A Rare Presentation of Ewing's Sarcoma Presenting in the Third Metatarsal.

Ewing's Sarcoma family of tumors are rare, malignant round cell tumors arising from undifferentiated mesenchymal cells. This aggressive neoplastic disease has a quick metastatic onset often resulting in a poor prognosis. In this case study we present a 21-year-old female diagnosed with Ewing's sarcoma of the third metatarsal bone. She initially presented in the emergency room with a 2-day onset of right foot pain following a minor injury. Radiographs taken in the emergency room revealed a cystic lesion in the third metatarsal. The patient presented to the author's clinic and following evaluation, surgical excision and curettage of the bone cyst was performed supplemented with allogenic bone graft. Due to a high clinical suspicion of malignancy, intraoperative culture and biopsy of the third metatarsal were sent to pathology and microbiology. Following evaluation of the bone biopsy with immunohistochemical staining as well as fluorescent in-situ hybridization studies, a diagnosis was made for Ewing's Sarcoma. This case report serves to display the significance of a timely workup as well as the importance of multiple pathology assessments to obtain a definitive pathologic diagnosis when clinical suspicion of malignancy is high.

Principles of Triple Arthrodesis and Limited Arthrodesis in the Cavus Foot.

Cavus foot is a complex podiatric deformity that requires precise and in-depth work-up through an objective, physical, and radiographic examination. The goal of surgical treatment is to eliminate pain while establishing a plantigrade foot structure. Triple arthrodesis has proven to be an effective surgical procedure for treatment of moderate to severe rearfoot deformity with or without the presence of rearfoot arthritic changes. The foot and ankle surgeon must always be aware that no two cavus deformity cases are alike, therefore one may require additional surgical procedures including soft tissue balancing, joint-sparing osteotomies, and/or supplementary arthrodesing procedures.

Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures.

Fifth metatarsal avulsion fractures are among the most common fractures seen by foot and ankle surgeons. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The present study focused on quantifying the time for healing fifth metatarsal base avulsion fractures. Specifically, we compared healing time, displacement, and incidence of nonunion among surgically managed and conservatively managed avulsion fractures. Surgically managed patients underwent either open reduction with internal fixation or closed reduction with percutaneous fixation. Conservatively managed fractures were immobilized with a below-knee cast or pneumatic walking boot. Fifty-one patient records (51 feet) were retrospectively compared for basic demographics, smoking, and diabetes status, presence of peripheral neuropathy, Stewart classification, amount of displacement, rate of nonunion, and radiographic healing time. The groups did not differ significantly based on age, sex, or the remaining clinical characteristics including time to consolidation. However, among the 31 conservatively managed patients, 11 (35.5%) developed an asymptomatic nonunion versus none among the 20 patients treated surgically (p = .004). All patients were asymptomatic at 1 year. This study provides insight into the time required for fifth metatarsal avulsion fractures to heal or become asymptomatic. The surgical management of these fractures helped to eliminate the risk of nonunion and helped ensure a timely return to preinjury activity. We recommend surgical management of any fifth metatarsal avulsion fracture displaced >2 mm. Both patients and physicians should have realistic expectations when making decisions regarding treatment modalities for fifth metatarsal avulsion fractures.

Correction of Hallux Abducto Valgus Deformity Using Closing Base Wedge Osteotomy: A Study of 101 Patients.

