The Role of Arthroscopy After Total Ankle Replacement.

Alongside advances and trends in foot and ankle surgery, arthroscopy provides a minimally invasive option in exploring and addressing pain after total ankle replacement (TAR). It is not uncommon for patients to develop pain months or even years after TAR implantation for both fixed and mobile-bearing designs. Arthroscopic debridement of gutter pain can provide successful outcomes in the hands of the experienced arthroscopist. Surgeon preference and experience will dictate the threshold for intervention, approach, and tool selection. This article provides a brief look into the background, indications, technique, limitations, and outcomes for arthroscopy after TAR.

Time to Revision After Periprosthetic Joint Infection in Total Ankle Arthroplasty: A Systematic Review.

While not a common complication after total ankle arthroplasty (TAA), periprosthetic joint infection (PJI) presents a significant risk of implant failure. The primary aim of this systematic review was to evaluate time to revision after PJI in patients who had undergone TAA. An extensive search strategy via electronic databases initially captured 11,608 citations that were evaluated for relevance. Ultimately, 12 unique articles studying 3040 implants met inclusion criteria. The time to revision surgery due to PJI was recorded for each study and a weighted average obtained. The prevalence of PJI was 1.12% (n = 34). We found that the average time to revision due to PJI was 30.7 months, or approximately 2.6 years after the index TAA procedure. By literature definitions, the majority of cases (91.2%, n = 31) were beyond the "acute" PJI phase. The population was divided into 2 groups for further analysis of chronic infections. PJIs before the median were classified as "early" and those after as "late" chronic. The majority of cases (61.8%) were late chronic with an average time to revision of 44.3 months. A smaller number were early chronic (29.4%) with revision within 10.8 months. After summarizing the rates of infection and times to revision reported in the literature, we suggest modifying the current PJI classification to include early chronic and late chronic subgroups so that the total ankle surgeon is better prepared to prudently diagnose and treat PJIs.

Gas-Producing Infections in the Foot at a Large Academic Medical Center: A 10-Year Retrospective Review.

Gas-producing infections, such as clostridial and nonclostridial gas gangrene, crepitant cellulitis, and necrotizing fasciitis, are characterized in the literature by a variety of initial presentations, microbial burdens and surgical outcomes-ranging from debridement to amputation to death. The primary aim of this study was to identify the organisms cultured in gas-producing infections of the foot in patients that presented to a large academic medical center over a 10-year period. Our secondary aims were to report the prevalence of sepsis in this population upon presentation, and patient outcomes upon discharge. After a retrospective chart review of 207,534 procedures, 70 surgical cases met inclusion criteria. The most common organisms that grew in operating room cultures were Staphylococcus aureus, Group B Beta Streptococcus, and Enterococcus species. Just over half of the population presented with sepsis. After an average of 2 or more operations, 64% of patients underwent amputation. One death occurred. Gas-producing infections, or "gas gangrene," are primarily polymicrobial infections, rarely due to Clostridium perfringens, that warrant surgical exploration for optimal outcomes.

Plate Fixation in Midfoot and Ankle Charcot Neuroarthropathy.

Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity.

Perceptions Surrounding Onychomycosis in the Health Professions Student Population: The Disease, Treatments, and Quality of Life.

BACKGROUND: Discolored toenails is a common complaint presented to podiatric physicians, dermatologists, and primary-care physicians. Although various local and systemic conditions influence changes in nails, nearly 50% is due to fungal infections. We surveyed the health professions student population to gain insight into how future medical professionals may approach this condition and to explore perceptions of onychomycosis, treatments, and effects on quality of life. METHODS: The primary outcome measure was a self-reported online Google Forms survey developed by the authors and sent to podiatric, allopathic, and osteopathic medical students and nursing students in Philadelphia, Pennsylvania. RESULTS: Of the 245 respondents, 92% agreed that toenail fungus is both a health and a cosmetic concern. Seventy-seven percent of respondents said "yes" when asked if they would seek treatment, and 67% would wait 1 month to 1 year to see a medical professional. When seeking treatment, 57% reported that they would see a primary-care physician initially, and 27% and 5% would seek care from a podiatric physician or dermatologist, respectively. A total of 91% would spend up to $300 annually for treatment, with only 4% willing to spend more than $500 per year. Respondents' greatest concern would be physical appearance. CONCLUSIONS: Although agreement exists among the health professions students surveyed that toenail fungus presents both a cosmetic and a health concern, inconsistencies regarding time to treatment, treating professional, and effects on quality of life persist. It is not reasonable for all medical professionals to effectively recognize and treat nail disease, but it is paramount that patients are directed to medical professionals who can accurately exclude other conditions to alleviate social and financial burdens patients may face due to onychomycosis.

Subtalar Arthroereisis Implantation in Acquired Neuropathic Pes Planus: A Preliminary Report Detailing a Minimally Invasive Approach to Healing Medial Column Ulcerations.

Ulcerations under the medial column in patients with acquired neuropathic pes planus may be intractable to conservative techniques such as regular debridement, offloading, bracing, and accommodative shoes. When surgery becomes necessary for these patients, the foot and ankle surgeon has the option of exostectomy, medial column beaming, medial column fusion, and external fixation, among others. In the case of a flexible midfoot collapse, the option of arthroereisis for indirect medial column support may be warranted. In this preliminary report, the authors detail a technique of Achilles tendon lengthening, arthroereisis implantation, and advanced cellular tissue product application in an attempt at wound coverage and prevention of recurrence. Three patients presenting with intractable medial column ulcerations of ∼1 year's duration underwent this procedure, and within 7 weeks (range 5 to 7), all medial column ulcerations healed. These patients remained healed at last follow-up (average 29 months; range 8 to 44). This preliminary report provides evidence for a minimally invasive procedure aimed at offloading, healing, and preventing recurrence of medial column ulcerations in patients with flexible neuropathic pes planus.

The Unusual Presence of Gas From a Puncture Wound: A Case Report.

The presence of gas within soft tissues as suggested by plain film radiographs and magnetic resonance imaging is usually sufficient evidence for a gas-producing bacterial infection. A thorough clinical examination and history and tissue culture are necessary to better determine the source of the gas. However, despite the unremarkable physical examination findings, the present case of a plantar puncture wound rapidly developed gas in the tissues and warranted surgical exploration and repair. Delaying treatment in any case of potential gas gangrene can be limb- and life-threatening. Only later was it revealed by the patient's husband that the wound might have been contaminated soon after the injury from a source other than the puncture, which led to the early presentation of gas on the imaging studies.