Do Patients With Functional Hallux Limitus Have a Low-Lying or Bulky FHL Muscle Belly?

Background: Functional hallux limitus (FHLim) refers to a limitation of hallux dorsiflexion when the first metatarsal head is under load, whereas physiologic dorsiflexion is measured in the unloaded condition. Limited excursion of the flexor hallucis longus (FHL) in the retrotalar pulley has been identified as a possible cause of FHLim. A low-lying or bulky FHL muscle belly could be the cause of this limitation. However, to date, there are no published data regarding the association between clinical and anatomical findings. The purpose of this anatomical study is to correlate the presence of FHLim and objective morphologic findings through magnetic resonance imaging (MRI). Methods: Twenty-six patients (27 feet) were included in this observational study. They were divided into 2 groups, based on positive and negative Stretch Tests. In both groups, we measured on MRI the distance from the most inferior part of the FHL muscle belly and the retrotalar pulley as well as the cross-sectional area of the muscle belly 20, 30, and 40 mm proximal to the retrotalar pulley. Results: Eighteen patients had a positive Stretch Test and 9 patients had a negative Stretch Test. The mean distance between the most inferior part of the FHL muscle belly and the retrotalar pulley was 6.0 ± 6.4 mm for the positive group and 11.8 ± 9.4 mm for the negative group (P = .039). The mean cross section of the muscle measured at 20, 30, and 40 mm from the pulley were 190 ± 90, 300 ± 112, and 395 ± 123 mm2 for the positive group and 98 ± 44, 206 ± 72, and 294 ± 61mm2 for the negative group (P values .005, .019, and .017). Conclusion: Based on these findings, we can conclude that patients with FHLim do have a low-lying FHL muscle belly causing limited excursion in the retrotalar pulley. However, the mean volume of the muscle belly was comparable in both groups, and therefore bulkiness was not found to be a contributing factor. Level of Evidence: Level III, observational study.

Articular Cartilage Repair After Implantation of Hyaline Cartilage Beads Engineered From Adult Dedifferentiated Chondrocytes: Cartibeads Preclinical Efficacy Study in a Large Animal Model.

BACKGROUND: Chondrocyte-based cell therapy to repair cartilage has been used for >25 years despite current limitations. This work presents a new treatment option for cartilage lesions. HYPOTHESIS: High-quality hyaline cartilage microtissues called Cartibeads are capable of treating focal chondral lesions once implanted in the defect, by complete fusion of Cartibeads among themselves and their integration with the surrounding native cartilage and subchondral bone. STUDY DESIGN: Controlled laboratory study. METHODS: Cartibeads were first produced from human donors and characterized using histology (safranin O staining of glycosaminoglycan [GAG] and immunohistochemistry of collagen I and II) and GAG dosage. Cartibeads from 6 Göttingen minipigs were engineered and implanted in an autologous condition in the knee (4 or 5 lesions per knee). One group was followed up for 3 months and the other for 6 months. Feasibility and efficacy were measured using histological analysis and macroscopic and microscopic scores. RESULTS: Cartibeads revealed hyaline features with strong staining of GAG and collagen II. High GAG content was obtained: 24.6-µg/mg tissue (wet weight), 15.52-µg/mg tissue (dry weight), and 35 ± 3-µg GAG/bead (mean ± SD). Histological analysis of Göttingen minipigs showed good integration of Cartibeads grafts at 3 and 6 months after implantation. The Bern Score of the histological assay comparing grafted versus empty lesions was significant at 3 months (grafted, n = 10; nongrafted, n = 4; score, 3.3 and 5.3, respectively) and 6 months (grafted, n = 11; nongrafted, n = 3; score, 1.6 and 5.1). CONCLUSION: We developed an innovative 3-step method allowing, for the first time, the use of fully dedifferentiated adult chondrocytes with a high number of cell passage (owing to the extensive amplification in culture). Cartibeads engineered from chondrocytes hold potential as an advanced therapy medicinal product for treating cartilage lesions with established efficacy. CLINICAL RELEVANCE: This successful preclinical study, combined with standardized manufacturing of Cartibeads according to good manufacturing practice guidelines, led to the approval of first-in-human clinical trial by the ethics committee and local medical authority. The generated data highlighted a promising therapy to treat cartilage lesions from a small amount of starting biopsy specimen. With our innovative cell amplification technology, very large lesions can be treated, and older active patients can benefit from it.

