Anthropometric measurements of the foot cannot predict the screw diameter for fifth metatarsal fractures intramedullary fixation.

PURPOSE: The present study aimed to evaluate the accuracy of anthropometric foot measurements in predicting the diameter of the intramedullary screw for fifth metatarsal fracture fixation. Secondary aim was to identify whether the fifth metatarsal intramedullary canal diameter is correlated to the fifth metatarsal length and the foot dimensions. METHODS: In 29 cadaveric feet, the maximum length of the plantar surface of the foot (PL) and the perimeter of the foot at the level of the fifth metatarsal base (PBFM) were measured using a measuring tape. Subsequently, the fifth metatarsal was excised. Using Computed Tomography scan, the metatarsal length (FML), and the horizontal (HDI) and vertical diameter (VDI) at the isthmus level were measured. The HDI values were grouped in 5 mm increments to correspond to the recommended screw diameter (RSD) for intramedullary fixation. A univariate linear regression analysis considered RSD and HDI as the dependent variables and FML, PL, PBFM as the independent variables. A multivariate regression analysis was performed to examine the predictive value of the two anthropometric measurements. A p-value < 0.05 was considered statistically significant. RESULTS: All six univariate analyses revealed that the dependent variable was significantly correlated with the independent variable. However, the multivariate regression models showed that the anthropometric measurements were not significantly correlated with the RSD and HDI. CONCLUSION: The current study found an association between the fifth metatarsal intramedullary canal diameter and the fifth metatarsal length and foot anthropometric dimensions. However, the anthropometric measurements of the foot presented a low predictive value for the decision of an intramedullary screw diameter in the treatment of fractures of the base of the fifth metatarsal.

Diffuse Tenosynovial Giant Cell Tumor Encircling the First Metatarsal Bone Remodeling after Resection. A Case Report.

Introduction: The term tenosynovial giant cell tumor encompasses a group of rare soft-tissue tumors. A new classification divides the group in localized and diffuse type, depending on the involvement of the surrounding tissues. Due to the unclear origin and heterogeneity in extend of the diffuse-type giant cell tumors, there is only limited evidence on the tumor-specific treatment. Thus, every case report has an added value toward setting disease-specific guidelines. Case Report: Presentation of a diffuse type tenosynovial giant cell tumor encircling the first metatarsal. The tumor had mechanically eroded the plantar aspect of the distal metaphysis, with no signs of tumor spread. After an open biopsy, resection of the mass was performed without debriding or resecting the first metatarsal. Repeat imaging postoperatively showed no recurrence at 4-year follow-up and a bony remodeling of the lesion. Conclusion: Bone remodeling is possible after complete resection of diffuse tenosynovial giant cell tumor when the erosion is caused by mechanical pressure and no intraosseous expansion of the tumor is present.

Physical Examination of Ankle Sprain and Ankle Instability: Can We Really Divide It into Low and High Ankle Sprains?

Lateral ankle ligament sprains and syndesmotic injuries are two different entities. However, they may be combined under the same spectrum depending on the arch of violence during the injury. Currently, the clinical examination has a limited value in the differential diagnosis between an acute anterior talofibular ligament rupture and a syndesmotic high ankle sprain. However, its use is indispensable for raising a high index of suspicion for detecting these injuries. Based on the mechanism of injury, clinical examination plays an essential role in guiding further imaging and early diagnosis of low/high ankle instability.

Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve.

BACKGROUND: There is a considerable overlap of symptoms between chronic exertional compartment syndrome (CECS) of the anterior and lateral compartments of the lower leg and entrapment neuropathy of the superficial peroneal nerve (SPN). We describe a minimally invasive, single incision surgical technique for release of both the compartments and the SPN in the same setting. The operative technique involves a minimal anterolateral approach at the level where the SPN pierces the subcutaneous fascia. METHODS: Nineteen patients were operated with the method and 24 anterolateral compartments (5 cases with bilateral CECS) were released. Anterior and lateral, proximal and distal fasciotomies were performed sequentially with the use of a specific instrument designed for carpal tunnel release (KnifeLight®, Stryker). This is a modification of a fasciotome with an intergrated light source which allows for transillumination of the subcutaneous tissues. The SPN and its main branches with their anatomical variations were explored and decompressed at the same setting. RESULTS: Patients who met the inclusion criteria were reviewed at one year postoperatively with a Numeric Analog Pain Scale (NAS) and the Linkert satisfaction scale. There were 5 men and 10 women, aged 35.7 (21-60) years. The NAS scores improved by a mean 6 points (p<0.0001) postoperatively and 86.6% (13/15) of the patients were either satisfied or very satisfied with the operation. There were no intraoperative complications. There were two patients with SPN neuropathy symptoms postoperatively, one of whom required revision surgery. One patient had recurrence of less intense symptoms in the first postoperative year with no need for reoperation. CONCLUSIONS: The simultaneous release of the anterolateral compartment of the leg and decompression of the SPN with the described technique was safe and effective. It combined the advantages of a single, minimally invasive approach with the subcutaneous transillumination, and had a high patient satisfaction and a low recurrence rate. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Arthroscopic os trigonum en-bloc removal outcomes at 6-month follow-up are better compared to Stieda's process resection in patients with posterior ankle impingement syndrome: a prospective comparative study.

