Peroneus brevis tendon tears.

Tears of the peroneus brevis tendon are more frequent than reported in the literature. Because of the vague pain associated with structures of the lateral ankle, peroneal tears are frequently misdiagnosed. Physical signs such as swelling along the course of the peroneal tendon sheath, pain with eversion, and subluxing tendons are diagnostic of peroneal pathologic conditions. The cause of peroneal tears is not completely understood. Possible causes include subluxing peroneal tendons, a sharp posterior ridge of the fibula, overcrowding of the peroneal groove, instability of the superior peroneal retinaculum, lateral ankle instability, contraction of the peroneus longus, hypovascularity of the peroneus brevis tendon, and a shallow peroneal groove of the fibula. Although conservative measures are almost always attempted, surgical repair of peroneus brevis tears remains the standard of care. Débridement and tubularization are recommended for less extensive tears. In more severe cases, resection of the damaged tendon and tenodesis of the proximal and distal segments to the peroneus longus are necessary. Return to maximum activity is prolonged, but with proper patient selection, evaluation, and treatment, good to excellent results can be expected.

Tenodesis for chronic lateral ankle instability.

The goal of lateral ankle stabilization is restoration and stability without any functional deficit. Obviously, only anatomic reconstruction can prevent deficits in range of motion. As a result, motion loss is unavoidable with tenodesis procedures. Unfortunately, no procedures are available for anatomic reconstruction of subtalar joint instability. Therefore, when there is objective evidence of subtalar joint instability, tenodesis procedures must be considered. The authors believe that stability is more important than range of motion when degenerative changes are present within the ankle joint. Tenodesis results are good for the short term (less than 5 years) but may deteriorate over time (after more than 9 years). Some residual pain is common following tenodesis procedures.

Mosaicplasty for the treatment of osteochondral defects of the ankle joint.

Autogenous osteochondral transplantation is a relatively new procedure for the treatment of osteochondral lesions of the ankle joint. The procedure is reserved for larger stage III and stage IV lesions. The corresponding author has had good preliminary results with a high level of patient satisfaction. The procedure is relatively straightforward and reliable. The need for a second surgical site has not proved to be a great disadvantage of the procedure; no complications have occurred to date at the knee donor site. This procedure, which was first described for use in the knee joint, shows excellent promise for use in the ankle and warrants larger investigational studies to assess outcomes.

Basal cell carcinoma of the nail unit: a case report.

Basal cell carcinomas (BCC) of the foot are rare. A review of the English literature found only 23 cases of BCC reported in the foot, none of which involved the nail unit. The nail unit, which is composed of the nail bed and nail-folds, is an exceedingly atypical site for basal cell carcinomas. A case of BCC of the proximal nail fold of the hallux which was treated with Mohs Micrographic Surgery (MMS) is presented.

Low-molecular-weight heparin for deep vein thrombosis prophylaxis in foot and ankle surgery: a review.

The necessity of prophylaxis for deep vein thrombosis (DVT) in those patients who undergo foot and ankle surgery remains poorly defined. The authors explore and review the low-molecular-weight heparin (LMWH) preparations for use by foot and ankle surgeons. Recent literature has described a low incidence of DVT and pulmonary embolus (PE) following foot and ankle surgery. Nonetheless, it is paramount that foot and ankle surgeons be aware of the potential risk factors and methods of prophylaxis for DVT. Many options are available for prophylaxis. This article presents a review of DVT with particular attention given to distinguishing risk factors, prophylaxis, and LMWH preparations.

Predislocation syndrome: a review and retrospective analysis of eight patients.

Predislocation syndrome is defined as an either an acute, subacute, or chronic inflammatory process involving the lesser metatarsophalangealjoints. If left untreated, this process can lead to plantarplate and capsular attenuation and metatarsophalangeal joint instability. A retrospective analysis were performed on eight patients who were treated with a flexor tendon transfer for this condition. A subjective analysis and chart review were performed to determine the final outcome of these patients. All patients had a chief complaint of a painful second metatarsophalangeal joint with seven of eight patients having an associated hallux valgus deformity. Excellent results were achieved in six patients. Residual stiffness was the primary complaint of two patients following surgery, suggesting that metatarsophalangeal joint stiffness may be a potential problem after flexor digitorum longus tendon transfers. However, we concluded that the flexor digitorum longus tendon transfer remains an excellent procedure for second toe instability and late-stage predislocation syndrome. A literature review describing the epidemiology, symptom complex, physical findings, radiographic signs and therapies used to manage predislocation syndrome were also discussed.

