Does foot shape really matter? Correlation of patient reported outcomes with radiographic assessment in progressive collapsing foot deformity reconstruction: A systematic review.

BACKGROUND: In progressive collapsing foot deformity (PCFD), the goal of surgery is to obtain a well-balanced plantigrade foot. It remains unclear if restoration of the alignment and subsequent improvement in radiological parameters is associated with improved patient-reported outcome measures (PROMs). The aim of the current systematic review was to investigate whether there is a correlation between radiographic assessment and PROMs in patients treated surgically for flexible PCFD. MATERIALS AND METHODS: The study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A comprehensive literature search was performed in Pubmed, EMBASE, Cochrane Central Register of Controlled Trails (CENTRAL), and KINAHL. We included all the studies reporting both PROMs and radiological outcomes in patients treated surgically for PCFD. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. RESULTS: Six retrospective studies were included. Radiological parameters related to forefoot plantarflexion were associated with statistically significant differences in postoperative PROMs. A neutral hindfoot and midfoot position was positively correlated with postoperative PROMs but a statistically significant difference could not be established in all studies. The medial arch height was positively correlated with PROMs, but in one study this was the case only in revision surgeries. CONCLUSION: The literature so far suggests restoration of the alignment may be associated with improved PROMs. Future prospective studies that investigate possible radiological and clinical correlations in PCFD surgery are needed. LEVEL OF EVIDENCE: III.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork.

Background: Following Lisfranc injury fixation, no consensus exists on whether to routinely remove metalwork. The aim of this study was to evaluate functional outcomes and complications in patients following routine removal of metalwork and in those with retained metalwork. Methods: A systematic review of literature (1999-2020) reporting results of metalwork removal vs retention following Lisfranc injury fixation, was undertaken. The primary outcome was functional outcomes at 1 year following index surgery. Secondary outcomes were rates of complications including unplanned removal of metalwork. Results: No studies directly comparing routine metalwork removal vs retention were found. A total of 28 studies reporting on 1069 patients were included. Of these, 10 studies (317 patients) reported on retention and 18 (752 patients) on routine removal of metalwork. The difference in the American Orthopaedic Foot & Ankle Society (AOFAS) score between removal and retention groups was 3.38 (95% CI 6.3-0.48), P = .02 (removal 79.97 [±16.09; 71-96]; retention 76.59 [±20.36; 65.4-94]). No difference in reported rates of infection was found between the 2 groups (0%-12% for both groups). Of the 317 patients in the retention group, metalwork was removed in 198 cases, resulting in a 62.5% unplanned removal rate. Conclusion: In conclusion, this systematic review found limited evidence comparing different strategies of metalwork management after Lisfranc injury fixation. A randomized controlled trial is necessary to elucidate if routine removal of metalwork confers any true benefit. Level of Evidence: Level IV, systematic review including case series.

Elective removal of metalwork following Lisfranc injury fixation: Results of a national consensus survey of practice.

No consensus exists regarding whether metalwork should be routinely removed following fixation of a Lisfranc injury. When metalwork is removed, notable variation in the timing of surgery is reported in current literature. With the support of the British Orthopaedic Foot & Ankle Society (BOFAS) and the Orthopaedic Trauma Society (OTS) an online 10-question survey was distributed and completed by a total of 205 consultant surgeons in the UK between April-June 2020. Excluding the 20 consultant responses from a regional pilot survey, 185 responses were used to form the main analysis. Over one third (69/183, 37.7%) of surgeons reported they routinely remove metalwork following Lisfranc injury fixation at a median time of 6 months post fixation (interquartile range 4-10). The two most commonly chosen reasons for removal of metalwork were 'to optimise physiological function' and 'to reduce the risk of broken metalwork and risk of making subsequent surgery more difficult' (55/78 responses, 70.5%). Over two thirds of survey respondents (126/184, 68.5%) expressed interest to participate in a randomised controlled trial to compare outcomes of metalwork retention versus removal following Lisfranc injury fixation. Community clinical equipoise exists nationally regarding routine metalwork removal following Lisfranc injury fixation. Considering the paucity of literature, the current survey supports the development of a randomised controlled trial to establish the risks and benefits of metalwork retention versus removal, and would be of value to foot & ankle and trauma surgeons in the UK.

A Prospective Evaluation of First Metatarsophalangeal Fusion Using an Innovative Dorsal Compression Plating System.

