Posttraumatic ankle arthrosis.

Until there is a total ankle implant developed that stands the test of time, ankle arthrodesis will continue to be the gold standard in the operative treatment of the arthritic ankle joint. Ankle arthrodesis techniques include minimally invasive methods that can be performed via arthroscopy or with miniarthrotomy. Extensile techniques include extra-articular fusions, the transfibular approach, removal of both malleoli, and the Blair fusion. An ankle arthrodesis can be fixated utilizing either internal or external fixation. The form of fixation chosen depends on availability and surgeon preference and/or experience, and most importantly, which is the optimal method for the patient. Although ankle arthrodesis is the mainstay treatment for posttraumatic arthrosis, innovations and technical improvements have resulted in reconstructive alternatives for ankle arthritis, including distraction ankle arthroplasty, supramalleolar osteotomy, and total ankle replacement. Advances in biomaterials and instrumentation have allowed for the evolution of arthrodesis techniques as evidenced by the myriad of techniques reported in the literature.

Percutaneous injuries in a high-volume podiatric surgical residency program.

Percutaneous injuries (i.e., needlesticks) are a possible occupational hazard to all residents performing invasive procedures. Transmission of blood-borne pathogens has become a potential risk in these injuries. As such, the purpose of this investigation was to assess the frequency and circumstances involving percutaneous injuries in the podiatric surgical resident. A survey of 20 present residents from July 1991 to July 1999 was conducted to assess percutaneous injuries. These residents participated in 19,505 surgical cases in this timeframe; 16,185 were podiatric cases and 3,347 were nonpodiatric. Using a two-part questionnaire to assess the circumstances surrounding any percutaneous injury, 80% of the residents reported at least one percutaneous injury during their training. A total of 33 were injuries reported for the 19,505 cases. The incidence of injury per surgical case was 0.17% overall, and 0.14% for foot and ankle cases. Analysis of the data showed a median = 2, mode = 2, and a mean = 1.63 injuries per resident with a range of 0-5. When analyzing the circumstances involving the injuries, most injuries were self-inflicted (66.7%), occurred during wound closure (72.7%), and were caused by a nonhollow bore needle or instrument (81.8%). Also, no correlation could be made to the time of day during which the procedure was performed, the year of residency training, or the number of cases that the resident performed that day before the injury occurred. Interestingly, over 67% of the injuries occurred to the resident's left hand. Although 97% of the injuries were reported to the employee health officer, the patient and resident were screened for HIV and hepatitis B or C in only 78.8% of the cases. In those tested, no resident was exposed to HIV or hepatitis B or C.

Mechanical comparison of two extensor tendon repairs of ankle tendons.

Complete disruption of the extensor tendons is commonly encountered with lacerations to the dorsal aspect of the ankle. The purpose of this study was to compare two tendon repairs (modified Krackow and Kessler-Tajima) to determine which repair was stronger in an anatomical cadaver model. Twenty tendons (10 extensor hallucis longus and 10 tibialis anterior tendons) from 10 fresh-frozen cadaver legs were lacerated and then repaired with either a modified Krackow or Kessler-Tajima repair. Each tendon repair was tested for gap formation and maximum load failure. Results showed that the mean force to produce gap formation in the modified Krackow repair was 64.7 N in the extensor hallucis longus and 82.3 N with the tibialis anterior. Mean gap formation for the Kessler-Tajima in the extensor group was 26.0 N and the tibialis anterior was 41.8 N. This represented a 40% and 50% greater resistance to gap formation for the modified Krackow in these groups. With maximum load failure, the mean for the modified Krackow was 99.5 N for the extensor hallucis longus and 126.8 N for the tibialis anterior, while the Kessler-Tajima was 45.6 N and 72.1 N for these groups. This represented a 45% and 58% greater difference in the maximum load failure for the modified Krackow. Statistical analysis using a Student's t-test (p < .05) showed that there was a significant statistical difference between the two repairs for gap formation and maximum load failure. The authors conclude that the modified Krackow is stronger than the Kessler-Tajima repair.

Proximal shortening lesser metatarsal osteotomy: a mathematical-geometric basis.

