Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation.

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.

The Aggressive Open Anterior Ankle Cheilectomy as Joint Salvage for Anterior Ankle Impingement Syndrome and Arthritis.

Anterior ankle impingement syndrome can frequently present in athletes and post-traumatic patients who have osteophytes contributing to limited dorsiflexion and pain. Surgical treatment options include arthroscopy, open arthrotomy, arthrodesis, and total implant arthroplasty. For many, joint-sparing arthroscopy or arthrotomy yield satisfactory results if significant debridement is performed. If debridement is not aggressive, patients may not obtain the desired improvement. In cases where a larger amount of bone must be removed, or the patient does not have an anatomic appearing talar neck due to osteophytic changes, we have found that an open approach is necessary to achieve good results. To the best of our knowledge, no such technique has been previously published detailing a standard approach to open ankle arthrotomy. Our technique is coined the "Aggressive Open Anterior Ankle Cheilectomy" and involves a systematic 3-step approach. First, the tibial osteophytes are resected with an osteotome; second, the ankle gutters are addressed, and all hypertrophic bones removed; and third, an anatomic talar neck is fashioned. We herein describe our surgical technique and case examples.Level of Evidence: 5.

Postoperative Maintenance of Sagittal Plane Positioning of the First Metatarsophalangeal Joint After Arthrodesis with an Isolated Dorsal Plate Construct: A Retrospective Review of 43 Feet.

BACKGROUND: First metatarsophalangeal joint arthrodesis with isolated dorsal plating without a lag screw and without a compressive mechanism incorporated into the plate is not well studied. Although surface area for bony fusion is increased, there is concern for lower fusion rates and progressive loss of sagittal plane positioning. We present fusion rates and progressive sagittal plane deviation with isolated dorsal plate fixation. METHODS: A retrospective review was performed of 41 patients (43 feet) who underwent first metatarsophalangeal joint arthrodesis with isolated dorsal plate fixation. Patients were excluded if another form of fixation was used, if there was a compressive feature to the dorsal plate, or if a lag screw was used. Preoperative, immediate postoperative, and final postoperative radiographs were reviewed to assess radiographic alignment and fusion about the first metatarsophalangeal joint. Specific attention was placed on hallux dorsiflexion in relation to the first metatarsal. Statistical significance was set at P ≤ .05 a priori. RESULTS: Patients were followed for an average of 55.7 weeks. Overall union rate was 97.62%. The average time to union was 42.55 days. Reoperation rate was 4.65%, with one patient requiring revisional arthrodesis with a lag screw construct. Hallux abduction and first-second intermetatarsal angle correction reached significance (P < .00001). Hallux dorsiflexion increased by 1.05° between initial postoperative and final postoperative radiographs (P = .542). CONCLUSIONS: Although fusion rates and progressive loss of sagittal plane position have been concerns for first metatarsophalangeal joint arthrodesis with an isolated dorsal plate construct, these results suggest this to be a stable construct without loss of positioning over time.

Peroneus brevis muscle flap for a 20-year-old neuroischemic diabetic ulcer induced by traumatic injury: a case report detailing the efficacy of advanced combined treatment modalities for chronic wound closure.

INTRODUCTION: Peroneus brevis flaps provide a viable option to achieve soft tissue coverage in hard-to-heal lower extremity wounds, specifically those to the lateral ankle and hindfoot. CASE REPORT: The authors present a unique case of a patient with a 20-year-old wound dehiscence complicated by osteomyelitis. The wound was a complication from a lateral extensile incision utilized during prior calcaneal open reduction and internal fixation. Due to many factors, including multiple comorbidities, the patient could not obtain complete healing despite IV antibiotics, vascular optimization, local wound care, surgical debridement, and grafting. Wound closure was ultimately achieved with a PB muscle flap. Adjunctive therapies also utilized included multilevel ring external fixation, negative pressure wound therapy, and hyperbaric oxygen therapy. On follow-up 32 months after the procedure, the patient continued to be wound free and satisfied with the results. CONCLUSIONS: This case report demonstrates the utility of PB muscle flaps for hard-to-heal lower extremity wounds in patients with comorbidities.

Diabetes-Related Major and Minor Amputation Risk Increased During the COVID-19 Pandemic.