Hallux abducto valgus is a functionally disabling deformity with lateral deviation of the hallux and medial prominence of the first metatarsal head. Various surgical techniques have been used in the treatment of this deformity. In this retrospective review, we assess the outcomes of proximal closing base wedge osteotomy (CBWO). A single-surgeon database was reviewed for patients who underwent proximal CBWO between January 1, 2012, and December 31, 2017. A total of 101 patients were identified with a mean age of 49 years (range 13 to 80) and mean body mass index of 29 kg/m2 (range 19 to 53). The medical records were reviewed for smoking status, time to heal, rates of nonunion, shortening of the first metatarsal, intermetatarsal angle, hallux valgus angle, elevatus, mean loss of correction, complication rates, and pain scores. Pre- and postoperative variables were compared using Student's t test for continuous variables. The mean pre- and postoperative intermetatarsal angles were 15.46° (range 10° to 21°) and 3.77° (range 0° to 10°; p < .05). The mean pre- and postoperative hallux abductus valgus angles were 34.57° (range 12° to 60°) and 9.24° (range, 0° to 30°;p < .05). The mean metatarsal length shortening was 3.72 mm, and the mean postoperative elevatus was 2.73 mm. We have demonstrated excellent outcomes of CBWO with correction of intermetatarsal and hallux valgus angles. This procedure allows for superior reduction of moderate to severe intermetatarsal angles in rigid first rays. The mean postoperative elevatus of 2.73 did not result in any adverse sequelae.

An Unusual Case Report of a Stage IV Osteochondral Defect Imitating a Medial Malleolar Avulsion Fracture.

Osteochondral lesions of the talar dome are severely debilitating injuries that frequently can be missed on initial radiographic evaluation. In this case, we present the case of a 17-year-old male who injured his right ankle while skateboarding. Initial radiographic findings showed what appeared to be an avulsion fracture of the medial malleolus, and the patient was subsequently treated with immobilization. It was not until more advanced imaging of computed tomography was performed that the patient was appropriately diagnosed with a displaced talar dome fragment that was positioned in the medial gutter, requiring surgical intervention. This case report serves to show the importance of a proper workup, including advanced imaging, when clinical suspicion of a talar dome lesion is suspected. To the best of our knowledge, this is the only case in literature where a talar defect presents in the medial gutter of the ankle, imitating an avulsion of the medial malleolus.

Single-Stage Tibiotalocalcaneal Arthrodesis With Use of an Antibiotic-Coated Intramedullary Nail for Limb Salvage Following an Open Pilon Fracture Complicated by Osteomyelitis: A Case Report.

Severe limb deformity can create a major disability, which can ultimately lead to a nonambulatory lifestyle. Limb deformities created by open fractures not only put a patient at risk for a nonfunctional lifestyle but also may lead to gross contamination and osteomyelitis of the osseous structures. At times, these deformities require amputation for better functionality. It is our belief, however, that an attempt at limb salvage should always be considered. When encountering limb deformities with osteomyelitis, most literature refers to a staged technique in which 2 procedures need to be performed: this includes external fixation and/or a temporary antibiotic spacer followed by a permanent intramedullary nail after complete resolution of the infection. Staged procedures prolong the non-weightbearing status of the patient, often decreasing quality of life. The use of a single-stage antibiotic-coated nail has rarely been discussed in the literature. Here we discuss a single-stage technique that may be an option for major deformity limb salvage in the setting of chronic osteomyelitis. This is a case report presenting a 60-year-old female who suffered an open pilon fracture resulting in osteomyelitis and was successfully treated with use of an antibiotic-coated intramedullary nail in a single stage.

Open Talar Neck Fracture With Medial Subtalar Joint Dislocation: A Case Report.

We present a unique case of an open talar neck fracture with medial subtalar joint dislocation. This rare and traumatic injury was treated with immediate open reduction of the subtalar joint and open reduction internal fixation of the talar neck fracture. After a follow-up of 2.2 years, highlighted by numerous complications including posttraumatic arthritis, soft tissue abscess, and fibrotic adhesions, the patient recovered sufficiently to return full activity.

Gouty Tophi in Sinus Tarsi of Bilateral Feet Mimicking Synovial Sarcoma:A Case Report.