Hyaline Cartilage Microtissues Engineered from Adult Dedifferentiated Chondrocytes: Safety and Role of WNT Signaling.

The repair of damaged articular cartilage is an unmet medical need. Chondrocyte-based cell therapy has been used to repair cartilage for over 20 years despite current limitations. Chondrocyte dedifferentiation upon expansion in monolayer is well known and is the main obstacle to their use as cell source for cartilage repair. Consequently, current approaches often lead to fibrocartilage, which is biomechanically different from hyaline cartilage and not effective as a long-lasting treatment. Here, we describe an innovative 3-step method to engineer hyaline-like cartilage microtissues, named Cartibeads, from high passage dedifferentiated chondrocytes. We show that WNT5A/5B/7B genes were highly expressed in dedifferentiated chondrocytes and that a decrease of the WNT signaling pathway was instrumental for full re-differentiation of chondrocytes, enabling production of hyaline matrix instead of fibrocartilage matrix. Cartibeads showed hyaline-like characteristics based on GAG quantity and type II collagen expression independently of donor age and cartilage quality. In vivo, Cartibeads were not tumorigenic when transplanted into SCID mice. This simple 3-step method allowed a standardized production of hyaline-like cartilage microtissues from a small cartilage sample, making Cartibeads a promising candidate for the treatment of cartilage lesions.

Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm.

Current literature has described many of the complications following hallux valgus surgery and their treatment options. Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet. Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique. We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication. With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Computer-assisted surgery and navigation in foot and ankle: state of the art and fields of application.

Computer-assisted orthopaedic surgery (CAOS) is a real-time navigation guidance system that supports surgeons intraoperatively.Its use is reported to increase precision and facilitate less-invasive surgery.Advanced intraoperative imaging helps confirm that the initial aim of surgery has been achieved and allows for immediate adjustment when required.The complex anatomy of the foot and ankle, and the associated wide range of challenging procedures should benefit from the use of CAOS; however, reports on the topic are scarce.This article explores the fields of applications of real-time navigation and CAOS in foot and ankle surgery. Cite this article: EFORT Open Rev 2021;6:531-538. DOI: 10.1302/2058-5241.6.200024.

[Clinical experience of an offloading orthosis to prevent and heal diabetic foot ulcers of the digits]. / Expérience clinique d'une orthèse de décharge pour prévenir et guérir les ulcères digitaux du pied diabétique.

Globally, every 30 seconds a lower limb amputation is carried out due to diabetes, in 85 % of cases preceded by a foot ulcer. One of the main causes of foot ulcer formation is abnormal mechanical pressure and shear, the alleviation of which is therefore a key element in the management of diabetic foot ulcers. The toes, often neglected in routine clinical examinations, are particularly vulnerable because of the thin soft tissue between the bones and the skin and because of trauma due to ill-fitting shoes. The orthosis described in this article provides effective protection of protruding and injured areas while being comfortable to wear with everyday shoes and compatible with an active lifestyle. When correctly designed, worn and monitored, it has the potential to prevent and heal diabetic ulcers of the Hallux and the lesser toes.

Toutes les 30 secondes, une personne dans le monde subit une amputation du membre inférieur due au diabète, précédée dans 85 % des cas d'un ulcère au pied. L'allègement d'une pression mécanique néfaste est un élément clé dans la prise en charge du pied diabétique. Les orteils, souvent négligés dans l'examen clinique, sont particulièrement vulnérables en raison de la minceur des tissus mous entre les os et la peau et à cause des chaussures potentiellement nuisibles car inadaptées à la forme et au volume de l'avant-pied. L'orthèse de décharge décrite dans cet article assure une protection efficace des zones saillantes et lésées tout en étant confortable à porter et compatible avec une vie active. Conçue et portée correctement, elle a le potentiel de prévenir et guérir les ulcères digitaux du pied diabétique.

What Is the Optimal Protocol for Performing Debridement, Antibiotics and Implant Retention (DAIR) in an Infected Total Ankle Arthroplasty (TAA) (Type and Volume of Irrigation Solution, and so on)?

RECOMMENDATION: Debridement, antibiotics, and implant retention (DAIR) in acute total ankle arthroplasty (TAA) infections may be an acceptable treatment option. If performed, DAIR should be done meticulously, ensuring that all necrotic or infected tissues are removed and modular parts of the prosthesis, if any, exchanged. The infected joint should also be irrigated with antiseptic solutions. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Does Intra-articular Injection of the Ankle With Corticosteroids Increase the Risk of Subsequent Periprosthetic Joint Infection (PJI) Following Total Ankle Arthroplasty (TAA)? If So, How Long After a Prior Intra-articular Injection Can TAA Be Safely Performed?

