Impact of Podiatric Surgery Consultation for Foot and Ankle Wounds on Patient Outcomes in a Community Hospital.

Previous studies have demonstrated that timely podiatric surgery consultation results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The primary aim of this study is to determine if consulting podiatric services was associated with lower 30-day readmission rates and impact on length of stay in patients with lower extremity wounds. The secondary aim was to investigate medical and socio-economic factors associated with better outcomes. This study was a cross-sectional descriptive study. A retrospective chart review utilizing the hospital's electronic medical record system identified patients with lower extremity wounds (based on ICD-10 codes) admitted between July 2018 and December 2020. The results showed a 3-fold decrease in 30-day readmission rates in patients with podiatric surgery consultation compared to patients without consultation with lower extremity wounds (4.2% vs 11.3%, p = .03). Multivariate regression models showed patients with gangrene (AOR = 7.61; p = .04) or osteomyelitis (AOR = 9.07; p = .013) had a higher likelihood of readmission than patients with venous ulcer (reference category) after controlling for podiatric consultation. Among the group of patients with podiatric consultation, earlier podiatric consultations resulted in decreased length of stay. This study identifies prior amputation history and lack of podiatric consultation increased 30-day readmission rates.

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury.

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

Functional Outcomes After Gunshot Wounds to the Foot and Ankle.

The peer-reviewed, clinical data focusing on foot and ankle gunshot wounds are limited. The present study aimed to evaluate functional outcomes in a case series according to the area of injury, articular involvement, and the presence of infection. From January 2003 through February 2011 (8 years), 37 patients treated at Sinai-Grace Hospital (Detroit, MI) for civilian gunshot wounds localized to the foot and/or ankle were reviewed. Of these, 27 (72.97%) met the inclusion criteria. All acute wounds were thoroughly irrigated in the emergency room (8 of 27, 29.63%) or operating room (19 of 27, 70.37%) within 1 hour of presentation. The injuries were categorized as either zone 1 or 2, if localized distally or proximally to the midtarsal joint, respectively. The Maryland Foot Score was recorded and compared based on the location, articular involvement, and infection status, using analysis of variance. The mean Maryland Foot Score in patients with zone 1 injuries was 89.3 (range 72 to 100) and in patients with zone 2 injures was 61.8 (range 13 to 97; p = .001). The mean Maryland Foot Score in patients with type A injuries was 93.1 (range 72 to 100) and in patients with type B injures was 69.2 (range 13 to 99; p = .001), regardless of location. Intraoperative cultures yielded Staphylococcus epidermidis (7 of 27, 25.93%) and Enterococcus cloacae (1 of 27, 3.7%). No cases of Pseudomonas aeruginosa were found, although 9 cases (33.33%) involved shoe penetration. One third of the cases (9 of 27) yielded intra-articular pain, of which 4 (14.82%) required joint arthrodesis.

Early clinical and radiographic outcomes after treatment of displaced intra-articular calcaneal fractures using delta-frame external fixator construct.

Intra-articular calcaneal fractures are associated with high morbidity, persistent pain, and long-term disability. This retrospective study assesses early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large fragment external fixator. Minimally invasive percutaneous reduction of calcaneal fractures is an alternative treatment for Sanders type II, III, and IV fractures. Ten patients from the Detroit Medical Center were followed between January 2002 and December 2004 for follow-up over a mean of 353.5 ± 85.45 days postoperatively. The mean age of the patients was 45.8 ± 12.3 years. There were 2 patients with Sanders type IIA, 3 patients with type IIIAB, 1 patient with type IIIAC, and 4 patients with type IV fracture patterns. The results demonstrated that the mean calcaneal width decreased, the calcaneal height increased, and the calcaneal length increased when comparing preoperative to postoperative measurements. Böhler's angle increased from 20.8 ± 8.27° preoperatively to 25.7 ± 5.21° postoperatively, and Gissane's angle decreased from 127.4 ± 45.22° preoperatively to 111.2 ± 39.38° postoperatively. The posterior facet step-off on CT examination reduced from 2.6 ± 0.82 mm preoperatively to 0.4 ± 0.26 mm postoperatively. The mean postoperative total subtalar joint range of motion was 19.0 ± 4.5° on the affected side and 34.4 ± 4.58° on the contralateral foot. The mean Maryland Foot score was 85.8 ± 6.41 in the 10 patients. With the exception of the change from preoperative to postoperative Böhler's angle, and the comparison of the ipsilateral (side of the fracture) to contralateral resting calcaneal stance position, all of the comparisons revealed statistically significant (P ≤ .05) differences. The authors conclude that the delta frame construct is a viable alternative method to open reduction and internal fixation for treating intra-articular calcaneal fractures.

