30-Day Readmission Following Outpatient Transmetatarsal Amputation in the Geriatric Population: An ACS NSQIP Analysis.

Whether secondary to deformity, traumatic injury, infection, neoplasm, or ischemic disease, the transmetatarsal amputation provides a functional means of limb preservation prior to major proximal amputation. With similar readmission rates following inpatient and outpatient surgery, prevention of an unnecessary admission among vulnerable patients, specifically geriatrics, proves beneficial. This investigation examines differences among geriatric patients admitted and not requiring readmission following outpatient transmetatarsal amputation. An ACS NSQIP database analysis following filtering for CPT 28805, specific for transmetatarsal amputations, was performed among geriatric patients. Patient demographic, medical history, operative characteristics, and social/functional determinants were compared between the no admission and readmission cohorts. The threshold for statistical significance was set at p ≤ .05. Overall, a 19% readmission rate was reported among geriatric patients who underwent an outpatient transmetatarsal amputation. No statistically significant difference among patient demographics, past medical history, or surgical presentation was found between cohorts. Geriatric patients that maintained some level of functional dependence were 3.41 times more likely to be readmitted than the nonreadmission cohort (p = .006). Among geriatric patients undergoing outpatient transmetatarsal amputation, function status should be taken into account prior to surgery. Greater consideration should also be given to patients who do not maintain independence during their activities of daily living. As the population continues to age, recognizing social circumstances associated with the geriatric population proves important in preventing readmission.

"No Care Pin Care" Following Charcot Reconstruction With Static External Fixation.

Charcot reconstruction with static external fixation provides stability in deformity correction. Concern for pin site health remains forefront to prevent premature fixator removal should infection develop. While previous investigations examined a spectrum of pin care protocol with a similar variation in outcomes, this study assesses results following a "no care pin care" routine. A retrospective analysis of patients with Charcot neuroarthropathy treated with static external fixation was performed where all pin sites were dressed using a chlorhexidine-soaked sponge without postoperative maintenance. Demographics, reconstruction-specific, and postoperative variables including pin site irritation, pin site infection, and pin tract infection were collected through frame removal. A comparison between uncomplicated and complicated pin sites was made. Statistical significance was set as p ≤ .05. Among 85 patients and their respective pin holes that posed potential spots of infection, 6 (7%) experienced pin site irritation and 5 (6%) experienced pin site infection. Moreover, 2 (2%) experienced a pin tract infection requiring removal. Out of the 768 wires/half-pins 2 (0.3%) were removed. There existed no statistically significant predictors of pin site irritation/infection other than age (p = .03). "No care pin care" proves an effective means at pin site care following static external fixation in Charcot reconstruction. Limited maintenance reduces the postoperative burden on providers and patients.

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction.

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.

Comparing Clinical Characteristics and Short-Term Outcomes Between Adult and Geriatric Patients Undergoing Charcot Reconstruction.

Maintaining an acceptable quality of life following a lifetime of chronic diseases and resulting physiologic effects poses a challenge when treating an aging population. In those with Charcot neuroarthropathy, wounds and infection complicate decision making when considering limb preservation versus amputation. The purpose of this investigation is to describe the clinical characteristics and short-term outcomes of geriatric patients undergoing Charcot reconstruction. A retrospective chart review of patients who underwent Charcot reconstruction from 2016-2022 was conducted. Demographics, medical history, deformity type, surgical intervention, discharge planning and short-term complications were collected. Descriptive statistics were calculated, and clinical characteristics and short-term outcomes were compared between the non-geriatric, adult, (A) and geriatric (G) cohorts using Student's t-test or Chi-squared test. Overall, 125 patients were reviewed for final analysis. Charcot deformity type, prevalence of wounds, osteomyelitis, and fixation construct did not significantly differ between groups. While the proportion of those experiencing a prolonged admission did not significantly differ between cohorts, the geriatric group showed age-related pathology including delirium and urinary tract infections. While discharge to nursing facilities did differ between groups (G 43% versus A 19%), baseline function did not. The 30-day unplanned readmission and mortality rates did differ between groups, though this difference was not statistically significant. Prior to geriatric Charcot reconstruction, consideration should be given to age-related comorbidities. Specifically, with a greater incidence of age-related complications unrelated to the surgery as well as mortality in the geriatric group, complications should be discussed at length. Level of Evidence: III.

