Donor-Site Complication of Severe Valgus Ankle Deformity in an Adult With Ehlers-Danlos Syndrome Following Free Vascularized Fibular Grafting.

Valgus deformity of the ankle joint is a well-known and relatively common donor-site complication of free vascularized fibular graft harvest in children. Due to children having naturally greater ligamentous laxity than adults, the tibiofibular syndesmosis can be compromised with the loss of the fibular shaft, leading to valgus ankle deformity (VAD). Syndesmotic stabilization with screws is commonly recommended in subsets of pediatric patients at the greatest risk of this complication. In adults, the occurrence of VAD is seldom reported in the literature following fibular graft harvest. As such, no recommendation for syndesmotic stabilization exists in the adult population. We present a case of end-stage VAD in an adult patient with Ehlers-Danlos syndrome (EDS) following free vascularized fibular graft harvest. We hypothesize that other patients with generalized joint hypermobility may face the same complication and, thus, recommend the consideration of syndesmotic stabilization or primary syndesmotic fusion at the time of graft harvest in this patient population.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus.

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Incidence and risk factors for venous thromboembolic disease in podiatric surgery.

BACKGROUND: The Agency for Healthcare Research and Quality ranks prevention of venous thromboembolism (VTE) as a top priority for patient safety; however, no guidelines or population-based research exist to guide management for podiatric surgery patients. The objective of our study was to determine the incidence and risk factors for postprocedure VTE in podiatric surgery. METHODS: A 5-year retrospective analysis of patients undergoing podiatric surgery in a large not-for-profit health maintenance organization serving > 485,000 members in the Pacific Northwest from 1999 to 2004. RESULTS: We identified 16,804 surgical procedures in 7,264 patients and detected 22 symptomatic postprocedure VTEs. The overall incidence of postprocedure VTE was 0.30%. Three risk factors were significantly and independently associated with VTE in podiatric surgery: prior VTE (incidence, 4.6%; relative risk, 23.0; p < 0.001), use of hormone replacement therapy or oral contraceptives (incidence, 0.55%; relative risk, 4.2; p = 0.01), and obesity (incidence, 0.48%; relative risk, 3.0; p = 0.02). CONCLUSIONS: We identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. However, for patients with a history of VTE, periprocedure prophylaxis is suggested based on the level of risk. For podiatry surgery patients with two or more risk factors for VTE, periprocedure prophylaxis should be considered. Until a prospective study is completed testing recommendations, guidelines and care decisions for podiatric surgery patients will continue to be based on retrospective data, expert consensus, and clinical judgment.