Foot & ankle specialist最新文献

Background: Amputation level in diabetic foot osteomyelitis (DFO) is most determined based on surgeon visualization of macroscopic criteria, leading to subjective variability. Wide variance in methods of bone histological analysis and culture are utilized to determine the presence of residual infection. We therefore conducted a systematic, qualitative review to evaluate the current available data on objective measures to delineate the appropriate level of resection in diabetic toe and forefoot amputations, as well as the accuracy of different methods to assess for persistent infection.

Methods: We performed a systematic review of studies from 1990 to 2023 performed on methods to determine margins in toe and forefoot amputations for DFO following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were summarized to discuss the study main objectives, methods utilized to determine amputation level, and techniques used to assess margins for persistent deep infection.

Results: 568 articles were identified, and 18 articles met the final inclusion criteria after review. All studies used plain radiographs for preoperative assessment. 13 used magnetic resonance imaging (MRI) as part of their algorithm to determine general amputation level and 3 used MRI to determine exact depth of resection. 15 studies used microbiological cultures and 13 used histopathological margins intraoperatively to assess margins for deep infection. Of those, 7 studies found that those with positive margins had higher rates of treatment failure.

Conclusion: Overall, majority of studies used combination of plain radiographs of MRI to determine amputation level. Patients who ultimately had positive margins correlated with longer antibiotic duration and higher rates of continued infection, impaired wound healing, reoperation, or readmission. Elucidating the optimal method of evaluating clean surgical margins is critical to lessen the burden on health care systems and improve patient care.Level of Evidence: Level III: Qualitative Review.

Background: Chronic ankle instability (CAI) commonly follows ankle sprains and significantly affects walking patterns and daily activities. Two main surgical treatments exist: Broström repair and anatomic allograft reconstruction. It remains unclear which technique better restores normal ankle movement. This study compared how these 2 surgeries affect ankle function during walking.

Methods: We conducted a prospective study with 30 CAI patients. Fifteen received Broström repair and 15 received anatomic allograft reconstruction. We also included 16 healthy controls. We analyzed ankle joint kinematics (range of motion in dorsi/plantar flexion and inversion/eversion), and kinetics (joint moments, power, and ground reaction force [GRF]) during the gait cycle using 3D motion capture and force plate measurements. Assessments were performed before and 8 months after surgery.

Results: Both surgical techniques altered ankle biomechanics compared with controls. However, the Broström repair group demonstrated gait patterns more similar to healthy controls in most parameters. The reconstruction group showed greater deviation from normal, with increased plantarflexion and eversion throughout the gait cycle. Kinetic analysis revealed that Broström repair better preserved normal ankle moment patterns, while reconstruction resulted in significant alterations in ankle power generation.

Conclusion: Both surgical techniques alter ankle mechanics, but Broström repair more effectively restores normal ankle biomechanics compared with allograft reconstruction in CAI patients during walking. These findings can guide surgeons in selecting the most appropriate surgical technique for restoring natural gait patterns.

Level of evidence: II.

Checkrein deformity is a rare entity that results in alteration of the normal flexion and extension of the hallux, caused by a retraction or adhesion of the flexor hallucis longus (FHL) in its tendinous or muscular portion. It is usually caused by the sequelae of ankle and tibia fractures, such as adhesions and neuropathies, and often undiagnosed compartment syndromes. Its treatment is mainly surgical, and different techniques of release or lengthening of the FHL have been described. We present the clinical case of a 61-year-old patient treated by a simple arthroscopic tenotomy of the FHL at the retromalleolar level of the ankle, with complete functional recovery and absence of recurrence after 2 years of evolution. We recommend that this procedure should be considered for this pathology due to its technical simplicity, low iatrogenicity, early recovery, and theoretical absence of recurrence.Level of Evidence: Level V: Expert opinion, case report.

