A Prospective Evaluation for a Possible Safe Skin Bridge in Elective Foot Surgery.

Background: In foot and ankle surgery, adequate surgical exposure often requires multiple incisions to be used near one another, thus creating a skin bridge. As the skin bridge becomes narrower, the wound edge vitality is potentially compromised and therefore the wound's ability to heal. The impact of local, host, and surgical factors on wound healing are well documented in the literature; however, little is known about the role of the skin bridge. The aim of this study is to determine if there is a recommendable safe skin bridge in elective foot and ankle surgery. Methods: A prospective study was performed on 56 patients with 60 feet who had elective foot surgery. The length of each incision and distance between the incisions were recorded. The wounds were assessed for complications at 2, 4, and 6 weeks after surgery. Patient demographics and host risk factors were documented. Results: The average incision length was 5.5 (range: 3-8.5) cm. The average skin bridge was 3.9 (range: 2-6.8) cm. Five (8.3%) of the 60 feet developed a wound complication. Four (80%) of these patients had a known comorbidity. Two patients had diabetes and 2 were smokers. The incidence of relevant comorbidities was 5.5% (n = 3) for patients without a wound complication (P < .001). Age did not differ significantly between patients with and without a wound complication. Patients with a wound complication had significantly longer incision lengths (P = .047). There was no significant independent association between skin bridge width and risk of wound complications (P > .05) with skin bridge widths of 2 cm or larger. Conclusion: In this relatively small cohort of 60 elective operative foot surgeries, we did not find increased wound complications in skin bridges 2 cm or larger, when meticulous surgical technique is practiced and host risk factors are optimized. Level of Evidence: Level III, prospective case control study.

Outcomes of Total Ankle Arthroplasty After Periprosthetic Cyst Curettage and Bone Grafting.

Total ankle arthroplasty (TAA) has become a popular management option for ankle arthritis. Periprosthetic osteolysis is one of the most common causes for reoperation in TAA. A CT scan should be done in all suspected osteolysis cases to confirm location, quantify size and aid in surgical planning. These patients are often asymptomatic with limited evidence regarding appropriate management. Smaller lesions should be monitored for progression in size. Periprosthetic cysts measuring 10-15mm in all three axes should be considered for debridment and curettage with autogenous bone grafting. The authors believe that bone grafting of large asymptomatic periprosthetic cysts could prevent implant failure.

The use of a 3D printed titanium implant for arthrodesis in the management of large osseous defects in the ankle.

BACKGROUND: Large osseous defects (LOD) in the ankle occur because of multiple aetiologies. Advancement in 3-dimensional (3D) printing technologies has led to the use of custom implants and instrumentation their management. A 3D printed patient-specific porous titanium cage which allows for peripheral osteo-integration and autogenous bone-grafting could be an ideal implant in these cases. METHODS: Retrospective review of a multi-centre, multi-surgeon consecutive cohort of patients requiring either TTC or AA for a large osseous defect between June 2019 - August 2020. A custom titanium prosthesis was 3D-printed according to CT measurements for implantation. RESULTS: Mean follow up was 19.5 months (range 12-24 months). Plain radiographs and CT scans at 12 months confirmed osseointegration (stability) in 11of 13 patients (84%). Two patients developed late infection, one requiring revision surgery. CONCLUSIONS: 3D-Printed titanium implants in the management of LODs in the ankle offer a comparable success rate to other reported procedures, with unlimited geometric possibilities in the design allowing for accurate length correction. Their structural stability may offer an advantage over conventional bone graft techniques and limits the amount of bone-graft required. LEVELS OF EVIDENCE: LOE III.

Foot and Ankle Injuries in Elite South African Cricketers: A Descriptive Analysis of Injury Surveillance Data.

Introduction: Injury surveillance is an important part of injury risk reduction in the sporting population. This study describes the type, side (dominant or non-dominant), occurrence, impact, activity of onset, and severity of foot and ankle injuries in elite South African male and female cricketers. Methods: Foot and ankle injuries sustained by elite cricket players between 2018 and 2021, obtained from the records of Cricket South Africa, were descriptively analysed. Results: A total of 104 foot and ankle injuries in 82 players were recorded. The majority (n = 100; 96%) of injuries were on the non-dominant side. Bowling (n = 31; 30%) and fielding (n = 20; 19%) contributed to most injuries. The majority were first-time (n = 83; 80%) and non-impact injuries (n = 62; 60%). Fifty percent (n = 52) of injuries rendered players unable to participate in at least one match or practice session. Lateral ankle ligament injury was the most common injury sustained (n = 36; 35%). Conclusion: The findings from this study can inform future researchers and assist healthcare service needs relating to injury risk reduction and management programmes. Effective rehabilitation programmes may reduce the risk of reinjury. Ideally, these programmes need to be role specific.

