Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital

BACKGROUND

Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team.

METHODS

The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up.

RESULTS

The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months.

CONCLUSION

Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Staged treatment and internal fixation of floating ankle: A case report and literature review

RATIONALE

Floating ankle is a rare traumatic condition characterized by a combination of tibial and ipsilateral foot fractures, with the ankle remaining intact. It is usually caused by high-energy trauma and also presents with serious soft tissue damage. Its treatment is mainly restricted to external fixation, which results in poor outcomes. We present a patient with a floating ankle who underwent staged treatment and achieved full internal fixation, subsequently returning to normal activity.

PATIENT CONCERNS

A 26 year- old man had an accident with an reel machine and sustained an open fracture on his right lower extremity.

DIAGNOSES

Digital radiograph demonstrated a distal tibial fracture, fibular fracture, and multiple metatarsal fractures, which fulfilled the criteria for a floating ankle.

INTERVENTIONS

Initial ankle-spanning external fixation was performed. After 21 days, the patient underwent open reduction and internal fixation on his first and fifth metatarsals, and K-wire fixation on his fourth metatarsal. The external fixator was replaced by plaster fixation. Seven days later, the patient underwent internal fixation of his leg, open reduction and internal fixation with plating was applied of the fibular fracture, and minimally invasive plate osteosynthesis of the tibial fracture.

OUTCOMES

At 1-year follow-up, bone union was identified by digital radiograph; after 2 years, his ankle function had fully recovered, and he resumed his normal activities.

LESSONS

In the staged treatment protocol of the floating ankle, temporary external fixation provided traction and immobilization of the skeletal and soft tissues. Secondary internal fixation maintained the reduction and alignment and allowed early exercise, which is critical to the prognosis of a floating ankle.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND

Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference.

QUESTIONS/PURPOSES

To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data.

METHODS

A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty.

RESULTS

The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective.

CONCLUSIONS

Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Publishing Characteristics of Foot and Ankle Research Over a 15-Year Time Interval: A Review of The Journal of Bone & Joint Surgery from 2004 to 2018

BACKGROUND

As the foot and ankle subspecialty continues to grow in orthopaedics, trends in published literature provide valuable insights to help understand and strengthen the field. The current study evaluates the changes in the characteristics of foot and ankle articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS-A) from 2004 to 2018.

METHODS

Foot and ankle-related articles in JBJS-A from 2004 to 2018 were identified and categorized by type of study, level of evidence, number of authors, academic degree(s) of the first and last authors, male and female authorship, number of citations, number of references, region of publication, and use of patient-reported outcomes (PROs).

RESULTS

A total of 336 foot and ankle articles from 2004 to 2018 were reviewed. The type of study published has changed over time, with more clinical therapeutic evidence and less case reports. The level of evidence grades, as rated by JBJS-A and objective evaluators, have increased over the past 15 years. The total number of authors per article has increased, and female authorship has increased significantly. The number of references per article has increased, and the number of citations per year has decreased. The field of foot and ankle surgery has seen an increase in global publications.

CONCLUSIONS

The results of this study suggest that the foot and ankle literature that has been published in JBJS-A has continued to increase in quality and diversity over the past 15 years.

Clinical features and outcomes in children with bone and joint infections of the ankle or foot

BACKGROUND

The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae.

METHODS

We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed.

RESULTS

The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess.

CONCLUSION

Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients

OBJECTIVE

The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations.

METHODS

In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined.

RESULTS

Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis.

CONCLUSION

With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Osseous Metastatic Disease to the Hands and Feet

Osseous metastases to the hands and feet (acrometastases) are exceedingly rare. Historically, the most common primary cancer observed has been lung carcinoma, treated either nonoperatively or with amputation. The aim of this study was to describe the clinical characteristics associated with acrometastases. This was a retrospective review of 28 patients with histologically proven osseous metastatic disease to the hands and feet. Variables recorded included primary cancer histology, age at diagnosis of primary and acrometastases, location of acrometastases, burden of disease, treatment, and age at death. Kaplan-Meier curves were used to estimate survival, and log-rank tests were used for comparison. The median age at acrometastases diagnosis was 61.5 years, and the most common associated primary cancer was lung carcinoma (n=9). Sixteen patients had acrometastases to the foot, and 12 had acrometastases to the hand. In the foot, most acrometastases were located in the tarsal bones (n=11), followed by the metatarsals (n=4) and the phalanges (n=3). In the hand, most were in the metacarpals and the phalanges (n=6 each), and 2 were in the carpals. The most common treatment was resection or curettage only (n=7). The median duration of survival after acrometastases diagnosis was 9.7 months. Despite advances in cancer treatment and shifting patterns of metastatic disease, there has been little change in the distribution of primary malignancies responsible for acrometastases, with lung carcinoma remaining the most common. Ablative procedures are rarely required, with limb-salvage interventions predominating. [Orthopedics. 2019; 42(2):e197-e201.].

Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis

BACKGROUND

Although Lisfranc injuries are uncommon, representing approximately 0.2% of all fractures, they are complex and can result in persistent pain, degenerative arthritis, and loss of function. Both open reduction and internal fixation (ORIF) and primary fusion have been proposed as treatment options for these injuries, but debate remains as to which approach is better.

QUESTIONS/PURPOSES

We asked whether ORIF or primary fusion led to (1) fewer reoperations for hardware removal; (2) less frequent revision surgery; (3) higher patient outcome scores; and (4) more frequent anatomic reduction.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Three trials met the criteria for inclusion within the meta-analysis. Qualifying articles for the meta-analysis had data extracted independently by two authors (NS, AF). The quality of each study was assessed using the Center for Evidence Based Medicine's evaluation strategy; data were extracted from articles rated as good and fair: two and one article, respectively.

RESULTS

The risk ratio for hardware removal was 0.23 (95% confidence interval [CI], 0.11-0.45; p < 0.001) indicating more hardware removal for ORIF than fusion. For other revision surgery, the risk ratio for ORIF was 0.36 (95% CI, 0.08-1.59; p = 0.18) favoring neither. Similarly, neither was favored using patient-reported outcomes; the standard mean difference was calculated to be 0.50 (95% CI, -2.13 to 3.12; p = 0.71). When considering the risk of nonanatomic alignment, neither was favored (risk ratio, 1.48; 95% CI, 0.34-6.38; p = 0.60).

CONCLUSIONS

The surgeon should consider the increased risk of hardware removal along with its associated morbidity and discuss this with the patient preoperatively when considering ORIF of Lisfranc injuries. Because no new trials have been performed since 2012, further randomized controlled trials will be needed improve our understanding of these interventions.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Osteosarcoma of the Foot

A 40-year-old man presented with a large and painful right foot mass. The patient reported a history of a recurrent right foot mass treated elsewhere with 3 prior surgical excisions.

[A Clinical Comparison of Continuous Sciatic Nerve Block and Epidural Anesthesia for Postoperative Pain Control in Patients with Fracture of the Foot]

BACKGROUND

Epidural analgesia provides good pain relief for patients with fracture of the foot Ultrasound-guided peripheral nerve block offers safety and efficacy without affecting the leg.

METHODS

We compared the continuous sciatic nerve block with the continuous epidural anesthesia regarding postoperative pain after the open reduction and internal fixation (ORIF) of the ankle fracture or calcaneal bone fracture.

RESULTS

Fifteen patients were included in the epidural group (group E), and 17 patients in the sciatic nerve block group (group S). The postoperative pain scores were significantly lower in group S 3 hours and 12 hours after the procedure, and tended to be lower in other periods. Perioperative periods were uneventful in both groups.

CONCLUSIONS

Continuous sciatic nerve block developed good postoperative analgesia in ORIF of ankle fracture or calcaneal bone fracture compared with continuous epidural anesthesia.

[Double arthrodesis through a single medial incision approach for flatfoot]

OBJECTIVE

To investigate the effectiveness of double arthrodesis to correct flatfoot deformity with pes valgus.

METHODS

Between May 2009 and May 2012, 12 patients with flatfoot deformity and pes valgus were treated using subtalar and talonavicular joints arthrodesis through a single medial incision approach. There were 5 males and 7 females with an average age of 53.3 years (range, 21-78 years), including 5 left feet and 7 right feet. Of them, 11 cases had posterior tibial tendon dysfunctions; 6 cases were at Johnson-Strom stage III, 5 cases at stage II(c); and 1 case had tarsal coalition. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score were 48.75 ± 3.46 and 6.08 ± 1.14, respectively.

RESULTS

The mean operation time was 85.6 minutes (range, 65-125 minutes). Eleven patients were followed up for 19.4 months on average (range, 13-30 months). All of the cases obtained primary healing of incision, with no complication of infection and nerve or blood vessel injury. X-ray film showed that the mean time of bone union was 9.8 weeks (range, 7-18 weeks): no bone nonunion occurred. No loosening or breakage of internal fixation was observed. Pain occurred at the calcaneal-cuboid joint (1 case) and at fixation site (1 case), and was relieved after symptomatic treatment. The mean AOFAS score and VAS score were significantly increased to 81.36 ± 2.98 and 0.72 ± 0.11 respectively, showing significant differences when compared with preoperative scores (t = 19.946, P = 0.000; t = 16.288, P = 0.000).

CONCLUSION

Subtalar and talonavicular joints arthrodesis by a single medial incision approach is a useful alternative to triple arthrodesis for the correction of flatfoot deformity with pes valgus.

