Management and Outcome of Feet Deep Frostbite Injury (III and IV Degrees): A Series Report of 36 Cases.

Deep feet frostbite is a severe trauma and often leads to amputation due to full-thickness skin necrosis and subcutaneous tissue damage. A retrospective analysis was performed between June 2013 and June 2019 to review the management measures and outcomes of clinical treatment, and available data had been collected including demographic characteristics, risk factors, and injury environment record. Treatment protocols, wound management, and outcomes were also presented. There were 36 patients diagnosed with deep feet frostbite with a mean age of 51.5 years; the ratio for male to female is 5:1. Drunk and mental disorders were the main risk behaviors for frostbite occurrence. As for the injury environment, mean temperature and wind speed were -20.5 °C and 3.3 m/s, respectively. Fourteen cases achieved wound healing without surgery intervention, 5 cases received skin graft, and 17 cases received amputation. Most amputations (12 cases) were restricted at toe level; only 1 case received whole feet amputation. Our finding indicated that feet deep frostbite in our hospital showed a male predominant and older age including various risk behaviors and coexistence risk factors. Clinical management based on pathology mechanism needs further improvement, as the amputation rate was still high. How to avoid amputation and lower the amputation level are the focus of future efforts.

Pediatric Sports Injuries.

Recreational sports are more popular, with many athletes involved year-round in multiple sports and on multiple teams. Most athletes do not take proper rest, making them more susceptible to stress-related injuries. There are numerous sports-related injuries in the foot and ankle. These issues can be non-traumatic, due to chronic repetitive stresses, or traumatic. Most of these injuries are managed conservatively, and athletes do well and return to play, while some do better with operative management. This article discusses a few of the sports injuries that are common in the leg, foot, and ankle and the recovery process.

Worldwide epidemiology of foot and ankle injuries during military training: a systematic review.

INTRODUCTION: Musculoskeletal foot and ankle injuries are commonly experienced by soldiers during military training. We performed a systematic review to assess epidemiological patterns of foot and ankle injuries occurring during military training. METHODS: A review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search, done on 14 February 2019, resulted in 1603 reports on PubMed, 565 on Embase and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 91 studies. RESULTS: Among a population of 8 092 281 soldiers from 15 countries, 788 469 (9.74%) foot and ankle injuries were recorded. Among the 49 studies that reported on length of training, there were 36 770/295 040 (18.17%) injuries recorded among women and 248 660/1 501 672 (16.56%) injuries recorded among men over a pooled mean (±SD) training period of 4.51±2.34 months. Ankle injuries were roughly 7 times more common than foot injuries, and acute injuries were roughly 24 times more common than non-acute injuries. Our findings indicated that, during a 3-month training period, soldiers have a 3.14% chance of sustaining a foot and ankle injury. The incidence of foot or ankle injury during military parachutist training was 3.1 injuries per thousand jumps. CONCLUSIONS: Our findings provide an overview of epidemiological patterns of foot and ankle injuries during military training. These data can be used to compare incidence rates of foot and ankle injuries due to acute or non-acute mechanisms during training. Cost-effective methods of preventing acute ankle injuries and non-acute foot injuries are needed to address this problem.

Painful Accessory Navicular and Spring Ligament Injuries in Athletes.

Painful accessory navicular and spring ligament injuries in athletes are different entities from more common posterior tibialis tendon problems seen in older individuals. These injuries typically affect running and jumping athletes, causing medial arch pain and in severe cases a pes planus deformity. Diagnosis requires a detailed physical examination, standing radiographs, and MRI. Initial treatment focuses on rest, immobilization, and restriction from sports. Orthotic insoles may alleviate minor pain, but many patients need surgery to expedite recovery and return to sports. The authors review their approach to these injuries and provide surgical tips along with expected rehabilitation to provide optimal outcomes.

Osteochondral Defects of the Talus: How to Treat Without an Osteotomy.