Chronic gout is defined as accumulation of monosodium urate crystals in joints, cartilage, tendons, bursae, bone, and soft tissue. The foot is the most common location for acute gout flares, with the first metatarsophalangeal joint being the most frequent site of tophus formation. However, few studies have reported gouty tophus formation in the subtalar joint. Gout has been termed the "great mimicker" because of its tendency to mimic other pathologic conditions, such as pigmented villonodular synovitis and synovial sarcoma. Herein, we present a rare case of chronic tophaceous gout in the sinus tarsi in both feet in a 23-year-old healthy male, with extensive bony erosions mimicking pigmented villonodular synovitis and synovial sarcoma. We discuss the clinical presentation, distinguishing radiologic characteristics, surgical procedures, and outcome regarding this unique presentation.

Surgical Management of Stage 2 Adult and Pediatric Acquired Flatfoot Without Tendon Transfer or Arthrodesis: A Retrospective Study.

Posterior tibial tendon dysfunction (PTTD) is a common pathology of the foot and ankle. Numerous techniques are available to reconstruct the flatfoot. Fusions and tendon transfers are popular methods; however, a wide range of complications have been associated with these procedures. The objective of the present study was to demonstrate the outcomes of reconstructive surgery for flatfoot correction without tendon transfer or arthrodesis. We performed a retrospective study of 43 patients and 56 feet who had undergone flatfoot reconstructive surgery from November 2011 to June 2016, with a mean follow-up period of 60 weeks (range 12 to 60 months). Each patient demonstrated a stage 2 flatfoot deformity classified using the Johnson and Strom classification. Depending on the patient's deformity, the procedures consisted of different variations of gastrocnemius recession, medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy. Six different preoperative and postoperative angles were radiographically measured on each foot studied. In all cases, the differences in the preoperative versus postoperative measurements were statistically significant (p < .003). We believe the foot and ankle surgeon can correct flatfoot deformity with the use of extraarticular procedures and create a plantigrade functional foot without fusion or tendon transfer.

Retrospective Analysis of the Akin Osteotomy.

Hallux abductovalgus is one of the most common deformities addressed by foot and ankle surgeons. Surgically, it can be approached using a wide variety of procedures. After performing the first metatarsal osteotomy, the final step is often to realign the great toe in a rectus position. This is performed with an osteotomy of the proximal phalanx. The Akin osteotomy is a medially based closing wedge osteotomy of the proximal phalanx. When executing the osteotomy, the goal is not only to correct abduction, but also to keep the lateral cortex intact, which allows it to act as an additional point of fixation. However, the lateral cortex can be iatrogenically compromised during surgery or in the postoperative period. We investigated the frequency of disruption of the lateral cortex, osteotomy displacement, healing time, and the need for surgical revision associated with the Akin procedure. A total of 132 patients who had undergone Akin osteotomy were included in the present retrospective study. Intraoperative fluoroscopy showed the lateral cortex was compromised in 47 (35.6%) patients and remained intact for 85 (64.4%) patients. Of the 47 (35.6%) patients with lateral cortex disruption intraoperatively, 9 (19.1%) experienced displacement during the postoperative period, of whom, 3 (6.38%) required surgical revision. Although intact during surgery, the other 6 (4.55%) patients sustained lateral cortex fractures postoperatively, 2 (33.3%) of whom required surgical revision. A statistically significant difference was found between the integrity of the lateral cortical hinge and the healing time of the osteotomy. All the osteotomies with displacement postoperatively were noted to have lateral cortex failure, either during surgery or during the follow-up period.

Surgical Management of Fifth Metatarsal Diaphyseal Fractures: A Retrospective Outcomes Study.