OBJECTIVE: To evaluate the potential differences in American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot Function Index (FFI) at 6-month and 12-month postoperative follow-up of arthroscopic treatment for posterior ankle impingement (PAIS) between os trigonum (OT) and Stieda's process (SP) patients. METHODS: Thirty consecutive patients (32 ankles) treated in our Institution for PAIS with posterior arthroscopy were prospectively enrolled in the study from December 2012 to July 2019. Indications were patients with PAIS with persistent symptoms following conservative management. Exclusion criteria were the coexistence of concomitant pathologies and patients who underwent additional surgical procedures. An independent investigator interviewed and evaluated the patients according to the AOFAS hindfoot score and FFI preoperatively, at 6-month and 12-month follow-up. RESULTS: Except for AOFAS scores in the SP group (MD (mean difference) 11.28, p=0.08), patients undergoing arthroscopic treatment for bony PAIS had an overall significant improvement in AOFAS score (OT MD 22.29, p<0.05) and FFI (OT MD -70.07, p<0.05; SP MD -50.96, p<0.05) from their preoperative scores at 6-month follow-up. Similarly, a significant improvement in AOFAS score (OT MD 5.78, p=0.01; SP MD 12.14, p<0.05) and FFI (OT MD -9.36, p=0.04; SP MD -26.43, p<0.05) was observed from the 6-month to 12-month follow-up in all groups. At 6-month follow-up, the OT group had significantly better FFI outcomes (MD -33.57, p=0.04) compared with the SP group. No differences were found by group when comparing AOFAS score and FFI score at 12-month follow-up. CONCLUSIONS: When comparing patients undergoing OT excision or SP resection, better FFI outcomes were observed in the OT group at 6-month follow-up. LEVEL OF EVIDENCE: Prospective comparative study. Level II.

Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review.

IMPORTANCE: Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries. OBJECTIVE: To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies. EVIDENCE REVIEW: Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms "anterior cruciate ligament," "peroneus longus" and "fibularis longus" alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool. FINDINGS: Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7 mm among the different preparation techniques, which is comparable with reports of HT grafts. CONCLUSIONS AND RELEVANCE: The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions. LEVEL OF EVIDENCE: Level III.

Talonavicular Dislocation-What Lies Beneath?

BACKGROUND: The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management. METHODS: We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them. RESULTS: There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively. CONCLUSIONS: Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.

Minimal resection interposition arthroplasty of the first metatarsophalangeal joint.

BACKGROUND: Interposition arthroplasty of the first metatarsophalangeal (MTP) joint is a viable alternative to fusion in patients with advanced hallux rigidus. The purpose of this study is to evaluate the midterm results of a modification of the technique. METHODS: Case series of 18 interposition arthroplasties were performed on 13 female patients with Grade III-IV hallux rigidus. The technique included cheilectomy, bunionectomy when needed, minimal resection of the base of the proximal phalanx and interposition of a fascia lata allograft in the first metatarsophalangeal joint. Mean follow up was nine years (range 75-136 months). Patients were evaluated according to the AOFAS score, the ability to tip toe and their subjective satisfaction. RESULTS: There was a significant difference between preoperative (mean 43.2, range 15-83) and postoperative (mean 77.3, range 40-100) AOFAS scores (p<0.001). The patients were able to tip toe on 12 of the 18 operated feet and 9 of the 13 patients were satisfied from the operation. All dissatisfied patients had a coexistent hallux valgus deformity. CONCLUSIONS: The technique had satisfactory midterm outcomes in older patients with advanced hallux rigidus without hallux valgus. Advantages of the method are the preservation of tip toe function in most patients and a technically easy conversion to fusion when needed.

Surgical management of hallux valgus and hallux rigidus: an email survey among Swiss orthopaedic surgeons regarding their current practice.