Split Anterior Tibial Tendon Transfer to Dorsal Lateral Foot for Cavovarus Deformities With Neuropathic Ulcerations: A Case Series.

Cavovarus deformity leads to increased peak pressure on the plantar lateral foot, which can lead to ulceration, and can potentially progress to amputation. Techniques have been suggested in the treatment of cavovarus deformity, such as peroneus brevis or longus tendon transfer, anterior tibial tendon lengthening, posterior tibial tendon transfer, or boney resection. This case series shows split anterior tibial tendon transfer as a surgical reconstruction of cavovarus pedal deformity. Our technique of split anterior tibial tendon in-phase transfer to the dorsal lateral foot, restores the eversion and dorsiflexory pull necessary to offset peroneal attenuation. The procedure can be performed primarily or staged, in order to achieve infection temporization prior to the transfer. A total of 14 patients underwent split anterior tibial tendon transfer, 57.14% (8/14) of which had preoperative ulcerations, and 42.86% (6/14) of which had preoperative hyperkeratotic pre-ulcerative lesions. The preoperative ulcerations were present for an average of 67.89 weeks (range 2-232), with an average area of 6.09 ± 7.44 cm2. The ulcerations healed in 75% (6/8) of the patients, at 19.67 weeks (range 1.57-76), with new ulceration occurrence in 7.14% (1/14) of patients, 7.14% (1/14) rate of ulceration recurrence. None of the patients went on to minor or major amputation. The goal of the tendon transfer is to decrease midfoot plantar pressures on the lateral foot and allow for resolution of pre-existing ulcerations and rebalancing the foot and ankle.

Risk Factors and Outcomes After Surgical Reconstruction of Charcot Neuroarthropathy in Fracture Versus Dislocation Patterns.

The primary aim of this study is to compare the preoperative risk factors and postoperative outcomes between Charcot neuroarthropathy patients with dislocation versus purely fracture pattern breakdown. The secondary aim is to compare the same factors between Charcot neuroarthropathy patients with dislocation versus fracture-dislocation pattern breakdown. A total of 55 patients with forefoot, midfoot, or hindfoot Charcot Neuroarthopathy were assessed at a mean follow up of 2.99 years. Bivariate analysis compared preoperative risk factors and postoperative outcomes, and segmented multivariable regression analysis was performed. Dislocation pattern Charcot had statistically significant higher rates of broken hardware (p = .05), mean age (p = .01), and revisional exostectomy (p = .01) compared to pure fracture pattern Charcot. Dislocation pattern Charcot was 12 times more likely to have revisions exostectomy (odds ratio [OR] 12.0, 95% confidence interval [CI] 1.84-78.37), and was 8 times more likely to have osteomyelitis (OR 7.8, 95% CI 1.4-42.7, p = .02) compared to the fracture-dislocation pattern Charcot. The patients with pure fracture pattern Charcot were 58.8 times more likely to have Charcot breakdown involvement of the talonavicular joint compared to the dislocation pattern cohort (OR 58.83, 95% CI 1.1-3220.3). Involvement of the talonavicular joint, in the fracture pattern Charcot associate with medial column collapse occurring at the onset of Charcot breakdown. The dislocation pattern in Charcot Neuroarthropathy demonstrated a higher propensity for residual collapse as demonstrated by the higher rates of broken hardware, osteomyelitis, and need for revisional exostectomy.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy.

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Double Versus Triple Arthrodesis Fusion Rates: A Systematic Review.