[Progress in soft tissue reconstruction of adult-acquired flatfoot deformity]

OBJECTIVE

To review the progress in clinical and biomechanical study on soft tissue reconstruction of adult-acquired flatfoot deformity (AAFD).

METHODS

The recent original articles of soft tissue repair and tendon transfer for AAFD were extensively reviewed.

RESULTS

The soft tissue procedures for AAFD can be divided into two components: static restoration of medial column stability and dynamic reconstruction of the posterior tibial tendon. The most important static structure to be repaired for AAFD is the spring ligament. On the other hand, various methods can be used for dynamic reconstruction. The flexor digitorum longus transfer is widely used, but results of biomechanical studies do not support the advantage of this method. For patients having normal function of the posterior tibial muscle, the Cobb procedure may be more suitable.

CONCLUSION

The soft tissue reconstruction procedures of AAFD should be chosen individually based on the stage and type of the deformity.

Septic arthritis and osteomyelitis due to the chromoblastomycosis agent Fonsecaea pedrosoi

Fonsecaea pedrosoi is the most common agent of chromoblastomycosis, a chronic localized fungal infection of the skin and subcutaneous tissues mainly involving the lower extremities. We report a rare case of septic arthritis and osteomyelitis due to the chromoblastomycosis agent F pedrosoi, which was successfully treated with arthrotomy and debridement, followed by a long course of oral antifungal therapy. To our knowledge, this is the second case of F pedrosoi osteomyelitis treated successfully to be ever reported.

[Evaluation of the surgical treatment of Lisfranc injuries]

OBJECTIVE

To study the clinical results of surgical treatment for Lisfranc fracture-dislocation.

METHODS

From January 2003 to September 2009, 57 patients with Lisfranc injuries were treated by surgical operation included 41 males and 16 females with an average age of 33.8 years old ranging from 20 to 64 years. According to Myerson's classification, there were 31 cases of middle column injuries, 15 cases of medial-middle column injuries and 11 cases of three-column injuries. Among them, 25 patients accepted the emergency operation (<24 hours) and 32 patients were treated in average 7 days (3 to 11 days) after injury.

RESULTS

All the wounds were healed primarily with a mean operative time of 50 min (30 to 70 min). All patients were followed up for 4 to 70 months (averaged 35 months). The total AOFAS scores (American Orthopaedic Foot and Ankle Society) was in averaged of(84.73 +/- 14.26). All the patients returned to normal daily life after a mean time of 5.1 months (3 to 12 months). The average AOFAS scores of 52 anatomical reduction cases was (87.63 +/- 13.71), 5 non-anatomical reduction cases was (74.31 +/- 21.96), 26 multiple column trauma cases was (76.58 +/- 11.51). Complications of osteoarthritis occurred in 8 cases, confirming it was the main complication of these injuries.

CONCLUSION

Lisfranc injuries can be surgically treated well. Reduction of the middle column is the key to reestablishment the stability of the tarsometatarsal joint complex. The quality of the reduction correlated with treatment outcome.

Chondrosarcoma of the foot

Chondrosarcoma is a rare malignant cartilaginous tumor of the bone. It commonly occurs in the pelvis, proximal femur, and shoulder girdle. We present a case of a woman in her mid-50s with chondrosarcoma of the foot--a rare lesion that accounts for 0.5% to 2.97% of all chondrosarcomas. Distinguishing a chondrosarcoma of the foot from an enchondroma can prove difficult because of the greater cellularity and atypia that is allowable for enchondromas of the foot compared with those of other sites. There must be a combined clinical, radiographic, and histologic diagnosis. Treatment for chondrosarcoma is generally wide surgical excision. Chemotherapy or traditional radiation is not effective for most of these lesions.

Children hospitalized with lower extremity fractures in the United States in 2006: a population-based approach

OBJECTIVE

The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006.

METHODS

Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under "Injury and Poisoning (800-999)." Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance.

RESULTS

There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals.

CONCLUSIONS

This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine causality of the associations found including increased mortality risk for this population at rural and non-teaching hospitals.

[Subtalar arthrodesis through single medial approach in the treatment of acquired, fixed flatfoot deformity--preliminary report]

Authors presented the results of subtalar and in some cases talonavicular arthrodesis through single medial approach in the treatment of fixed planovalgus foot deformity. The procedure was performed in 15 feet with fixed hindfoot valgus deformity. In all cases, after achieving correct position, internal fixation of the subtalar and talonavicular joints was done with single, canulated, compressive screw 6.5 and 4.5 mm (Unima, Eos) respectively. Solid fusion was achieved within 8 to 12 weeks after surgery. Arthrodesis of the subtalar and talonavicular joints through a medial approach is usefull procedure in achieving correction and fusion of these joints while avoiding soft tissues healing problems often encountered with traditional lateral approaches.