Fifth metatarsal diaphyseal fractures are a common injury treated by foot and ankle surgeons. The limited data on this specific fracture type has promoted nonoperative treatment with immobilization. The primary objective of the present study was to record the radiographic healing time of fifth metatarsal diaphyseal fractures after surgical intervention and present the specific fracture characteristics. The medical records of a series of 64 patients with surgically managed fifth metatarsal diaphyseal fractures were retrospectively reviewed. The data collected consisted of radiographic healing times, fracture characteristics, and patient demographics. The mean average age at injury was 49.23 ± 15.35 years with greatest incidence in females at 73.44%. The mean healing time was 7.73 ± 4.74 weeks, with an overall complication rate of 6.25%. The fractures were classified into 2 specific categories according to the anatomic location. Type I fractures occurred in a significantly older population, were significantly longer in length, and healed faster. The mean displacement and angulation at injury was 3.20 ± 1.22 mm, and 5.89° ± 4.60°, respectively, for all fractures. Of the 64 patients, 1 (1.56%) experienced nonunion, 2 (3.13%) delayed unions, and no malunions. One patient (1.56%) underwent repeat operation for hardware removal. One case (1.56%) of superficial postoperative infection developed and was treated with oral antibiotics. We observed good surgical outcomes with minimal postoperative complications. We also identified 2 specific entities of fifth metatarsal diaphyseal fractures. On the basis of our results, we advocate surgical intervention even for minimally displaced diaphyseal fractures to maintain even weightbearing across the metatarsal parabola.

Intraneural Lipoma of the Tibial Nerve: A Case Report.

Intraneural lipomas, neurofibrolipomas, lipofibromatous hamartomas, and perineural lipomas are subsets of hamartomas that typically present as fibroadipose, soft tissue masses within the epineurium of a nerve. Several cases involving intraneural lipomas of the median nerve in the upper extremity have been reported; however, owing to the lesion's rare incidence in the foot and ankle, only a select few cases involving the superficial peroneal nerve have been reported. We present the first case of a tibial nerve intraneural lipoma in a 42-year-old female with a follow-up period of 2 years. We discuss the clinical presentation, distinguishing features, surgical procedures, and short-term outcome regarding this unique tumor.

Surgical Outcomes for Resection of the Dorsal Exostosis of the Metatarsocuneiform Joints.

A retrospective case series testing the efficacy of surgical resection of the dorsal exostosis deformity of the metatarsocuneiform joints was performed. Surgery was performed in 26 consecutive patients (28 feet), in whom previous conservative therapy had failed. All 26 patients had bursitis at the level of the dorsal exostosis deformity. The patients were separated into 2 groups: group 1, those with bursitis and neuritis before surgery (n = 13; 46.4%), and group 2, those with bursitis without neuritis (n = 15; 53.5%). Both groups were evaluated using an 11-point visual analog scale administered preoperatively and ≤1 year postoperatively. The mean pain rating in the patients with neuritis and bursitis before surgery (7.31 ± 2.8) and in those with bursitis without neuritis (6.67 ± 3.4) had both decreased to 0 at 6 months and 1 year after surgery. After surgery, 7 patients (25.2%) experienced neuritis. Of these 7 patients, 4 (57.1%) had continuation of neuritis that was present before surgery and 3 (42.9%) had an onset of neuropraxia that was secondary to the surgery itself. This might have resulted from retraction of the nerves during spur removal. Eventually, all the cases of neuritis resolved. One patient (3.6%) experienced regrowth of their dorsal exostosis deformity, 1 (3.6%) developed an abscess at the surgical site, and 1 (3.6%) developed pain elsewhere at the Lisfranc joint. All patients were subsequently treated at our institution and were pain free and had returned to full activity within 1 year. These results suggest that resection of the dorsal exostosis deformity of the metatarsocuneiform joints is an effective surgical procedure for patients with this deformity.

Empty Toe Phenomenon: A Rare Presentation of Closed Degloving Injury of the Foot.

Traumatic degloving injuries of the lower extremity are commonly diagnosed by soft tissue deficits and separation of soft tissue planes. The management of open degloving injuries is well documented with established treatment protocols. Because closed degloving injuries of the lower extremity are so rare, the protocol management is not well established. Unlike open degloving injuries, evidence of soft tissue injury and detachment of the tissue planes can be subtle. Owing to the rarity of these injuries, little has been described regarding the long-term outcomes. In the present report, 2 closed degloving cases are presented. The first case presented is of a 27-year-old railroad worker who sustained a severe closed degloving injury of his foot with digital soft tissue envelope transposition. The second case involved a 60-year-old automobile manufacturer, whose foot was crushed by a hydraulic fork lift, creating a degloving injury of the third, fourth, and fifth toes. The follow-up duration from the date of injury for patient 1 was 26 months and for patients 2 was 16 months. The purpose of presenting these cases is to report these rare injuries with the treatment, complications, and outcomes.