Hindfoot arthrodesis is often required for end-staged deformities, such as posterior tibial tendon dysfunction, osteoarthritis, or rheumatoid arthritis. Although the need for hindfoot arthrodesis is generally accepted in severe deformities, there is a debate whether a double or triple arthrodesis should be performed. The aim of our systematic review is to review the fusion rates and mean time to fusion in double and triple arthrodesis. A total of 184 articles were identified using the keyword search through the database of articles published from 2005 to 2017. After review by 3 physicians, a total of 13 articles met the eligibility criteria. The reason for double or triple arthrodesis within the studies were posterior tibial tendon dysfunction, tarsal coalition, degenerative joint disease, osteoarthritis, rheumatoid arthritis, Charcot Marie Tooth, Multiple Sclerosis, Polio, neuromuscular disorder, cerebral palsy, acrodystrophic neuropathy, clubfoot, post-traumatic, and seronegative arthropathy (spondyloarthritis). Within these 13 studies, there were a total of 343 (6-95) subjects extremities operated on. The overall fusion rate for double arthrodesis was 91.75% (289/315) compared to 92.86% (26/28) triple arthrodesis fusion rate, p value .8370. The mean time to fusion for double arthrodesis was 17.96 ± 7.96 weeks compared to 16.70 ± 8.18 weeks for triple arthrodesis, p value = .8133. There are risks associated with triple arthrodesis including increased surgical times, lateral wound complications, residual deformity, surgical costs and peri-articular arthritis. Given the benefits of double arthrodesis over triple arthrodesis and the nearly equivalent fusion rates and time to fusion, double arthrodesis is an effective alternative to triple arthrodesis. The authors of this systematic review recommend double arthrodesis as the hindfoot fusion procedure of choice.

Safety of Tibial Half Pins With Circular External Fixation for Foot and Ankle Reconstruction in Patients With Peripheral Neuropathy.

The primary aim of the study was to evaluate the rate of tibial fracture with half pin placement in conjunction with tensioned wires in Ilizarov static external fixator in patients with peripheral neuropathy. Concentric visualization through a rancho cube and careful identification of anterior, posterior, medial, and lateral borders of the tibia, the "perfect circle" technique was used to ensure avoidance of cortical breach. Bivariate analysis was performed comparing the rates of tibia fractures in those who did and did not employ the "perfect circle" technique for placement of tibial half pins; evaluating for demographics, rationale for external fixation use, and postoperative amputation and complication rates. Tibial stress fractures, and early removal of pin/wires from external fixator secondary to breakage both occurred at statistically significant higher rates in patients in which the "perfect circle" technique was not employed (p < .001 and p = .03 respectively). The overall rate of tibia stress fractures was 2.08% (2/96), 0% (0/85) when "perfect circle" technique was used, compared to 18.18% (2/11) when it was not used. This study demonstrates a substantially low rate of tibia stress fractures with half pin use, in contrast to prior literature and should provide foot and ankle surgeons confidence, particularly when appropriate placement is observed in this high-risk population.

Screw Length Associated With Fracture Gapping of Fifth Metatarsal Base Fracture With Intramedullary Screw Fixation: A Cadaveric Study.

Intramedullary screw fixation is a well-established surgical treatment for fifth metatarsal Jones fractures, due to its minimally invasive nature, and potential early return to activity. Due to the curvature of the fifth metatarsal, optimal length of the screw is needed to prevent gapping at the fracture site. The placement of a straight screw induces straightening of a naturally curved bone. The purpose of this study was to aid surgeons in determining an appropriate screw length for intramedullary fixation of a fifth metatarsal Jones fracture in order to prevent fracture gapping. A transverse osteotomy of the fifth metatarsal was made in 10 cadaver specimens at the level of a traditional Jones fracture. Inserted screws were sequentially increased in length until plantar gapping at the fracture site was noted. The angle (degree) of plantar gapping was measured with each increase in screw length and diameter. The mean length of the cadaveric fifth metatarsals was 73.76 mm (range 67.42-81.73). The mean screw length that caused gapping at the fracture site was 49.89 mm (range 44-55), representing 67.05% (range 61.26-75.35) of the fifth metatarsal length. The correlation coefficient revealed that gapping of the fracture site is most likely to occur when the screw length is 66% the length of the metatarsal length (rs = 0.66; 95% confidence interval: 0.06-0.91; p = .04). The angle of the initial gapping was 2.85° (range 2°-4°). With an incremental increase in screw length, the angle was 3.85° (range 3°-6°), and with an incremental increase in screw diameter, the angle was 3.70° (range 2°-5°). Our study demonstrated that screw lengths exceeding 66% of the metatarsal length lead to plantar fracture gapping. Additionally, gapping was accentuated with larger diameter screws due to angle variance.