ObjectiveThe purpose of this study was to determine whether the number of cannulated screws used during ankle arthrodesis (AA) might influence the union and complication rate.MethodsIn this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant PROSPERO-registered systematic review, multiple databases were searched including studies in which patients undergone AA using cannulated screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion, and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Two groups were built (arthrodeses fixed with 2 screws [group 1, G1] vs arthrodeses fixed with 3 screws [group 2 G2]) and compared.ResultsFifteen series of patients from 15 studies (667 ankles) were selected (G1 = 458 ankles and G2 = 209). The pooled proportion estimate revealed a similar nonunion rate in the 2-screw group as compared with the 3-screw group (4% vs 3%; P = .68). The pooled proportion of complications was higher in G1 (19%) than in G2 (8%), but it was not significantly different either (P = .45). After exclusion of "symptomatic hardware and screw removal," the difference was still not significant (P = .28) although it resulted lower in G1 than in G2 (4% vs 8%, respectively).ConclusionsUsing 3 cannulated screws during AA as compared with a 2-screw construct does not significantly reduce the risk of nonunion nor the risk of complications.Level of EvidenceLevel IV, Systematic review of level IV.

BackgroundThe purpose of this study is to define the effect of facility type (inpatient vs outpatient) for the use of supplemental regional anesthesia (SRA), and SRA's effect on complications, readmissions, operation time, and length of hospital stay after elective foot and ankle surgery.MethodsWe performed a retrospective review to identify a large cohort of adult patients who underwent elective foot and ankle surgery between 2006 and 2020 from the American College of Surgeons National Surgical Quality Improvement Program database. We fit log-binomial generalized linear models to estimate risk ratios for general anesthesia (GA) with SRA versus GA alone, and linear regression models to estimate the effect of GA with SRA on the average total hospital length of stay (in days) and operation time (in minutes); we also performed inverse propensity scores.ResultsWe found that there is no statistical difference in the rate of readmissions (P = .081) between patients under GA alone versus GA with SRA. In the propensity score analysis, patients who underwent midfoot/forefoot surgery had 3.85 times the risk of complications under GA with SRA compared with GA alone (P = .045). Also, patients who received GA with SRA had a longer unadjusted operative duration (102.22 minutes) when compared with patients who received GA alone (93.84 minutes) (P < .001). However, patients who received GA alone had a longer unadjusted hospital length of stay (0.88 days) when compared with patients who received GA with SRA (0.70 days) (P = .006).ConclusionThis study found that, when compared with GA alone, GA with SRA leads to a statistically significant increased operative time but a shorter hospital stay without significantly increasing readmissions and only increasing the risk of complications for midfoot/forefoot surgery within 30 days postoperatively for elective foot and ankle surgery.Level of Evidence:Level III.

IntroductionTotal ankle arthroplasty (TAA) through anterior approaches is a common treatment for end-stage tibiotalar arthritis. The occurrence of wound healing problems can lead to severe consequences. The aim of this systematic review is to summarize the available methods to minimize postoperative wound complications after TAA through standard anterior approaches.MethodsThree databases were searched for original articles concerning methods to reduce anterior wound complications after TAA. Eligible articles were examined to extract studies' characteristics, population data, type of intervention, and related wound complications. Study risk of bias assessment was conducted through the Newcastle-Ottawa Scale.ResultsThirteen articles were included for analysis, investigating 8 types of intervention, which were grouped into 3 classes: biological, mechanical, and pharmacological methods. A significant decrease in wound complications was reported for negative pressure wound therapy (3% vs 24%, P = .014), soft tissue expansion strips (2% vs 12%, P = .04), and tranexamic acid (TXA) administration (9% vs 22%, P = .002).ConclusionDespite the limitations of the included studies, this review showed encouraging results for TXA administration. Good results were found for mechanical methods, despite each intervention being supported by only 1 comparative study. Careful selection of patients is recommended to identify potential benefits or contraindications to such interventions. Further prospective randomized studies would be helpful to confirm these results.Levels of Evidence: 3.