Screw Versus Plate Fixation for Chevron Osteotomy: A Retrospective Study.

The chevron osteotomy is a popular procedure used for the correction of moderate hallux abducto valgus deformity. Fixation is typically accomplished with Kirschner wires or bone screws; however, in cystic or osteoporotic bone, these could be inadequate, resulting in displacement of the capital fragment. We propose using a locking plate and interfragmental screw for fixation of the chevron osteotomy that could reduce the healing time and decrease the incidence of displacement. We performed a retrospective cohort study for chevron osteotomies on 75 feet (73 patients). The control groups underwent fixation with 1 screw in 30 feet (40%) and 2 screws in 30 feet (40%). A total of 15 feet (20%) were included in the locking plate and interfragmental screw group. The patients were followed up until bone healing was achieved at a median of 7 (range 6 to 14) weeks. Our hypothesis was that those treated with the locking plate and interfragmental screw would have a faster healing time and fewer incidents of capital fragment displacement compared with the 1- or 2-screw groups. The corresponding mean intervals to healing for the 1-screw group was 7.71 ± 1.28 (range 6 to 10) weeks, for the 2-screw group was 7.27 ± 1.57 (range 6 to 14) weeks, and for the locking plate and interfragmental screw group was 7.01 ± 1.00 (range 6 to 9) weeks. One case of capital fragment displacement occurred in the single screw group and one in the 2-screw group. No displacement occurred in the locking plate and interfragmental screw group. Neither finding was statistically significant. However, we believe the locking plate and interfragmental screw could be a viable option in patients with osteoporotic and cystic bone changes for correction of hallux abducto valgus.

Axial loading screw fixation for chevron type osteotomies of the distal first metatarsal: a retrospective outcomes analysis.

The distal chevron osteotomy is a widely accepted technique for the treatment of hallux abductovalgus deformity. Although the osteotomy is considered to be stable, displacements of the capital fragment has been described. We propose a new method for fixation of the osteotomy involving the axial loading screw (ALS) used in addition to single screw fixation. We believe this method will provide a more mechanically stable construct. We reviewed the charts of 46 patients in whom 52 feet underwent a distal chevron osteotomy that was fixated with either 1 screw or 2 screws that included the ALS. We hypothesized that the ALS group would have fewer displacements and would heal more quickly than the single screw fixation group. We found that the group with ALS fixation had healed at a mean of 6.5 weeks and that the group with single screw fixation had healed at 9.53 weeks (p = .001). Also, 8 cases occurred of displacement of the capital fragment in the single screw, control group compared with 2 cases of displacement in the ALS group. However, this finding was not statistically significant. The addition of the ALS to single screw fixation allowed the patients to heal approximately 3 weeks earlier than single screw fixation alone. The ALS is a fixation option for the surgeon to consider when osseous correction of hallux abducto valgus is performed.

A retrospective comparison of percutaneous plantar fasciotomy and open plantar fasciotomy with heel spur resection.

Minimally invasive surgery for the treatment of recalcitrant heel pain is a relatively new approach. To compare the 2 approaches, a retrospective chart review was conducted of 53 patients (55 feet) who had undergone surgical treatment of plantar fasciitis by either open fasciotomy with heel spur resection or percutaneous medial fascial release. The outcomes measures included perioperative pain and the interval to return to full activity. Pain was measured on a subjective 10-point visual analog scale. Of the 55 fasciotomies performed, 23 were percutaneous and 32 were open, with adjunctive heel spur resection. The percutaneous group experienced a mean pain reduction of 5.69 points at the first postoperative visit, whereas open fasciotomy group experienced a mean pain reduction of 3.53 points. At 12 months postoperatively, no statistically significant difference was found in the pain levels between the 2 groups. The results also showed that the percutaneous group returned to normal activity an average of 2.82 weeks (p < .001) faster than the open group. In the patient cohorts studied, percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and involved less postoperative pain and a faster return to full activity.