Tumor induced osteomalacia from a peripheral mesenchymal tumour of the foot.

Tumour induced osteomalacia (TIO) is a rare condition caused by peripheral mesenchymal tumours (PMT) which produce fibroblast-growth factor 23 (FGF23). FGF23 inhibits renal phosphate reabsorption leading to vitamin D resistant osteomalacia. The rarity of the condition and difficulty with isolating the PMT make diagnosis difficult, with delayed treatment leading to significant patient morbidity. We present a case of PMT of the foot with TIO, with a discussion on diagnosis and treatment.

CT Scan Assessment and Functional Outcome of Periprosthetic Bone Grafting After Total Ankle Arthroplasty at Medium-term Follow-up.

BACKGROUND: Periprosthetic cysts can occur in up to 95% of total ankle arthroplasties (TAA) and have been correlated with implant failure. The aim of this study was to determine the clinical and radiologic outcomes, using computed tomographic (CT) scan, after periprosthetic cyst bone grafting and assess for the minimum cyst size that should be grafted. METHODS: A retrospective review was performed of all TAA procedures performed between 2007 and 2014 (n=93). A CT scan was done to assess cyst size and operative planning. Eight patients with 9 periprosthetic cysts larger than 1.75 cm3 were grafted and specimens sent for histology. The mean time to bone grafting was 7.3 (3.8-9.5) years. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society ankle score, visual analog scale, and Self-reported Foot and Ankle Score. A CT scan was performed at follow-up to assess graft incorporation and cyst size progression. The mean time to CT scan post grafting was 3.0 (0.7-4.7) years. RESULTS: There was no implant malalignment identified and no differences in the pre- and postoperative functional scores. Preoperatively cysts had a mean volume of 8.16 (2.04-14.03) cm3. The mean percentage incorporation was 89% (69%-100%). Eight of the grafted cysts were considered successful on CT, with the ninth having 69% incorporation. Five cysts were not grafted, as they were below 1.75 cm3, and remained the same size or had minimal enlargement. CONCLUSION: The satisfactory results in this small cohort suggests that prophylactic bone grafting may extend implant survival. We recommend that periprosthetic cysts greater than 1.75 cm3 be prophylactically bone grafted, and that cysts smaller than 1.75 cm3 be monitored for progression in size. LEVEL OF EVIDENCE: Level IV, Case Series.

Reliability of the Radiographic Measurement of the Hallux Interphalangeal Angle.

BACKGROUND: The hallux valgus interphalangeus (HVI) deformity has a common association with hallux valgus and hallux rigidus. The HVI is formed by the angle between the long axes of the proximal and distal phalanges. The normal value for this angular deformity in the coronal plane is less than 10°. The aim of this study was to analyze the intra- and inter-observer reliability of measuring the interphalangeal angle by orthopaedic surgeons. This study is the first study to evaluate specifically the reliability and reproducibility of measuring the HVI angle. METHODS: Twenty-one X-ray prints of weightbearing feet constituted a set. Sixteen qualified orthopaedic surgeons were asked to measure the HVI angle of all 21 X-ray images in the set. Three randomized sets were sent to each evaluator at 4-week intervals. After all 3 sets were measured, data were retrieved and statistically analyzed to determine the inter- and intraobserver variability and reliability in the measurement of the HVI angle. Reproducibility of the HVI measurement was assessed using 3 categories, which included the ability to measure the same angle 3 times and achieve: 3° or less, 5° or less, and more than 5° variation. RESULTS: The intraobserver reliability was found to be 5° or less in 85.2% of participants and the interobserver reliability was 81.2%. The researcher did not find significant correlation between the surgeons' level of experience with regard to the reliability of measuring the HVI angle. CONCLUSION: The inter- and intraobserver reliabilities of measuring the HVI angle is 81.2% and 85.2%, respectively. The level of experience of the surgeon does not improve this reliability. LEVELS OF EVIDENCE: Level II.

