Foot and Ankle Surgery

Announcement: IFFAS, 2011, Nora, Japan, Sept 21-23 2011

2010-09-01

Is it Morton's or Civinini's syndrome?

Giacomo Pisani — 2009-09-07

Morton's syndrome is a condition of metatarsalgia commonly known as third common digital nerve neuroma. Morton considered it as “A peculiar and a painful affection of the fourth metatarso-phalangeal joint.”

Overview of subtalar arthrodesis techniques: Options, pitfalls and solutions

2009-08-28

Abstract: Background: Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified.Materials and methods: A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation.Results: The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68–100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36–96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications.Pitfalls: The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion.Solutions: The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment.Conclusion: The review provides practical suggestions to optimize SA-techniques.

Reconstructing the rheumatoid forefoot

Huub J.L. van der Heide, Jan Willem K. Louwerens — 2009-08-25

Abstract: Introduction: The standard procedure when operating on the rheumatoid forefoot is resection arthroplasty of the metatarsophalangeal joints of the lesser rays. Good clinical results (with a follow-up of over 10 years) have been reported when this technique is used. Another technique is repositioning of the metatarsophalangeal subluxation or dislocation of the lesser rays.Aim: To assess the results of forefoot reconstruction using the repositioning technique performed in 54 feet (39 patients) by one surgeon using this technique.Methods: 39 RA patients (15 bilateral, 54 feet) were treated with the technique of repositioning the metatarsophalangeal subluxation or dislocation. All surgery was performed by one orthopaedic surgeon. In case of severe deformity or degeneration of the metatarsophalangeal joint of the hallux, an arthrodesis was performed. All patients were reviewed after a mean follow-up of 40 months (range 12–72 months) and an American Orthopaedic Foot and Ankle Society (AOFAS) foot score, and Foot Function Index (FFI) were obtained.Results: When, in addition to repositioning the metatarsophalangeal joints, an arthrodesis of the hallux was performed, the mean AOFAS-forefoot score was 69.80 (SD=11.8) at a mean of 40 months (SD=15.6 months) postoperatively. In cases with no operation on the hallux, the AOFAS score was 42.2 (SD=18.8) (p=0.001). The postoperative FFI-scores were 23.0 (SD=17.5) and 43.9 (SD=14.6) respectively (p=0.026). When comparing the patients who were satisfied (satisfaction VAS>7) and those who were not, the most important factor was also fusion of the first metatarsophalangeal (MPJ) joint, without a fusion only 50% was satisfied, with a fusion the satisfaction rate was 93%. In four patients a recurrence of the deformity of one of the lesser rays developed, for which a re-operation has been performed.Conclusions: Reconstruction of the rheumatoid forefoot by repositioning the metatarsophalangeal joints of the lesser rays, thereby preserving the joints, can be considered as a procedure that provides improvement in the clinical outcome. Best results were seen in patients in whom, in addition to reconstruction of the lesser rays, an arthrodesis of the hallux was performed.

“Mini-open” repair of acute tendo Achilles ruptures—The solution?

C. Mukundan, M. El Husseiny, F. Rayan, J. Salim, A. Budgen — 2009-09-09

Abstract: Background: The standard surgical exposure for repair of acute tendo Achilles rupture gives favourable results, but such extensive exposure increases the possibility of peritendinous adhesion, wound breakdown and infections which increases morbidity and impairs functional outcome. Open repair also increases post-operative hospital stay and hence encroaches on valuable bed space availability. To evade this mini-open technique was developed which provide anatomic apposition of the tendon ends and minimal damage to epitendon.Methods: We describe a retrospective case series of 21 patients who were treated with mini-open technique as a day case, between 2004 and 2007 operated by a single surgeon. They were followed up for a year. Both the Leppilahti score and the American Orthopaedic Foot and Ankle Society for the Ankle Hind foot Clinical Rating System (AOFAS) were calculated. The patients (8 males and 13 females) had a mean age of 43.4 years. Post-operatively the leg was placed in an air cast boot with 3 heel wedges allowing 30 degrees of plantar flexion. The foot is brought into plantigrade position by 6 weeks with serial removal of heel wedges followed by a rehabilitative training programme.Results: There was one superficial infection which settled on oral antibiotics, no re-rupture or sural nerve involvement was noted in this series. All patients returned to previous work and sports activities. All patients scored above 90 in the American Orthopaedic Foot and Ankle Hind foot Clinical Rating System and on the Leppilahti Scoring System. Mini-open procedure is an excellent alternative to open exposures reducing the inpatient post-operative stay. All patients were discharged home on the same day of the procedure.Conclusion: Our pilot study has helped us to implement a standardised pathway by which patients have benefitted with improved rehabilitation and return to their pre-injury status.