Soft tissue procedures for the stabilization of medial arch pathology in the management of flexible flatfoot deformity

Soft tissue procedures for the stabilization of symptomatic, advanced hyperpronation deformity are performed most frequently in conjunction with osteotomy, arthrodesis, or arthroereisis of the subtalar joint. A variety of such procedures are available for the selective reinforcement or repair of the posterior tibial tendon, spring ligament, deltoid ligament, or medial intertarsal joint capsules. Recently, the focus has been on the direct repair or reinforcement of the posterior tibial tendon using the long flexor tendons. This article reviews additional procedures that have been of value in the management of posterior tibial tendon dysfunction and the procedures now most commonly employed.

Open grade III "floating ankle" injuries: a report of eight cases with review of literature

INTRODUCTION

"Floating ankle" injuries result from high-energy trauma and are usually associated with extensive soft tissue damage. Such rare and complex injuries in the acute phase pose therapeutic dilemma to the treating surgeon. When salvage instead of amputation is preferred, a variety of treatment options are available ranging from open reduction along with minimal internal fixation to external fixation. In this retrospective case series study we report eight patients with open "floating ankle" injuries who had been treated with external fixation with or without internal fixation.

MATERIALS AND METHODS

Eight consecutive patients (7M: 1F) with mean age of 28 years (range 18-35 years) were treated. All had Grade III open fractures of the distal tibia with foot fractures and various degrees of soft tissue injuries. ISS and MESS were used to assess injury severity. Immediate radical wound debridement; skeletal stabilization and early soft tissue coverage were done by combined trauma and plastic surgical services followed by standard post-operative rehabilitation. All the patients were assessed with SF-36 questionnaire at mean follow-up of 2.5 years (range 2-4 years).

RESULTS

Three patients were treated primarily with Ilizarov ring fixators, one had hybrid fixation and the other four had Hoffman frames. Four patients needed further surgeries. One patient developed metatarsal osteomyelitis, which was debrided and treated with antibiotics. The SF-36 results were compared with age matched UK norms for men and women in all categories. Only two patients returned to their previous employment. Six suffered varying degrees of disability out of which one underwent amputation.

CONCLUSIONS

External fixation with or without internal fixation is an option when salvaging rare injuries like open grade III "floating ankle" injuries. Salvaged patients do suffer a cocktail of crippling disease characterized by psycho-socio-economic and physical disability and result in increased hospital costs. We recommend more prospective studies with long-term follow-up of such complex injuries to identify the indications for salvage and also the criteria for a successful salvage.

Medial column procedures in the acquired flatfoot deformity

This article focuses on the medial column procedures for the treatment of the acquired flatfoot. When performing a medial column procedure alone, in combination with soft tissue reconstruction, or with concomitant lateral bony procedure, the deformity being addressed should include significant abduction or collapse through the talonavicular (TN), naviculocuneiform (NC), or tarsometatarsal (TMT) joints. The procedures covered in this article include arthrodesis of the TN, NC, and metatarsocuneiform (MTC) joints, together or in isloation. Osteotomies of the cuneiforms will also be addressed.

Tendon transfers and realignment osteotomies for treatment of stage II posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction (PTTD) has been approached with a multitude of surgical techniques. This article outlines the current understanding of the flexor digitorum longus transfer and flexor hallucis longus transfer in the context of various osteotomy techniques for the correction of stage II PTTD. Pertinent clinical literature and scientific evidence will also be compared and analyzed.

MRI of rupture of the spring ligament complex with talo-cuboid impaction

The spring ligament complex is essential for the stability of the longitudinal arch of the foot and includes the ligaments between the calcaneus and the talus at the superomedial to inferoplantar aspect of the foot. Tears of the spring ligament complex are most commonly degenerative in etiology and secondary to concomitant abnormality of the posterior tibial tendon. We report MRI findings in a 30-year-old man who presented with traumatic rupture of the spring ligament complex, seen following dislocation of the talonavicular joint. We also describe the previously unreported MRI features of talo-cuboid impaction secondary to disruption of the spring ligament complex.

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.

Biomechanical criterion for selecting cancellous bone screws: arthrodesis in the hindfoot

The aim of the paper was to compare primary biomechanical stability of different arthrodesis screws (7.3 mm AO screw with and without washer, 6.5 mm Herbert screw and 6.5 mm Ideal Compression Screw (I.CO.S)). The work necessary to achieve an adequate compressive force with them was compared to the measurement with the AO screw with washer, because this method is for the time being the most commonly used one and is called the golden standard. Compressive force was measured indirectly, via screw tension measurement, with strain gauges method. From the measurements we calculated the work to reach a limit of 60 N and the ratios corresponding to the value of the golden standard: I.CO.S (35.2%), Herbert (89.0%), AO-screw without washer (116%). The I.CO.S showed superior results. Only in the case of extremely poor bone quality, a clear advantage of I.CO.S could be expected in practice.

Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity

BACKGROUND

Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction.

METHODS

Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs.

RESULTS

The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months.

CONCLUSIONS

This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.

Pediatric and adult flatfoot reconstruction: subtalar arthroereisis versus realignment osteotomy surgical options

One of the most common presenting problems to most foot and ankle surgical practices is the painful flatfoot. Often, the problem is treated with excellent outcomes through a combination of conservative options. In certain cases, conservative care may not alleviate the associated symptoms of foot, ankle, knee, and possibly even back fatigue, pain of the foot and leg, and arthritis of the midfoot, rearfoot, or ankle. In such cases, multiple surgical options are available to treat the underlying deformity and associated symptoms. it is essential to treat the foot and leg as a unit and not to perform surgical based on rapid recovery abut rather on a long-term stable and lasting outcome.

Oral antimicrobial therapy for diabetic foot osteomyelitis

BACKGROUND

Osteomyelitis in the foot of a diabetic individual is a common complication of peripheral neuropathy, peripheral vascular disease, and infection. Operative facilities and home intravenous antibiotic therapy programs may not be available in remote or rural communities. Limited data are available regarding the treatment results of oral antimicrobial therapy, with or without limited office debridement for diabetic foot osteomyelitis.

METHODS

This retrospective medical record review of 325 consecutive diabetic patients who were evaluated at a multidisciplinary foot clinic identified 94 (29%) patients with 117 episodes of osteomyelitis. The most common group of organisms isolated were aerobic gram-positive cocci, and the single most frequent organism was Staphylococcus aureus. A mean of 1.6 +/- 0.8 (range 1 to 4) pathogens were recovered per episode of osteomyelitis. Therapy was guided by culture results. There were 93 episodes of osteomyelitis (79 patients) that were treated with a mean of 3 +/- 1 oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents) and had adequate followup to evaluate outcome of treatment; office treatment included bone debridement in 26 (28%) and toe amputation in nine (10%) of the 93 episodes (79 patients).

RESULTS

Of the 93 episodes treated with oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents), 75 (80.5%) episodes were put into remission. Mean duration of oral antimicrobial therapy was 40 +/- 30 weeks. Mean relapse-free followup duration was 50 +/- 50 weeks.

CONCLUSIONS

Diabetic foot osteomyelitis was effectively managed with oral antimicrobial therapy with or without limited office debridement in most patients. This regimen may be especially useful in communities where infectious disease specialists and operative resources are limited.

Nitinol compression staples for bone fixation in foot surgery

We reviewed the use of compression staples made of the memory metal alloy nitinol for fixation in foot surgery. A retrospective study was performed of 31 feet in 27 patients who underwent arthrodesis or an osteotomy fixated using compression staples. OSStaples (BME, San Antonio, Texas) were used in 18 feet, and Memodyn staples (Telos Medical, Fallston, Maryland) were used in 13 feet. A total of 48 compression staples were implanted. The following procedures were performed and fixated using compression staples: 15 Akin osteotomies, 2 first metatarsal base epiphysiodeses, 3 first metatarsal-cuneiform fusions, 2 naviculocuneiform fusions, 3 calcaneocuboid fusions, 4 talonavicular fusions, 3 subtalar joint fusions, and 2 Evans osteotomies. In our clinical experience, compression staples provide an adequate source of internal fixation in foot surgery. Good bone apposition and stabilization and compression of the bone surfaces before staple fixation are important when using staple fixation to promote an optimal environment for bone healing.

Clinical and radiographic features of operatively treated stiff clubfeet after skeletal maturity: etiology of the deformities and how to prevent them

BACKGROUND

Residual deformities of operatively treated severe clubfeet evaluated radiographically have been rarely studied in detail in adults.

METHODS

Twenty-five operatively treated stiff clubfeet were analyzed at a mean age of 21 years and 6 months. The clinical evaluation used the Laaveg and Ponseti scale for clubfeet. Radiographic assessment was done with weightbearing and dynamic views.

RESULTS

Clinical evaluation was globally good except for motion (poor). Radiographic assessment showed residual abnormalities in all feet. The distal tibial epiphysis showed slanting of its posterior part in seven feet (28%) and notching of its anterior lip in 13 (52%). Talar length, calcaneal length, and talar trochlear height were significantly smaller in clubfeet compared to normal feet. Undercorrection of hindfoot varus, was found in 19 feet (76%) but was well tolerated. Navicular wedging was present in seven (28%), and cavus deformity was found in seven (28%). Dorsal bunion, hallux varus, and skewfoot were found in four (16%), two (8%), and three (12%), respectively. The dynamic views demonstrated a significant decrease in the foot and ankle mobility with compensation mechanisms such as anterior talar incongruence or midfoot hypermobility.

