Comparison of tunnel ligament release instrument assisted minimally open surgery and conventional open surgery in the treatment of tarsal tunnel syndrome.

AIM: This study compared the results of tarsal tunnel syndrome release surgeries using mini-open incisions and standard incisions. PATIENTS AND METHODS: From January 2012 until April 2018, 31 feet of 29 patients diagnosed with tarsal tunnel syndrome were treated surgically. 15 feet of 15 patients underwent surgeries utilizing minimally open technique and 16 feet of 14 patients underwent surgeries utilizing standard incisions. The following preoperative and postoperative data was obtained: foot and ankle muscle testing results, posture analyses, anthropometric measurements, joint movement ranges, pain complaints, endurance evaluation results, and functional test results. The mean follow-up period was 38 months (13-88 months). RESULTS: The mean operation times were 26.8 min (23-30 min) using the standard incision and 13.3 min (9-17 min) using the mini-open incision (p < 0.05). In the preoperative and postoperative comparisons of the total muscle strength and total joint limit values of the healthy and affected feet, statistically significant improvements were observed in both the mini-open incision and standard incision groups (p < 0.05). Moreover, statistically significant improvements were seen in both groups in the postoperative repeated toe raises for 1 minute assessments of the affected foot (p < 0.05). In the foot function index and functional foot score values, statistically significant improvements were seen between the preoperative and postoperative values in both groups (p < 0.05). CONCLUSIONS: Based on the results of this study, using a tunnel ligament release instrument assisted minimally open surgery to loosen the laciniate ligament may present an alternative to the standard incision, with its significantly decreased morbidity rate and cosmetic success.

Partial calcanectomy and Ilizarov external fixation may reduce amputation need in severe diabetic calcaneal ulcers.

Objective: The treatment of diabetic hindfoot ulcers is a challenging problem. In addition to serial surgical debridements, hyperbaric oxygen therapy and local wound care play important roles in the surgeon's armamentarium, for both superficial infection and gangrene of the soft tissue, often complicated by osteomyelitis of the calcaneus. The purpose of this study was to evaluate the results of an aggressive approach from diagnosis to treatment of calcaneal osteomyelitis in foot-threatening diabetic calcaneal ulcers. Methods: The study included 23 patients with diabetic hindfoot ulcers who were treated with radical excision of the necrotic tissue and application of circular external fixation. The treatment protocol was a combination of magnetic resonance imaging (MRI)-guided debridement of the necrotic tissues and application of an Ilizarov external fixator in plantarflexion to decrease the soft-tissue defect. Primary outcome measures were total cure of infection and obvious healing of the osteomyelitis at 12 weeks determined by MRI, and clinical cure through objective assessment of the appearance of the wound. Results: The wounds healed in 18 of the 23 patients (78%), partial recovery occurred and subsequent flap operation was performed in three patients (13%), and below-the-knee amputation was performed in two patients (9%). Conclusions: This surgical protocol is effective in ameliorating diabetic hindfoot ulcers with concomitant calcaneal osteomyelitis, and satisfactorily reduces the need for amputation.

The Use Of Suture Anchors In Akin Osteotomy : A New Surgical Technique.

To perform an Akin osteotomy using suture anchors to achieve stability of the osteotomy line and avoid the need for a further operation to remove an implant. Akin osteotomy using suture anchors was performed on 35 feet of 30 patients (21 female, 9 male ; mean age 45 years, range 18-60 yrs) diagnosed with hallux valgus. In bilateral cases, surgery was firstly carried out on the foot in the more serious condition, followed by the second foot 2 months later. Preoperative and postoperative clinical evaluation of the patients was made using American Orthopaedic Foot and Ankle Society (AOFAS) scores. Preoperative AOFAS values for pain, function and alignment were measured. Pain values were 8 patients 20 points, 27 patients 0 points. Function values were, activity, 14 patients 4 points, 21 patients 0 points ; footwear requirements, 18 patients 5 points, 17 patients 0 points, MTP joint movement, 11 patients 5 points, 24 patients 0 points, Post-operative AOFAS values were measured and evaluated as follows. Pain values were 33 patients 40 points, 2 patients 30 points. Function values were, activity, 30 patients 10 points, 5 patients 7 points ; footwear requirements,32 patients 10 points, 13 patients 5 points, MTP joint movement, 22 patients 10 points, 13 patients 5 pointsThese results were found to be statisically highly significant (p<0.001). Rigid fixation was achieved with suture anchors and patients made an early return to normal activities. Postoperative shoes were used for early mobilisation.

Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy.

The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2 ± 2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p = .82 and p = .53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p = .16), one-leg hop (p = .15), and balance (p > .05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.

Correction of Brachymetatarsia and Medial Angulation of the Great Toe of Apert Foot By Distraction Osteogenesis: A Review of 7 Years of Experience.

BACKGROUND: Apert foot anomalies may cause severe problems such as pain and development of callus formation related to weight redistribution, problems with footwear, and gait disturbances that may limit their daily activities. The main purpose of this study was to review our experience with distraction osteogenesis for the correction of brachymetatarsia and the great toe angulation of the patients with Apert syndrome. METHODS: This study retrospectively reviewed 7 patients (14 extremities) followed up for Apert syndrome who underwent distraction for the correction of bilateral congenital brachymetatarsia and angulation of the great toe between 2004 and 2008. Correction of the metatarsal inclination angle, the medial angulation of the great toe, the percentage of lengthening, and lengthening rates of distracted bones were evaluated. RESULTS: Patients ranged in age from 4 to 8 years at the distraction operation, with a mean age of 5.4±1.3 years, and the average length of follow-up was 86.6±21.0 months. The length of the first metatarsal bone increased significantly from the average length of 32.6±5.7 mm to an average of 46.7±6.5 mm (P<0.001). The mean lengthening rate and lengthening percentages of distracted bones were 0.4%±0.1%/month and 30.2%±6.4%/month, respectively. Preoperative and postoperative metatarsal inclination angles were at a mean of 43.8±5.12 and 32.6±3.8, respectively, and the correction of metatarsal inclination was considered as statistically significant (P<0.001). The mean angulation of the great toe reduced significantly from 49.8±11.76 to 13.2±8.5 degrees after distraction (P<0.001). Minor complications such as pin loosening, pin-tract infection, and early union that required reoperation were observed in 5 extremities (35.7%). CONCLUSIONS: Anatomic features of Apert foot may lead to complaints that may limit patients' daily activities and require as much attention as associated hand and craniofacial anomalies. Distraction appears to be an effective and safe approach for the simultaneous correction of the shortness of the first ray and medial angulation of the great toe. LEVEL OF EVIDENCE: Level IV.

Application of C-Shaped Osteotomy and Distraction Osteogenesis for Correction of Radial Angulation Deformities of the Hand in Children With Apert Syndrome: Review of 10 Years of Experience.

Apert syndrome is characterized by short, radially deviated thumbs, leading to difficulties in daily life such as holding a fork or a spoon and buttoning up. The main goal of surgery is to achieve thumb to index finger pinch to overcome these difficulties. Seven patients (14 extremities) followed up with Apert syndrome underwent distraction after a C-shaped osteotomy to simultaneously correct the brachydactyly and the angulation deformity of the bilateral thumbs. The patients ranged in age from 4 to 7 years at the distraction operation, with a mean (SD) of 4.7 (1.7) years, and the mean (SD) length of follow-up was 100.6 (14.95) months. The mean (SD) length of the phalanges at the beginning of distraction was 19.1 (3.26) mm, and the mean (SD) length of the distracted phalanx at long-term follow-up visit was 26.2 (5.63) mm. The mean (SD) correction of radial angulation was calculated as 42.6 (9.95) degrees, and the difference was considered as being statistically significant (P < 0.001). Minor complications such as pin loosening were observed in 6 extremities of 4 patients, and 2 patients were treated for pin tract infection. Index-to-thumb pinching was acquired by all the patients after distraction and correction of angulation. The hand features of Apert syndrome are as noteworthy as the craniofacial features and thus may lead to functional impairment and limitations in daily life. Distraction with a C-shaped osteotomy seems to be a promising method to correct both the shortness and the radial angulation of the thumb to achieve functional results.

Charcot foot in diabetes and an update on imaging.

Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus that can cause major morbidity including limb amputation. Since it was first described in 1883, and attributed to diabetes mellitus in 1936, the diagnosis of CN has been very challenging even for the experienced practitioners. Imaging plays a central role in the early and accurate diagnosis of CN, and in distinction of CN from osteomyelitis. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, and positron emission tomography are the imaging techniques currently in use for the evaluation of CN but modalities other than magnetic resonance imaging appeared to be complementary. This study focuses on imaging findings of acute and chronic neuropathic osteoarthropathy in diabetes and discrimination of infected vs. non-infected neuropathic osteoarthropathy.

Current challenges in imaging of the diabetic foot.

Although a variety of diagnostic imaging modalities are available for the evaluation of diabetes-related foot complications, the distinction between neuroarthropathy and osteomyelitis is still challenging. The early and accurate diagnosis of diabetic foot complications can help reduce the incidence of infection-related morbidities, the need for and duration of hospitalization, and the incidence of major limb amputation. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, ultrasonography, and positron emission tomography are the main procedures currently in use for the evaluation of diabetes-related foot complications. However, each of these modalities does not provide enough information alone and a multimodal approach should be used for an accurate diagnosis. The present study is a review of the current concepts in imaging of diabetes-related foot complications and an analysis of the advantages and disadvantages of each method.

Differential diagnosis in a professional basketball player with foot pain: is it an avulsion fracture or an os supranaviculare?

The os supranaviculare is an accessory bone located on the dorsal aspect of the talonavicular joint close to the midpoint. This rare incidental skeletal variant has an estimated prevalence of 1%. It may rarely become symptomatic and should not be confused with cortical avulsion fractures of navicular or talar head. We present the case of a 25-year-old professional basketball player with pain on the dorsum of his right foot after twisting his ankle during a regular season match. Magnetic resonance imaging findings of the player's foot represented a flake of bone on the superior part of the talar head. The differential diagnosis and clinical outcome of this unusual case are briefly discussed.

Minimum-incision ray resection.

Ray resection for localized necrosis, infection, and osteomyelitis is an accepted procedure allowing removal of the diseased toe and metatarsal. The traditional approach involves a rather lengthy incision and dissection that can compromise the vascular supply to the remaining forefoot. The use of minimum incision techniques to perform metatarsal ray resection as presented here represents a simple, reliable, and easily reproduced procedure that limits soft-tissue dissection and the associated wound healing-related complications inherent to the traditional approach. Following minimum incision metatarsal ray resection, the resultant defect from the toe amputation can be primarily closed, covered with a split-thickness skin graft, or closed in delayed primary fashion with the use of a mini-external fixation device. The authors present the proper indications and a step-by-step guide for performing minimum incision metatarsal ray resection with and without the supplemental use of mini-external fixation to close the soft-tissue defect about the toe amputation site.

Transarticular versus extraarticular ankle pin fixation: a biomechanical study.

BACKGROUND: Transarticular pin fixation for ankle stabilization has drawbacks, including ankle joint arthrosis. An extraarticular technique could help avoid these problems. We compared stiffness under minimal dorsiflexion loading with transarticular versus extraarticular fixation. METHODS: Cadaveric specimens from ten lower extremity matched pairs were randomized to receive transarticular or extraarticular fixation. For transarticular fixation, axial pins were passed retrograde through the plantar heel, calcaneus, subtalar joint, talar body, and ankle joint. For extraarticular fixation, the first pin was inserted antegrade from the anterior distal tibia to the posterolateral aspect of the calcaneus tuberosity. The second pin was inserted percutaneously antegrade from the distal medial tibial metaphysis to the dorsal navicular, passing anterior to the ankle and dorsal to the talonavicular joint. Each specimen was subjected to 1000 cycles at 5 mm/s to 100 N. After testing, the extraarticular specimens were dissected to establish the distance of the pin from the flexor hallucis longus (FHL) tendon. RESULTS: There was no significant difference in stiffness between the transarticular and the extraarticular group (mean+/-standard error of the mean) (17.93 N/mm+/-1.0 N/mm and 18.61 N/mm+/-1.07 N/mm, respectively). The lateral pin was 4.2+/-1.4 mm (range, 2.5 to 6.0 mm) from the FHL. CONCLUSIONS: Fixation stiffness with extraarticular crossed antegrade pins was not different from that of transarticular fixation and did not disrupt the ankle or the plantar skin. CLINICAL RELEVANCE: Extraarticular ankle fixation may help avoid the complications found with the joint, cartilage, and plantar skin disruption associated with transarticular fixation.