Correction of severe hallux valgus using a basal chevron osteotomy and distal soft tissue release

Turlough O’Donnell, Niall Hogan, Matthew Solan, Michael M. Stephens — 2010-09-01

Abstract: Background: There are many procedures described for the correction of severe hallux valgus. This is the first to examine the role of a basal osteotomy with distal soft tissue release.Methods: 26 patients with severe hallux valgus underwent a basal chevron osteotomy with distal soft tissue release. All were reviewed at an average of 38 months.Results: The mean AOFAS score improved from 24 to 82 points (p<0.001). The IMA improved from an average of 23.90 to 130 (p<0.01). The HVA improved from an average of 490 to 170 (p<0.005). The correlation coefficient between the AOFAS score and various radiological angles was low (0.47).Conclusions: Good clinical outcomes in cases of severe hallux valgus can be achieved without full restoration of normal radiological values. Furthermore, a basal chevron osteotomy with a distal soft tissue release offers a high satisfaction rating with regards to both clinical and functional outcomes in the short to medium-term.Level of evidence: Level IV – Case series.

Opening first metatarsal osteotomy and resection arthroplasty of the first MPJ in the treatment of first ray insufficiency associated with degenerative hallux valgus

L. García-Bordes, M. Jiménez-Potrero, J. Vega-García, A. Yunta-Gallo — 2009-09-14

Abstract: Background: Opening wedge proximal metatarsal osteotomy combined with first metatarsophalangeal arthroplasty can be used to correct first metatarsus primus varus with a high intermetatarsal angle and a short first metatarsal.Methods: 147 feet in 138 patients with degenerative first metatarsophalangeal arthrosis, ≥15° of metatarsus primus varus and, a short first metatarsal were included. Preoperative and postoperative clinical, radiographic, and subjective outcome measurements were taken (Scale AOFAS).Results: The mean first intermetatarsal angle decrease was 7.79±1.43° and the mean increase in first metatarsal length was 2.88±0.45mm. The pre-intervention mean values were 52.6 points in the AOFAS scale, and an overall result of 92.95 obtained after surgery (P<0.001).Conclusions: The opening proximal first metatarsal osteotomy without internal fixation and with first metatarsophalangeal resection arthroplasty can correct severe hallux valgus with an intermetatarsal angle ≥15° and a short first metatarsal, achieving low rate of complications.

Temporal and spatial expression of TGF-β1 in an Achilles tendon section model after application of platelet-rich plasma

2009-11-13

Abstract: Background: To investigate the effect of platelet-rich plasma (PRP) on TGF-β1 expression during tendon healing.Methods: We used 48 skeletally mature New Zealand White rabbits. 24 rabbits received the PRP, and 24 rabbits served as an untreated control group. Equal numbers of animals were sacrificed at 1st, 2nd, 3rd, and 4th week. The surgical procedure involved a transverse incision to transect the Achilles tendon. A volume of 1ml of PRP was then injected into the tendon mass in the PRP group. Histological and immunohistochemical evaluations with an anti-TGF-β primary antibody were performed.Results: The pattern of expression of TGF-β1 in the PRP group was characterized by a significant upregulation during the first 2 weeks and subsequently significant downregulation in the 3rd and 4th week in comparison with the controls.Conclusions: Our results suggest that PRP may affect the tendon healing process by altering the expression of TGF-β1.

