Intravascular Endothelial Hyperplasia of the Foot.

Intravascular endothelial hyperplasia is a benign soft tissue mass rarely reported in the foot. Advanced imaging and confirming a benign diagnosis are critical for any soft tissue mass. This paper identifies 2 patients that developed intravascular endothelial hyperplasia tumors which required surgical excision. A 17-year-old male patient presented to clinic complaining of a painful bump to the arch of his right foot which he related to an injury 9 months prior. Magnetic resonance imaging of the right foot revealed a mass within the plantar subcutaneous fat that was serpiginous in nature similar to adjacent branching vessels favoring a low-flow vascular malformation. A 38-year-old female with Multiple Sclerosis presented with complaints of persistent symptoms of pain to the 1st interspace, difficult ambulation and neuritis. Ultrasound and MRI observed solid, multilobulated mass, with internal vascular malformation, MRI describing intrinsic involvement along the abductor musculature and flexor tendons. Both lesions were surgically excised and sent for pathology. Pathology report indicated a diagnosis of intravascular papillary endothelial hyperplasia or Masson's tumor in both cases. Pathology diagnosis of intravascular papillary endothelial hyperplasia is generally good with wide resection leading to low recurrence rates. Both patients in the current study have progressed postoperatively with resolution of symptoms and without recurrence.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction.

Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction.

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Effect of the First Tarsometatarsal (Modified Lapidus) Arthrodesis on Hindfoot Alignment.

The purpose of this study is to demonstrate the effect of first tarsometatarsal (modified Lapidus) arthrodesis on hindfoot alignment. We reviewed the radiographs of 39 patients, 40 feet (16 right feet and 24 left feet in 6 males and 34 females; mean age 43 years) who underwent hallux valgus reconstruction and isolated first tarsometatarsal arthrodesis. Patients who had ancillary osseous procedures were excluded from the study, with the exception of proximal phalangeal osteotomy to address hallux interphalangeus. The mean time to follow up was 33.78 weeks (8.45 months), median 21.5 weeks. Statistically significant differences were found between preoperative and postoperative measurements for talar declination (-3.3 ± 3.5), lateral talocalcaneal angle (-3.1 ± 3.9), lateral Meary's angle (-4.2 ± 4.9), medial cuneiform height (3.5 ± 4.6), medial cuneiform to fifth metatarsal distance (4.7 ± 4.5), AP talocalcaneal angle (-2.8 ± 5.3), and percentage of talar head uncovering (-6.6 ± 7.6). Our results suggest that first tarsometatarsal arthrodesis can affect hindfoot alignment on AP and lateral radiographs.

Calcific Insertional Achilles Tendinopathy-Achilles Repair With Flexor Hallucis Longus Tendon Transfer: Case Series and Surgical Technique.

Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (n = 33) of the 45 patients responded to the following question: "Would you have this surgery done again?" Of these patients, 93.9% (n = 31) responded "Yes" and 6.1% (n = 2) responded "Unsure." Of the same 33 patients, 84.8% (n = 28) responded that they were "Very Satisfied" with the procedure and 15.2% (n = 5) responded that they were "Satisfied." Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.

Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study.

Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.

Cutaneous myoepithelioma in the foot: case report.

Cutaneous myoepithelioma is a very rare, benign, subcutaneous and dermal tumor. It usually presents as a slow-growing and painless mass on the extremities. We report a case of cutaneous myoepithelioma that was located on the foot. A 68-year old woman presented with a slowly growing pain-free mass on the right third toe measuring 0.8 × 0.7 × 0.4 cm(3). We performed an elliptical excision, with histological and immunohistochemical analysis. The lesion showed dermis with cords of cytologically uniform ovoid cells with moderate amount of pale cytoplasm. No pleomorphism, mitotic activity, or necrosis was visualized. The tumor cells were positive for S-100 protein, epithelial membrane antigen and negative for smooth-muscle actin. From these findings, the tumor was diagnosed as a cutaneous myoepithelioma extending to the deep resection margin. To our knowledge, there are only 2 documented cases in the literature in English, and none have been reported in the foot and ankle literature.

Deep vein thrombosis after bunionectomy: a case report of two genetic mutations.

Deep venous thrombosis after foot and ankle surgery is a serious complication that can have potentially life-threatening complications, such as pulmonary embolus. Genetic mutations have been reported in the published data to cause an increased risk of developing deep vein thrombosis. Two such genetic mutations are the methylenetetrahydrofolate reductase gene variant C677T and the 4G/5G polymorphism of the plasminogen activator inhibitor gene. This case report presents a female patient who developed a postoperative deep vein thrombosis after hallux valgus reconstruction. A hypercoagulable panel revealed the 2 mentioned genetic mutations. We hope this case study will highlight the importance of ascertaining all patient risk factors and the relation to perioperative deep vein thrombosis prophylaxis.

Subtalar joint arthrodesis.

Forty patients (12 men and 28 women) treated with isolated subtalar joint arthrodesis were retrospectively reviewed. The average patient age was 50 years (range, 21-76 years). Preoperative diagnoses included posterior tibial tendon dysfunction, post-traumatic arthritis, nontraumatic arthritis, and subtalar joint middle facet coalition. The average follow-up was 15 months (range, 12-74 months). Subjective postoperative questionnaire results were classified as satisfied (n = 32), satisfied but with reservations (n = 4), or dissatisfied (n = 4). Eighty-three percent of the patients (n = 33) stated that they would undergo the procedure again. Minor complications (those that resolved with nonoperative treatment) occurred in 55% of the patients. However, the major complication rate was only 12.5%. This study showed no statistical correlation between the preoperative diagnosis and the postoperative outcome. Our results also suggested that the prevalence of complications is slightly higher than in previous reports. Isolated subtalar joint arthrodesis is an effective treatment for pain and deformity of the rearfoot.

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing.

Nineteen patients (20 feet) with severe hindfoot and ankle deformity underwent tibiotalocalcaneal fusion with a retrograde locked intramedullary nail as a limb-salvage procedure. The purpose of this study was to compare the complication rates of this procedure in diabetic versus nondiabetic patients. There were 8 men and 11 women with preoperative diagnoses including Charcot neuroarthropathy, primary osteoarthritis, rheumatoid arthritis, equinocavovarus, posttraumatic osteoarthritis, gouty arthritis, and ankle malunion. Ten of 20 procedures were performed in patients with diabetes. The average patient age was 56 years, and the average postoperative follow-up was 19.8 months. Nineteen of 20 ankles (95%) achieved successful fusion with an average time of 4.1 months. Four patients (21%) required either a fracture brace or an ankle foot orthosis at final follow-up. Five patients (25%) had major complications and 11 patients had minor complications. Major complications included osteomyelitis (n = 2), Charcot arthropathy (n = 2), failure of fixation (n =1), soft-tissue necrosis (n = 1), cardiac arrest (n = 1), cerebral vascular accident (n = 1), and fatal pulmonary embolus (n = 1). All patients with major complications were diabetic, and 14 of 20 combined major and minor complications occurred in patients with diabetes. The complication rate was found to be high in diabetic patients with end-stage deformity undergoing a limb salvage