Surgical management of osteochondral lesions of the talus without an osteotomy depends on the size, location, and chronicity of the lesion. Bone marrow stimulation techniques, such as microfracture, can be performed arthroscopically and have consistently good outcomes in lesions less than 1 cm in diameter. For lesions not amenable to bone marrow stimulation, one-stage techniques, such as allograft cartilage extracellular matrix and allograft juvenile hyaline cartilage, may be used. Arthroscopy may be used in many cases to address these lesions; however, an arthrotomy may be required to use osteochondral autograft and allograft transplantation techniques.

Novel dynamic stabilization method for medial instability of the first metatarsophalangeal joint.

Medial collateral ligament injury of the first metatarsophalangeal (MTP) joint is rare. If it is missed, chronic instability and traumatic hallux valgus develop, requiring surgical treatment. Different methods have been reported in the limited available literature aiming to restore the balance between the lateral and medial stabilizers by tightening the medial joint capsule with or without additional tendon graft. Our described method utilizes a suture button device (Mini TightRope, Arthrex, Naples, Florida) for reconstruction. This device applies tension to hold the hallux in the correct position, providing stability. Relevant diagnostic regimen, surgical technique, and postoperative care are described, along with a case of a handball player who underwent this procedure. He continues to perform at the same level 38 months postoperatively. Mini TightRope fixation for chronic medial first MTP instability has not been reported. It does not require postoperative immobilization and allows faster return to sport, so it seems superior to other methods when treating athletes.

Categorization of single cuneiform fractures and investigation of related injuries: A 10-year retrospective study.

PURPOSE: The purpose of this study was to define the fracture type and investigate the injuries related to single medial, intermediate, or lateral cuneiform fracture. METHODS: From January 2008 to December 2018, 30 consecutive patients (30 cases) who were treated in the single institution for the single cuneiform fractures were reviewed retrospectively. Each fracture was categorized by location and type (intra- or extra-articular avulsion, axial compression, and direct blow). We also investigated the related foot bone fractures or dislocations on the affected side. RESULTS: Twenty-one, one, and eight cases with single medial, intermediate, and lateral cuneiform bone fractures, respectively, were identified. More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. The single medial cuneiform fracture was associated with various types of foot injuries including Lisfranc injury, naviculo-cuneiform joint dislocation, or calcaneo-cuboidal dislocation. Single lateral cuneiform fractures were more frequently observed than single intermediate cuneiform fractures. CONCLUSION: More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. Most intra-articular avulsion fractures were associated with high-energy trauma. LEVEL OF EVIDENCE: 4.

LisFranc Fusion.

Lisfranc injuries remain a frequently missed pathology and may present as an isolated injury or as a component of a polytrauma case. Weight-bearing films or advanced imaging such as CT may be imperative in identifying or further classifying the injury. Common indications for fusion after lisfranc injury include primarily ligamentous injuries, delayed/chronic presentations, or post-traumatic arthritis, although primary fusion in the setting of acute fracture may be considered as an alternative to open reduction internal fixation techniques. The primary goals of surgery are to provide stability to the midfoot and restoration of the anatomical arch/cascade. The purpose of this video is to demonstrate a technique for tarsometatarsal joint fusion in the setting of acute lisfranc injury. This technique may be used for both ligamentous as well as bony varieties.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap.

BACKGROUND: This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients. PATIENTS AND METHODS: From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases. RESULTS: All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ±â€¯25 min vs. 202.4 ±â€¯24.3 min, p < 0.05) and flap harvest time (29.7 ±â€¯8.1 min vs. 52.2 ±â€¯9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05). CONCLUSIONS: The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Hallux sesamoid fractures in young athletes.