BACKGROUND: Various clinical and radiological criteria have been suggested to choose one of the numerous techniques in surgical treatment of hallux valgus and rigidus. We hypothesized that the surgeons' professional background will influence that choice depending on specialization, age, type and institution of training as well as his orthopaedic cultural orientation. Since Switzerland is characterized by regional languages (the most important being German and French), we were interested to learn if the linguistic differences had an influence on the orientation of the surgeons towards e.g. Anglo-American or French surgical traditions and/or sources of literature on the subject. METHODS: A survey was e-mailed to all members of the Swiss Orthopaedic Society (SGOT-SSOT). Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 separate cases of (1) moderate and (2) severe hallux valgus and (3) hallux rigidus. The responses were collected and statistically analyzed. RESULTS: Two hundred thirty of 322 respondents completed the survey(response rate 46 %). as they perform foot surgery on a regular base; 39 % were members of the Swiss Orthopaedic Foot and Ankle Society (SFAS). Selected surgical treatments differed as follows: in joint sparing procedures older and busier surgeons were more likely to use Chevron osteotomies, however more than 50 % preferred a Scarf-type of osteotomy. Along the so-called "Rösti-Graben" separating the French from the German speaking part of Switzerland no significant difference was found in the choice of operation technique. Nevertheless the fact being a member of SFAS showed significant differences in technical choice in case 2 and 3. CONCLUSIONS: There are significant associations between the surgeons' age, expertise and training and their preferred operative intervention. Considerable differences in the surgical management were found in the practice of the general orthopaedic surgeons 72 and the foot and ankle specialists. The cultural background and training is not mirroring the classical Swiss east west discrepancy. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons.

Late diagnosis of a McFarland fracture: imaging and treatment.

McFarland fractures represent a type of oblique medial malleolar fracture in children that can be challenging to diagnose and treat. A 14-year-old junior league soccer player with a Salter Harris type IV McFarland fracture presented late, as the initial routine two views radiological assessment failed to reveal a clear fracture line. The addition of a mortise ankle view led to the correct diagnosis and subsequent MRI findings guided nonsurgical treatment with an excellent outcome. The debate between obtaining two or three views in closed pediatric ankle injuries according to the so-called Ottawa rules and the usefulness of magnetic resonance imaging (MRI) in the decision making for the choice of treatment of McFarland fractures are discussed in this case report.

Common pitfalls in syndesmotic rupture management: a clinical audit.

BACKGROUND: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. MATERIALS AND METHODS: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients' notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. RESULTS: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. CONCLUSIONS: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Perioperative variations of the intracompartmental pressures of the paraspinal muscles.

STUDY DESIGN: Study of the influence of thoracolumbar spinal surgery through a posterior approach to the intercompartmental pressure of the paraspinal muscles. OBJECTIVE: To create waveforms according to the pressure variations up to 24 hours postoperatively and relate these measurements to independent parameters. SUMMARY OF BACKGROUND DATA: The existence of a paraspinal anatomic compartment and a relevant compartment syndrome has been supported theoretically, proven experimentally, and confirmed in clinical cases. The perioperative variations of the intercompartmental pressures remain largely unknown. METHODS: Five measurements were taken from both paraspinal compartments in each operated patient: preoperatively, intraoperatively, immediately after wound closure, and at 6 and 24 hours postoperatively. The recorded pressures were grouped as normal, elevated, or suggestive of a paraspinal compartment syndrome. Abnormal pressures were correlated with patient-related and operation-related parameters. Forty-two patients participated in the study, 21 male and 21 female patients aged 13 to 83 years (mean age 51 y). Seventy compartments were included in the final analysis. RESULTS: Forty-two compartments developed abnormally elevated pressures postoperatively and in 22 of these, pressures suggestive of a compartment syndrome were recorded. In no case was there a clinical presentation of a true compartment syndrome. Different waveforms were created for the normal and elevated pressures group. In compartments with high measurements, pressures were likely to continue to rise at 6 and 24 hours postoperatively. The body mass index was greater in both the elevated pressures and compartment pressures groups. Procedures lasting >2 hours, extended approaches, and instrumented posterior interbody fusion operations were related with lower postoperative pressures. CONCLUSIONS: A large percentage of patients develop increased paraspinal muscle pressures up to 24 hours after posterior thoracolumbar spine surgery. These increases are related to patient-related and operation-related factors and may not present clinically as a compartment syndrome.

Prevalence of interdigital nerve enlargements in an asymptomatic population.