Flexible cavovarus feet in Charcot-Marie-Tooth disease treated with first ray proximal dorsiflexion osteotomy combined with soft tissue surgery: A short-term to mid-term outcome study

A.E.E.P.M. Leeuwesteijn, E. de Visser, J.W.K. Louwerens — 2009-11-18

Abstract: Objectives: The purpose of this paper was to retrospectively evaluate the short-term to mid-term results of combined first ray proximal dorsiflexion osteotomy and soft tissue surgery in treatment of pes cavovarus with a fixed plantar flexed first ray and a passively correctable tarsus due to Charcot-Marie-Tooth disease.Patients and methods: Between January 1995 and July 2005, thirty-three patients with pes cavovarus deformity due to Charcot-Marie-Tooth disease were included. All patients had in common that prior to surgery the hindfoot was passively still adequate correctable at the talonavicular joint. The Coleman block test was performed to establish with certainty that hindfoot varus was a secondary deformity. Fourteen patients were male (21 feet) and nineteen were female (31 feet). Mean age at surgery was 28.1 years (range 13–59 years). Mean follow-up time was 56.9 months (range 13–153 months). Evaluation consisted of physical examination of all patients with assessment of early and late complications. The validated Foot Function Index (FFI) was used to measure pain and impairment. Patients’ satisfaction was assessed by a Quality of Care Through the Patients’ Eyes (QUOTE) questionnaire.Intervention: Surgical correction of cavovarus foot deformity consisted of dorsiflexion osteotomy at the base of the first metatarsal combined with tendon transfers. Secondary calcaneal osteotomy was performed in case of persistent varus of the calcaneus.Results: No major complications were seen. Recurrence of cavovarus deformity in two feet resulted in triple arthrodesis 37 and 64 months postoperatively. The FFI 5-point score for pain improved from a mean 29.3% to a mean 14.8% (p=0.005). The score for disability improved from a mean 37.8% to a mean 23.5% (p<0.001). Patients’ satisfaction was assessed by the QUOTE questionnaire. Seventy percent of the patients could walk barefoot after the operation and 77% of the patients had less pain after surgery. Pressure callosities diminished in 81%. Foot function was considered better after surgery by 84%. Ninety percent was satisfied with the correction of the deformity.Conclusions: First ray dorsiflexion osteotomy combined with tendon transfers is a good and consistent solution to realign the foot and provides short-term to mid-term satisfactory results in 90% of patients with a rigid forefoot cavus deformity due to plantar flexion of the first ray and with a still passively reducible tarsus.

Tenosynovial osteochondromatosis of the flexor hallucis longus tendon

Jeremy Oakley, Alun Yewlett, Nilesh Makwana — 2009-01-27

Abstract: We present a case of tenosynovial osteochondromatosis affecting the flexor hallucis longus tendon in a 29-year-old male with chronic ankle pain. Clinical examination was normal. Plain radiographs and MRI revealed multiple calcified lesions. These were removed surgically and histological analysis confirmed the diagnosis.This condition is rare, particularly in the foot and ankle. This is the first reported case of such a lesion with an absence of any clinically palpable nodules and highlights the need for a high index of suspicion and the need for imaging.

Pseudoaneurysm of the dorsalis pedis artery after ankle arthroscopy

Abdulla Kashir, Paul Kiely, Waqas Dar, Lester D'Souza — 2009-02-26

Abstract: Arthroscopic ankle synovectomy is believed to be associated with few complications. Vascular complications are rare, and we describe a case of iatrogenic pseudoaneursym formation of the dorsalis pedis artery (DPA) after ankle arthroscopy, using standard anteromedial and anterolateral ports, which has not been, we believe, previously reported in the literature.This rare complication required surgical exploration and ligation, and the patient had an uneventful recovery.

Alveolar rhabdomyosarcoma originating between the fourth and fifth metatarsal—Case report and literature review

J.C. Bolger, J.C. Walsh, R.E. Hughes, S.J. Eustace, P. Harrington — 2010-04-12

Abstract: We report a case of alveolar rhabdomyosarcoma arising between the fourth and fifth metatarsal. A 13-year-old boy presented to outpatients with a history of pain and swelling in the lateral aspect of his left forefoot. Plain radiographs and MRI showed a soft tissue mass displacing the fourth metatarsal. Percutaneous biopsy revealed an alveolar rhabdomyosarcoma. Staging scans showed advanced metastatic disease. The patient was treated with chemotherapy. This highly malignant lesion remains challenging to diagnose, and difficult to treat successfully.

Osteochondral lesion of the talus in homozygous twins—The question of heredity

Rodney B. Hammett, Terence S. Saxby — 2010-04-14

Abstract: We present a case of osteochondral lesion of the talus (OLT) in homozygous twins in adolescence occurring with no history of trauma. The aetiology of OLT is discussed.