Objective: To describe the evaluation, management and recovery time of hallux sesamoid fractures in young athletes.Methods: A retrospective chart review was performed in a large academic teaching institution over a 5-year period (1/1/2010-12/31/2014). All patients with a sesamoid injury were initially included. Excluded were those patients who: 1) did not receive the diagnosis of hallux sesamoid fracture, had a history of prior foot surgery, or had medical records inadequate for analysis, 2) had missing or unclear diagnostic imaging, 3) were age >21 years, or 4) did not report sports participation. Descriptive statistics were employed to analyze the data.Results: Fifty-eight patients (51 females and 7 males) with a mean age of 15.4 years (range: 9-21) were identified with a total of 59 sesamoid fractures. Dancing (37.9%), running (13.8%), and gymnastics (13.8%) were the most common sports reported among these patients. A greater number of fractures were classified as repetitive stress injuries (83.1%), rather than acute traumatic injuries (16.9%). Fractures were treated conservatively in the majority of cases (89.8%), and only six fractures (10.2%) were treated surgically. Most patients (84.7%) were able to return to sports and activities. The average time from diagnosis/start of treatment to pain-free state/cleared to return to sport was 161.4 days.Conclusion: Diagnosis of sesamoid fractures can be challenging, but overall most patients do well with conservative treatment and are able to return to sports and activities. Providers should keep sesamoid fracture in the differential when evaluating patients with pain in the area around the base of the first toe, especially in dancers, gymnasts, and runners. Understanding that the recovery from a sesamoid fracture can be a prolonged process may help patients develop realistic expectations.

Trauma-induced concomitant psoriatic arthritis and complex regional pain syndrome.

To report the simultaneous occurrence of psoriatic arthritis (PsA) and chronic regional pain syndrome type I (CRPS I) both triggered by intense walking in a male golfer with a history of scalp psoriasis. Sequential existence of these two conditions have been reported in the literature; however, to our knowledge, this is the first report of a simultaneous occurrence of PsA and CRPS I. This case illustrates the complex interplay between genetic predisposition and environmental risk factors with the central nervous and immune systems. As the pathogenesis of PsA has been better understood in recent years, we propose a mechanism that explains how the release of pro-inflammatory cytokines and neuropeptides following a traumatic event elicits a vicious cycle that is a common ground for the development of both PsA and CRPS I. Even unperceived trauma, such as intense walking, when directed to the synovio-entheseal complex, can precipitate the development of PsA and CRPS I in predisposed individuals.

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint.

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Utility of weight-bearing radiographs compared to computed tomography scan for the diagnosis of subtle Lisfranc injuries in the emergency setting.

OBJECTIVE: The goal of the present study was to compare the diagnostic yield of weight-bearing radiographs with non-weight-bearing computed tomography (CT) scan for subtle Lisfranc (LF) injuries in the ED. METHODS: Retrospective analysis of patients presenting with a suspected LF injury over a 2 year period from 2016 to 2017 who had both weight-bearing bilateral foot radiographs and CT scan. Information extracted included patient demographics, radiographic findings of metatarsal fractures, fleck sign and measurements of diastasis between the medial cuneiform and second metatarsal expressed as a ratio of the uninjured side, clinical findings and treatment modality. Radiologist reports were recorded as either positive, negative or equivocal for a LF injury. RESULTS: A total of 117 patients were included with a mean age of 38 years and 54% (n = 63) women. When initial weight-bearing radiographs were positive, 54% of subsequent CT scans were reported as either equivocal or negative. Of the patients who had a negative or equivocal weight-bearing radiograph, only 12% had a positive CT scan. The mean diastasis ratio in patients undergoing surgery was 1.53 (95% confidence interval 1.41-1.65) compared to 1.11 (95% confidence interval 1.07-1.16) for patients with injuries not requiring operative intervention (P < 0.001). There was a statistically significant correlation between a positive weight-bearing radiograph and surgical treatment (R = 0.339, P < 0.001), and between diastasis measurements and surgical treatment (R = 0.576, P < 0.001). CONCLUSIONS: CT provides limited benefit in the diagnosis and initial management of suspected subtle LF injuries in the ED. We advocate for the use of bilateral weight-bearing radiographs as a first-line investigation.

Incidence and Risk Factors of Foot and Ankle Disorders in Male Finnish Conscripts.