RECOMMENDATION: Every intra-articular injection of the ankle is an invasive procedure associated with potential healthcare-associated infections, including periprosthetic joint infection (PJI) following total ankle arthroplasty (TAA). Based on the limited current literature, the ideal timing for elective TAA after corticosteroid injection for the symptomatic native ankle joint is unknown. The consensus workgroup recommends that at least 3 months pass after corticosteroid injection and prior to performing TAA. LEVEL OF EVIDENCE: Limited. DELEGATE VOTE: Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).

What Tests Are Useful to Investigate a Possible Infection of Total Ankle Arthroplasty (TAA)? What Are Their Thresholds?

RECOMMENDATION: Overall, the approach to a potentially infected total ankle arthroplasty (TAA) does not change compared to other periprosthetic joint infections (PJIs). There are no novel or unique diagnostic procedures for TAA infection, specifically. Joint aspiration or intraoperative tissue/synovial biopsies with microbiological cultures are the most important diagnostic tests for suspected TAA infections. In the absence of specific data related to TAA, the threshold for these tests should be derived from the hip and knee PJI literature. LEVEL OF EVIDENCE: Strong. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort.

OBJECTIVE: The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS: Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS: We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION: According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.

Muscular Versus Non-Muscular Free Flaps for Soft Tissue Coverage of Chronic Tibial Osteomyelitis.

BACKGROUND: Eradication of chronic tibial osteomyelitis necessitates aggressive debridement is often followed by soft tissue reconstruction. Muscular flaps are said to be more effective than non-muscular flaps for infection treatment, while fasciocutaneous and perforator flaps are considered to be less invasive and offering a better aesthetic result. METHODS: In this study, we reviewed 24 consecutive cases of chronic tibial osteomyelitis treated according to a specific protocol in a tertiary hospital. Soft tissue coverage was done with either muscular or non-muscular free flaps. Infection recurrence and complications were compared between different flap types. Additionally, we assessed the long-term functional and aesthetic results and patient's satisfaction. RESULTS: Muscular flap was used in 13 patients (13 latissimus dorsi and 1 serratus anterior) and 11 patients underwent fasciocutaneous/perforator flaps [1 anterolateral thigh flap, 4 lateral arm flaps, 5 thoracodorsal artery perforator (TAP) flaps and 1 radial forearm flap]. Infection was resolved for 84.6% of patients in the muscular flaps group and 90.9% in the non-muscular flaps group. None of the patients with muscular flaps were satisfied with the aesthetic appearance of their reconstructed leg when compared to 83.3% of patients with non-muscular flaps. Also, a slight regain of touch sensitivity was acknowledged in the non-muscular flap group compared to the muscular. CONCLUSION: In this study of adult chronic tibial osteomyelitis cases, we demonstrated that fasciocutaneous and perforator free flaps offer a comparable efficacy to the muscle flaps for infection treatment, with a significantly higher patient satisfaction and aesthetic result.

Repair of syndesmosis injury in ankle fractures: Current state of the art.

Conventional treatment of syndesmosis injuries in rotationally unstable ankle fractures is associated with an unacceptably high rate of malreduction, and this has led to a paradigm shift in the approach to a newer concept of anatomical repair.In the anatomical approach, the principle is to 'directly fix what is broken and repair what is torn'. The approach is effective in reducing the rate of syndesmosis malreduction, increasing the biomechanical strength of syndesmosis fixation and avoiding the need for trans-syndesmotic fixation and its secondary removal.The objective of this review article is to compare the conventional treatment of these injuries (accepted usage, general consent, traditional, generally accepted) with a newer anatomical approach to be considered as a shift in thinking. Cite this article: EFORT Open Rev 2018;3:24-29. DOI: 10.1302/2058-5241.3.170017.

Additional muscular slip of the flexor digitorum longus muscle to the fifth toe.

Despite the fact that there are numerous reports on muscular variations in the sole of the foot, routine dissection in a formaldehyde-fixed cadaver revealed an accessory flexor digiti quinti muscle, which to the best of our knowledge is a very unusual variant. This was in the form of a slender, 38 mm long muscular slip, with a proximal and distal tendon extending from the common flexor digitorum longus tendinous plate out to the distal phalanx of the fifth toe. An associated finding was the absence of the musculotendinous portion of the flexor digitorum brevis to the same toe. A developmental explanation for this variation is presented. Clinical implications with regard to this anatomical condition may result in clawing of the fifth toe.

