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

Diabetes is an epidemic in the United States contributing to poor outcomes related to ulceration and lower leg amputations. Physicians from a number of specialties are continuing to seek opportunities to improve patient outcomes and maintain independence. Podiatric surgeons have an affinity for limb salvage in the face of acute or chronic ulcer complications of the lower extremity. In particular, heel ulcerations increase the risk of proximal amputation due to locality and the propensity for heel osteomyelitis. Partial calcanectomy (PC) had been a viable option prior to below knee amputation, but recent literature by Elmarsafi et al. shows an increasing number of positive outcomes with a new procedure called the vertical contour calcanectomy (VCC). This has prompted researchers from Georgetown University to develop and publish this technique since 2019. The purpose of this article was to validate the versality and reproducibility of limb salvage with use of the VCC in the rural region of Northeast Pennsylvania in the management of complicated infections of the heel.

Managing osteomyelitis in the adult population poses a complex challenge, especially when in the presence of comorbidities such as diabetes, peripheral arterial disease, soft tissue infection, and a history of ulcerations. Traditionally, the standard treatment for osteomyelitis has involved surgical excision, intravenous antibiotics and/or amputation. However, the need for recurrent surgical intervention remains frequent. While osseous resection can be achieved, complications include soft tissue infections and delayed wound healing which lengthens the postoperative recovery. In this research we explore an innovative three-pronged approach modifying the conventional treatment paradigm: minimally invasive surgical bone harvesting via a suction curettage technique, localized antibiotic administration and systemic antibiotics.

Background

The Lauge-Hansen classification system is most commonly used for ankle fractures and dictates treatment options. In this report, a new perspective to the Lauge-Hansen classification system involving the influence of the peroneal muscles for ankle fractures is presented.

Methods

The classification is based on a review of 29 ankle fractures treated by a single physician at a healthcare facility. A chi-square test of independence was completed with the provided data. The relationship between peroneal classification and fracture pattern was evaluated. In addition, the relationship between peroneal classification and gender was also evaluated within this study.

Results

When comparing peroneal classification and gender, the chi-square test indicates that there is no significant association between peroneal classification (plus or minus) and gender (p-value = 0.8171). Therefore, we do not have sufficient evidence to conclude that there is an association between these variables. When comparing peroneal classification to fracture pattern, the chi-square test reveals a significant association between peroneal classification and fracture patterns (p-value = 0.019). This suggests that there is a relationship between the type of peroneal classification and fracture patterns observed.

Conclusion

Failure of the peroneal muscles to control supination of the ankle at heel strike may be a contributing factor to inversion injuries of the ankle. The peroneal muscle contraction may also be a contributing factor in the etiology, displacement, difficulty in reduction and recurrent displacement of the fibula and ankle mortise in abduction with external rotation injuries of the foot/ankle.

Actinomyces infections are rare but can lead to severe complications if not promptly diagnosed and treated. We present a case of a 36-year-old male from Yemen who developed an Actinomyces infection in his right foot. Despite initial antibiotic treatment, the infection persisted, necessitating surgical intervention twice. This case underscores the importance of considering Actinomyces infections in patients with chronic non-healing wounds, particularly in regions where such infections are prevalent.

A non-salvageable talus, often secondary to avascular necrosis, is a difficult pathology to treat. A standard technique for talar defects includes tibiotalocalcaneal fusion with plating or a hindfoot intramedullary nail. The 21st century has brought about the increasing use of total talus replacements as an alternative procedure for severe osteonecrosis of the talus. As total talus replacement becomes more popular, the need for revision options will increase. The present study's evaluates the viability of revision TTR with a talar component constrained into the navicular and calcaneus. Three consecutive patients undergoing revision total ankle total talus replacement were retrospectively reviewed. Two males ages 62 and 57 and a female aged 55 failed conservative therapy at 41, 34, and 29 months after index total talus replacement. Single Photon Emission Computed Tomography (SPECT) was obtained to confirm uptake in the talonavicular and subtalar joint implant interfaces. At 26, 20, and 14 months postoperatively all patients on computed tomography possessed at least 30 % osseous bridging at hindfoot joints. No patient has had a reoperation, and one complication of medial gutter pain was observed. All patients with revision total talus replacement to a combined constrained implant returned to function and avoided tibiotalocalcaneal fusion or below knee amputation. There is a clear need to standardize reporting and establish the safety and efficacy of TTR. Furthermore, more comparative studies between total talus replacement and tibiotalocalcaneal arthrodesis are needed.

