Determining the strongest orientation for "Lisfranc's screw" in transverse plane tarsometatarsal injuries: a cadaveric study.

UNLABELLED: The treatment of tarsometatarsal joint fracture-dislocations generally consists of realignment followed by stabilization with rigid internal fixation. The purpose of this study was to determine the strongest orientation for the "Lisfranc's screw" for repair of disruption of the articulation between the first and second metatarsals and the medial and intermediate cuneiforms. To this end, Lisfranc's ligament was sectioned in 6 pairs of fresh-frozen, human cadaver feet, after which a 3.5-mm partially threaded, cannulated screw was placed across the Lisfranc joint in 1 of 2 opposing directions. In one group, the screw was oriented in the more traditional medial cuneiform to second metatarsal base direction. In the other group, the screw was oriented from the second metatarsal base to the medial cuneiform. After fixation, each construct was pulled to transverse plane failure at the tarsometatarsal joint with a servohydraulic mechanical testing system. The overall force to failure was 157.04 +/- 54.79 N (range, 96.8-249.2 N). For the traditional medial cuneiform to second metatarsal base screw orientation group, the mean force to failure was 148.97 +/- 54.93 N, whereas for the second metatarsal base to medial cuneiform group the mean force to failure was 165.12 +/- 58.57 N, and this difference was not statistically significant (P = .2475). Although not statistically significantly different in regard to force to failure strength, the authors describe an alternative approach to the orientation of "Lisfranc's screw" for stabilization of the relationship of the medial cuneiform to the second metatarsal. LEVEL OF CLINICAL EVIDENCE: 5.

Salvage of the first ray with concomitant septic and gouty arthritis by use of a bone block joint distraction arthrodesis and external fixation.

Gouty arthropathy about the first metatarsal-phalangeal joint with a superimposed deep infection poses a great challenge to the foot and ankle surgeon. The inflammatory nature of gout compromises the soft-tissue envelope and vasculature to the area. Acute gouty arthropathy is usually a contraindication to surgical intervention secondary to wound-healing complications and possible vasospasm leading to tissue necrosis. However, if deep infection is present this must be managed with adequate surgical débridement followed by delayed soft-tissue and osseous reconstruction to prevent amputation. The authors present an exceptional clinical manifestation of gouty arthropathy of the first metatarsal-phalangeal joint concomitant with deep abscess and osteomyelitis and the surgical approach taken to afford functional limb salvage.

Surgical treatment of Charcot neuropathy.

Charcot neuroarthropathy, a chronic progressive destruction of joint integrity, is believed to result from a disturbance in pain and proprioceptive sensation. It is most commonly treated in patients with uncontrolled diabetes mellitus and dense peripheral neuropathy. Prevention, early diagnosis, and early treatment are key to a patient's successful outcome. Educating the patient is paramount to avoid further complications and subsequent amputations. This article describes the pathophysiology, staging, surgical treatment, and natural course of Charcot neuroarthropathy.

Split-thickness skin grafts for closure of diabetic foot and ankle wounds: a retrospective review of 83 patients.

The aim of this study was to determine if split-thickness skin grafts could be successfully used for closure of foot and ankle wounds in diabetic patients. The authors retrospectively reviewed the charts of 100 consecutive patients who underwent a soft tissue surgical reconstruction with split-thickness skin grafts to their foot and/or ankle in our institution from 2005 to 2008. After application of inclusion criteria, 83 eligible charts remained. Of the 83 patients, 54 (65%) healed uneventfully, 23 (28%) required regrafting, and 6 (7%) had a complication resolved with conservative management. All patients had a successful surgical outcome, defined as having achieved complete wound closure at the final follow-up. Surgical outcome was not significantly associated with age, gender, race, hemoglobin A1C, wound size, wound location, illicit drug use, amputation history, Charcot history, or preoperative infection. However, postoperative graft complications were significantly associated with current or previous smoking history (P = .016) and the level of previous pedal amputation to which the split-thickness skin graft was applied (P = .009). This study demonstrates that application of split-thickness skin grafts with an appropriate postoperative regimen is a beneficial procedure to achieve foot and ankle wound closure in diabetic patients.

Pan-metatarsophalangeal joint arthrodesis for the severe rheumatoid forefoot deformity.

The standard approach for correction of severe painful rheumatoid forefoot deformities has involved resection of the metatarsal heads with realignment of the lesser toe deformities and first metatarsophalangeal joint (MTPJ) arthrodesis. Modifications of this procedure may include a pan-metatarsal head resection, including the first metatarsal head, or resection of the lesser metatarsal heads in conjunction with an interpositional arthroplasty of the first MTPJ. The authors describe a novel surgical approach that involves the correction of severe rheumatoid forefoot deformities through a pan-MTPJ arthrodesis. Arthrodesis of all five MTPJs for the surgical treatment of the painful rheumatoid forefoot deformity with chronic plantar callosities and dislocated digits has yet to be reported in the scientific literature. The goal of this article is to provide the treating physician with another alternative and safe surgical approach when dealing with the painful rheumatoid forefoot deformity.