Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study".

Background: The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Methods: Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Results: Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Conclusions: Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Level of Evidence: Therapeutic Level III, retrospective cohort.

Management of Periprosthetic Polyvinyl Alcohol Synthetic Cartilage Implant Infection with Staged First Metatarsophalangeal Joint Arthrodesis.

Surgical management of hallux rigidus using a polyvinyl alcohol synthetic cartilage implant has gained popularity among foot and ankle surgeons. Although uncommon, appropriate diagnosis and management of a periprosthetic implant infection is critical in limiting morbidity. We present a case report and staged technique for converting a first metatarsal synthetic cartilage hemiarthroplasty to arthrodesis in the setting of a periprosthetic joint infection.

Paradigm Shift for the Surgical Management of Calcaneal Fractures?

Calcaneal fractures account for up to 75% of all foot fractures and 1% to 2% of all fractures. Approximately 75% of calcaneal fractures are intraarticular, resulting in a prolonged recovery, more pain, and disability. The most common mechanism of injury includes falls from a height and motor vehicle accidents. This article reviews studies that compare nonoperative with operative treatment. The literature continues to support surgical intervention; however, these injuries can still be managed nonoperatively in certain clinical scenarios. This article focuses on the surgical management of intraarticular calcaneal fractures and highlights the sinus tarsi approach.

Revisional Surgery of the Diabetic Charcot Foot and Ankle.

Charcot neuroarthropathy (CN) is a difficult problem for the foot and ankle surgeon. If surgery is required, little is known or available regarding the best methods and timing. When the initial attempt of reconstruction fails, revision of CN is even more demanding. One must take in to account all aspects, including nutrition, vascular status, infection control, short- and long-term blood glucose management, as well as other factors requiring laboratory monitoring and consult services. Once optimized, the biomechanics of the deformity can be addressed and decisions can be made on fixation devices.

Staged Reconstruction for Acute Charcot's Subtalar Joint DislocationA Case Report.

Charcot's neuroarthropathy can have devastating consequences if left untreated or misdiagnosed. With progression of the disease from the acute to the chronic phase, substantial deformity and instability may result, leading to ulceration and a nonfunctional limb. The purpose of this case report is to present a staged reconstruction for active Charcot's neuroarthropathy involving the subtalar joint with complete dislocation that resulted in limb salvage and maintenance of limb function at 1-year follow-up. Although for many patients the mainstay of treatment for early Charcot's neuroarthropathy is conservative care with off-loading, early surgical correction that includes external fixation followed by definitive arthrodesis for select patients may be warranted.

Subtalar Distraction Arthrodesis with Fresh Frozen Femoral Neck Allograft: A Retrospective Case Series.

UNLABELLED: Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Utility of Fresh Frozen Section Analysis in Foot and Ankle Surgery: A Pilot Study.

The use of intraoperative fresh frozen section (FFS) analysis to determine the presence of infection has been well reported in orthopedic studies. Specifically, the number of polymorphonuclear leukocytes per high-power field has been used to diagnose total joint arthroplasty-related infection. Less commonly, reconstructive surgeons have extended the use of FFS analysis for intraoperative evaluation when suspicion of deep infection with or without hardware is high. The purpose of the present study was to retrospectively review the data from 11 patients undergoing foot and ankle reconstruction in the setting of possible deep infection and determine the usefulness of FFS analysis. A retrospective review of the medical records of patients who had undergone reconstructive foot and ankle revision surgery with intraoperative FFS analysis and tissue/swab cultures available was performed. A positive FFS was defined as >5 polymorphonuclear leukocytes per high-power field. A positive frozen section was associated with a positive tissue culture 4 of 7 times (57%). The sensitivity and specificity of FFS analysis for infection was 80% and 50%, respectively. The positive and negative predictive value of the FFS result was 57.1% and 75%, respectively. In conclusion, FFS analysis and intraoperative cultures correlated only 57% of the time in the present series. This test had moderate sensitivity for detecting infection at 80%, but the specificity was poor (50%). More research is needed to further evaluate the role of FFS analysis in foot and ankle surgery.

Fibular Strut Graft for Revisional Tibiotalocalcaneal Arthrodesis.

Tibiotalocalcaneal arthrodesis with an intramedullary nail is a procedure reserved for patients who have conditions affecting the ankle joint and subtalar joint. The most common complications include nonunion, malunion, delayed union, infection, periprosthetic fracture, hardware failure, lateral plantar nerve injury, and wound healing. Significant bone void may result if the hardware requires removal secondary to one of these complications. The purpose of this article is to report on 2 cases of infected intramedullary nails, which were revised with fibular inlay strut grafts. Both cases were augmented with either internal or external fixation. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Topically Applied Vancomycin Powder Reduces the Rate of Surgical Site Infection in Diabetic Patients Undergoing Foot and Ankle Surgery.

BACKGROUND: The purpose of this study was to evaluate the efficacy of topically applied vancomycin powder in reducing the rate of surgical site infections (SSIs) in patients with diabetes mellitus (DM) undergoing foot and ankle surgery. METHODS: Eighty-one patients with DM who underwent reconstructive surgery of a foot and/or ankle deformity and/or trauma and who received topically applied vancomycin were matched to 81 patients with DM who did not receive topically applied vancomycin. The mean age was 60.6 years in the vancomycin group and 59.4 years in the control group (P < .05). The 2 groups were similar with regard to gender, body mass index, duration of DM, short-term and longer term glycemic control, and length of surgery. RESULTS: The overall likelihood of SSI was decreased by 73% in patients who received topically applied vancomycin (odds ratio [OR], 0.267; 95% CI, 0.089-0.803; P = .0188). The rate of superficial infection was not significantly different between the 2 groups (OR, 0.400; 95% CI, 0.078-2.062; P = .2734); however, deep infections were 80% less likely in patients who received vancomycin powder (OR, 0.200; 95% CI, 0.044-0.913; P = .0377). CONCLUSION: High-risk diabetic patients undergoing foot and ankle surgery were notably less likely to develop an SSI with the use of topically applied vancomycin powder in the surgical wound, particularly with regard to deep infections. Topically applied vancomycin was associated with a very low rate of complications and was inexpensive ($5 per 1000 mg). Based on this study, foot and ankle surgeons may consider applying 500 to 1000 mg of vancomycin powder prior to skin closure in diabetic patients who are not allergic to vancomycin. LEVEL OF EVIDENCE: Level III, retrospective case control series.

Squamous Cell Carcinoma With Chronic Osteomyelitis: A Case Report.

UNLABELLED: Squamous cell carcinoma is one of the most common human malignancies; however, it is uncommon in the lower extremity. These lesions require prompt surgical attention and a delay in diagnosis can be harmful to the patient. We present a case report of squamous cell carcinoma with chronic osteomyelitis in a patient without diabetes. Definitive treatment included a transtibial amputation and metastatic workup was negative for active malignancy. Surgeons who treat chronic wounds should be cognizant of the potential for malignant degeneration. LEVEL OF EVIDENCE: Therapeutic, Level IV: Case report.