Lisfranc Injuries in the Athlete.

LisFranc injuries in the active, athletic, and military populations can be devastating injuries. There has been much debate over open reduction and internal fixation versus arthrodesis as primary treatment in these injuries. This article aims to present the existing evidence-based medicine to help guide appropriate treatment in this population. With the introduction of flexible fixation, the variety of ways to address these injuries surgically has expanded.

The Podiatric Medical Profession: A Gender Comparison.

The number of women in podiatric medicine and surgery has increased steadily over the past 4 decades; however, there appears to be a large and continued gender gap with respect to representation in academic medicine and other positions of power. National and state level organizational data were obtained from multiple podiatry professional societies to evaluate the rate at which women achieved leadership roles within the podiatric profession over time. A secondary questionnaire was also developed and electronically mailed to 8684 doctors of podiatric medicine to help capture additional leadership information and to provide further insight into the trends observed. The response rate was 26% (2276/8684). Female representation in academia, research/publications, most leadership positions, and board certifications has increased over time, but at a slower rate than the number of women entering the profession. We observed a decreasing trend of females completing fellowships, speaking at national meetings, becoming residency directors, and receiving American College of Foot and Ankle Surgeons- and American Podiatric Medical Association-sponsored grants/awards. Based on the survey results, female podiatric physicians were more likely to be single, have fewer children, spend more time in a clinical setting, be less satisfied with work, and experience higher work stress levels than their male colleagues. Of the female respondents, 73% described experiencing gender discrimination at some point in their career, and 42% reported experiencing sexual harassment, compared with only 6% and 5% of men, respectively. There continues to be a gender gap in leadership roles, which may be explained partially by work/life balance issues, gender discrimination, and other issues.

Rare Presentation of Kaposi's Sarcoma in an HIV-Negative Patient.

Kaposi's sarcoma (KS) in the United States is prevalent in Eastern European or Mediterranean males. KS in HIV-negative patients is becoming increasingly prevalent and should not be limited to the 4 subtypes: classic, endemic, iatrogenic immunosuppression, and epidemic. We present a rare pedal presentation of KS in an immunocompetent, HIV-negative man who has sex with men (MSM) and was followed for 12 months. The prevalence of KS in HIV-negative MSM is slowly rising and fits into the rare, fifth subtype.

First Metatarsophalangeal Joint Space Area Decreases Within 1 Month After Implantation of a Polyvinyl Alcohol Hydrogel Implant: A Retrospective Radiographic Case Series.

In 2016, the U.S. Food and Drug Administration approved the first and only polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus. The implant functions as a bumper to maintain first metatarsophalangeal joint space to prevent contact of the phalangeal base with the first metatarsal head. Short-term and intermediate outcomes with this implant have reported positive outcomes with no radiographic outcomes of implant wear or subsidence. We performed a retrospective radiographic review of 27 consecutive patients who received the implant and measured preoperative and postoperative joint space area (JSA). We found a significant improvement in JSA (p < .001) between the preoperative JSA and JSA at the first postoperative visit at 1 to 2 weeks. We also found a significant decrease in JSA (p < .001) between the first postoperative visit and the second postoperative visit at 5 to 12 weeks. This information could have further implications for implant design as well as how we can better achieve functional improvements in the first metatarsophalangeal joint in patients with hallux rigidus.

Updates in Tendinopathy Treatment Options.

Tendinopathy is a common but disabling condition. The term describes a complex, multifaceted pathology of the tendon characterized by pain, decreased function, and reduced exercise tolerance. Tendinopathy accounts for up to 30% of general practice musculoskeletal consultations. Advances in understanding the disease process include inflammation as part of the early tendinopathy process. Once thought to not contribute to the early process of tendon degeneration, this hypothesis has been refuted. This allows guidance in conservative treatment. However, when conservative treatments fail, there are minimally invasive injections and ultrasonic debridement techniques that offer an intermediate treatment step with low reported morbidity.

Women in Podiatry and Medicine.

