Elective foot and ankle surgery following the peak of the COVID-19 pandemic is safe: A report of 30-day morbidity and mortality.

INTRODUCTION: The safety of resuming elective surgical services remains unclear following several surges of the COVID-19 pandemic worldwide. Multiple studies have reported high rates of post-operative mortality and pulmonary complications. 30-day outcomes on an initial cohort of patients undergoing elective foot and ankle surgery at 3 central London hospitals are presented. MATERIALS AND METHODS: This study is a retrospective review of the first 63 patients undergoing surgery following the first UK surge via a modified treatment pathway, based on published national guidelines, designed to minimise the risks to patients and staff associated with COVID-19. RESULTS: 90% of patients were ASA 1 or 2, with an average age of 46. All tested negative for COVID-19 pre-operatively and all but one underwent a general anaesthetic. 10 patients required one night hospital stays and 1 was admitted for four nights. 52 were day case procedures. 2 complications were identified, not relating to COVID-19 infection. No 30-day mortalities or pulmonary complications were recorded. CONCLUSIONS: With a community prevalence of COVID-19 of between 1 in 1500 and 1 in 1700, elective foot and ankle surgery was safe following the first surge of the pandemic in the UK. This data can guide elective service planning in countries with pandemic curves behind the UK's or in the event of further surges in national cases.

Making Things Easier: A Simple Novel Method to Fix a Dorsiflexion Osteotomy of the First Metatarsal.

A first ray dorsiflexion osteotomy is commonly performed for cavovarus foot correction. There are multiple techniques to fix this osteotomy, ranging from wires, screws, and plates or a combination of these. We present our results using a varisation staple (Biomet©) as an alternative fixation device. We performed a retrospective outcome analysis of a consecutive series of 10 cavovarus feet that underwent a dorsiflexion osteotomy (dorsal closing wedge) of the first metatarsal fixed with two varisation staples. The results were measured at a mean three monthly follow-ups and included union and complication rates, as well as clinical and radiographic assessment of cavus deformity correction. There was a 100% union rate with no complications or cases of delayed union. No metalwork removal was requested in any case at follow-up. First ray dorsiflexion osteotomies are most commonly fixed using a 3.5mm cortical screw. We demonstrate that our alternative and novel technique using varisation staples achieved a 100% union rate while avoiding the prominent hardware complications known to occur with cortical screws or plates.

Delayed Allergic Reaction to ChloraPrepTM in Foot and Ankle Surgery.

Chlorhexidine-based skin preparations are frequently used in orthopaedic surgery. We report 2 recent cases of patients suffering significant allergic reactions to ChloraPrepTM complicating routine foot and ankle surgery. We advise vigilance for this possible issue and recommend thorough removal of all preparation at the end of the procedure.

Correlation and comparison of syndesmosis dimension on CT and MRI.

INTRODUCTION: Various methods using CT scan have been described to diagnose distal tibiofibular syndesmotic injuries. However, CT scan does not take into account the amount of cartilage within the distal tibiofibular joint and could therefore lead to false positive results. We present the first study correlating the findings of the distal tibiofibular syndesmosis on CT and MRI scans. METHODS: CT and MRI scan of consecutive patients over a period of 18 months, and of a time lapsed less than 12 months between the two imaging modalities, were reviewed. Measurements of the distal tibiofibular syndesmosis were taken according to a previously published study at the level of the distal tibial physeal scar. RESULTS: Twenty-six ankles from 25 patients were included in this study for analysis. Significant difference between CT and MRI assessments in the overall distal tibiofibular dimensions and in the posterior distal tibiofibular distance for those ankles with evidence of osteoarthritis was found. Interclass correlation coefficients suggest that such methodology was reproducible and reliable. CONCLUSION: When the widening found on a CT scan is minor or the diagnosis is equivocal, a contralateral comparative CT or an ipsilateral MRI scan is recommended to prevent misdiagnosis. LEVEL OF EVIDENCE: Level IV.

Severe scar problems following use of a locking barbed skin closure system in the foot.