A new lesser metatarsophalangeal joint replacement arthroplasty design - in vitro and cadaver studies.

BACKGROUND: Isolated degenerative joint disease and/or Freiberg's infraction of the lesser metatarsophalangeal joint, although not frequent may become debilitating in the younger individual. Currently, once conservative management fails, the mainstay of treatment is debridement and excision-interposition arthroplasty. Replacement arthroplasty has been ineffective in the long term as the joints are subject to severe repetitive fatigue loading over small articulating surfaces through a wide range of motion. This is an in vitro and cadaver study of a new design replacement arthroplasty developed by the senior author. The aim of this study is to evaluate this novel replacement arthroplasty of the lesser metatarsophalangeal joint in a laboratory setting and cadaver implantation. METHODS: This three-component mobile bearing device is made of titanium and high density polyethylene which evolved over 4 years. It was subjected to 5,000,000 cycles in a laboratory under physiological and excessive forces to assess resistance to fatigue failure and wear pattern of the polyethylene liner. Following these tests, it was implanted in 15 fresh frozen cadavers at various stages of its development, during which the surgical technique was perfected. Range of motion and stability was tested using custom made instrumentation in four cadavers. The implant was inserted in a further two cadavers by an independent foot and ankle surgeon to check reproducibility. RESULTS: The device showed almost no signs of wear or surface deformation under physiological forces. The surgical technique was found to be simple and reproducible in the cadaver trial. The average dorsiflexion was 28.5° and 28.9° pre- and post-implant respectively. The average plantar flexion was 33.8° and 20.8° pre- and post- implant respectively. The joints were stable both pre- and post-operatively. Post-operative stability was objectively assessed for dorsal displacement and dorsiflexion using a 5 kgf (49 N) and was found to be excellent. CONCLUSION: This novel lesser metatarsophalangeal joint replacement arthroplasty has been developed as an option in the surgical treatment of symptomatic degenerative joint disease and/or Freiberg's infraction resistant to conservative treatment. The implant was found to be durable and resistant to wear in the laboratory testing. The cadaver studies have shown it to require minimal specialized instrumentation with good surgical reproducibility. This proof of concept study is the basis for clinical trials.

Outcomes of bilateral simultaneous hallux MTPJ fusion.

BACKGROUND: Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a frequently performed surgical procedure. Many patients have bilateral hallux MTPJ pathology requiring bilateral arthrodesis. There are concerns that bilateral simultaneous hallux surgery, under one anaesthetic, results in the patient being severely incapacitated in the early post-operative period. We hypothesize that bilateral simultaneous hallux MTPJ fusions does not compromise outcomes or the patients' post-operative comfort and rehabilitation and is cost and time effective. METHODS: In this retrospective study, 16 patients who underwent bilateral simultaneous first MTPJ arthrodesis were compared to 16 patients who had unilateral MTPJ arthrodesis with regards to outcome, tolerance, cost and time effectiveness. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Self-Reported Foot and Ankle questionnaire (SEFAS). RESULTS: There was a significant improvement in the AOFAS scores post surgery in the bilateral group and according to the SEFAS grading, 14 patients (87.5%) had good or excellent outcome scores with 13 (81.25%) of these patients having excellent scores. This was comparable to the outcome scores in the unilateral group. Two patients developed non-unions bilaterally compared to one in the unilateral group. There is also a notable general cost saving and less time off work when bilateral fusions are done at the same setting. CONCLUSION: Bilateral simultaneous hallux MTPJ arthrodesis is an effective, convenient and cost effective option for patients requiring MTPJ fusions for bilateral hallux pathology. LEVEL OF EVIDENCE: Level 4.

Use of locking barbed sutures in foot and ankle surgery. A case series.

