Retrospective Analysis of Radiographic Outcomes After Closing Base Wedge Osteotomy for Correction of Bunion Deformity.

BACKGROUND: Closing base wedge osteotomy (CBWO) is a common procedure to correct severe bunion deformities with high intermetatarsal angles. There are few data demonstrating the radiographic success of CBWOs. METHODS: We evaluated the radiographic outcomes of a CBWO. The primary aim was to assess the change in elevatus after a CBWO. Secondary aims included measuring the change in hallux abductus (HA) and intermetatarsal angles after the osteotomy. The medical records of 24 consecutive patients across 4 years were reviewed. All of the CBWOs were fixated with either one screw and one Kirschner wire or two screws. We hypothesized that the CBWO would reduce the amount of elevatus present. RESULTS: The mean patient age was 35 years. Average preoperative HA and intermetatarsal angles were 35.2° and 15.7°, respectively. Mean postoperative HA and intermetatarsal angles at last radiographic follow-up were 13.3° and 6.1°, respectively. The change in HA and intermetatarsal angles was 21.9° and 9.6°, respectively. All of the patients achieved clinical union. Mean radiographic follow-up was 6 months; median radiographic follow-up was 5 months. The mean preoperative elevatus measurement was 3.5 mm; the mean postoperative elevatus measurement was 2.0 mm (difference, -1.6 mm; P = .0282), indicating that the osteotomy plantarflexed the first metatarsal. Three patients had radiographic evidence of postoperative elevatus; they were asymptomatic at the last clinical follow-up. CONCLUSIONS: Although clinical concern persists for the development of postoperative elevatus with CBWO, this case series showed plantarflexion of the CBWO. The CBWO is a powerful yet stable procedure for severe bunion deformities and should be viewed as a viable alternative to the Lapidus procedure.

Assessment of Flap Viability for Complex Transmetatarsal Amputation Using Indocyanine Green Fluorescent Angiography: A Case Study.

Despite advancements in the treatment of diabetic patients with "at-risk" limbs, minor and major amputations remain commonplace. The diabetic population is especially prone to surgical complications from lower extremity amputation because of comorbidities such as renal disease, hypertension, hyperlipidemia, microvascular and macrovascular disease, and peripheral neuropathy. Complication occurrence may result in increases in hospital stay duration, unplanned readmission rate, mortality rate, number of operations, and incidence of infection. Skin flap necrosis and wound healing delay secondary to inadequate perfusion of soft tissues continues to result in significant morbidity, mortality, and cost to individuals and the health-care system. Intraoperative indocyanine green fluorescent angiography for the assessment of tissue perfusion may be used to assess tissue perfusion in this patient population to minimize complications associated with amputations. This technology provides real-time functional assessment of the macrovascular and microvascular systems in addition to arterial and venous flow to and from the flap soft tissues. This case study explores the use of indocyanine green fluorescent angiography for the treatment of a diabetic patient with a large dorsal and plantar soft-tissue deficit and need for transmetatarsal amputation with nontraditional rotational flap coverage. The authors theorize that the use of indocyanine green may decrease postoperative complications and cost to the health-care system through fewer readmissions and fewer procedures.

Reulceration and Reoperation Incidence After Isolated Partial Fifth Ray Amputations: A Multicenter Study.

Ulceration or reulceration is a common complication following partial or total fifth ray amputations. The primary aim of this study was to evaluate the incidence of reulceration following partial fifth ray amputations. This was a multicenter review of 117 consecutive limbs that underwent partial fifth ray amputations at the University of Pittsburgh Medical Center and Wake Forest Baptist Medical Centers. Procedures were performed at various levels along the fifth metatarsal. Incidence of postoperative ulceration was evaluated on the ipsilateral foot. We hypothesized there would be an association between location of resection and development of reulceration. Seventy-one of 117 patients (60.7%) experienced repeat ulceration following a partial fifth ray amputation. Median follow-up time was 19 months. There was no statistical difference based on location of amputation (proximal, middle, distal, isolated base) with regards to reulceration (p = .166), further amputation (p = .271), transmetatarsal amputation (p = .160), or below knee amputation (p = .769). There was statistical significance in the follow up time between study sites (p = .013), fifth ray amputation reoperation rate between study sites (p = .001), and reulceration rates between study sites (p = .017). Partial fifth ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. The results of the present study put forward that there is not an association between location of amputations of the fifth ray and development of reulceration, transfer lesions or more proximal amputations.

Atypical Presentation of Navicular Aneurysmal Bone Cyst in a Symptomatic Pediatric Flatfoot Deformity: A Case Report.

Aneurysmal bone cysts (ABCs) are rare in the foot, accounting for 4% to 6.3% of all ABCs found in the body. Approximately 80% of patients diagnosed with an ABC are in the second decade of life. While benign, pain and deformity are often the presenting symptoms. This report's objective is to describe, to our knowledge, the first reported case of a pediatric navicular ABC in association with pediatric flatfoot deformity that was successfully treated with curettage and bone grafting. An additional goal of the report is to highlight how the diagnosis of these osseous tumors can easily be missed given the overlap in symptoms with pediatric flatfoot deformity. An 11-year-old female presented to clinic with a chief complaint of painful, flatfoot deformity and discomfort to the medial midfoot after walking for more than 2 city blocks. The patient was conservatively treated for pediatric flatfoot deformity at an outside institution and advised that a surgical flatfoot reconstruction would be necessary to relieve her symptomology. On examination, the patient exhibited focal pain to the medial aspect of the navicular. Radiographs revealed an ill-defined, expansile, sclerotic lesion of the navicular, and MRI demonstrated a multicystic lesion filling the navicular, consistent with an ABC. Treatment included curettage and packing with allograft. At 1-year follow-up, the patient is well, with minimal pain and return to full activity without functional limitations. Local recurrence of an aneurysmal bone cyst following curettage and bone grafting is as high as 22% with patient age and lesion size comprising the main risk factors. This report demonstrates successful curettage of an ABC within the navicular and preservation of osseous articulations in a pediatric patient. At 1-year follow-up, the patient had minimal pain with no evidence of recurrence.