Preoperative Planning and Intraoperative Technique for Accurate Translation of a Distal First Metatarsal Osteotomy.

We used preoperative radiographic and intraoperative anatomic measurements to predict and achieve, respectively, the precise amount of capital fragment lateral translation required to restore anatomic balance to the first metatarsophalangeal joint. Correlation was used to relate the amount of capital fragment translation and operative reduction of the first intermetatarsal angle (IMA), hallux abductus angle (HAA), tibial sesamoid position (TSP), metatarsus adductus angle, and first metatarsal length. The mean capital fragment lateral translation was 5.54 ± 1.64 mm, and the mean radiographic reductions included a first IMA of 5.04° ± 2.85°, an HAA of 9.39° ± 8.38°, and a TSP of 1.38 ± 0.9. These changes were statistically (p < .001) and clinically (≥32.55%) significant. The mean reduction of the metatarsus adductus angle was 0.66° ± 4.44° and that for the first metatarsal length was 0.33 ± 7.27 mm, and neither of these were statistically (p = .5876 and 0.1247, respectively) or clinically (≤3.5%) significant. Pairwise correlations between the amount of lateral translation of the capital fragment and the first IMA, HAA, and TSP values were moderately positive and statistically significant (r = 0.4412, p = .0166; r = 0.5391, p = .0025; and r = 0.3729, p = .0463; respectively). In contrast, the correlation with metatarsus adductus and the first metatarsal shortening were weak and not statistically significant (r = 0.2296, p = .2308 and r = -0.2394, p = .2109, respectively). The results of our study indicate that predicted preoperative and executed intraoperative lateral translation of the capital fragment correlates with statistically and clinically significant reductions in the first IMA, HAA, and TSP.

Pigmented Onychomatricoma: A Rare Pigmented Nail Unit Tumor Presenting as Longitudinal Melanonychia That Has Potential for Misdiagnosis as Melanoma.

Pigmented onychomatricoma is a rare nail unit tumor that can clinically mimic nail unit melanoma. We report the case of a 63-year-old male with new-onset longitudinal melanonychia involving his right second toe. An excisional biopsy was performed and demonstrated pigmented onychomatricoma. We present this case to alert clinicians of this rare nail unit tumor and the importance of clinicopathologic correlation to avoid misdiagnosis.

Assessing vascular status and risk of latent ischemia with ankle fracture: a case report and algorithm for treatment.

A paucity of published studies and clinical recommendations are available regarding ankle fracture and its association with vascular injury, likely because of the lower incidence relative to the more commonly seen popliteal artery injury after knee dislocation. In the present case report, we describe a previously healthy patient who experienced a pilon type ankle fracture (AO 43C2) with fibular and syndesmotic involvement, followed by a subacute presentation of vascular ischemia weeks after the initial injury and repair, ultimately leading to a major amputation. The failure to identify an occult, vascular injury can have devastating consequences. Guidelines regarding the identification and management of displaced ankle fracture-associated vascular injury, drawing evidence from other traumatic injury complexes, could improve the clinical outcomes. We aim to raise awareness of the association of vascular embarrassment secondary to ankle fracture by proposing a clinical practice algorithm to aid clinicians in recognizing traumatic vascular injury at the earliest and most treatable stage.

Immediate weightbearing after Lapidus arthrodesis with external fixation.

A common surgical treatment of severe hallux abductovalgus deformity with coincident first ray hypermobility is metatarsal-cuneiform fusion or Lapidus procedure. The aim of the present study was to illustrate a reliable and novel method of fixation for Lapidus fusion using an external fixation device through a retrospective cohort investigation of consecutive patients. Twenty Lapidus fusions were performed in 19 patients, including 17 females (89.47%) and 2 males (10.53%). The mean age at surgery was 41 (range 20 to 64) years. The patients were evaluated clinically and radiographically pre- and postoperatively. The mean duration in the fixator was 12 (range 3 to 34) weeks. The mean interval to radiographic union was 9.2 (range 4.7 to 30.7) weeks in 18 of 20 feet (90%) and 2 (10%) were designated as nonunion. The mean follow-up period was 37 (range 5.6 to 211.1) weeks. The most common complication was pin tract infection in 5 patients (6 feet) and was treated with oral antibiotics; only 1 foot required early hardware removal. According to the visual analog scale, the mean patient pain score decreased significantly from 8.2 ± 2.7 to 0.83 ± 0.98 postoperatively (p < .001). Our results highlight that immediate weightbearing after Lapidus fusion with external fixation is a viable treatment option for the correction of severe hallux abductovalgus with associated hypermobility.