CONCLUSION

Severe clubfeet never become normal at adult age either clinically or radiographically. Multiple radiographic deformities exist. Their etiology and possible prevention are discussed. Despite the numerous abnormalities, clinical results were good at skeletal maturity.

[Initial clinical experience in treatment of diaphyseal fractures small bones with the original extramedular osteosynthesis]

In this paper the author presents initial results of original operative technique of the extramedular osteosynthesis (EFIKS). In the period 01.01. to 30. 06. 2006. in the Clinical University Center of Sarajevo we have operated 5 patients. We have controled healing process, relationship betwen bone--implant, joint's move and possible complications. EFIKS technique is very sufficient in established "biological fixation". Function and definitive results of treatment are satisifactory.

Lengthening procedures of small bones of foot and foot stump

Foot length discrepancy may result from congenital or acquired causes. If the absence of the foot is more proximal than the metatarsal level, push off and foot resilience will be disturbed and rapid walking and spring will be awkward. Those patients have to be fitted with a prosthesis extending above the ankle to the distal leg. The functional impairment and poor cosmetic appearance become social problems especially for adolescents. Twelve cases underwent a lengthening procedure of small bones of the foot in our clinic since 1995 to lengthen the foot or a foot stump. Results were satisfactory.

Druckverteilungsmessung nach Scarf-Osteotomie bei Hallux valgus

AIM

This study evaluates the pressure distribution, the radiological and clinical results in patients before surgery and 6 months after scarf osteotomy for hallux valgus.

METHODS

29 patients were examined before surgery and 6 months after surgery for symptomatic hallux valgus. Pedographic analysis was performed by dividing the footprint of the patients into 8 regions of interest. For each region the maximum mean pressure and the peak pressure were evaluated. Moreover, clinicofunctional results (AOFAS score) and radiological results were evaluated.

RESULTS

6 months postoperatively, maximum mean pressure increased significantly under the medial forefoot where as the peak pressure in this region revealed indifferent results. Significant improvement of clinicofunctional results and a significant reduction of the intermetatarsal and metatarsophalangeal angle could be seen.

CONCLUSION

These results confirm the clinical and radiological findings of other studies, but this study shows for the first time an increase of pressure under the first ray of the foot after hallux valgus surgery and an adaptation to the pressure distribution of normal feet.

Osteoid osteoma: our experience using radio-frequency (RF) treatment

PURPOSE

To present the results of two years experience with a minimally invasive radio-frequency technique designed by our team in the treatment of osteoid osteoma.

MATERIALS AND METHODS

A total of 21 osteoid osteoma patients (15 males, 6 females, age range 13 to 34 yrs) were treated between January 2001 and April 2003. Localizations of the osteoid osteoma were the pelvis (n = 1), the femur (n = 12), the tibia (n = 3), the foot (n = 3), and the humerus (n = 2). All patients underwent an X-ray examination, a CT scan and a bone Scintiscan. In the initial phase, a K-wire just slightly larger than the 17G needle electrode is positioned manually at the zenith of the target area under CT guidance and using an orthopaedic drill it is inserted at the centre of the nidus. A tailor-made metal sheath is inserted on the K-wire to create a ''tunnel'' through which the needle electrode can substitute the K-wire; at the same time, the electrode needle is positioned inside the lesion. The temperature of the exposed tip of the needle is 90 degrees C and duration of hyperthermia is 6 minutes on average. Once the procedure has been completed, a scan os performed to measure the density of the treated site and this measurement is then used as an evolution index for the evaluation of the healing process during follow-up.

RESULTS

No serious complications were observed at follow-up. General anaesthesia was only required in the case with hip involvement; peripheral anaesthesia was used in all the other cases. Complete resolution of the pain was reported in all cases after a maximum of three weeks.

DISCUSSION AND CONCLUSIONS

After two years experience, we believe percutaneous RF treatment of osteoid osteoma to be the first choice technique when compared to traditional surgery due to the fact that it is almost non-invasive, quick, repeatable if need be and offers a high reduction in costs. Moreover early weight bearing is the norm and the patient is dismissed after only one day of hospitalization. The clinical results indicate a 100% success rate with complete remission of symptoms and no relapses having been reported at the time of writing for those patients who have arrived at the two year follow up (4 out of 21).

The great toe proximal phalanx osteotomy: the final step of the bunionectomy

As the final step of correction of hallux valgus deformity, the great toe proximal phalanx osteotomy is useful. It is popular in France and throughout Europe. Our purpose is to distinguish and to describe different locations and three types of osteotomies according to the required final correction of the hallux valgus.