BACKGROUND: Morton's neuroma is a common primary diagnosis for referral to foot and ankle surgeons. On presentation, many patients have had an ultrasound reporting the presence of Morton's neuroma, which may not correlate with the clinical examination findings. The prevalence of such sonographic findings in the general population remains unknown. METHODS: In this observational prospective study, patients with asymptomatic forefeet who were seen by two foot and ankle surgeons for unrelated mid- or hind foot pathology were examined clinically and sonographically for the presence of interdigital nerve thickening. Forty-eight volunteers participated in the study (96 feet). For the purpose of this study, asymptomatic thickenings greater than 5 mm in diameter were termed sonographic neuromas. Ultrasound examination was performed by two specialist musculoskeletal radiologists. RESULTS: Fifty-four percent of the volunteers (26 of 48) had sonographic nerve thickening and in 17 cases (35.4%) enlarged nerves were found bilaterally. Differences for gender, original diagnosis or side of original pathology were not significant. Older subjects were more likely to have a sonographic neuroma (p = 0.018). Feet with a positive Mulder's click were more likely to have a sonographic neuroma (p = 0.015). CONCLUSION: Ultrasound, even in highly skilled hands, has a high rate of incidental finding of an asymptomatic interdigital nerve enlargement, which can lead to a false diagnosis of a Morton's neuroma. Sonographic evidence of Morton's neuroma per se is unreliable unless it is correlated with an equivocal clinical examination. Clinical examination is still the gold standard for the diagnosis of a Morton's neuroma.

Sutures versus sterile strips for closure of ankle arthroscopy portals: prospective crossover trial.

BACKGROUND: Either a nylon single suture or adhesive tape in the form of Steri strip are commonly used for the closure of portals in ankle arthroscopy. The purpose of this study was to compare the two methods with regards to their safety, complications and cosmetic result. METHODS: This was a prospective cross over study of 100 patients who underwent ankle arthroscopy. Materials used for wound closure were either a 3-0 nylon suture or a single Steri strip. Portals were reviewed according to a validated wound scoring system. Parameters such as the age and gender of the patients, the duration of tourniquet use and the use of an intraarticular corticosteroid injection at wound closure were also studied. RESULTS: Ninety-five patients were included in the statistical analysis. No technique was found to be superior in terms of the wound description (p = 0.164), infection grade (p = 0.232), infection treatment (p = 0.557) and the cosmetic appearance (p = 0.371). Seventy-two percent of patients had a good to excellent cosmetic result. There were two cases of infection requiring administration of antibiotics, one from each method of closure. Of the independent parameters, the use of cortisone was related to a lower infection treatment score (p = 0.013). Patients with signs of infection had a shorter total tourniquet time compared to the patients with no infection (p = 0.002). CONCLUSION: The use of either a single suture or Steri strip in the closure of ankle arthoscopy portals has equivalent results. Both methods were safe with equivalent cosmesis and low infection rates.

Operative management of common forefoot deformities: a representative survey of Australian orthopaedic surgeons.

BACKGROUND: Hallux valgus and hallux rigidus are common conditions for which numerous operative interventions have been described in the literature. Various clinical and radiological measurements have been used to help grade severity and to guide treatment. MATERIALS AND METHODS: A survey was e-mailed to all members of the Australian Orthopaedic Association. Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 separate cases of hallux valgus and hallux rigidus of varying severity. They were specifically asked about type of deformity correction and type of fixation. The responses were collected and statistically analyzed. RESULTS: The authors collected the answers of 454 respondents with a response rate of 36%. There was a disproportionately large percentage of respondents who were members of the Australian Orthopaedic Foot and Ankle Society. Preferred treatments were different for the 3 different cases. Older surgeons were more likely to use Chevron osteotomies, and Australian Orthopaedic Foot and Ankle Society members were more likely to use a scarf. Scarf osteotomy was preferred by more than 50% for the cases of moderate and severe hallux valgus, whereas first metatarsophalangeal joint fusion was preferred for the case with significant arthritic changes. CONCLUSIONS: There are significant associations between the surgeons' age and expertise and their training and their preferred operative intervention. Considerable differences were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons. Although anecdotally aware that lesser deformity is treated with distal osteotomies and more severe deformity with a proximal osteotomy, the authors are unaware of any current literature that verifies this.

Solitary navicular metastasis of a pulmonary adenocarcinoma.

UNLABELLED: The authors present a case of a 62-year-old male with a symptomatic isolated midfoot metastasis as the first clinical presentation of a primary pulmonary tumor. In this case of a metastatic adenocarcinoma, the lesion leading to diagnosis was located in the foot. The poor outcome and the sparse relevant literature are presented in brief. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head.

BACKGROUND: The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed. OBJECTIVE: To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head. METHOD: Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements. RESULTS: Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control (P<0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads (P<0.01), and the oblique position of the bars was more effective than the perpendicular one (P<0.01). CONCLUSIONS: The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.

Osteoid osteoma of the posterior talar dome.

Osteoid osteoma of the foot and ankle can be challenging to diagnose. A case of an osteoid osteoma of the posterior talar dome is presented in this article. The lesion mimicked other local pathologies resulting in considerable delay in diagnosis and unnecessary therapeutic interventions. Osteoid osteoma should be included in the differential diagnosis of intractable hindfoot pain.