Numerous techniques have been described for first metatarsophalangeal joint (MTPJ) fusion. The aim of this study was to prospectively evaluate an innovative plating system which uses a cross plate compression screw. Thirty consecutive first MTPJ fusions in 28 patients were evaluated. All procedures were performed by a single fellowship trained consultant foot and ankle surgeon. Patient function was evaluated preoperatively at 6 and at 12 months using the Manchester-Oxford Foot Questionnaire (MOXFQ). Union rates and complications were recorded. Postoperative MOXFQ scores demonstrated significant improvement in all domains, with mean improvement at 12 months of 35, 27, 17 and 106 points for pain, walking/standing, social interactions and combined scores respectively (p value ≤.0001). In all 30 cases, clinical and radiological evidence of union was achieved by 6 months. Superficial infection occurred in 1 (3%) case. One (3%) case required plate removal due to soft tissue irritation. There were no plate failures. This evaluation study demonstrates that this cross-plate compression plating system is safe, provides high patient satisfaction and reliable union, with low complication rates. Prospective comparative research is now required to determine the optimal technique for first MTPJ fusion.

Cytohistological correlation, immunohistochemistry and Murine Double Minute Clone 2 amplification of pulmonary artery intimal sarcoma: A case report with review of literature.

Pulmonary artery intimal sarcoma is a rare aggressive intraluminal tumor often misdiagnosed as acute or chronic pulmonary thromboembolism due to its clinical presentation and radiological findings. Thus early diagnosis is very crucial and may improve patient outcome. There is limited literature on diagnosis of pulmonary artery sarcoma by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Herein, we report a case of mass-like lesion in the PA diagnosed on cytological material obtained by EBUS-TBNA with rapid on-site evaluation (ROSE). The aspirate showed pleomorphic malignant spindled cells arranged in loosely cohesive clusters. The intraluminal origin of PAIS was supported by radiographic findings. Subsequently, the patient received preoperative chemotherapy and underwent tumor resection with reconstruction. This report describes the cytomorphologic features of this rare intravascular tumor and demonstrates how limited cytological sample obtained from EBUS-TBNA with ROSE can be triaged efficiently for ancillary studies like immunohistochemistry and MDM2 amplification, thus expediting the management.

Fusion of the First Metatarsophalangeal Joint: Precontoured or Straight Plate?

Precontoured, low-profile plates with fixed dorsiflexion angles are becoming increasingly popular for first metatarsophalangeal joint fusion. We have concerns that the routine use of a precontoured plate can lead to excessive clinical dorsiflexion. The aim of our study was to investigate the relationship between the first metatarsophalangeal joint dorsiflexion intramedullary angle and the angle formed at the dorsal cortices where the plate is applied. We hypothesized that the dorsal cortical angle was significantly less dorsiflexed than the intramedullary angle. We measured both angles on lateral weightbearing radiographs of 40 consecutive individuals presenting with forefoot symptoms. The results demonstrated that the mean dorsal cortical angle was significantly smaller (mean 0.2° plantarflexion) compared with the intramedullary angle (mean 10.6° dorsiflexion; p < .001). The interobserver and intraobserver reliability of both the intramedullary and the dorsal cortical measurements was very good. In conclusion, the dorsal cortical angle is, on average, 10.8° smaller than the intramedullary angle, with a mean angle of almost 0°. This finding should be considered when selecting plates for first metatarsophalangeal joint fusion.

Audit of foot and ankle surgeons' management of acute peroneal tendon tears and review of management protocols.

INTRODUCTION: The aim of this audit was to identify whether there is consistent and successful management of acute peroneal tendon tears within orthopaedic foot and ankle consultants in the Wessex area of the UK. It was suspected that there was an absence of consistency between surgeons' practices and a more evidenced based management protocol could be developed. MATERIALS AND METHODS: A questionnaire of the orthopaedic surgeons in Wessex investigated whether there was consistency in surgical management of peroneal tears. RESULTS: Our results demonstrate that each of the nine surgeons' management of acute peroneal tendon tears varied greatly. CONCLUSION: The evidence in the literature was examined in an attempt to produce a protocol to aid surgical decision-making. A randomised controlled trial is required for consistent evidenced based surgical management of peroneal tendon tears.

Stress fractures of the tibia and medial malleolus.

