Trombose da artéria dorsal do pé como complicação de os intermetatarseum sintomático: relato de caso raro / Thrombosis of the dorsalis pedis artery as a complication of symptomatic os intermetatarseum: a rare case report

Introdução: O os intermetatarseum é um ossículo acessório do pé observado mais frequentemente entre o cuneiforme medial e a base do primeiro e segundo metatarsal. Desde sua descrição, há raros relatos na literatura de casos sintomáticos e até o momento de produção desse relato não foi descrito a relação com a trombose da artéria dorsal do pé. Relato de caso: Paciente do sexo masculino, 24 anos, atleta não profissional, relata dor súbita no dorso do mediopé associado a atividade esportiva, sem melhora ao tratamento conservador, sendo submetido a ressecção do osso acessório e do trombo da artéria pediosa, evoluindo com melhora dos sintomas iniciais. Discussão: O os intermetatarseum é um dos mais raros dos ossos acessórios que podem ser encontrados no pé e geralmente é assintomático, sendo correlacionado como causa de hálux valgo secundário. Porém, é um importante diagnóstico diferencial a ser lembrado em quadros dolorosos no dorso do mediopé e em caso de sintomas compressivos do nervo fibular profundo. Conclusão: O os intermetatarseum é tipicamente assintomático, porém deve ser lembrado em quadros álgicos do dorso do pé e sintomas compressivos do nervo fibular profundo, especialmente em jovens praticantes de atividades esportivas. Palavras-chave: Intermetatarseum. Ortopedia. Pé. Artéria dorsal do pé.

Ultrasonographic diagnosis of closed pedal bone fractures in bovine claws: An ex-vivo study in slaughterhouse specimens.

Pedal bone fractures are one of the most common fracture locations in adult cattle and can be diagnosed by radiographs in two planes. Most bovine practitioners do not have access to such X-ray machines, but many use ultrasound units on a daily basis, primarily for reproductive medicine. For this reason, in this double-masked, randomized controlled study, we aimed to investigate the suitability of ultrasonographic examination using a 5 MHz linear transducer for diagnosing closed fractures of the pedal bone in cattle. A total of 54 hindlimb claws from slaughtered cattle were prepared and approximately 50% of the claws were artificially fractured. All claws were ultrasonographically examined twice by two examiners to determine the presence or absence of fractures and their locations. Ultrasound results were confirmed using radiographs of the claws as the reference standard method. All fracture locations as determined by ultrasonography were situated within ±2 mm of the radiographically-determined fracture zone. Ultrasound examination yielded a calculated sensitivity of 93%, a specificity of 91% and an inter-rater reliability of 0.77. The intra-rater reliability for the examiners were 0.96 and 0.88. Examiner experience with ultrasound examination and using ultrasound images for diagnosis could have influenced diagnostic accuracy. We conclude that artificially-created pedal bone fractures in ex-vivo bovine claws can be diagnosed using ultrasonography; similar results are expected in live animals. These results should encourage veterinarians to use ultrasonography for diagnosing pedal bone fractures in cattle.

Population-based incidence and epidemiology of 5912 foot fractures.

BACKGROUND: The present study aimed to report a full overview of the incidence and epidemiology of foot fractures. METHOD: Population-based epidemiological cohort study including all foot fractures over 5 years. All patient charts and radiology were manually assessed. RESULTS: A total of 4938 patients sustained 5912 foot fractures during the study period. Patients' mean age at the time of fracture was 36.1 (21.7 SD) years. The overall incidence of foot fractures was 142.3/100,000/year. The hind foot incidence was 13.7/100,000/year, the mid foot incidence 6.5/100,000/year, and the fore foot incidence 123.9/100,000/year. The most common mode of injury was due to low energy trauma (98.7%). CONCLUSION: This study shows an overall incidence of foot fractures to be 142.3/100,000/year. The hind foot incidence is 13.7/100,000/year, the mid foot incidence 6.5/100,000/year, and the fore foot incidence 123.9/100,000/year.

Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients.

BACKGROUND: Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries. METHODS: In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. RESULTS: In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery. CONCLUSION: Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies. LEVEL OF EVIDENCE: IV, retrospective case series.

Staged treatment and internal fixation of floating ankle: A case report and literature review.