Subcutaneous polypoid lipoma of the first intermetatarsal space mimicking rudimentary polydactyly.

A case of a subcutaneous polypoid lipoma, presenting as a rudimentary polydactyly, is reported. The lesion was located between the first and second digits and extended into the first intermetatarsal space in a polypoid fashion. Radiographically, there were no osseous structures associated with the mass, and preliminary biopsy results showed no evidence of malignancy. The patient was treated with marginal excision of the mass and reduction of the intermetatarsal space with a Mini TightRope (Arthrex, Inc., Naples, FL). The final pathological diagnosis was polypoid lipomas, and the patient experienced a full and uneventful recovery.

Chondroblastic osteosarcoma of the cuboid: a literature review and report of a rare case.

UNLABELLED: Chondroblastic osteosarcoma accounts for about 25% of all cases of osteosarcoma, which is the most common primary malignancy of the skeleton. Currently, only a few cases of chondroblastic osteosarcoma have been reported to involve the bones of the foot. In this report, we describe the previously unreported occurrence of chondroblastic osteosarcoma involving the left tarsal cuboid in a 15-year-old male. Histologically, the tumor showed an unusually extensive osteoclastic giant cell reaction that initially led to an erroneous diagnosis of giant cell tumor of bone. Because treatment and prognosis are very different for chondroblastic osteosarcoma as compared to giant cell tumor of bone, it is important to make the distinction between these 2 different bone tumors. In this report, we wish to draw attention to occurrence of chondroblastic osteosarcoma in the small bones of the foot, and to the possibility of an extensive giant cell reaction making accurate diagnosis difficult. We also provide a comprehensive review of the literature related to chondroblastic osteosarcoma. LEVEL OF CLINICAL EVIDENCE: 4.

A prospective investigation of the BioPro hemi-arthroplasty for the first metatarsophalangeal joint.

First metatarsophalangeal joint hemi-implant arthroplasty is commonly used for 1-sided degenerative joint disease. This study examined outcomes in patients that underwent hemi-arthroplasty using the BioPro hemi-implant. Twenty-three of 30 patients completed the 12-month follow-up between October 2001 and June 2003. Repeated measures multivariate analysis of covariance was used to consider the influence of the implant on a number of dependent variables, while controlling for the amount of first metatarsal head cartilage degeneration. The average amount of first metatarsal head cartilage degeneration visualized intra-operatively was 71.8% +/- 21.7%. From the preoperative to postoperative periods, the average hallux abductus angle went from 12.6 degrees +/- 6.5 degrees to 10.2 degrees +/- 5.3 degrees (P = 0.521), the average first intermetatarsal angle went from 11.0 degrees +/- 2.3 degrees to 10.5 degrees +/- 2.0 degrees (P = 0.434), the average first metatarsal declination angle went from 18.5 degrees +/- 4.1 degrees to 18.3 degrees +/- 4.1 degrees (P = 0.297), the average ACFAS score went from 41.2 +/- 11.6 to 80.4 +/- 8.8 (P = 0.003), average dorsiflexion went from 12.6 +/- 12.4 to 50.0 +/- 8.7 (P = 0.009), and average plantarflexion went from 8.0 +/- 8.0 to 17.5 +/- 6.7 (P < 0.001). Despite the presence of first metatarsal head cartilage degeneration, the ACFAS outcome score and the range of motion improved following implant arthroplasty, and these findings support the use of this procedure as a useful salvage intervention even in patients with pre-existing double-sided first metatarsophalangeal joint disease.

Osteochondroma of the distal tibia in an adolescent: a case report.