Are Biodegradable Calcium Sulfate Antibiotic Beads Effective and Safe Adjuvants for Diabetic Foot Osteomyelitis?

INTRODUCTION:  Diabetic foot osteomyelitis (DFO) is a highly morbid condition that commonly affects diabetic patients. Biodegradable calcium-sulfate antibiotic beads (CaSO4) are theoretical adjuvant agents to reduce morbidity in DFO. However, there is a paucity of research on the safety and effectiveness of CaSO4 beads in DFO. Therefore, the purpose of this study was to assess the safety and effectiveness of CaSO4 beads in different DFO locations. METHODS: We conducted a retrospective cohort study between January 1, 2015 and January 1, 2022 of patients with DFO who underwent surgical intervention and adjuvant CaSO4 beads placement. The location of DFO was determined based on the forefoot, midfoot, or hindfoot locations. Outcomes measured were ulcer-free time points of three and six months as well as recurrence of DFO at 12 months. Safety was also evaluated with incidences of acute kidney injury, wound drainage, and hypercalcemia. RESULTS: Forty-five cases were included. Of these, only 9/45 (20%) and 13/45 (29%) were ulcer-free at three months and six months, respectively. DFO recurred in 19/45 (42%) patients. Safety outcomes were significant for wound drainage (62%) and acute kidney injury (9%). Stratifying according to the location of DFO showed no statistically significant difference in outcomes. CONCLUSION: In this cohort study, adjuvant CaSO4 beads showed high rates of ulcer persistence and DFO recurrence. Given the limited benefits seen here and the potential for high rates of wound drainage, the use of adjuvant CaSO4 beads should be used cautiously until a multicenter randomized clinical trial is conducted to definitely evaluate the safety and effectiveness of CaSO4 beads in DFO.

Subtalar joint septic arthritis in a patient with hypogammaglobulinemia.

The clinical presentation of a monoarticular, red, hot, and swollen joint has many possible diagnoses, including septic arthritis, which is 1 of the most devastating. The morbidity associated with this pathologic process involves permanent joint damage and the potential for progression to systemic illness and, even, mortality. The common risk factors for joint sepsis include a history of rheumatoid arthritis, previous joint surgery, joint prosthesis, intravenous drug abuse, alcoholism, diabetes, previous intra-articular steroid use, and cutaneous ulceration. The diagnosis is primarily determined from the culture results after arthrocentesis and correlation with direct visualization, imaging, and various serologies, including synovial analysis. In the present report, a case of an insidious presentation of subtalar joint septic arthritis and its association with a unique patient presentation concomitant with primary immunodeficiency and culture-proven Myocplasma hominis infection is discussed. Septic arthritis has a predilection for the lower extremities and typically is isolated to the hip or knee, with less common involvement of the ankle or metatarsophalangeal joints. Owing to the uncommon nature of primary immunodeficiency disorders and the paucity of studies discussing their association with septic arthridites, we aimed to raise awareness of subtalar joint septic arthritis and to provide a brief overview of the pathogenesis as it presented in a 33-year-old male with X-linked hypogammaglobulinemia/agammaglobulinema.

The Navicular Cuneiform Joint: Updates on Avoiding and Managing a Nonunion.

Naviculocuneiform arthrodesis, while often used to support the medial column during management of primary/post-traumatic arthritis, deformity correction, or in the surgical treatment of progressive collapsing foot deformity, can develop nonunion. Addressing this condition hinges on the assessment of various parameters such as patient/host factors and recognition of the etiology of the nonunion. In this article, methods of optimizing this surgical intervention through anatomic and physiologic considerations are highlighted. Further, information is provided to assist foot and ankle surgeons in performing a comprehensive work-up to allow for successful reconstruction and optimal patient outcomes.