Ostectomy for diabetic neuroarthropathy involving the midfoot.

Diabetic neuroarthropathy is a frequent complication of diabetes mellitus that results in instability of the foot, structural deformity, and soft-tissue breakdown secondary to increased plantar pressure. The midfoot is commonly involved in diabetic neuroarthropathy. Collapse of the medial, lateral, or both longitudinal arches may result in increased plantar pressures and subsequent midfoot ulceration. The majority of these wounds can be managed with local wound care, off-loading, and other forms of nonoperative care. Surgical intervention becomes necessary when the wound fails to heal with conservative measures. The authors performed a retrospective review of patients who underwent ostectomy for chronic or recurrent ulceration in the midfoot secondary to diabetic neuroarthropathy. The authors reviewed 27 procedures in 20 patients. There were 18 medial ulcers and 9 lateral ulcers. Wounds had resolved in 20 of 27 cases for 74% healing rate. The majority of failed procedures involved lateral column wounds (six of seven). Revisional surgery was required in five of the nine lateral column wounds for limb salvage. There was a statistically significant difference between the rate of complications by ulcer location (p = .00174). The rate of complications was significantly higher for lateral column ulcers. These results indicate that ostectomy is a reasonable option for medial column ulcers that fail nonoperative care. However, ostectomy for ulcers involving the lateral column is less predictable and failure often requires complex reconstructive soft tissue and osseous procedures for limb salvage.

Posterior calcaneal displacement osteotomy for adult acquired flatfoot.

The authors retrospectively reviewed 24 patients who underwent posterior calcaneal displacement osteotomy (PCDO) for posterior tibial tendon dysfunction and adult acquired flatfoot deformity from 1991 to 1996. The average follow-up was 27 months. Analysis consisted of preoperative and postoperative evaluation of radiographs, as well as postoperative subjective results. Ancillary procedures included flexor digitorum longus tendon transfer (n = 19), tendo Achilles lengthening (n = 21), tibialis anterior tendon transfer (n = 5), naviculocuneiform joint arthrodesis (n = 4), and first metatarsocunieform joint arthrodesis (n = 1). The talo-first metatarsal angle on the lateral view decreased from a preoperative average of 22.13 degrees to a postoperative average of 8.50 degrees. The talo-first metatarsal angle on the anteroposterior view decreased from an average preoperative value of 22.96 degrees to a postoperative average of 11.04 degrees. In all cases, talar head coverage at the talonavicular joint improved. Subjective results were categorized as good (n = 17), satisfactory (n = 5), and poor (n = 2). Complications included sural neuritis (n = 6), Achilles tendon rupture (n = 2), difficulty with fixation (n = 2), and undercorrection of deformity (n = 2). Patients who had higher preoperative and postoperative talo-first metatarsal angles on either the anteroposterior or lateral radiographs had significantly poorer outcomes (p = .0403, p = .002, p = .009, p = .001, respectively). In addition, those patients who had medial column fusions had statistically significant poorer subjective results (p = .015). Patients who had flexor digitorum longus (FDL) tendon transfers did significantly better than those patients who did not have FDL transfer (p = .004). The authors conclude that the posterior calcaneal displacement osteotomy is a reasonable option for management of posterior tibial tendon dysfunction in the adult acquired flatfoot.

The modified Lapidus arthrodesis: a retrospective analysis.

The authors present a review of 47 modified Lapidus arthrodesis procedures performed between 1985 and 1995. There were 29 females and 10 males. Eight patients underwent bilateral procedures. The average follow-up was 6.3 years (range, 1.5-10.6 years). The patients were evaluated preoperatively and postoperatively using standard weightbearing radiographs, clinical examination, and chart review. The average preoperative intermetatarsal angle was 13.8 degrees degrees, and the average postoperative intermetatarsal angle measured 2.1 degrees degrees, with a mean improvement of 10.8 degrees. The average effective shortening of the first metatarsal was 4.7 mm in those patients without bone graft. In patients whom bone graft was utilized, an average effective increase in first metatarsal length of 2.6 mm was identified. Complications included delayed union (n = 2), nonunion (n = 3), postoperative development of hyperkeratosis beneath the second metatarsal head (n = 4), elevation of the first ray (n = 3), and hallux varus (n = 2). There were no recurrences of hallux abducto valgus at follow-up. The average return to preoperative activity level was 13 weeks. Forty-two of the 47 procedures healed uneventfully. Of the remaining five feet, two required the use of a bone growth stimulator, and three required revisional surgery with autogenous bone graft to promote arthrodesis and restore alignment. In conclusion, the modified Lapidus arthrodesis is both a predictable and durable procedure for the correction of hallux abducto valgus.