Phalangeal osteotomy versus first metatarsal decompression osteotomy for the surgical treatment of hallux rigidus: a prospective study of age-matched and condition-matched patients

The surgical options for hallux rigidus in the presence of painful but moderate degenerative metatarsophalangeal joint disease are limited to either joint-destructive or joint-preserving procedures. The following study compared the effectiveness of 2 joint-preservation procedures. Forty-nine patients, with a mean age of 53 years, underwent phalangeal osteotomy and were reviewed at an average 29 months postoperatively. A subsequent group of 59 patients, with a mean age of 51 years, underwent first metatarsal decompression osteotomy and were reviewed at an average 15 months postoperatively. In the phalangeal osteotomy group, 65% of patients were completely satisfied, 24% were satisfied with reservation, and 11% were dissatisfied. Three patients suffered continued metatarsophalangeal joint pain, 3 developed hallux interphalangeal joint pain, and 4 patients developed transfer metatarsalgia. The postoperative decrease from 36 degrees to 35 degrees in mean peak hallux dorsiflexion on walking was not significant. In the first metatarsal decompression osteotomy group, 54% were completely satisfied, 13.5% were satisfied with reservations, and 32% were dissatisfied. Continued metatarsophalangeal joint pain occurred in 2 patients, 18 developed transfer metatarsalgia, and 6 of these patients required lesser metatarsal osteotomy. Peak hallux dorsiflexion during walking increased from 36 degrees to 42 degrees (P < .001). First metatarsal decompression osteotomy will increase joint range of motion but the risk of complication and patient dissatisfaction is less after phalangeal osteotomy. Neither procedure could be considered definitive for hallux rigidus.

Early surgical repair of macrodactyly

We report a case of macrodactyly of the foot in a 3-year-old girl. The standard treatment for this condition has been ablation. Studies of phalangeal resection, phalangeal amputation, syndactylization, digit shortening, tissue debulking, and osteotomy have shown varying results. In the case reported here, debulking combined with a shortening osteotomy was the treatment of choice. Although the pediatric patient may require additional surgeries because the deformity will continue to grow, early treatment has allowed this child the benefit of a functional, cosmetically appealing foot that can be fitted with normal footwear.

The bridge and barrel hoop plates as alternatives to external fixation techniques in the foot and ankle

External fixation is a useful tool for treating severe traumatic injuries to the foot and ankle. External fixation, however, does have associated complications, such as inadequate fixation and pin tract infections. Temporary bridge plating of the medial, lateral, or both columns is a useful alternative to external fixation for treating multilevel foot injuries. This article describes the technique of temporary bridge plating which may be used as an alternative to external fixation.

Recent innovations and future directions in external fixation of the foot and ankle

Although the basic design of external fixators has changed little in the last 50 years, advances in pin engineering are decreasing rates of infection and loosening. Newer limb-specific frames are easier to apply to the ankle and novel designs in ring fixators are improving the field of deformity correction. Just as important as any technical improvement, though, is a more refined understanding of the merits and weaknesses of the technique. There are many applications in which external fixation is the best option and others in which it is the only surgical option. Because of this, external fixation will remain an essential tool for future orthopedic surgeons.

Hallux valgus and first ray mobility: a cadaveric study

BACKGROUND

Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device).

METHODS

Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site.

RESULTS

The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm).

CONCLUSION

After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.

Application of bone grafts in podiatric surgery

The application of bone grafting was first reported in the late 1600s, but has only recently become widely used in podiatric surgery. This increase can be accredited to many sources, such as the recent surge in literature advocating its use and the advances in allograft technology that have made it more readily available. There are many new types of allograft bone implants evolving each year with better osteogenic potential and structural rigidity.

Clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery

INTRODUCTION

The harvesting of autogenous cancellous bone graft has many uses in foot and ankle surgery. The most common referenced donor sites are the iliac crest, distal tibia, and calcaneus. These all have demonstrated limitations, the high morbidity rate associated with the iliac crest and the poor quantity of graft from distal sources.

MATERIALS AND METHODS

Between April 1995 and February 2000, 155 patients were retrospectively identified who had undergone a foot or ankle procedure utilizing the ipsilateral, proximal tibia as the donor site for autogenous cancellous graft. The patients were 18 years or older with no history of previous bony surgery to the tibia used and no history of previous injury or pain in the knee. The group included patients with isolated reconstructions as well as multiextremity trauma patients. All were kept nonweightbearing on the involved extremity for a minimum of 6 weeks postoperatively.

