within the Lisfranc complex, the dorsal ligament is the smallest. The plantar ligament is twice as large as the dorsal ligament. The interosseous ligament is the largest. It is, on average, 4.5 times larger than the dorsal ligament and twice as large as the plantar ligament.

A Retrospective Review of Immediate Weightbearing After First Metatarsophalangeal Joint Arthrodesis

Berlet, G. C., Hyer, C. F., Glover, J. P. — 2008-02-01

First metatarsophalangeal (MTP) joint arthrodesis is a proven technique as a salvage procedure for many foot pathologies. Many studies have looked at joint preparation techniques, position of the fusion, and construct stability. In this retrospective study, the authors report the overall fusion rate after first MTP joint fusion with full immediate postoperative weightbearing. Forty-five first MTP arthrodeses were performed during the study period. Eight fusions were excluded, leaving 37 fusions for review. The overall fusion rate was 91.1%. The mean time to fusion was 69.0 ± 37.6 days. Complications included 2 delayed unions (1 screw, 1 plate), 3 nonunions (1 screw, 2 plates), and 2 hardware removals (1 screw, 1 plate). Fixation stability is important to allow immediate postoperative weightbearing. A fusion rate of 91.1% was seen in a diversity of patients after first MTP fusion with immediate weightbearing.

The Practical Application of Multimedia Technology to Facilitate the Education and Treatment of Patients With Plantar Fasciitis: A Pilot Study

2008-02-01

This study was designed to evaluate the efficacy of a multimedia patient education module when incorporated into the standard treatment protocol for patients diagnosed with plantar fasciitis. A thorough, standardized surgeon-patient education discourse took place following diagnosis. At the conclusion of the consultation, patients viewed the multimedia module. Questionnaires designed to assess understanding and satisfaction with information delivery were completed by patients following the consultation and again after viewing the module. Forty-one patients participated in the study. After viewing the module, patients achieved an average of 87% correct responses on the knowledge questionnaire, a significant improvement (P < .0001) over the 64% achieved following the surgeon-patient discourse. Ease of understanding of the information delivered by the module was rated significantly better (P < .0001) than the surgeon-patient discourse. Ninety-eight percent of patients indicated they felt well informed about plantar fasciitis following viewing the module compared with 68% following the surgeon-patient discourse. Sixty-three percent of patients indicated that the module best answered their questions, 7% preferred the surgeon, and 30% rated both equally. Multimedia plantar fasciitis educational material improved patient understanding of the standard treatment protocol and satisfaction with the information delivery in an orthopedic private practice.

Characteristics of Lower Extremity Pressure Sensation Impairment in Developing Diabetic Sensory Polyneuropathy

Rader, A. J., Barry, T. P., Stanley, O. L. — 2008-02-01

The medical literature presents diabetic sensory polyneuropathy as a length-dependent process producing a stocking distribution of sensory loss in the lower extremities. If a purely length-dependent etiology for diabetic sensory polyneuropathy were true, then a validated comparison of sensory loss at any equidistant site about the forefoot will reveal findings consistent with the accepted stocking pattern of anesthesia. A single-blinded, age-matched, control/experimental study is made into the frequency of apparent purely length-dependent A-beta fiber pathology in developing diabetic sensory polyneuropathy. Control (n = 46) and experimental (n = 83) central US subjects are examined with a subjective neuropathy screening questionnaire, vibratory threshold, and single-point pressure threshold testing. There is a plantar predominant pattern (61.5%) of sensory loss in developing diabetic sensory polyneuropathy, even after adjusting for sensitivity differences between different areas of the foot. A typical stocking pattern of sensory loss was not found. Although axonal pathology is length dependent, it is not apparently a purely length-dependent process. Therefore, a purely metabolic explanation for sensory loss is unlikely. In addition, an anatomic component for A-beta fiber pathology is implied by this study.

A Stepwise Approach to the Surgical Management of Severe Diabetic Foot Infections

Zgonis, T., Stapleton, J. J., Roukis, T. S. — 2008-02-01

Foot infections are common among diabetic patients with ulceration and are a major cause of hospitalization and lower extremity amputation. Aggressive and emergent surgical intervention is essential in the face of life- or limb-threatening infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning multidisciplinary team that specializes in diabetic limb preservation. Timing of surgery and strategies employed should be understood and agreed on by both the surgical and medical disciplines managing the diabetic patient with a limb-threatening infection. The overall strategy for surgically managing a severe diabetic foot infection is as follows: the first step is infection control through aggressive and extensive surgical debridement, the second step is a comprehensive vascular assessment with possible vascular surgery and/or endovascular intervention, and the final step is soft tissue and skeletal reconstruction after infection is eradicated to obtain wound closure and limb salvage. A consistent stepwise surgical approach combined with sound surgical principles is paramount for successful management of the severe diabetic foot infection. The authors discuss their stepwise surgical approach to reduce the mortality, morbidity, psychological distress, and length of hospitalization associated with life- or limbthreatening diabetic foot infections.

Roundtable Discussion: Treatments for Plantar Fasciitis

Bluman, E. M., Sella, E. J., Weil, L., Baravarian, B. — 2008-02-01

Master Surgeon: How Does One Become an Exceptional Foot and Ankle Surgeon?

Roukis, T. S. — 2008-02-01

Technology: Correction of Deformities of the Lesser Digits

Soomekh, D. J. — 2008-02-01

Book Review: Master Techniques in Podiatric Surgery: The Foot and Ankle

Chang, T. J. — 2008-02-01

Foot & Ankle 2008 Conferences

2008-02-01