Reconstruction and restoration of the lesser metatarsal parabola after an iatrogenic complication of a lesser metatarsal osteotomy provides a difficult surgical dilemma for the foot and ankle surgeon. This study's purpose was to determine if a formula could be developed, through a geometric and mathematical basis, for the proximal shortening lesser metatarsal osteotomy to aid the surgeon in determining the amount of bone needed to be resected to correct the deformity. This study was divided into three parts. In part I, 15 lesser metatarsals (metatarsals 2, 3, and 4) harvested from fresh frozen cadavers had shortening proximal osteotomies performed. This osteotomy removes a cylindrical piece of bone that is perpendicular to the metatarsal shaft from the proximal aspect of the lesser metatarsal to create axial shortening of the metatarsal and changes the relationship of the metatarsal head to the weightbearing surface. These metatarsals had five radio-opaque markers placed into them and were radiographed pre- and postosteotomy. These markers created a pre- and postgeometric graphic plotting for the changes in length, height, and dorsiflexion. Computer graphing was then utilized to analyze changes in height, length, and dorsiflexion of each metatarsal. Formulas were created from these plottings to determine the actual change in height, length, and dorsiflexion for a set amount of bone removed. The formulas created from these data were: Length: Actual change = Bone removed *0.95; Height: Actual change = Bone removed *0.54; and Dorsiflexion: Actual change = Bone removed *0.44 mm/deg. In part II of study, 15 identical saw bone lesser metatarsals were used to verify the formulas, by taking out the amount of bone needed for 0.5-mm increment change, starting at 1.0 mm and increasing to 8.0 mm. Techniques used were identical to part one. Part III was performed to demonstrate that the formula would be reproducible for height when there is a difference in the angulation of the metatarsal. Fifteen identical sawbones where plotted in plaster at declinations ranging from 8 degrees to 42 degrees. Then the osteotomy was performed removing 4.0 mm of sawbone from each specimen using the same technique as parts I and II. All parts and the formulas were statistically analyzed using a bivariate regression model, which showed that the formulas were valid for length, height, and dorsiflexion with a 95% confidence. With these experimental models, the authors found reproducible formulas that hopefully could aid the surgeon in determining the amount of bone they needed to resect to effect correction of this difficult reconstruction.

Isolated medial cuneiform fracture: review of the literature and report of two cases.

The authors present two unusual cases of isolated medial cuneiform fracture. Both fractures were difficult to see on plain films and therefore diagnosed with ancillary tests (computed tomography and magnetic resonance imaging). Treatment was nonweightbearing cast immobilization, in which both patients healed within twelve weeks of treatment without complication and returned to full work related activities.

Peroneus brevis tendon rupture with tophaceous gout infiltration.

The authors present a patient with a history of chronic lateral ankle instability and pain. Physical and diagnostic evaluation revealed anterior ankle instability and peroneus brevis weakness. An MRI showed an attenuated anterior-talofibular ligament and a longitudinal tear of the peroneus brevis tendon. Surgical exploration exhibited tophaceous gout within the tear of the peroneus brevis as well as within the attenuated anterior-talofibular ligament. Presented is an unusual case of a longitudinal tear of the peroneus brevis tendon with tophaceous gout infiltration.

Is glass visible on plain radiographs? A cadaver study.

Eighteen randomly selected pieces of nonleaded glass from a collection of 30 pieces from broken bottles of four known color types found on the streets of Houston were sorted into four sets with one control. The purpose of this study was to determine if regular glass is visible on plain radiographs and whether color, location, or volume of these fragments had any effect on the detection of nonleaded glass. These sets were then placed into a fresh-frozen cadaver foot and ankle with a history of insulin-dependent diabetes and peripheral vascular disease. This foot was radiographed utilizing four standard foot projections. Five examiners read these five sets of radiographs twice and recorded the number seen. Overall sensitivity for all of the examiners was 90% with an overall false-positive rate of 10%. Intraobserver and interobserver Pearson's correlation coefficients showed that there was reliability between the first and second readings and between observers. The authors concluded that regular nonleaded glass is radiographically visible and that factors such as color and location of the glass have no effect on its detection, while a volume of less than 15 mm3 may have an effect on the detection of glass.

The use of ultrasound in the foot and ankle.

Ultrasonography is an underutilized tool in the armamentarium of the foot and ankle surgeon. The purpose of this article is to review and illustrate the different applications of musculoskeletal ultrasonography of the foot and ankle. The advantages and disadvantages of this imaging modality are described.

Enchondroma as a cause of midfoot pain.