RESULTS

There were 90 male and 65 female patients. The average age was 41 years and 5 months. There were 51 smokers averaging 17.6 pack years (range, 1-50 pack years). Twenty-six patients were admitted alcoholics, and 12 admitted to prior intravenous drug use. Cancellous graft was utilized in both traumatic and reconstructive settings. Eighty-nine fractures in 86 patients received grafting. Sixty-nine reconstructions or fusions of the hindfoot or midfoot were done using this technique. There were no reported major complications due to this procedure. No fractures, infections, or wound breakdowns occurred during this study. There were no reported long-term problems with knee pain or function. There was one postoperative hematoma that resolved over time. There were three incidents of sensory changes at the incision site.

CONCLUSION

The use of the ipsilateral proximal tibia as a source for autogenous cancellous bone graft is a procedure with low added morbidity and a source of adequate graft material.

Revision of failed triple arthrodesis with an opening-closing wedge osteotomy of the midfoot

BACKGROUND

This investigation reviewed the clinical and radiographic results of a biplanar opening-closing wedge osteotomy of the midfoot to revise failed triple arthrodeses with severe rocker-bottom deformity. Five cases were reviewed to determine if this osteotomy corrects the rocker-bottom deformity, improves function and provides satisfaction to the patient.

METHODS

American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scores obtained before and after the procedure were compared to assess the functional outcome. The patients' satisfaction with their results of surgery was also determined. Three parameters of foot alignment were measured from preoperative and postoperative anteroposterior and lateral weightbearing radiographs to assess the correction of the rocker-bottom deformity and the effect of the osteotomy on valgus tilting of the talus was evaluated with weightbearing views of the ankle.

RESULTS

All clinical and radiographic measures of outcome significantly improved at a mean follow-up of 18 months (range, 13-32 months). The mean clinical rating score increased from 33 +/- 14 points (range, 14-49 points) to 70 +/- 11 points (range, 62-87 points) after the surgery (p < or = .05). Every patient was satisfied with the result and would repeat the procedure under the same circumstances. All four measures of foot and ankle alignment demonstrated significant correction after surgery.

CONCLUSIONS

The osteotomy effectively realigned the rocker-bottom deformity. The procedure normalized the angular relationships of the foot by correction of the abduction and dorsiflexion deformities of the midfoot and valgus deformity of the hindfoot. The reduction in pain, increased functional capacity, and ability to wear conventional shoes, achieved without any major complication, account for the improved clinical rating scores and high rate of the satisfaction observed with this procedure.

Hallux proximal phalanx Akin-Scarf osteotomy

Numerous hallux proximal phalanx osteotomies have been described, but the Akin-type varisation or adduction osteotomies are currently the most commonly used by foot and ankle surgeons. This article describes the hallux proximal phalanx Akin-Scarf osteotomy. This osteotomy combines the inherent stability of the Scarf-type osteotomy with the versatility of the Akin-type osteotomies to correct pathologic hallux abductus interphalangeus, hallux equinus, or an abnormal digital length pattern, and it is an invaluable tool during the global surgical approach used for hallux valgus repair.

Chondrosarcoma of the distal phalanx of the second toe: a case report

Although chondrosarcoma is a relatively common malignant bone lesion, these lesions rarely affect the foot. This article presents the case of a 32-year-old woman with a chondrosarcoma in the distal phalanx of the right second toe. Radiography and computed tomography showed cortical disruption and soft-tissue expansion. Histologically, the tumor was classified as grade 2 chondrosarcoma according to the American Joint Committee of Cancer pathologic staging system. Amputation at the distal half of the second proximal phalanx was performed to obtain clear surgical margins. A literature review and discussion of salient diagnostic and treatment issues is included.

Island nail transfer in the treatment of macrodactyly of the great toe: a case report

Macrodactyly involving the great toe is difficult to treat when both the functional and cosmetic problems are addressed simultaneously. Partial resection of the distal phalanx is an easy way to reduce the length of the involved toe. However, there are cosmetic concerns with loss of the toenail. The authors report on a clinical case in which shortening and debulking of the toe was performed while preserving the hallux nail. The nail complex was transferred as an island flap to the dorsal aspect of the proximal phalanx. At the 1-year follow-up, the length of the reconstructed toe was significantly decreased, with a normal-looking nail.

Foot function after ray resection for malignant tumors of the phalanges and metatarsals

Four patients with malignant tumors of the proximal toe phalanx who had closed contact or direct involvement of the metatarsophalangeal joints or direct infiltration of the metatarsal bone were treated. Treatment included ray resection and reconstruction either by free microvascular fibula transfer, intermetatarsal bony fusion, or soft-tissue stabilization. Foot function was analyzed by Novel pedobarography. The four patients with a follow-up between 21 months and 8 years show almost normal gait. All patients have remained relapse free. If adequate margins can be achieved, ray resection and appropriate reconstruction may be an alternative to amputation.