BACKGROUND: Barbed sutures provide a novel technique for knotless wound closure. They have mainly been used in plastic and general surgery. There are no reports about its use in the foot. METHODS: We present a case series of 11 feet in 8 patients whose wounds were closed with barbed sutures. Ten had primary hallux valgus correction and one had a revision correction. RESULTS: No problems were noted at 2-weeks follow-up. Four of the 11 cases required open suture excision due to an adverse reaction. Five were followed to delayed wound healing. Histology results from one scar showed a localised histiocytic reaction and superficial dermal abscess formation. CONCLUSIONS: We feel the thin subcutaneous tissue of the foot, the amount of motion and pressure from the shoe causes the barbs to repeatedly irritate the soft tissue. Based on our short case series we cannot recommend the use of a barbed skin closure system in the foot.

Open ankle arthrodesis with a fibular-sparing technique.

BACKGROUND: Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique. METHODS: A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring. RESULTS: At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being "completely satisfied" with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment. CONCLUSION: This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores.

A case report of three peripheral schwannomas attached to the Achilles paratenon.

BACKGROUND: Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. OBJECTIVE: To report a case of multiple schwannomas arising form the achilles paratenon. METHODS: A 38 year old man presented lumps on the dorsum of his leg. He was clinically evaluated, subjected to imaging studies and surgery. RESULTS: 3 separate lumps where removed measuring 10, 12, and 12mm. They here confirmed to be schwannomas on hitochemical staining. CONCLUSION: A schwannoma must be considered in the differential of lumps in the lower leg. This is the first report of schwanommas associated with the paratenon. Removal of such masses is warranted to prevent local erosion.

Post-operative stress fractures complicating surgery for painful forefoot conditions.

A stress fracture is caused by repetitive or unusual loading of a bone leading to mechanical failure. Fatigue type stress fractures occur in normal bone exposed to abnormally high repetitive loads, whereas insufficiency type stress fractures occur in abnormal bone exposed to normal loads. We describe three cases of insufficiency stress fractures that have complicated surgery for painful forefoot conditions. The diagnosis and management of these cases are discussed. Stress fractures should be included in the differential diagnosis of any patient who continues or develops pain after surgery to the forefoot.

Small joint arthroplasty.

There is little published on the radiology of small joint arthroplasty when compared with the commonly performed hip or knee replacement. The types of joint replacement, their clinical efficacy, and the expected radiographic appearances are reviewed for each of these upper and lower extremity joints. Potential complications and their radiographic appearances are presented.

Use of a simple suture to stabilize the chevron osteotomy: a prospective study.

A clinical and radiographic review was undertaken in 27 patients (30 feet) who underwent a chevron osteotomy stabilized with a double loop of polydioxanone suture. The mean patient age at the time of surgery was 40 years (range, 16 to 66 years). At 6 weeks postoperatively, all patients showed clinical and radiographic union at the osteotomy site. In 1 foot, the initial correction was lost with radiographic evidence of an angulated distal fragment with no medial translation. There were no cases of wound infection, sinus formation, or avascular necrosis of the metatarsal head. No patients required further surgery. This method of stabilizing a chevron osteotomy is technically straight forward, with a predictable outcome, and provides a valid low cost alternative to screw, bioabsorbable implant, or Kirschner wire.

Bulk femoral-head autografting in uncemented total hip arthroplasty for acetabular dysplasia: results at 8 to 11 years follow-up.

Acetabular dysplasia causes difficulty in achieving adequate coverage of the acetabular component during total hip arthroplasty (THA). Bulk femoral-head autografting is one technique that has been used to achieve better coverage of the acetabular component. Long-term follow-up studies have shown a significant failure rate when this technique has been used in conjunction with a cemented acetabular component; however, with uncemented components, early results have been encouraging. In our study, 15 patients with acetabular dysplasia underwent uncemented THA, during which bulk femoral-head autografts were used. At an average follow-up of 10 years, no cases required revision, and radiologically, the bone graft had united. Our results support the use of bulk femoral-head autografting in patients with acetabular dysplasia requiring hip arthroplasty.