Foot & ankle surgery (New York, N.Y.)最新文献

Tibial nerve injury is a rare complication of total ankle arthroplasty (TAA) that has been outlined in the literature. However, the literature is sparse regarding the treatment of iatrogenic tibial nerve injury in situations of delayed diagnosis. This case report highlights a nerve repair technique using a nerve graft for a severe complication associated with total ankle arthroplasty. Our patient had a TAA in November 2021, and presented to our clinic in March 2022 with loss of sensation and increasingly rapid loss of the motor function in the tibial nerve distribution. Nerve conduction and electromyography studies revealed injury to the deep peroneal and tibial nerves at the lower leg. Surgical intervention revealed a large neuroma-in-continuity with near complete transection of the tibial nerve. She subsequently underwent large neuroma excision, and tibial nerve repair with nerve graft. This procedure resulted in almost complete reversal of symptoms including pain relief and improvement in motor function. While tibial nerve injury during TAA is rarely reported, it is likely unrecognized or misdiagnosed resulting in significant complication for patients. Where complete or near-complete nerve transection results in neuroma formation, we recommend repair using a nerve graft as neuroma resection with end-to-end repair has been shown to have high failure rates with recurrence in the foot. Nerve grafts reduce the risk of recurrent symptomatic neuromas by allowing nerve endings to exhaust any subsequent outgrowth.

Introduction

The typical circular external fixator possesses radiodense multi-level ring tibial blocks ad struts for stability, even in patients with intact osseous architecture. We analyzed the applications and outcomes of a fully radiolucent limited ring external fixation in the orthoplastic management of complex bone and soft tissue pathology.

Methods

Consecutive patients were selected and followed, and data collected during the use of a fully radiolucent external fixation system in patients without large segment tibial bone loss. Basic patient demographics, risk factors, body mass index, the clinical indication, the use of external fixator, and time in external fixation were analyzed. All patients underwent early mobilization with full weight bearing with an assistive device. Any untoward external fixator complication and outcome was recorded. Institutional Review Board approval was obtained.

Results

There were nine patients with a mean age of 44 (range = 22–73) with a mean follow-up of 17 months (range-6–26 months). Fifty-six percent were enrolled in the study who all received a two-ring radiolucent external fixation device. All patients had risks for external fixation complications with 89 % possessing multiple risk factors. Four patients (44 %) had neuropathy from the mid tibia to the foot. Bone stabilization was performed for 67 %, soft tissue offloading/limb stabilization for 55 %, a combination of bone and soft tissue stabilization for 33 % of patients.

Conclusion

Lightweight radiolucent circular external fixation of the lower extremity in patients without intercalary bone loss can provide satisfactory stability and allow early mobilization with minimal component complications. The added advantage of having radiolucent rings and struts allows for better visualization of osseous structures such as fractures care and fusions. The ability to manipulate foot position required for a particular bone/soft tissue reconstruction is also possible.

Literature reports cutaneous metastatic carcinoma as an uncommon finding. This foreboding phenomenon accounts for 0.7%-9% of metastases and may foreshadow a grim prognostic outcome. Ductal-type breast cancer is associated with an increased incidence of cutaneous metastasis in women. Current literature documents cutaneous malignancy to the chest wall or surrounding anatomic locations however there is no literature that currently details three forms of cutaneous manifestations to the lower extremities.¹

A 62-year-old diabetic female received a routine mammogram yielding an architectural distortion within the right breast. Biopsy revealed infiltrating carcinoma. The patient underwent a mastectomy, axillary sentinel node biopsy and dissection. Pathology results yielded multifocal disease with positive lymph nodes. The patient was placed on an oral chemotherapeutic agent with adjutant radiation. She began outpatient podiatric treatment for venous leg ulcerations with concomitant cellulitis and lymphedema from December 2020 through 2022. The patient noted chronically inflamed and bleeding lesions with slow response to treatment despite use of appropriate modalities including compression, unna boot application, antibiosis, and topical steroids.

In June of 2022, a verrucous outpouching of tissue was noted to the right lateral leg. A punch biopsy yielded irregular glassy islands with keratinocyte atypia consistent with invasive squamous cell carcinoma. Furthermore, the patient was found to have malignant melanoma to her left thigh and recurrent basal cell carcinoma nodular type to the left lateral leg. The patient was referred to dermatology and plastic surgery for excision of lesions with Mohs surgery. She maintains perpetual observation via podiatry, dermatology, and hematology/oncology.

Background

The challenge of surgical treatment of hindfoot collapse can be exacerbated by host conditions. Many patients with neuropathy, Charcot joint, or end-stage arthritis that undergo tibiotalocalcaneal (TTC) fusion with bulk allograft progress to nonunion and often require amputation. 3D-printed implants may improve outcomes within this population, but long-term outcomes of these implants have not yet been reported. This study reports mid-term outcomes of patients with Charcot arthropathy or end-stage arthritis who received 3D-printed titanium cage and dynamic hindfoot fusion nail combination fixation for limb salvage.

Methods

This study was a retrospective review of consecutive patients who underwent hindfoot arthrodesis with a combination of patient-specific 3D-printed titanium cage and dynamic hindfoot fusion nail by a single surgeon at a single institution. The primary outcome was to establish the safety of the 3D-printed cage in a medically complicated population. The secondary outcome was to evaluate the efficacy of the 3D-printed cage, as evaluated by patient-reported pain score, ambulation status, and satisfaction. Deformity correction was evaluated by radiograph.