RATIONALE: Floating ankle is a rare traumatic condition characterized by a combination of tibial and ipsilateral foot fractures, with the ankle remaining intact. It is usually caused by high-energy trauma and also presents with serious soft tissue damage. Its treatment is mainly restricted to external fixation, which results in poor outcomes. We present a patient with a floating ankle who underwent staged treatment and achieved full internal fixation, subsequently returning to normal activity. PATIENT CONCERNS: A 26 year- old man had an accident with an reel machine and sustained an open fracture on his right lower extremity. DIAGNOSES: Digital radiograph demonstrated a distal tibial fracture, fibular fracture, and multiple metatarsal fractures, which fulfilled the criteria for a floating ankle. INTERVENTIONS: Initial ankle-spanning external fixation was performed. After 21 days, the patient underwent open reduction and internal fixation on his first and fifth metatarsals, and K-wire fixation on his fourth metatarsal. The external fixator was replaced by plaster fixation. Seven days later, the patient underwent internal fixation of his leg, open reduction and internal fixation with plating was applied of the fibular fracture, and minimally invasive plate osteosynthesis of the tibial fracture. OUTCOMES: At 1-year follow-up, bone union was identified by digital radiograph; after 2 years, his ankle function had fully recovered, and he resumed his normal activities. LESSONS: In the staged treatment protocol of the floating ankle, temporary external fixation provided traction and immobilization of the skeletal and soft tissues. Secondary internal fixation maintained the reduction and alignment and allowed early exercise, which is critical to the prognosis of a floating ankle.

Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients.

OBJECTIVE: The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations. METHODS: In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined. RESULTS: Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis. CONCLUSION: With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Change in the First Cuneiform-Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans.

BACKGROUND: This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans. METHODS: Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments-conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]-conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac-transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data. RESULTS: No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7. CONCLUSIONS: Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition. CLINICAL RELEVANCE: This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

Reconstruction of a Traumatic Partial First-Ray Amputation with the Use of an Induced Pseudosynovial Membrane and Corticocancellous Autograft.

Reconstruction of large bone defects of the metatarsals, whether resulting from trauma, infection, or a neoplastic process, can be especially challenging when attempting to maintain an anatomical parabola and basic biomechanical stability of the forefoot. We present the case of a 42-year-old man with no significant medical history who presented to the emergency department following a severe lawnmower injury to the left forefoot resulting in a large degloving type injury along the medial aspect of the left first ray extending to the level of the medial malleolus. The patient underwent emergent debridement with application of antibiotic bone cement, external fixation, and a negative-pressure dressing. He was subsequently treated with split-thickness skin graft and iliac crest tricortical autograft using a locking plate construct for reconstruction of the distal first ray. Although the patient failed to advance to radiographic osseous union, clinically there was no motion at the attempted fusion site and no pain with ambulation, suggestive of a pseudoarthrosis. The patient has since progressed to full nonpainful weightbearing in regular shoes and has returned to normal activities of daily living. The patient returned to his preinjury level of work and has had complete resolution of all wounds including his split-thickness skin graft donor site. This case shows the potential efficacy of the Masquelet technique for spanning significant traumatic bone defects of the metatarsals involving complete loss of the metatarsophalangeal joint.

Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

BACKGROUND: Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries. METHODS: Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of the medial 3 TMT joints, whereas 24 patients were randomized to temporary bridge plate (BP) over the first TMT joint and primary arthrodesis of the second and third TMT joints. The main outcome parameter was the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale and the secondary outcome parameters were the 36-Item Short Form Health Survey (SF-36) and visual analog scale for pain (VAS pain). Computed tomography (CT) scans pre- and postoperatively were obtained. Radiographs were obtained at follow-ups. Pedobarographic examination was performed at the 2-year follow-up. Twenty-two of 24 patients in the PA and 23/24 in the BP group completed the 2-year follow-up. RESULTS: The mean AOFAS midfoot score 2 years postoperatively was 89 (SD 9) in the PA group and 85 (SD 15) in the BP group (P = .32). There were no significant differences between the groups with regard to SF-36 or VAS pain scores. The alignment of the first metatarsal was better in the BP group than in the PA group measured by the anteroposterior Meary angle (P = .04). The PA group had a reduced peak pressure under the fifth metatarsal (P = .047). In the BP group, 11/24 patients had radiologic signs of osteoarthritis in the first TMT joint. CONCLUSION: Both treatment groups had good outcome scores. The first metatarsal was better aligned in the BP group; however, there was a high incidence of radiographic osteoarthritis in this group. LEVEL OF EVIDENCE: Therapeutic level I, prospective randomized controlled study.

Comparison of Suture-Augmented Ligamentplasty to Transarticular Screws in a Lisfranc Cadaveric Model.