The role of female physicians has advanced among western medicine. Women now constitute a majority within medical schools, and the number of women in podiatric medicine and surgery has increased over the last 5 decades. Conversely, female physicians continue to face barriers to closing the gender gap. They have lower academic standings and fewer publications, receive less awards/grants, are underrepresented in leadership positions, have a lower incidence pursuing surgical specialties, and receive lower compensation. Women experience an increased rate of burnout, gender discrimination, and sexual harassment. Increasing awareness of the gender gap is vital to the enhancement of the medical community.

Modified Blair tibiotalar arthrodesis for post-traumatic avascular necrosis of the talus: a case report.

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.

Practical aspects of foot and ankle arthroscopy.

Arthroscopy of the foot and ankle, although sometimes technically challenging, is a useful tool for the foot and ankle surgeon. Burman in 1931 was the first to attempt arthoscopy of the ankle joint and surmised that it was not a suitable joint for arthroscopy because of its narrow intra-articular space. With the development of smaller-diameter arthroscopes and improvements in joint distraction techniques, Watanabe was the first to present a series of 28 ankle arthroscopes in 1972. At present, arthroscopy is used not only to evaluate and treat intra-articular abnormalities but also for endoscopic and tendoscopic procedures.

Closure of deep fascia in ankle fracture surgery.

Closure of the deep fracture after open reduction and internal fixation of the ankle is often difficult due to the damage from the injury or from the intraoperative exposure. The technique described herein provides a consistent method for coverage of the hardware. The specific maneuver capitalizes on the unique arrangement of the fascial overlying the anterior compartment of the leg.

An anatomic and autologous lateral ankle stabilization.

A new technique for stabilization of the lateral ankle ligaments is presented. The procedure uses a split peroneus longus tendon to recreate the calcaneofibular and anterior talofibular ligaments. The new ligaments follow a precise anatomic course that replicates the pathway of the original ligaments. The procedure also capitalizes on interference screw technology so that accurate ligament tension can be obtained. This technique is most useful for severe ligamentous insufficiency involving both the calcaneofibular and anterior talofibular ligaments. Biomechanical rationale for the use of peroneus longus is also discussed.

Normal and abnormal function of the first ray.

The first ray is the most important structure of the forefoot in its contribution to normal locomotion. Because first ray dysfunction is encountered in clinical practice with the development of hallux valgus, metatarsus primus varus, and hallux rigidus, there has been a belief that there is a mechanical basis for these conditions. Since publications in the 1930s, there has been significant research focused on the first ray. This article discusses the subtleties of normal and abnormal mechanics of the first ray to promote a better understanding for foot and ankle practitioners when treating these various disorders.

Talus fractures: surgical principles.

Surgical treatment of talus fractures can challenge even the most skilled foot and ankle surgeon. Complicated fracture patterns combined with joint dislocation of variable degrees require accurate assessment, sound understanding of principles of fracture care, and broad command of internal fixation techniques needed for successful surgical care. Elimination of unnecessary soft tissue dissection, a low threshold for surgical reduction, liberal use of malleolar osteotomy to expose body fracture, and detailed attention to fracture reduction and joint alignment are critical to the success of treatment. Even with the best surgical care complications are common and seem to correlate with injury severity and open injuries.

Reconstruction of the extruded talus with large allograft interfaces: a report of 3 cases.

UNLABELLED: Although replant of the extruded talus would be preferable at the time of initial management, some patients present with a talus that had not been recovered. A series of 3 cases of the extruded talus that were reconstructed with large allograft interfaces are presented. Two of the cases had femoral head allografts and the other used morcellized cancellous allograft. Several orthobiologic substances were used in various proportions for each case. All 3 resulted in a solid union with minimal shortening of the extremity. LEVEL OF CLINICAL EVIDENCE: 4.

Fixation of the medial malleolar fracture: a simplified technique.