[Evidence based treatment of hallux valgus]. / Traitement de l'hallux valgus basé sur l'évidence.

Hallux valgus is a frequent disorder of the foot and decision-making about the best treatment provokes many questions among patients and specialists. These include the need for surgery, which surgical technique is the best choice, and is minimally invasive surgery going to replace open techniques? While the modern media provides patients with easy access to details concerning surgical techniques, they rarely include means for the patient to distinguish between objective information and publicity. The general practitioner is a person of trust for the patient and should help him or her consider treatment proposals. With these factors in mind, the aim of this paper is to share the evidence-based information regarding the treatment of hallux valgus with the general practitioner.

L'hallux valgus est une pathologie du pied fréquente et sa prise en charge suscite actuellement beaucoup de questions tant parmi les patients que parmi les experts. La chirurgie est-elle indispensable ? A quel moment faut-il opérer ? Quelle technique utiliser ? La chirurgie mini-invasive va-t-elle remplacer les techniques ouvertes ? Les médias modernes permettent aux patients un accès facile aux détails concernant les techniques chirurgicales existant sur le marché, sans pour autant leur donner des moyens de distinction entre l'information objective et la promotion. Le médecin traitant est un spécialiste de confiance vers lequel le patient doit pouvoir se tourner avant d'accepter une proposition thérapeutique. C'est pourquoi, et c'est le but de cet article, il nous paraît essentiel de partager la connaissance du traitement de l'hallux valgus basée sur l'évidence avec le médecin traitant.

How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches.

OBJECTIVE: Our objective is to review the anatomy and exposure of the posterior column and posterior tibial malleolus (the posterior tibial plafond) by defining the access corridors through 3 different approaches-posteromedial, posterolateral, and modified posteromedial. METHODS: Cadaveric dissection with percentage of posterior tibial malleolus exposed, and strain gauge measurements to evaluate traction on the neurovascular bundle. RESULTS: The 3 different approaches are applicable for exposure of different portions of the distal posterior tibial malleolus. Strain gauge measurements reveal the least traction on the flap containing the neurovascular bundle with the modified posteromedial approach (7.0 N) compared with the posteromedial (21.5 N) and posterolateral (16.8 N) approaches. Exposure of the posterior tibial malleolus was greater with the modified posteromedial approach (91%) compared with the other 2 approaches (posteromedial = 64%, posterolateral = 40%). CONCLUSIONS: Depending on the location of the principal fracture fragments, particularly in high energy ankle and pilon fractures, each of the posterior approaches has its indication, with the modified posteromedial approach revealing more of the posterior anatomy than the other 2 approaches. The latter approach places the least traction on the flap containing the neurovascular bundle.

Technique tip: Simultaneous first metatarsal lengthening and metatarsophalangeal joint fusion for failed hallux valgus surgery with transfer metatarsalgia.

BACKGROUND: Failed hallux valgus surgery may result in residual or recurrent hallux valgus, and as well transfer metatarsalgia. The present technical tip concerns the combination of fusion of the first metatarsophalangeal (MTP) joint and lengthening of the first metatarsal (MT) through a scarf osteotomy. MATERIALS AND METHODS: Six patients underwent the presented technique, all for the indication of failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint. RESULTS: Follow-up at six months revealed all patients had complete healing of the osteotomy and arthrodesis sites. They were all asymptomatic and fully active, completely satisfied with the outcome. CONCLUSIONS: Combined fusion of the first MTP joint and lengthening of the first MT through a scarf osteotomy results in an excellent outcome in patients with failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint.

Calcified desmoplastic fibroblastoma of the foot: imaging findings.

We report a case of desmoplastic fibroblastoma (DF) of the foot in a 65-year-old woman. The tumor presented as a slow-growing, painless mass located in the first intermetatarsal space of the right foot. Ultrasound showed a well-circumscribed hypoechoic lesion containing hyperechoic calcifications confirmed on standard radiographs. At magnetic resonance imaging (MRI), the mass appeared isointense to the muscles on T1-weighted (T1W) images, hyperintense on proton-density-weighted fat-saturated images, and presented scattered internal hypointense foci. Post-contrast T1W spectral presaturation with inversion recovery (SPIR) images showed heterogeneous, mostly peripheral, contrast enhancement. DF must be considered in the differential diagnosis of soft-tissue calcified tumors of the foot.