BACKGROUND: Lisfranc injuries represent a spectrum of trauma from high-energy lesions, with significant instability of the midfoot, to low-energy lesions, with subtle subluxations or instability without gross displacement. Recently, treatment options that allow for physiologic fixation of this multiplanar joint are being evaluated. The purpose of this study was to analyze the stability of a cadaveric Lisfranc injury model fixed with a novel suture-augmented neoligamentplasty in comparison with a traditional transarticular screw fixation construct. METHODS: Twenty-four fresh-frozen, matched cadaveric leg and foot specimens (12 individuals younger than 65 years of age) were used for this study. Two different types of Lisfranc ligament injuries were tested: partial and complete. Two different methods of fixation were compared: transarticular screws and augmented suture ligamentplasty with FiberTape. Specimens were fixed to a rotation platform in order to stress the joints while applying 400 N of axial load and internal and external rotation. Six distances were measured and compared between the intact, injured, and fixed states with a 3D Digitizer arm, in order to evaluate the stability between them. Analysis of variance was used with P < .05 considered significant. RESULTS: Using distribution graphs and analyzing the grouped data, it was observed that there was no difference between the 2 stabilization methods, but the augmented suture ligamentplasty presented lower variability and observed distance shortenings were more likely to be around the mean. The variability of the stabilization with screws was 2.9 times higher than that with tape (P < .001). CONCLUSION: We suggest that augmented suture ligamentplasty can achieve similar stability to classic transarticular screws, with less variability. CLINICAL RELEVANCE: This cadaveric study adds new information on the debate about Lisfranc lesions treatment. Flexible fixations, such as the synthethic ligamentplasty used, can restore good stability such as conventional transarticular screws.

What Is the Optimal Antibiotic (Type, Dose and Route of Administration) Treatment for Infections After Foot/Ankle Fracture or Fusion Procedures?

RECOMMENDATION: The optimal antibiotic treatment after foot/ankle fractures or fusion should be determined based on the result of culture. In the absence of culture results, administered antibiotics should include coverage against common pathogens such as Staphylococcus aureus. LEVEL OF EVIDENCE: Strong. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Radiologic Evaluation of Lower Leg, Ankle, and Foot Fracture Fixation Hardware.

Radiologists should be familiar with basic principles of fracture fixation and the normal imaging appearances of implant constructs and their complications. The surgeon's selection of external fixation, intramedullary nail fixation, open reduction and internal fixation, or some combination depends on patient factors, fracture configuration, injury to the soft tissue envelope, and surgeon experience. Complications including loss of fixation with resultant malalignment, nonunion, infection, and posttraumatic osteoarthritis present additional challenges for the surgeon as well as the radiologist. This article reviews the rationale behind fracture fixation in fractures of the lower leg, ankle, and foot. Examples of postoperative complications are also reviewed.

Adult foot fractures: A guide.

This review can help you refine your approach to the diagnosis and management of adult foot fractures, while offering guidance on when to pursue advanced imaging.

Foot and Ankle Surgery in the Diabetic Population.

The surgical treatment of diabetic patients can be challenging. The physiologic and metabolic abnormalities seen in diabetic patients can adversely affect healing and outcomes in even the simplest of procedures. This article examines some of the special considerations in the treatment of diabetic patients undergoing foot and ankle surgeries.

Experience using the «Shetty test¼ for initial foot and ankle fracture screening in the Emergency Department. / Experiencia con la aplicación del test de Shetty para el despistaje inicial de fracturas del pie y tobillo en el área de Urgencias.

OBJECTIVE: The indiscriminate practice of radiographs for foot and ankle injuries is not justified and numerous studies have corroborated the usefulness of clinical screening tests such as the Ottawa Ankle Rules. The aim of our study is to clinically validate the so-called Shetty Test in our area. MATERIAL AND METHOD: A cross-sectional observational study by applying the Shetty test to patients seen in the Emergency Department. RESULTS: We enrolled 100 patients with an average age of 39.25 (16-86). The Shetty test was positive on 14 occasions. Subsequent radiography revealed a fracture in 10 cases: 4 were false positives. The test was negative in the remaining 86 patients and radiography confirmed the absence of fracture (with sensitivity of 100% and specificity of 95.56%, positive predictive value of 71.40%, and negative predictive value of 100%). CONCLUSIONS: The Shetty test is a valid clinical screening tool to decide whether simple radiography is indicated for foot and ankle injuries. It is a simple, quick and reproducible test.