A technique for fixation of the medial malleolar fracture is presented as an alternative to cannulated screws or conventional screw fixation. Two partially threaded screws are inserted in to the same corridors created by the temporary fixation after anatomic reduction. The procedure minimizes soft tissue stripping of the fracture fragments and facilitates expedient delivery of the hardware. In addition to the simplicity of the technique, there is substantial cost savings and better thread purchase compared to cannulated screws.

Arthroscopy-assisted repair of latent syndesmotic instability of the ankle.

PURPOSE: The purpose of this study was to investigate the results of repair of latent ankle syndesmotic instability and widening by an arthroscopic and percutaneous approach. METHODS: This case study series presents 6 patients who presented with latent syndesmotic instability after sustaining a rotational ankle injury. All 6 patients underwent arthroscopy-assisted repair and percutaneous fixation of the disrupted ankle mortise. Objective radiographic findings were obtained pre- and postoperatively as well as subjective patient outcomes using American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. RESULTS: After a minimum of 2 years of follow-up, all patients had improvement of their AOFAS scores with a mean change of 32 (standard deviation, 7.0; P = .0001). The function component of the AOFAS score had the largest change from preoperative to postoperative status, with a value of 15 (P = .0009). Radiographic parameters were improved in all 6 patients. The reduction of the medial clear space was the most consistent finding, with a postoperative medial clear space ranging from 2.6 to 3.5 mm (mean change, 3.2 mm; P = .0002). CONCLUSIONS: Our small series, with a minimum follow-up of 24 months, suggests that arthroscopy-assisted treatment of latent syndesmotic instability is an effective method. The primary outcome measure of AOFAS scores showed statistically significant improvement in pain and function at final follow-up. Alignment of the ankle did not exhibit statistically significant changes. Both of the secondary radiographic outcome measures were statistically improved at final follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The effects of sectioning the spring ligament on rearfoot stability and posterior tibial tendon efficiency.

UNLABELLED: Posterior tibial tendon insufficiency has been implicated as a cause of adult acquired flatfoot. Multiple theories are debated as to whether or not a flatfoot deformity develops secondary to insufficiency of the posterior tibial tendon or of the ligamentous structures such as the spring ligament complex. This cadaveric study was undertaken in an attempt to determine the effect that sectioning the spring ligament complex has on foot stability, and whether engagement of the posterior tibial tendon would be able to compensate for the loss of the spring ligament complex. A 3-dimensional kinematic system and a custom-loading frame were used to quantify rotation about the talus, navicular, and calcaneus in 5 cadaveric specimens, before and after sectioning the spring ligament complex, while incremental tension was applied to the posterior tibial tendon. This study demonstrated that sectioning the spring ligament complex created instability in the foot for which the posterior tibial tendon was unable to compensate. Sectioning the spring ligament complex also produced significant changes in talar, navicular, and calcaneal rotations. During simulated midstance, the navicular plantarflexed, adducted, and everted; the talar head plantarflexed, adducted, and inverted; and the calcaneus plantarflexed, abducted, and everted, after sectioning the spring ligament complex. The results of this study indicate that the spring ligament complex is the major stabilizer of the arch during midstance and that the posterior tibial tendon is incapable of fully accommodating for its insufficiency, suggesting that the spring ligament complex should be evaluated and, if indicated, repaired in flatfoot reconstruction. LEVEL OF CLINICAL EVIDENCE: 5.

Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures.

The purpose of this study was to present the long-term follow-up of a case series of arthroscopically assisted fixation of juvenile intraarticular epiphyseal ankle fractures. The functional and radiographic outcomes of 6 patients with a range of follow-up of 1 to 5 years were evaluated. Five of the 6 patients had triplane injuries, whereas the remaining patient sustained a juvenile Tillaux fracture. All of the patients returned to full activity within 14 weeks of surgery, and none of the patients had any restriction in the ankle range of motion at the time of last follow-up. The results of this small series of patients suggest that arthroscopic-assisted, percutaneous fixation of intraarticular juvenile epiphyseal ankle fractures is an effective, less invasive surgical technique. Several surgical maneuvers that are helpful in the consistent execution of this technique are also mentioned.