Comparison of the Otto Bock solid ankle cushion heel foot with wooden keel to the low-cost CR-Equipements™ solid ankle cushion heel foot with polypropylene keel: A randomized prospective double-blind crossover study assessing patient satisfaction and energy expenditure.

BACKGROUND: The International Committee of the Red Cross supports a worldwide program of prosthetic fitting and rehabilitation. In this context, a prosthetic foot was developed and widely distributed in least developed countries. STUDY DESIGN: Prospective, randomized, double-blind, controlled study. OBJECTIVE: To compare patient satisfaction and energy expenditure during ambulation between a low-cost prosthetic foot designed with a polypropylene keel (CR-Equipements™ solid ankle cushion heel, International Committee of the Red Cross) to a well-recognized solid ankle cushion heel foot with a wooden keel (solid ankle cushion heel foot, Otto Bock). METHODS: A total of 15 participants with unilateral transtibial amputation were evaluated using the two prosthetic feet in a randomized prospective double-blind crossover study. Main outcomes were patient satisfaction questionnaires (Satisfaction with Prosthesis Questionnaire and prosthetic foot satisfaction) and energy expenditure (oxygen consumption-mL/kg/min, oxygen cost-mL/kg/m, and heart rate-bpm). RESULTS: There were no significant differences between the two prosthetic feet for satisfaction and energy expenditure. CONCLUSION: The low-cost solid ankle cushion heel foot with polypropylene keel provides comparable satisfaction and similar energy expenditure as the solid ankle cushion heel foot with wooden keel. Clinical relevance The results of this study support the application and widespread use of the CR-Equipements™ solid ankle cushion heel foot. From a cost-effectiveness standpoint, patients are well satisfied and exhibit similar outcomes at a substantially lower cost.

Syndesmosis reduction by computer-assisted orthopaedic surgery with navigation: Feasibility and accuracy in a cadaveric study.

INTRODUCTION: Syndesmotic disruption may be difficult to reduce and fix, and malreduction is associated with inferior outcomes. Intraoperative computed tomography (CT) can provide accurate assessment of syndesmotic reduction. We hypothesized that three-dimensional (3-D) computer-assisted orthopaedic surgery (CAOS) with navigation of syndesmotic reduction could avoid malreduction. Our goal was to assess feasibility and accuracy of such a technic in a cadaveric study. METHOD: Eleven through-the-knee cadaveric specimens were used. Ankle CT as control was obtained prior to intervention. The syndesmosis was destabilized by sectioning the tibiofibular ligaments, producing a malreduction temporarily fixed with a Kirschner wire (K-wire). With reference base fixed to the tibia an acquisition scan was made. A K-wire was fixed to the fibula. The K-wire holding the syndesmosis malreduced was removed. The fibula was reduced within the syndesmosis under 3-D CAOS using a navigated K-wire. Once optimal position was obtained by referencing control images, the syndesmosis was fixed with a 3.5mm screw. A CT scan was performed to assess quality of reduction. RESULTS: Position of the fibula in control and post-reduction CT scans showed a mean anterior-posterior displacement of 0.74 (±0.62)mm. The medial-lateral position measured a mean displacement of 0.68 (±0.76)mm. Rotation of the fibula revealed a mean difference of 0.99° (± 0.73). CONCLUSION: In this cadaveric study, CAOS with navigation allowed for very accurate syndesmosis reduction. This appears to be a promising technique to be confirmed by clinical study.

Intraoperative 3-Dimensional Computed Tomography and Navigation in Foot and Ankle Surgery.

Computer-assisted orthopedic surgery has developed dramatically during the past 2 decades. This article describes the use of intraoperative 3-dimensional computed tomography and navigation in foot and ankle surgery. Traditional imaging based on serial radiography or C-arm-based fluoroscopy does not provide simultaneous real-time 3-dimensional imaging, and thus leads to suboptimal visualization and guidance. Three-dimensional computed tomography allows for accurate intraoperative visualization of the position of bones and/or navigation implants. Such imaging and navigation helps to further reduce intraoperative complications, leads to improved surgical outcomes, and may become the gold standard in foot and ankle surgery. [Orthopedics.2016; 39(5):e1005-e1010.].