Enchondroma is a common bone tumor of the foot. It is often reported in the phalanges and distal metatarsals. The authors, however, present a rare case study of two patients with enchodromas as the cause of midfoot pain. One case presented in the lateral cuneiform which to the authors' knowledge is the first reported case in the literature. Two cases are presented with their surgical management including autogenous calcaneal graft and follow-up.

Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle.

A prospective study was performed on 28 patients who underwent surgery for tendon disorders around the ankle. Preoperatively, all patients had real-time, high resolution ultrasonography performed with a 7.5 or 10 mHz transducer. Twenty of these patients also had a preoperative magnetic resonance imaging (MRI) examination of the ankle. A total of 54 tendons were inspected intraoperatively, revealing a total of 24 intrasubstance or complete tendon tears. These surgical findings were compared with the ultrasound and MRI findings, from which the sensitivity, specificity, and accuracy were calculated for both modalities. Ultrasound produced results with a sensitivity measurement of 100%, specificity of 89.9%, and accuracy of 94.4%. MRI produced results with a sensitivity measurement of 23.4%, specificity of 100%, and accuracy of 65.75%. Ultrasound results were more sensitive and accurate than MRI in the detection of ankle tendon tears in our study.

Nonunion of a Hawkin's group II talar neck fracture without avascular necrosis.

The authors present an unusual case of talar neck nonunion without avascular necrosis following a Hawkin's group II fracture. A review of the literature and treatment of this rare complication are discussed. The nonunion was treated by debridement and iliac crest bone grafting to the defect and external electrical bone stimulation. The deformity of the rearfoot caused by the fracture nonunion was addressed by using a triple arthrodesis utilizing the Synthes 7.3-mm cannulated screw system.

Navicular body fractures: computerized tomography findings and mechanism of injury.

The case reports of five patients with signs and symptoms of a fracture of the tarsal navicular body are presented. Each patient underwent a computerized tomography examination to determine the extent of this fracture. Based on the computerized tomography findings, surgical or conservative management was carried out. The computerized tomography examination, combined with the patient's history, has shed new light on a previously undescribed mechanism of injury for this fracture.

Morton's neuroma. Update on diagnosis and imaging.

The diagnosis of Morton's neuroma is usually made from evaluation of a patient's subjective complaints, clinical findings, and exclusion of other differential diagnoses. Occasionally, when other neurological conditions exist or when the clinical findings are atypical, various imaging techniques may be helpful in the diagnosis of interdigital neuromas. This article will discuss these techniques and briefly review this common lower extremity disorder.

The use of the Synthes 7.3-mm. cannulated screw in rearfoot and ankle surgery: a preliminary prospective study.

The authors present a preliminary prospective study of the Synthes 7.3 mm. cannulated screw used in 31 rearfoot and ankle surgeries on 29 patients. The patients had a variety of rearfoot and ankle procedures performed, in which a total of 75 screws were placed across 47 arthrodesis or osteotomy sites. The percentage of union or healing was 95.74% for the joints or sites involved. The average healing time was 2.71 months. The techniques for placement of the screw are described.

Subcutaneous phaeohypomycosis caused by Scytalidium dimidiatum in the foot of an immunosuppressed host.

The authors present a case report of a subcutaneous phaeohypomycosis of the foot in an immuno-suppressed patient. The lesion was caused by Scytalidium dimidiatum, a dematiaceous fungus, which has only been reported to cause three previous similar lesions. To our knowledge, this is the first reported case of this fungus causing a deep-seated mycoses in the United States. A review of the literature concerning this organism is also presented.

The use of ultrasonography for the detection of retained wooden foreign bodies in the foot.

The efficacy of ultrasonography for the detection of wooden foreign bodies in the foot was analyzed retrospectively. Twenty patients underwent real-time, high-resolution ultrasound studies (7.5 or 10 MHz, linear array transducers) to rule out the presence of a wooden foreign body in their feet. Ten out of the 20 patients had positive ultrasound findings for a wooden foreign body. With the aid of the ultrasound study and preoperative markings, the subsequent mean surgical time was 20.8 minutes, with a 100% retrieval rate of the foreign body. Ultrasound was found to be 100% sensitive in the detection of wooden foreign bodies in the soft tissues of the foot. Ultrasonography should be considered an important diagnostic modality in the foot and ankle surgeon's armamentarium for the detection of retained wooden foreign bodies.