Necrotizing Fasciitis in Charcot-Marie-Tooth Treated with Debridement, Free Flap, and Extra-Articular Reconstruction.

Necrotizing fasciitis of the foot is a relatively rare diagnosis and has traditionally been treated with distal amputation. A 30-year-old diabetic man with Charcot-Marie-Tooth muscular atrophy developed necrotizing fasciitis of the dorsal foot and underwent surgical debridement resulting in a significant wound with exposed tendons. Serial debridements were performed, eventually followed by a staged free flap reconstruction using an anterolateral thigh fasciocutaneous flap. After allowing time for flap healing, subsequent staged equinovarus reconstruction was also performed successfully. There were no flap or postoperative complications, and the patient is progressing as expected. Flap refinement procedures have been used to enhance cosmetic and functional outcomes. This report not only showcases the success of a procedure high on the reconstructive ladder in a patient at high risk for complications but also highlights an approach in which functional recovery is also optimized successfully in a planned staged multidisciplinary manner.

Assessment of Pediatric Limb Length Inequality.

Limb length inequality or discrepancy (LLD) occurs when there is a difference in length between 2 limbs or when deviation exists from a normally expected length for a given age. The magnitude of the discrepancy is defined as the difference between the 2 extremities. Aside from congenital etiologies, LLD can also arise from infection, paralysis, tumors/neoplasm, and surgery. Approximately 70% to 90% of the world's population has some elements of LLD with compensation allowing for tolerance and potentially masking the extent to which one limb could be significantly shorter either functionally or structurally. Components of functional LLD could include congenital shortening of soft tissues, joint contractures, axial skeleton malalignment, and abnormal pedal biomechanics (ie, posterior tibial tendonitis or equinovarus). In accordance with literature reports, most individuals can tolerate upwards of a 2 cm discrepancy. Although a constellation of symptoms such as joint pain, arthritis, alterations in oxygen consumption/heart rate, and low back pathology can occur later on in adulthood, the focus in this review will be with early diagnosis and management in the pediatric population.

Surgical Treatment of Plantar First Metatarsal Ulcerations in High-Risk Patients: A Case Series.

BACKGROUND: Plantar first metatarsal ulcerations pose a difficult challenge to clinicians. Etiologies vary and include first metatarsal declination, cavus foot deformity, equinus contracture, and hallux limitus/rigidus. Our pragmatic, sequential approach to the multiple contributing etiologies of increased plantar pressure sub-first metatarsal can be addressed through minimal skin incisions. METHODS: A retrospective review was performed for patients with surgically treated preulcerations or ulcerations sub-first metatarsal head. All of the patients underwent a dorsiflexory wedge osteotomy, and the need for each additional procedure was independently assessed. Equinus contracture was treated with Achilles tendon lengthening, cavovarus deformity was mitigated with Steindler stripping, and plantarflexed first ray was treated with dorsiflexory wedge osteotomy. RESULTS: Eight patients underwent our pragmatic, sequential approach for increased plantar pressure sub-first metatarsal, four with preoperative ulcerations and four with preoperative hyperkeratotic preulcerative lesions. The preoperative ulcerations were present for an average of 25.43 weeks (range, 6.00-72.86 weeks), with an average size of 0.19 cm3 (median, 0.04 cm3). Procedure breakdown was as follows: eight first metatarsal osteotomies, four Achilles tendon lengthenings, and six Steindler strippings. Postoperatively, all eight patients returned to full ambulation, and the four ulcerations healed at an average of 24 days (range, 15-38 days). New ulceration occurred in one patient, and postoperative infection occurred in one patient. There were no ulceration recurrences, dehiscence of surgical sites, or minor or major amputations. CONCLUSIONS: The outcomes in patients surgically treated for increased plantar first metatarsal head pressure were evaluated. This case series demonstrates that our pragmatic, sequential approach yields positive results. In diabetic or high-risk patients, it is our treatment algorithm of choice for increased plantar first metatarsal pressure.