Metal hypersensitivity following total ankle arthroplasty (TAA) is an underreported complication that can manifest as dermal, systematic, and orthopaedic-specific symptoms. It is critical to recognize that metal hypersensitivity is a diagnosis of exclusion; only after all other potential sources of failure, such as loosening or infection are ruled out, can this diagnosis be considered. Aside from imaging and common laboratory analysis, skin patch testing, leukocyte migration inhibition test (LMIT), and lymphocyte transformation test (LTT) are the testing options available for metal allergy. With regards to management of metal hypersensitivity, nonoperative modalities involving topical dermatological management are generally preferred. Severe cases of metal allergy may necessitate operative management consisting of explantation of the implant and either revision TAA with a custom hypoallergenic implant or conversion to an ankle fusion. We present 3 cases of presumed metal hypersensitivity following TAA. In all 3 cases, other forms of TAA failure were carefully ruled out. One patient underwent explantation and conversion to hypoallergenic implant, 1 patient underwent explantation and ankle arthrodesis with hypoallergenic hardware, and 1 patient elected for conservative care. In patients who underwent explantation and conversion to hypoallergenic hardware, no further symptoms associated with metal allergy were noted. Additional research is necessary to improve diagnostic accuracy of metal allergy and make treatment options more effective and accessible.Level of Evidence: Retrospective case series, IV.

BackgroundAs total ankle arthroplasty (TAA) is increasingly performed in younger individuals in the United States, the aim of this study was to analyze TAA outcomes and complications by age.MethodsA total of 1619 primary and revision TAAs from 2012 to 2020 were collected and included from the National Surgical Quality Improvement Program. Patients were stratified by age into those younger than 55 years, between 55 and 70 years, and older than 70 years. Demographics, medical comorbidities, American Society of Anesthesiology Physical Classification (ASA) class, operative time, 30-day complications, and comorbid conditions were compared by univariable analysis. Multivariable analysis was used to analyze readmission rates, reoperation rates, operative time, and hospital length of stay.ResultsPatients younger than 55 years were found to have a significantly longer operative time compared to patients older than 70 years of age or between 55 and 70 years (P < .001, P = .034). Patients older than 70 years were found to have a significantly longer hospital stay (P < .001) and a greater risk of discharging to a nonhome location (P < .001). By multivariable analysis, patients 55 to 70 have a statistically lower risk of readmission compared to the other 2 cohorts (P = .043). No difference in postoperative complications was demonstrated between the different groups.ConclusionsAs the incidence of total ankle arthroplasty increases across all ages, it is important to understand specific perioperative risks for each age group. Younger patients tended to have longer surgeries and higher body mass indexes (BMIs). Patients aged 55 to 70 years had the lowest risks for perioperative complications. Patients greater than 70 years were at risk for longer hospital stays and discharge to nonhome locations. There were no differences in postoperative complications by age.Level of Evidence:Level III: Retrospective comparative study.

A Salter-Harris type III fracture of the distal tibia is a significant injury because of combined physeal damage and intra-articular extension. With a displaced fracture, anatomic physeal alignment and articular congruity are critical to minimize the risk of complications, but a preoperative delay makes the treatment challenging. Herein, we present a 12-year-old boy with a delayed presentation of a similar physeal injury managed by an open approach using a transfracture reduction technique. We have observed anatomic fracture healing and a favorable outcome with no signs of physeal arrest at a 2-year follow-up.Levels of Evidence:Level V.

BackgroundAfter talocrural arthrodesis, adjacent joints (subtalar, talonavicular, and calcaneocuboid) are often affected by osteoarthritis (OA)). It is unclear if OA is pre-existing to talocrural arthrodesis, or whether it develops after talocrural arthrodesis. This retrospective study is unique because it is the first study with preoperative and follow-up computed tomography (CT). The aim of this study is to investigate whether OA develops in adjacent joints after talocrural arthrodesis or if OA is already pre-existing. In addition, associations between degree of OA and patient-reported outcomes are investigated.MethodsPatients were selected from electronic files, and adjacent joint OA was assessed on preoperative CT and bilateral follow-up CT. Patient-reported outcomes were collected.ResultsTwenty-three patients were included with an average follow-up time of 7 years (SD = 2). In participants without pre-existing OA, OA significantly progressed in all adjacent joints. In participants with pre-existing OA, OA progressed in the subtalar joint. Patient-reported outcomes were not correlated to OA.ConclusionsOsteoarthritis in the adjacent joints progresses after talocrural arthrodesis, especially in participants without pre-existing OA. The severity of OA is not related to patient-reported outcomes. Therefore, the clinical impact of the progression of OA seems to be limited.Level of Evidence:Level III: retrospective.