Biomechanical comparison of internal fixation techniques for the Akin osteotomy of the proximal phalanx.

The Akin osteotomy is performed at the proximal phalanx for correction of an abducted great toe in a hallux abducto valgus deformity. Several internal fixation techniques have been widely advocated; however, their respective stabilities have not been compared. A biomechanical analysis was performed comparing 5 commonly used fixation techniques for the Akin osteotomy to determine the strongest method in simulated weightbearing in sawbone models. An Akin osteotomy was uniformly performed on 25 sawbones and fixated with 5 different internal fixation types, including a 2-hole locking plate and locking screws, a heat-sensitive memory staple (8 mm × 8 mm), a 28-gauge monofilament wire, 2.7-mm bicortical screws, and crossed 0.062-in. Kirschner wires. The results of simulated weightbearing load to failure rates with an Instron compression device demonstrated the following mean load to failures: crossed Kirschner wire, 57.05 N; 2-hole locking plate, 36.49 N; monofilament wire, 35.69 N; heat-sensitive memory staple, 34.32 N; and 2.7-mm bicortical screw, 13.66 N. Statistical analysis demonstrated the crossed Kirschner wire technique performed significantly better than the other fixation techniques (p < .007); the 4 other techniques were found not to be significantly different statistically (p = .041) from each another. Our study results suggest a crossing Kirschner wire construct significantly increases the stability of the Akin osteotomy in a sawbone model. This might be clinically extrapolated in an effort to improve patient outcomes because these osteotomies can undergo nonunion and malunion, resulting in postoperative pain and swelling.

Surgical correction of metatarsal malunion.

Central metatarsal malunion is sparsely described in the literature. There are differing opinions on the importance of open reduction and internal fixation for lesser metatarsal fractures and possible complications from lack of appropriate treatment for these common fractures. In general, little emphasis is placed on performing open reduction and internal fixation of displaced central metatarsal fractures. In this report, we describe 2 cases in which displaced lesser metatarsal fractures were not reduced and were treated with only immobilization. Both of the patients presented later with pain and stiffness in the area of the fractures and at the metatarsophalangeal joints. In both cases, treatment consisted of metatarsal osteotomies with realignment and fixation. In each case, this treatment provided relief of pain, increased range of motion, and return to normal activity. In cases of painful metatarsal malunion, restoration of anatomic alignment may be necessary for resolution of pain and disability.

Axial loading cross screw fixation for the Austin bunionectomy.

The Austin procedure has become a common method of osteotomy for the correction of hallux abductovalgus when indicated. The V-type configuration is intrinsically stable but not without complications. One complication encountered is rotation and/or displacement of the capital fragment. We present the use of an axial loading screw in conjunction with a dorsally placed compression screw. The benefit to this technique lies in the orientation of the axial loading screw, because it is directed to resist the ground reactive forces while also providing a second point of fixation in a crossing screw design. In a head-to-head biomechanical comparison, we tested single dorsal screw fixation versus double screw fixation, including both the dorsal and the axial loading screws in 10 metatarsal Sawbones(®) (Pacific Research Laboratories Inc, Vashon, WA). Five metatarsals received single dorsal screw fixation and five received the dorsal screw and the additional axial loading screw. The metatarsals were analyzed on an Instron compression device for comparison; 100% of the single screw fixation osteotomies failed with compression at an average peak load of 205 N. Four of five axial loading double screw fixation osteotomies did not fail. This finding suggests that the addition of an axial loading screw providing cross screw orientation significantly increases the stability of the Austin osteotomy, ultimately decreasing the likelihood of displacement encountered in the surgical repair of hallux abductovalgus.