An unusual presentation of talus fracture in a child: A case report

Hamidreza Yazdi, Mehdi Ramezan Shirazi — 2010-05-26

Abstract: Talar fracture in children is extremely rare. In 1919, Anderson described talar fractures and used the term of aviator astragalus in his series. We report a case of talar neck fracture in a 9-year-old boy which does not match with any type of Hawkins’ classification. We describe the radiological features of the fracture and outline its therapy and prognosis. To the best of the authors’ knowledge, such a case with this unusual presentation has not been previously reported in the literature.

Arteriovenous hemangioma of the foot—A case report

Venkat Perumal, Caycedo J. Francisco — 2010-05-06

Abstract: We report a case of a 40-year-old woman who presented with a heel mass on her left foot. She underwent removal of the mass, which was found to be an arteriovenous hemangioma (AVH). Arteriovenous hemangioma is a rare tumours, especially in the foot which is extremely rare. This tumour should be considered in the differential diagnosis of a mass presenting in the foot.

Non-union of Weber B distal fibula fractures: A case series

Lorcan McGonagle, Peter Ralte, Steven Kershaw — 2010-04-30

Abstract: Non-union of distal fractures of the fibula type Weber B is rare. Undisplaced and minimally displaced isolated lateral malleolar fractures (Weber B) usually unite without operative intervention. We present three cases of lateral malleolus non-union in healthy individuals. Two were treated with internal fixation plus bone grafting. The third patient remained asymptomatic and therefore did not undergo surgery for the fracture.

Irreducible Lisfranc dislocation due to the interposition of the tibialis anterior tendon: Case report and literature review

2010-06-28

Abstract: We report a case of a lateral type A (according to Myerson) Lisfranc dislocation irreducible by closed manipulation. Upon surgical exploration the lateral slip of the tibialis anterior tendon was found trapped between the medial and the middle cuneiform. Once the tendon was reduced, the dislocated first ray spontaneously reverted to its anatomical position and the joint was fixed with Kirschner wires. Seven similar cases have been reported in the literature. After analysis of all the reported cases we were able to describe a pattern of injury that may predict tibialis anterior interposition: (a) lateral type A according to Myerson dislocation; (b) after closed manipulation the 1st ray remains dislocated while the 5th metatarsal reduces; (c) there is a gap between the medial and the middle cuneiform or a fracture at the base of the 2nd metatarsal.

Compartment syndrome of the foot secondary to fixation of ankle fracture—A case report

Shigong Guo, Deepu Sethi, Divya Prakash — 2010-06-07

Abstract: Compartment syndrome in the leg after open reduction and internal fixation (ORIF) of ankle fractures is rare. Compartment syndrome in the foot after ORIF of ankle fractures has not been reported before. A high degree of vigilance must be exercised when managing these fractures in order to avoid complications and morbidity. We report a case in which a bimalleolar fracture of the left ankle resulted in compartment syndrome of the foot.

Soft-tissue osteochondroma of the heel pad: A case report and review of literature

2010-06-04

Abstract: Extraskeletal osteochondroma of the foot are rare benign cartilaginous tumours. We present a case of soft-tissue osteochondroma in the heel pad superficial to the postero-inferior aspect of the calcaneus. We propose the pathogenesis of this lesion might be related to metaplasia in the plantar aponeurosis as described in literature, or it may be a fracture of the calcaneal osteochondroma, growing and presenting as soft-tissue lesion in the heel pad.

Distally based sural lesser saphenous neuro-veno-adipo-fascial (NVAF) flap for reconstruction in the foot: Lessons learned

Kamlesh B. Patel, Samuel V. Bartholomew, Michael S. Wong, Thomas R. Stevenson — 2010-05-31

Abstract: We report nine cases in which the neuro-veno-adipo-fascial (NVAF) flap was used to perform reconstruction of foot wounds over a 7-year period. Complications occurred in five (56%) patients. One patient suffered total loss of the flap and four experienced partial loss of the NVAF flap. Complications are to be expected with the use of the NVAF flap for foot wounds, but in most cases the flap is salvageable. The NVAF flap is an option in foot reconstruction when free tissue transfer is not available, contraindicated due to patient factors or when a prior free flap has failed.

8TH EFAS CONGRESS, 2-4 September 2010, Geneva

2010-09-01