Results

This study evaluated 13 cases with at least one year follow-up. Mean follow-up was 3.72 years (range 2.67-4.60 years). As of the most recent follow-up, 11 of 13 cages remain implanted, with two cages having been explanted in the setting of amputations indicated by conditions unrelated to the cage itself. Patients reported a mean pre-operative NRS pain of 6.6 ± 2.9 points. At the last follow-up, mean NRS pain was 2.0 ± 1.7 points. Pre-operatively, six of 13 patients reported the ability to ambulate independently without an assistive device. Post-operatively, 11 of 13 patients were able to ambulate independently.

Conclusion

The results demonstrate no implant-related complications and promising outcomes in terms of fusion, deformity correction, and patient satisfaction, which are especially remarkable in the setting of Charcot arthropathy.

The treatment of displaced intra-articular calcaneal fractures is not standardized, as many surgeons prefer not to perform surgery, considering a high rate of cutaneous complications associated with the usual extensile lateral approach. The Calcanail® represents a percutaneous osteosynthesis device that is biomechanically more stable than multiple screws or locking plates. While it effectively restores the height and axis of the hindfoot, it appears to be less reliable in achieving articular reduction of the thalamic surface in cases of mixed fractures. Therefore, we developed a new technique suitable for comminuted mixed fractures, using the Calcanail® device with an arthroscopically guided closed reduction internal fixation of the thalamic surface.

Acute tarsal tunnel syndrome is a rare entity in general population. We present a case report of an acute onset after pes cavus correction, treated with gradual foot plantigrade repositioning with an external fixator, without need of tunnel release. The patient's vivid symptomatology and the good clinical course after conservative treatment, underlines the vulnerability of the tibial nerve when treating patients with stiff varus deformities, and further highlights the importance of gradual corrections by utilising the external fixators in the treatment plan.

We present a case report of a 48-year-old male marathon runner who was seen for initial evaluation in August of 2022 with a 3-day history of significant right arch pain limiting ambulation without a history of a traumatic event or inciting incident. Subsequent work-up with magnetic resonance imaging [MRI] without contrast revealed a plantar vein thrombosis [PVT]. The patient was placed on Eliquis [Apixaban] 5mg for 4 months with full resolution of his symptoms. With the use of oral anticoagulant therapy, the patient was able to compete in and complete 5 marathons over an 18-month period without return of the PVT.

Literature of fourth-generation minimally invasive surgery (MIS) on hallux valgus is scarce. In this study, extra-capsular transverse osteotomies were performed on ten cadaveric specimens. The capital fragment was shifted lateral to nearly 100% of the first metatarsal width and then fixated in contemporary fashion following MIS principles. A mixture of radio-opaque solution and methylene blue dye was injected through the second screw hole into the pyramid-shaped space created after the osteotomy shift. The injection was visualized under fluoroscopy and specimen were dissected in layered fashion to assess for containment versus extravasation. The purpose of this study is to observe and describe the preservation of the joint capsule, periosteum, and soft tissue structures adjacent to the osteotomy.

The journal publication rate for oral abstracts presented at the American College of Foot and Ankle Surgeons (ACFAS) is currently the highest reported for any national foot and ankle society, to date (80.7%). Conversion rates for abstracts presented at national society meetings has long served as an indirect proxy for the quality of the content presented. However, it is unclear why some abstracts ultimately fail to achieve publication. The purpose of the present study was to assess the publication barriers of oral abstracts from ACFAS: 2015–2019. Unpublished oral abstracts were procured from a database. A questionnaire was distributed to presenting authors to determine the current status of the abstract, as well as the reasons for the failure to achieve journal publication. Of the 22 oral abstracts that failed to achieve publication, 10 questionnaires were completed. At the time of the survey, none of the abstracts had been submitted for publication. An insufficient amount of time (30%), responsibility tasked to a co-author (30%), low perceived likelihood of acceptance (30%), and low perceived priority (10%), were citied by authors. The present study broadens our understanding regarding the barriers to the conversion of oral abstracts from ACFAS. Projects led by trainees accounted for 2/3′s of the unpublished abstracts; in some cases, the same author accounted for more than 1 unpublished abstract over subsequent years. The onus is on directors to ensure their trainees receive adequate research mentorship and disseminate clinically meaningful findings presented at ACFAS to a broader audience by journal publication.

The American College of Foot and Ankle Surgeons (ACFAS) oral abstract publication rate (80.7%) is currently the highest reported for any national foot and ankle society conference to date. Factors associated with the conversion of an abstract to a full text journal publication, as well as barriers to the conversion have been previously assessed for the ACFAS 2010 to 2014. The purpose of the present study was to re-assess factors associated with the journal publication, and time to publication of oral abstracts from the ACFAS 2015 to 2019. Databases containing abstract information were procured, and predictor variables were categorized as either abstract, or author specific. Bivariate analysis was conducted using the Mann-Whitney U-Test, Fisher's exact test, chi-square test of independence, or Spearman's rank correlation. Multivariable logistic regression, and generalized linear regression models were utilized to analyze predictor variables. Projects from academic institutions (p = 0.001), by attending faculty (p = 0.012), with formal research training (p = 0.035) were more likely achieve journal publication following conference presentation, in less time. The abstract/author specific variables were the only significant predictors of publication/time to publication, although trends with respect to other variables were identified (region of the college, funding). The present study further broadens our understanding on the factors associated with successful conversion of an oral abstract to journal publication following conference presentation. The associations and trends identified lend credence to previous studies, while also helping to form a foundation for meaningful discussion(s) on how best to aim the colleges research efforts moving forward.