Primary Arthrodesis in Severely Comminuted Fractures.

At present there is controversy regarding the appropriate treatment of severely comminuted fractures of the lower extremity. Even with near-perfect anatomic reduction of severely comminuted fractures, development of posttraumatic arthritis is still present at an increased rate. Primary fusion of comminuted fractures of the foot and ankle creates successful and predictable outcomes, which dismisses the chance of developing posttraumatic arthritis and decreases complications and the need for revisional procedures.

Imaging of pediatric foot disorders.

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient's comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn't  adequately define the bone's non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique.

Muscle atrophy and recovery of individual thigh muscles as measured by magnetic resonance imaging scan during treatment with cast for ankle or foot fracture.

PURPOSE: We aimed to longitudinally investigate individual thigh muscle changes using magnetic resonance imaging (MRI) during treatment with cast of ankle or foot fracture. Moreover, we aimed to demonstrate whether measurements of muscle cross-sectional area (CSA) are sensitive to muscle changes, contributing to simpler methods in clinical application . METHODS: Ten patients undergoing treatment with cast of acute ankle or foot fractures were studied. Axial MRI (1.5 T) was conducted around the affected mid-thigh region after the injury (Pre), after maintaining a nonweight-bearing (NWB) period (approximately 28 days), and after finishing rehabilitation (recovery). Regarding individual thigh muscles, the total CSAs corresponding to 40% of the femoral length (FL) and the CSAs at 5% interval of the FL were longitudinally measured. Standardized response means (SRMs) were accessed for sensitivity in the muscle changes. RESULTS: The total CSAs at NWB were significantly lower than those at Pre in vastus lateralis (10.9% ± 5.4%), vastus intermedius (8.4% ± 6.7%), and vastus medialis (11.2% ± 6.9%) ( p < 0.01 for all). In contrast, at recovery, the only significant muscle atrophy relative to that at Pre was observed in the semitendinosus of the proximal 15% and 10% CSAs ( p < 0.01 and p = 0.01, respectively). In all muscles, SRM using a single-slice CSA at or near the muscle belly was high. CONCLUSION: Thigh muscle changes differ according to the variations in individual muscles. CSA measurements at or near the muscle belly are simple methods and sensitive indicators of these muscle changes.

The virtual approach to the assessment of skeletal injuries in human skeletal remains of forensic importance.

While assessing skeletal injuries in human skeletal remains, forensic anthropologists are frequently presented with fractured, fragmented, or otherwise modified skeletal remains. The examination of evidence and the mechanisms of skeletal injuries often require that separate osseous elements be permanently or temporarily reassembled or reconstructed. If not dealt with properly, such reconstructions may impede accurate interpretation of the evidence. Nowadays, routine forensic examinations increasingly incorporate digital imaging technologies. As a result, a variety of PC-assisted imaging techniques, collectively referred to as the virtual approach, have been made available to treat fragmentary skeletal remains. The present study employs a 3D virtual approach to assess mechanisms of skeletal injuries, and provides an expert opinion of causative tools in three forensic cases involving human skeletal remains where integrity was compromised by multiple peri- or postmortem alterations resulting in fragmentation and/or incompleteness. Three fragmentary skulls and an incomplete set of foot bones with evidence of perimortem fractures (gunshot wounds) and sharp force trauma (saw marks) were digitized using a desktop laser scanner. The digitized skeletal elements were reassembled in the virtual workspace using functionalities incorporated in AMIRA® version 5.0 software, and simultaneously in real physical space by traditional reconstructive approaches. For this study, the original skeletal fragments were substituted by replicas built by 3D printing. Inter-method differences were quantified by mesh-based comparison after the physically reassembled elements had been re-digitized. Observed differences were further reinforced by visualizing local variations using colormaps and other advanced 3D visualization techniques. In addition, intra-operator and inter-operator error was computed. The results demonstrate that the importance of incorporating the virtual approach into the assessment of skeletal injuries increases with the complexity and state of preservation of a forensic case. While in relatively simple cases the virtual approach is a welcome extension to a traditional approach, which merely facilitates the analysis, in more complex and extensively fragmentary cases such as multiple gunshot wounds or dismemberment, the virtual approach can be a crucial step in applying the principles of gunshot wounds or sharp force traumatic mechanisms. The unrestricted manipulation with digital elements enabling limitless repairs and adjustments to a "best-case scenario" also produced smaller inter-operator variation in comparison to the traditional approach.