Untreated tibialis anterior tendon ruptures can lead to gait abnormalities, flatfoot deformities, drop foot and chronic pain. Both traumatic and atraumatic ruptures of the tibialis anterior tendon can occur, though, atraumatic ruptures are often spontaneous and less common. For many patients, their symptoms are vague, which can result in a delay in diagnosis. Drop foot is typically the most noticeable symptom. Surgical treatment has been recommended for both traumatic and atraumatic ruptures to restore normal gait and function of tendon. Several surgical techniques have been published, however, there is no consensus on “gold standard” for optimal treatment. Here, a surgical technique is discussed which involves tenodesis of the extensor hallucis longus tendon to the ruptured tibialis anterior tendon with subsequent transfer into the medial cuneiform along with extensor hallux brevis to extensor hallux longus tenodesis distally over the first metatarsophalangeal joint. The authors find that this technique is reproducible in terms of allowing patients to regain dorsiflexory strength at the ankle joint and avoid postoperative ankle-foot orthoses. To date, all patients that have been treated with this technique have been able to return to normal ambulation without the use of a brace or subsequent gait disturbances.

Ehlers-Danlos Syndrome (EDS) is a genetic condition that affects your body's connective tissues. There are many subtypes to the disease, the most relevant to the lower extremity is hypermobile EDS. In the lower extremity patients with hypermobile EDS present with abnormal mobility to all lower extremity joint articulations leading to the development of an often extreme and progressive form of pes planus. The degree of deformity and lack of intrinsic soft tissue stability leads to pain in the foot/ankle and compounds problems in the more proximal joint articulations. To our knowledge there has not been literature published regarding specifically the surgical management of hypermobile EDS in the lower extremity. Here we report, a case of an 11-year-old female with pes planus that was initially treated with standard joint sparing treatments including soft tissue procedures and extra-articular rearfoot osteotomies to address patient's pes planus. The procedures were performed with relatively few post-operative complications; however, the patient's deformity had reoccurred 5 years after the initial operation following the initial surgeries. It was discovered that the initial procedures were failing, and the arch had subsequently collapsed. After some research, the diagnosis of hypermobile EDS was made with the use of the Beighton scoring scale and other criteria as defined by the Ehlers-Danlos society. The patient then underwent a robust arthrodesis to help address the collapsing arch. This case was the beginning of the senior authors journey and long-term prospective cohort study on the surgical management of pes planus in children with hypermobile Ehlers-Danlos.

Tongue-type calcaneal fractures cause significant pressure on the soft tissue coverage of the posterior calcaneus, resulting in skin ischemia and necrosis. Literature shows most are fixated with ORIF weeks after the initial trauma, allowing for soft tissue stabilization. No previous case study has reported an open tongue-type calcaneal fracture that was immediately surgically corrected. This case study documents an open tongue-type calcaneal fracture that was surgically corrected immediately following a high energy trauma. A 48-year-old male had a zip lining accident where his brakes failed and he crashed into a tree feet first. The patient presented with a laceration and exposed calcaneal bone to the left lower extremity. Imaging confirmed a tongue-type calcaneal fracture with protrusion of the calcaneus. Procedures performed were incision and drainage of left heel wound, left Achilles tendon lengthening, and open reduction and temporary external fixation of left calcaneus. Surgical intervention resulted in a reduction of the left calcaneus with return to function. This case illustrates a rare occurrence with a novel fix: using an Achilles lengthening and temporary external pinning to reduce an open tongue-type calcaneal fracture immediately following the traumatic incident.

Osteoarthritis of the tibiotalar joint is a debilitating condition and often post-traumatic in nature and can contain deformity. Historically, significant coronal plane deformities were considered contraindications for total ankle arthroplasty. To preserve long term success and balance the loading of any ankle arthroplasty one must focus on correcting any aberrations in alignment of the foot, ankle, or leg. Varus deformity at the tibiotalar level is common but there is no standard treatment for its correction prior to prosthesis implantation. A retrospective review was undertaken to quantify deformity correction and viability of a medial malleolar lengthening technique with intercalary allograft. Ten patients met inclusion and exclusion criteria. Transverse opening osteotomy with bone allograft osteotomy was made just distal to the medial malleolar shoulder in a staged fashion or simultaneously with total ankle arthroplasty. A mean age of 60.3 years and mean body mass index of 26.3 (kg*m²) was observed. Seventy percent (7/10) of osteotomies progressed to union (7/10) at an average follow up of 24.7 months. All nonunions (3/3) were asymptomatic. Pre-operative average tibiotalar angle was 70.9 degrees, and post-operative was 87.9 (p < 0.001). All but 2 patients had ancillary procedures in addition to malleolar osteotomy and ankle arthroplasty. While promising, patients may need to be counseled that asymptomatic pseudoarthrosis is common (30 %). Further research is needed regarding management of coronal plane deformities of the ankle.

Frostbite is a common pathology seen in cold weather climates directly affecting peripheral tissues which at times can result in necrosis. While frostbite can be managed with rewarming, awaiting demarcation, and delayed surgical intervention. Indocyanine green angiography (IGA), makes use of a dye injection to evaluate the perfusion to an area of tissue. While the use of IGA has been used in the evaluation of major plastic surgery, vascular, and transplant procedures its use has not been studied in the usage of amputation planning to assess pedal perfusion. This is a proposed technique guide on the use of IGA in the planning of amputation secondary to frostbite injury. Results from this case show that the use of IGA was beneficial in establishing the proper amputation level to have the patient heal without major issue or have a need for additional procedures.