A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation.

Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.

Cheilectomy Combined With First Tarsometatarsal Joint Arthrodesis for Surgical Treatment of Midstage Hallux Rigidus Complicated by Medial Column Insufficiency: Prospective Evaluation of Outcomes.

The role of metatarsus primus elevatus and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, there is a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. While cheilectomy and decompression metatarsal osteotomy are commonly used to mitigate retrograde forces at the first metatarsophalangeal joint (MPJ) level, traditional hallux limitus procedures do not address more proximal deformity of the medial column. Although the authors prefer to treat this complex condition with cheilectomy combined with tarsometatarsal joint arthrodesis, there is a paucity of literature on this approach. A prospective cohort study of consecutive patients was therefore performed to assess outcomes. Ten patients (3 males, 7 females) and 11 feet (8 right and 3 left) met the inclusion criteria. Mean follow-up was 21.9 months (range 12 to 52). Average age was 50.4 years (range 28 to 61). The average preoperative ACFAS score of 49.6 (range 29 to 61) improved to 78 (range 51 to 92) at 10 weeks postoperatively and 85.4 (range 60 to 100) at 1 year postoperatively. By 1 year postsurgery, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 (10%) was somewhat satisfied.