BACKGROUND: Along with significant case transmission, hospitalizations, and mortality experienced during the global severe acute respiratory syndrome coronavirus 2 pandemic, there existed a disruption in the delivery of health care across multiple specialties. We studied the effect of the pandemic on inpatients with diabetic foot problems in a Level I trauma center in central Ohio. METHODS: A retrospective chart review of patients necessitating a consultation by the foot and ankle surgery service were reviewed from the first 8 months of 2020. A total of 270 patients met the inclusion criteria and were divided into prepandemic (n = 120) and pandemic groups (n = 150). Data regarding demographics, medical history, severity of current infection, and medical or surgical management were collected and analyzed. RESULTS: The odds of undergoing any level of amputation was 10.8 times higher during the pandemic versus before the pandemic. The risk of major amputations (below-the-knee or higher) likewise increased, with an odds ratio of 12.5 among all patients in the foot and ankle service during the pandemic. Of the patients undergoing any amputation, the odds for undergoing a major amputation was 3.1 times higher than before the pandemic. In addition, the severity of infections increased during the pandemic, and a larger proportion of the cases were classified as emergent in the pandemic group compared to the prepandemic group. CONCLUSIONS: The effect of the pandemic on the health-care system has had a deleterious effect on people with diabetes mellitus (DM)-related foot problems, resulting in more severe infections and more emergencies, and necessitating more amputations. When an amputation was performed, the likelihood that it was a major amputation also increased.

Functional Outcomes and Complications Associated With Total Talus Arthroplasty: A Systematic Review.

Total talus arthroplasty (TTA) is a motion sparing procedure which can be utilized in specific and unique cases of talar necrosis and/or collapse. Literature on TTA is limited and predominantly composed of case studies or case reports. The purpose of this publication is to compile a systematic review of functional outcomes and complications associated with TTA. A search of current literature on TTA with >1-year follow-up was performed. Studies that described talar body implants or talonavicular implants were excluded. Twenty articles met inclusion criteria, which represented 161 TTAs. The average follow-up was 37.35 months (9-60 months). The indication for a TTA was predominately avascular necrosis of the talus, comprising 75.78% (122/161) of cases. The overall complication rate was 9.32% (15/161), with wound healing complications (5/161), replacement or implantation of a tibial component (4/161), and medial malleolus fracture (3/161) being the most common. One patient required proximal amputation due to residual pain and deformity. Functionally, American Orthopedic Foot and Ankle Score increased from 27.93 preoperative to 81.99 postoperative and Japanese Society for Surgery of the Foot Score increased from 43.2 preoperative to 89.34 postoperative. Visual analog scale pain score decreased from 6.44 to 2.60. Total ankle range of motion increased from 36.60° to 46.74°. Ankle plantarflexion increased by 3.45° and ankle dorsiflexion increased by 6.69°. Overall, available literature on TTA appears to be in favor of the procedure when indicated.Levels of Evidence: 4.

The Resident-Run Clinic in Podiatric Medical Foot and Ankle Surgery Residency Training: A Study of Resident-Perceived Benefit.

BACKGROUND: Resident-run clinics provide autonomy and skill development for resident physicians. Many residency programs have such a clinic. No study has been performed investigating the effectiveness of these clinics in podiatric medical residency training. The purpose of this study was to gauge the resident physician-perceived benefit of such a clinic. METHODS: A survey examining aspects of a resident-run clinic and resident clinical performance was distributed to all Doctor of Podiatric Medicine residency programs recognized by the Council on Podiatric Medical Education. To be included, a program must have had a contact e-mail listed in the Central Application Service for Podiatric Residencies residency contact directory; 208 residency programs met the criteria. Statistical analysis was performed using independent-samples t tests or Mann-Whitney U tests and χ2 tests. Significance was set a priori at P < .05. RESULTS: Of 97 residents included, 58 (59.79%) had a resident-run clinic. Of those, 89.66% of residents stated they liked having such a clinic, and 53.85% of those without a resident-run clinic stated they would like to have one. No statistically significant differences were noted between groups in how many patients each resident felt they could manage per hour or regarding their level of confidence in the following clinical scenarios: billing, coding, writing a note, placing orders, conversing with a patient, working with staff, diagnosing and treating basic pathology, and diagnosing and treating unique pathology. CONCLUSIONS: Resident-run clinics provide autonomy and skill development for podiatric medical residents. This preliminary study found there was no difference in resident-perceived benefit of such a clinic. Further research is needed to understand the utility of a resident-run clinic in podiatric medical residency training.