Off-loading techniques in the treatment of diabetic plantar neuropathic foot ulceration.

In the individual with diabetes mellitus, foot ulceration represents the single most important risk factor in lower-extremity amputation. The goal of treatment is to obtain a healed and closed wound that (1) eliminates a portal of entry for bacterial invasion and development of limb-threatening infection, and (2) allows for tissue loading. This manuscript reviews current off-loading approaches to the treatment of plantar neuropathic foot ulcers, along with advantages and disadvantages of those techniques.

Oblique medial malleolar osteotomy for the management of talar dome lesions.

The purpose of this retrospective study was to determine the efficacy of the oblique medial malleolar osteotomy for the management of medial talar dome lesions. Arthroscopy remains a viable option for the management of these lesions; however, the central and posteromedial lesions are often difficult to gain access to with arthroscopy and may require open arthrotomy. Fourteen oblique medial malleolar osteotomies were performed for the surgical management of medial talar dome lesions. Subjective data were collected through the process of questionnaire. Objective criteria consisted of radiographic evaluation and retrospective medical record review. Seven of the 14 patients related a history of trauma preoperatively. The oblique medial malleolar osteotomy demonstrated osseous union at an average of 6.6 weeks. There were no delayed unions or nonunions. None of the patients required a second operative procedure. Nine patients reported excellent postoperative results, two patients had good results, two had fair results, and one patient related a poor postoperative outcome with only 50% relief of pain. Patients greater than the age of 30 were found to have less favorable results. Follow-up ranged from 6 to 72 months, with a mean follow-up of 34 months.

Lateral ankle instability and the Brostrom-Gould procedure.

Lateral ankle instability can present as either acute or chronic. Proper identification of the etiology is necessary to determine the proper treatment plan. The Brostrom-Gould procedure, when properly used, can provide adequate correction of the unstable ankle. A review of the procedure, its indications, and the results of 44 patients who underwent the procedure will be discussed.

Bone grafting in the surgical management of osseous neoplasms.

The diagnosis and treatment of osseous neoplasms are challenges for the foot and ankle surgeon. Osseous neoplasms are potentially debilitating, thus appropriate diagnosis and management are critical to success. Resection of these lesions can result in large osseous deficits, requiring bone grafting for replacement. The graft may provide osteogenesis, structural support, or both. This article presents possible surgical therapeutic alternatives in management of benign and low-grade malignant osseous neoplasms in the foot and ankle.

Techniques for harvesting autogenous bone graft of the lower extremity.

Autogenous bone grafts have several advantages over allogenic bone grafts, especially when being used for arthrodesis or for revision of malunions or nonunions. Procurement of these grafts can come from remote regions or from areas adjacent to the operative site. The lower extremity provides a source for obtaining cortical, corticocancellous, and cancellous bone for use in foot and ankle surgery. Harvesting techniques do not come without complications and the necessity for proper techniques in handling is crucial.

Chondroblastoma of the calcaneus: literature review and case presentation.

Chondroblastoma is a benign neoplasm of bone and most often arises from the epiphysis of long bones. Recognition of this tumor can be difficult and is often only confirmed on histological examination. Radiographic studies can demonstrate findings that mimic other tumors such as giant cell and aneurysmal cysts. Proper identification and management of this tumor has as high as a 90% success rate in eradication.

Grand rounds: first metatarsophalangeal joint replacement.

For approximately 30 years foot and ankle surgeons have been using a variety of techniques and devices to replace the first metatarsophalangeal joint. During this time there have been a multitude of implant designs and modifications, most attempting to anatomically and functionally replace the natural joint surfaces. The advantages and disadvantages of these many designs and various biomaterials has long been debated in scientific meetings and publications. Surgical technique, implant design, materials, and patient selection remain areas of heated debate and ongoing research. With this in mind, we asked leading foot and ankle surgeons to give their opinions on indications and utilization for joint replacement of the first metatarsophalangeal joint.

Compartment syndromes causing neuropathy.

Compartment syndromes of the lower extremity can cause significant mobidity when appropriate treatment is not rendered. Paramount to the management of a compartment syndrome is a timely diagnosis. The physician must be intimately familiar with the anatomy as well as the signs and symptoms that a compartment syndrome presents. This familiarity can provide the opportunity for early diagnosis and treatment to prevent debilitating sequalae.