Tibial diaphyseal stress fractures are rare in the general population, but are more frequently seen in the athletic and military communities. The diagnosis of this problem may be problematic and needs to be considered in all athletes and military recruits who present with shin or ankle pain. The female triad in athletes (low-energy availability/disordered eating, amenorrhea, and osteoporosis/osteopenia) should be considered in those women who sustain this injury. Management is usually conservative with a variety of rehabilitation programs suggested, but a pragmatic approach is to manage the patient symptomatically.

Failed operative treatment in two cases of pseudarthrosis of the clavicle using internal fixation and bovine cancellous xenograft (Tutobone).

The most commonly reported technique of reconstructive surgery for congenital pseudarthrosis of the clavicle involves resection of the pseudarthrosis, insertion of autologous iliac crest bone graft and internal fixation. In an attempt to avoid the potential complications of iliac crest bone graft harvest we used bovine cancellous xenograft (Tutobone). Two cases of pseudarthrosis of the clavicle treated with resection of the pseudarthrosis, Tutobone graft and internal fixation are presented. Both cases resulted in treatment failures, which were associated with significant osteolysis and failure of incorporation of the graft material. This required removal of the loose metal work and debridement of the failed graft material. We would caution surgeons against the use of Tutobone as a graft material in the surgical management of pseudarthrosis of the clavicle. The level of evidence was level IV case series.

Continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery: a prospective, randomized trial.

BACKGROUND: Popliteal sciatic nerve blockade is a commonly used technique employed in the management of postoperative pain following foot and ankle surgery. Recent studies have shown that for outpatient surgery, for moderately painful procedures, a continuous infusion of local anesthesia via an in-dwelling catheter for 48 to 72 hours leads to reduced opiate analgesic requirements and improved pain and patient satisfaction scores. MATERIALS AND METHODS: A prospective, randomized, double blind, placebo-controlled trial of a continuous infusion of bupivacaine verses normal saline via a popliteal catheter after a single bolus popliteal block for 72 hours after major ankle and hind foot surgery was performed in 54 patients. RESULTS: The average pain scores overall were low (range, 1.1 to 3.6 on a Visual Analogue Scale of 0 to 10) throughout the study period. Statistically significantly lower pain scores with significantly less requirement for supplementary opiate analgesic agents were seen in the treatment group. CONCLUSION: Despite the statistically significant findings, with such low pain scores in both groups, we believe it remains debatable whether the extra time and cost involved warrants the use of a continuous popliteal blockade over a single bolus injection.

Is it necessary to re-fuse a non-union of a Hallux metatarsophalangeal joint arthrodesis?

BACKGROUND: The standard treatment for a non-union of the hallux metatarsophalangeal joint fusion has been to revise the fusion. Revision fusion is technically more demanding, often involving bone grafting, more substantial fixation and prolonged period of immobilization postoperatively. We present data to suggest that removal of hardware and debridement alone is an alternative treatment option. MATERIALS AND METHODS: A case note review identified patients with a symptomatic non-union after hallux metatarsophalangeal joint (MTPJ) fusion. It is our practice to offer these patients revision fusion or removal of hardware and debridement. For the seven patients that chose hardware removal and were left with a pseudarthrosis, a matched control group was selected from patients who had had successful fusions. Three outcome scores were used. Hallux valgus and dorsiflexion angles were recorded. RESULTS: One hundred thirty-nine hallux MTPJ arthrodeses were carried out. Fourteen non-unions were identified. The rate of non-union in males and following previous hallux MTPJ surgery was 19% and 24%, respectively. In females undergoing a primary MTPJ fusion, the rate was 2.4%. Twelve non-union patients were reviewed at 27 months (mean). Eleven patients had elected to undergo removal of hardware and debridement. Four patients with pseudarthrosis were unhappy with the results and proceeded to either revision fusion or MTPJ replacement. Seven non-union patients, who had removal of hardware alone, had outcome scores marginally worse compared to those with successful fusions. CONCLUSION: Removal of hardware alone is a reasonable option to offer as a relatively minor procedure following a failed arthrodesis of the first MTPJ. This must be accepted on the proviso that in this study four out of 11 (36%) patients proceeded to a revision first MTPJ fusion or first MTPJ replacement. We also found that the rate of non-union in primary first MTPJ fusion was significantly higher in males and those patients who had undergone previous surgery.