A new perspective on management of open calcaneus fractures.

The treatment protocol of closed calcaneal fractures has been described in the literature extensively. However, treatment of open calcaneal fractures has not been discussed in detail. Various treatment alternatives have been suggested including external fixator, primary subtalar distraction arthrodesis, and partial calcanectomy according to the type of fracture. We have retrospectively reviewed 36 adult patients with 39 open calcaneal fractures who were treated with our new philosophy. Average follow-up time was 9.29 years (range, 1.25-28 years). The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used in functional evaluation. The average score was 77.9 (range, 67-92). All of the patients had limited subtalar movement. We propose an algorithm for the management of open calcaneus fractures, although treatment largely depends on the physical status of the patient, type of the fracture, localisation of the open wound and the surgeon's choice.

Closure of major diabetic foot wounds and defects with external fixation.

Amputation may become unavoidable in certain cases of severe ischemia, infection, or lower extremity ulcerations. When limb salvage procedures are indicated and available in diabetic patients, they will strongly support patient quality of life and prevent further complications when patients are educated appropriately. The authors describe their technique for limb salvage procedures based on a combination of an MRI-guided debridement of necrotic tissues, application of an antibiotic-impregnated bone cement, and closure of the soft tissue and bone defects with the use of an external fixation device.

[Osteometry of the femora in Turkish individuals: a morphometric study in 114 cadaveric femora as an anatomic basis of femoral component design]. / Türk toplumunda femur osteometrisi: femoral komponent tasarimi için 114 kadavra femurunda morfometrik çalisma.

OBJECTIVES: Clinical and experimental studies of total hip arthroplasty have demonstrated that a close geometric fit between the femoral component and supporting bone is essential for durable implant fixation. Long-term success of total hip prostheses depends on appreciation of the proximal femur anatomy and identification of mean reference values of critical landmarks. Current data on dimensions of prostheses and implantation are based on osteometric measurements of the femora in Western populations. This study was designed to evaluate osteometric features of femora in Turkish individuals and to establish a national database for future studies. METHODS: We conducted morphometric measurements of proximal femoral anatomy and its angular configuration on conventional radiograms of 114 cadaveric adult femora of Turkish individuals who did not have any developmental bone abnormality. Measurements were made according to the parameters defined by Noble et al. For comparison, we used morphometric data reported on Western populations by the same investigators. RESULTS: Several femoral features were found to be different in Turkish individuals. Although femur head size and offset were similar to Western values, Turkish subjects had a higher femoral head due to valgus position of the femoral head-neck angle, a narrower proximal femoral metaphysis, and a narrower medullary canal with a longer isthmic segment. CONCLUSION: Our data revealed diverse features of femoral geometry in Turkish individuals compared to Western populations. These differences should be taken into account in the design and development of hip prostheses.

A new technical approach for sternal closure with suture anchors (Dogan technique).

OBJECTIVES: Various methods for sternal approximation have been described previously. Some patients undergoing these procedures are at risk for sternal dehiscence and mediastinitis. We used a different method, with a suture anchor system, for median sternotomy closure as an alternate technique in patients with a high risk of postoperative sternal dehiscence and sternal nonunion. MATERIAL AND METHOD: Suture anchor systems have been developed principally for the fixation of tendons or ligaments to the bone. We first used the suture anchor system for median sternotomy closure, although it has been frequently used in various orthopedic surgical procedures. In this report, we describe the use, after fresh cadaveric tests, of an alternative technique in a patient undergoing coronary artery bypass grafting. RESULTS: There were no complications due to the suture anchor device, and successful application was performed for sternotomy fixation after surgical procedure in a patient. The standard techniques have several disadvantages, such as osteomyelitis, chondritis, cutting into the sternum and sternal dehiscence, prolonged hospitalization, and increased mortality and morbidity due to the listed complications, but these devices may protect the wire from cutting into the sternal bone. CONCLUSION: We propose suture anchors for reapproximation of the sternum to decrease the complications related to surgical steel wires. We therefore consider this technique to be easy, safe, and effective in patients with diabetes mellitus or severe osteoporosis considered to have risk for sternal dehiscence postoperatively. Another advantage of this suture system is that the titanium wire makes it more magnetic resonance compatible than systems using surgical steel wire.