A 14-year-old female presented with a painful right ankle that had been worsening over the preceding 2 years. Clinical and radiographic inspection revealed marked bowing with a pathologic fracture of the fibula secondary to the laterally outgrowing bone lesion from the distal tibia proximal to the growth plate. Computerized tomography revealed a 2.44 x 4.48-cm bone tumor proximal to the ankle joint, and this was consistent with her complaint of pain and the observed malposition of the distal leg and ankle. Although the radiographic characteristics of the lesion were indicative of osteochondroma, a typically asymptomatic and benign tumor that is usually identified as an incidental finding, the large size and symptoms associated with the lesion described in this article make it rather unusual. In this particular case, excessive bony outgrowth, pain, joint malposition, and pathologic fracture necessitated surgical intervention. The patient was successfully treated with resection of the tumor, after which gradual restoration of the alignment of the distal leg ensued without the need for fibular osteotomy. After more than 3 years of postoperative follow-up, neither radiographic nor clinical evidence of recurrence had been observed and the patient displayed a pain-free range of ankle motion without any physical limitations.

Maggot therapy for wound debridement in a traumatic foot-degloving injury: a case report.

A 43-year-old man was treated for a traumatic degloving injury to his foot with a transmetatarsal amputation and wound care because of the extensive soft tissue loss. After biweekly sharp debridements in the office for 4 weeks, very minimal skin ingrowth was noted. Maggot therapy was then implemented for a 48-hour treatment and a second treatment for 72 hours to help reduce excessive fibrosis and to painlessly debride the tissues to expose the granular base. Daily dressing changes for the next 6 weeks successfully allowed complete wound closure without any additional interventions. During the follow-up course, no complications were encountered and the patient has returned to ambulation with the use of a cane.

Biomechanical analysis of Maxwell-Brancheau arthroereisis implants.

The Maxwell-Brancheau arthroereisis (MBA) implant is currently used in treating flexible flatfoot deformities in children and adults. However, no guidelines have been established to determine the degree of correction with the five different MBA implant sizes (6-, 8-, 9-, 10-, and 12-mm diameters). A biomechanical analysis of these implants was performed in fresh-frozen cadaver limbs to quantitate the effects on subtalar joint (STJ) motion restriction and radiographic angles. This study found a restriction of subtalar joint range of motion that ranged from 32.0 +/- 5.4%, 44.8 +/- 7.7%, 59.0 +/- 7.2%, 65.5 +/- 8.7%, and 76.8 +/- 7.6% restriction with successively larger sized implants respectively (p < .001). Repeated measures analysis of variance (ANOVA) revealed alterations in the first intermetatarsal, lateral talo-first metatarsal, talar declination, calcaneal inclination, and first metatarsal declination angles with successively larger implant use. Analysis of the dorsal talo-first metatarsal, talo-second metatarsal, lateral talocalcaneal angles, and first to fifth metatarsal head splay showed no changes as implant size was altered. The study also attempted to assess the effects on the tendo Achillis when the subtalar joint was changed from a pronated to a supinated position. The observations showed a 6.33 +/- 1.40% (p = .001) increase in tendon length which suggests increased tension to the tendon. These findings can aid the surgeon in selection of the MBA implant size based on the desired amount of subtalar joint motion restriction. In turn, this may reduce errors in the correction of flexible flatfoot with the MBA implant.

A comparison of bicortical and intramedullary screw fixations of Jones' fractures.

Two different fixations for treatment of Jones' fracture were tested in bone models and cadaveric specimens to determine the differences in the stability of the constructs. A bicortical 3.5-mm cannulated cortical screw and an intramedullary 4.0-mm partially threaded cancellous screw were tested using physiologic loads with an Instron 8500 servohydraulic tensiometer (Instron Corporation, Canton, MA). In bone models, the bicortical construct (n = 5, 87+/-23 N) showed superior fixation strength (p = .0009) when compared to the intramedullary screw fixation (n = 5, 25+/-13 N). Cadaveric testing showed similar statistical significance (p = .0124) with the bicortical construct (n = 5, 152+/-71 N) having greater load resistance than the intramedullary screw fixation (n = 4, 29+/-20 N). In bone models, the bicortical constructs (23+/-9 N/mm) showed over twice the elastic modulus than the intramedullary screw fixations (9+/-4 N/mm) with statistical significance (p = .0115). The elastic modulus in the cadaveric group showed a similar pattern between the bicortical (19+/-17 N/mm) and intramedullary (9+/-6 N/mm) screw constructs. Analysis of the bicortical screw failure patterns revealed that screw orientation had a critical impact on fixation stability. The more distal the exit site of the bicortical screw was from the fracture site, the greater the load needed to displace the fixation.