BACKGROUND: Barbed sutures represent a novel technique for wound closure. By distributing tension forces across the length of a wound, it results in better wound healing. A recent article from Chowdhry et al. cautioned against the use of barbed sutures in foot and ankle surgery. Our experience with the Quill® (Angiotech, Vancouver, BC) barbed suture, showed a more positive outcome. MATERIALS AND METHODS: 123 surgical wounds were prospectively followed up after closure with a bidirectional barbed suture. The cohort represented a large range of patient ages and co-morbidities, as well as incision length and locations. RESULTS: Complication rates were low in this large cohort. The total complication rate was 6.5% (8 wounds). One wound (0.8%) had a major infection that needed further surgery, and 2 wounds (1.6%) showed inflammatory related complications. The remaining 5 wounds (4%) had minor wound complications, which resolved without any further surgical intervention. Patient satisfaction rates were high, with 78% of incisions scoring at maximum on the visual analogue cosmesis score. CONCLUSIONS: Use of the Quill® (Angiotech, Vancouver, BC) suture is a safe and effective alternative for wound closure in foot and ankle surgery.

Isolated Subtalar Arthrodesis.

INTRODUCTION: An isolated subtalar arthrodesis through a sinus tarsi approach with cannulated screw fixation is safe, reproducible, and effective for specific hindfoot pathology in adults. STEP 1 PREOPERATIVE PLANNING: Perform a comprehensive clinical and radiographic assessment. STEP 2 PATIENT POSITIONING: Position the patient supine on the operating table with a bump under the ipsilateral hip, to internally rotate the involved leg. STEP 3 INCISION: Mark a longitudinal incision from just inferior to the tip of the lateral malleolus and extending toward the base of the 4th metatarsal. STEP 4 APPROACH: Expose the subtalar joint by reflecting the extensor digitorum brevis and protecting the peroneal tendons. STEP 5 JOINT PREPARATION: Meticulously prepare the subtalar joint using osteotomes and curets down to healthy bleeding subchondral bone. STEP 6 REDUCTION AND FIXATION: Reduce the subtalar joint into 5° of valgus and fix it with cannulated screws. STEP 7 WOUND CLOSURE: Meticulously close the wound in layers and place the lower leg in a well-padded plaster back slab with the ankle in a neutral position. STEP 8 POSTOPERATIVE CARE: The operatively treated leg is kept immobilized and non-weight-bearing for the first 6 weeks. RESULTS: Numerous retrospective articles have reported high fusion rates and good functional outcomes after isolated subtalar arthrodesis, for all indications.

Rotational and opening wedge basal osteotomies.

There are more than 150 different procedures described for correction of the hallux valgus deformity, the treatment of which is usually guided by severity. Moderate to severe hallux valgus has traditionally been managed with a shaft or proximal osteotomy together with distal soft-tissue release. Proximal osteotomies can be classified as translation or rotational. Rotational osteotomies such as the Ludloff and proximal opening wedge have not been popular historically because of instability from lack of fixation, resulting in complications. This article describes modified techniques with modern fixation of these 2 osteotomies, which offer stable fixation and reproducible results.

Proximal opening-wedge osteotomy of the first metatarsal for hallux valgus using a low profile plate.

BACKGROUND: This retrospective study was conducted to evaluate the results of the proximal (basal) opening-wedge osteotomy of the first metatarsal for correction of symptomatic hallux valgus deformity, using a low profile plate. MATERIALS AND METHOD: The procedure was performed by a single surgeon over an 18-month period. Forty-six patients (64 feet) were treated for symptomatic hallux valgus with an average follow up of 20 months. A proximal opening-wedge osteotomy of the first metatarsal and fixation with a low profile plate in combination with a distal soft tissue release with the same postoperative protocol was used in all the patients. Improvement in the hallux valgus angle (HV) and I---II intermetatarsal angle (IM I---II) as well as the AOFAS forefoot score pre and postoperatively (obtained retrospectively from the medical records), were recorded; in particular, the length of the first metatarsal was noted pre- and postoperatively. RESULTS: The HV and IM I---II angles improved by a mean of 14.7 degrees and 6.4 degrees, respectively. The AOFAS forefoot score improved from a mean of 51.3 to 86.8. The mean increase in the length of the first metatarsal was 2.3 mm. Of the more significant complications, five patients developed a hallux varus (early in the series), one of which was symptomatic, and there was one non-union requiring bone graft. CONCLUSION: The proximal opening wedge osteotomy of the first metatarsal in combination with a distal soft tissue release and stable fixation of the low profile plate was an effective method for correcting a moderate hallux valgus deformity. Guidance provided by the "First Metatarsal Opening Wedge Angle Reference Chart'' was found to be helpful for the IM I-II angle correction.