INTRODUCTION: Many studies focusing on musculoskeletal disorders or injuries have been performed in countries where the army is recruited as volunteers. Little is known about foot and ankle disorders among young men in conscript armies. MATERIALS AND METHODS: We studied the incidence and risk factors of foot and ankle disorders in 4,029 Finnish army male conscripts of the same age among five different cohorts born in 1969, 1974, 1979, 1984, or 1989. Data were collected from the medical reports of the Finnish Defence Forces. Self-reported symptoms and diseases detected in the health examination prior to military service, and information obtained from visits to garrison health care centers were analyzed. RESULTS: A total of 1,623 conscripts visited health care professionals due to foot or ankle disorders during their military service. About 511 (31.5%) of those had suffered an injury. The majority of the visits to garrison health care centers due to foot or ankle disorders occurred during the first few months of military service. Smoking, flatfoot deformity, previous injuries, and Class A military service were statistically significantly related with the incidence of foot or ankle disorders. There were statistically significantly less foot and ankle disorders if previous mental symptoms were reported. The data suggest that poor adaptation to physically demanding military training may cause foot and ankle disorders among many conscripts. CONCLUSIONS: The study shows that foot and ankle disorders are common in this population. Most of them occur in the first 2 months of the military service. Further analysis of different conditions was not possible, as many of the diagnostic codes were missing.

Foot and Ankle Injuries in Soccer.

The ankle is one of the most commonly injured joints in soccer and represents a significant cost to the healthcare system. The ligaments that stabilize the ankle joint determine its biomechanics-alterations of which result from various soccer-related injuries. Acute sprains are among the most common injury in soccer players and are generally treated conservatively, with emphasis placed on secondary prevention to reduce the risk for future sprains and progression to chronic ankle instability. Repetitive ankle injuries in soccer players may cause chronic ankle instability, which includes both mechanical ligamentous laxity and functional changes. Chronic ankle pathology often requires surgery to repair ligamentous damage and remove soft-tissue or osseous impingement. Proper initial treatment, rehabilitation, and secondary prevention of ankle injuries can limit the amount of time lost from play and avoid negative long-term sequelae (eg, osteochondral lesions, arthritis). On the other hand, high ankle sprains portend a poorer prognosis and a longer recovery. These injuries will typically require surgical stabilization. Impingement-like syndromes of the ankle can undergo an initial trial of conservative treatment; when this fails, however, soccer players respond favorably to arthroscopic debridement of the lesions causing impingement. Finally, other pathologies (eg, stress fractures) are highly encouraged to be treated with surgical stabilization in elite soccer players.

Near-Infrared Spectroscopy Imaging for Assessing Skin and Wound Oxygen Perfusion.

Near infrared spectroscopy (NIRS) is a technique whereby light is transmitted to the skin or the surface of a wound. Light is selectively absorbed or reflected in order to calculate the percentage of oxygenated and deoxygenated hemoglobin. By calculating this ratio, the level of tissue oxygen perfusion can be assessed. This article describes an NIRS imaging device and demonstrates its use as a clinical tool to predict future viability of skin flaps, potential for wound healing, and progress of closure following application of a biologic wound product. Several cases are examined.

Retained Wooden Foreign Body in the Second Metatarsal.

The foot is considered the second most common location for foreign bodies. The most common foreign bodies include needles, metal, glass, wood, and plastic. Although metallic foreign bodies are readily seen on plain film radiographs, radiolucent bodies such as wood are visualized poorly, if at all. Although plain radiography is known to be ineffective for demonstrating radiolucent foreign bodies, it is often the first imaging modality used. In such cases, complete surgical extraction cannot be guaranteed, and other imaging modalities should be considered. We present a case of a retained toothpick of the second metatarsal in a young male patient who presented with pain in the right foot of a few weeks' duration. Plain radiography showed an oval cyst at the base of the second metatarsal of the right foot. Magnetic resonance imaging revealed a toothpick penetrating the second metatarsal. The patient recalled stepping on a toothpick 8 years previously. Surgical exploration revealed a 2-cm toothpick embedded inside the second metatarsal.

Patient-Reported Outcomes in Foot and Ankle Surgery.

Patient-reported outcomes (PROs) are a measure of health care quality that empower patients to share their health care perceptions with their providers. In orthopedic foot and ankle surgery, these measures can range from global assessments of pain or satisfaction to complex questionnaires designed to assess the function of specific anatomic regions or the recovery from specific procedures. This article seeks to characterize the use of PROs in foot and ankle surgery, describe some of the most commonly used measures, discuss implementation in everyday clinical practice, and explore the future of PROs in foot and ankle orthopedics.