ACFAS Clinical Consensus Statements: Hallux Rigidus.

The following are clinical consensus statements (CCS) on the topic of hallux rigidus sponsored by the American College of Foot and Ankle Surgeons. A core panel synthesized the data and divided the topic in to twelve sections, each section contained a variable number of consensus statements, based upon complexity. Overall there were 24 consensus statements synthesized for this subject matter. The 24 statements were provided to the expert panel with all available evidence to come to a consensus utilizing all available evidence.

Myoepithelioma-like hyalinizing epithelioid tumor of the foot with OGT-FOX03 fusion gene: Imaging findings, surgical implications, and pathological correlates.

Myoepithelioma-like hyalinizing epithelioid tumors are rare neoplasms that share morphological characteristics of myoepitheliomas but lack traditional immunophenotypic findings. Though little is known about these tumors at present, a handful of recent studies have confirmed that they harbor a novel fusion gene known as "OGT-FOXO." Though closely resembling myoeptheliomas, Myoepithelioma-like hyalinizing epithelioid tumors are considered a distinct tumor entity, and few studies have explored their clinical characteristics or their potential for malignancy. Furthermore, literature describing imaging findings of these tumors is virtually non-existent. Understanding the radiological and pathological differences between Myoepithelioma-like hyalinizing epithelioid tumors and myoepitheliomas is helpful in developing a comprehensive differential for soft tissue neoplasms of the foot. We describe a case of MHET of the foot and correlate MRI findings with pathology in addition to describing surgical technique and implications to care.

An Analysis of 50 Consecutive Total Ankle Replacements Undergoing Preoperative Computerized Tomography Scan-Based, Engineer-Provided Planning From a Single Noninventor, Nonconsultant Surgeon.

Preoperative computerized tomography (CT) scan-based, engineer-provided alignment plans and patient-specific pinning blocks for total ankle replacement (TAR) are available for use in the United States. However, nonbiased studies that justify the additional expense associated with this technology through support of the marketed benefits of less procedural complexity, less intraoperative radiation and reduced surgical time, are lacking. Therefore, to verify the manufacturer's proposed benefits, we sought to investigate our experience with this preoperative CT scan-based, engineer-provided plan and patient-specific pinning blocks during primary TAR. In review of our 50 TAR patients, we found that "perfect" radiographic alignment was not consistently achieved and the accuracy of component prediction was modest. Furthermore, the preoperative plans and patient-specific pinning blocks did not simplify the complexity of our operations since the operative time, intraoperative image intensification time and radiation dose per case all exceeded published historical TAR controls. Interestingly, we identified a significant difference in placement accuracy between the arced and flat-top talar component types that were implanted with the arced being more frequently malaligned. We did not find associations between preoperative deformity severity and accuracy of postoperative alignment. These findings suggest that it is imperative to have surgeons continue to rely on their own surgical planning and experience to achieve optimum radiographic alignment rather than depending on engineer-based recommendations or "surface matched" pinning blocks. Ultimately, we were unable to support the purported benefits of this CT scan-based, engineer-provided alignment plan and patient-specific pinning blocks for this manufacturer's primary TAR systems.

MR diagnosed chronic exertional compartment syndrome successfully treated by endoscopically-assisted fasciotomy.

Chronic exertional compartment syndrome is a subset of compartment syndrome that most frequently affects the lower extremities, often in athletic persons. It is most often characterized by calf pain shortly after the initiation of exercise and resolution of the pain soon after rest. While the pathophysiology is not completely understood, it is believed that compartment a lack of fascial compliance and increased compartment fluid leads to increased pressure, ultimately leading to a reversible ischemic state. Chronic exertional compartment syndrome was once considered a diagnosis of exclusion; however, needle manometry is an invasive way to measure intracompartmental pressure. Similarly, fasciotomy is the treatment of choice but is not without complications. We describe a case of chronic exertional compartment syndrome diagnosed by two-stage MRI and successfully treated by endoscopically-assisted fasciotomy.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity.

This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.

Incorporating Healthcare Risk Management into Podiatric Surgical Residency Training.

In an effort to emphasize the practical importance of patient safety to the next generation of podiatric surgeons, a short healthcare risk management seminar was implemented. The purpose of this course is to demonstrate how safer and more quality oriented practices such as better provider-patientcommunication can help reduce the risk of medical malpractice cases.

Pharmacodynamic Effects of Vorapaxar in Patients With and Without Diabetes Mellitus: Results of the OPTIMUS-5 Study.

Vorapaxar reduces thrombotic cardiovascular events at the expense of increased bleeding. However, the differential pharmacodynamic (PD) effects of vorapaxar according to diabetes mellitus (DM) status are unknown. Moreover, although withdrawal of aspirin has emerged as a bleeding reduction strategy, the PD effects of stopping aspirin in patients treated with vorapaxar also are unknown. In this prospective PD investigation, vorapaxar was associated with reduced platelet-mediated thrombogenicity without affecting clot kinetics irrespective of DM status. However, platelet-mediated thrombogenicity increased after aspirin withdrawal, particularly among patients with DM. (Optimizing anti-Platelet Therapy In diabetes MellitUS-5 Study [OPTIMUS-5]; NCT02548650).

Comparison of the Complication Incidence in Open Versus Endoscopic Gastrocnemius Recession: A Retrospective Medical Record Review.

Gastrocnemius recession is a practical and effective procedure to address gastrocnemius equinus. It has been shown that an equinus deformity can lead to the development of plantar fasciitis, osteoarthritis, and foot ulcerations. The 2 approaches to gastrocnemius recession are open and endoscopic. Both are viable options; however, both also have associated complications. We compared and evaluated the postoperative complications associated with these procedures. The electronic database of our orthopedics division at the University of Florida College of Medicine, Jacksonville, was retrospectively searched to identify all cases of gastrocnemius recession (Current Procedural Terminology [CPT] code 27687), and unlisted arthroscopy (CPT code 29999) from February 2006 to February 2016. The difference in the outcome variable, the incidence of postoperative complications, was assessed using Fisher's exact test. A total of 39 patients (41 procedures) were in the open gastrocnemius recession group and 35 (39 procedures) were in the endoscopic gastrocnemius recession group. The median follow-up time was shorter in the open gastrocnemius recession group than in the endoscopic gastrocnemius recession group (9 versus 12 months; p < .001). Postoperative complications developed after 12 of the 80 procedures (15%), with a greater incidence after open than endoscopic procedures (26.8% versus 2.6%; p = .003). The complications associated with the open technique included 1 case of scar pain (2.4%), 5 of dehiscence (12.2%), 1 of infection (2.4%), 2 of calf abscess (4.9%), and 2 cases of nerve injury (4.9%). A single complication occurred with the endoscopic technique-1 case of dehiscence (2.6%). To the best of our knowledge, ours is the first study to compare the postoperative complications between these 2 techniques. We found the incidence of postoperative complications was significantly lower in the endoscopic group, emphasizing the benefit of using the endoscopic approach. These findings could prove invaluable when addressing gastrocnemius equinus in those with a greater risk of postoperative complications.

Arthroscopic Ankle Arthrodesis: An Update.

Arthroscopic ankle arthrodesis provides an alternative to open techniques. Advancements in arthroscopic techniques and instrumentation have made the procedure easier to perform. Arthroscopic ankle arthrodesis has demonstrated faster rates of union, fewer complications, reduced postoperative pain, and shorter hospital stays. Sound surgical techniques, particularly with regard to joint preparation, are critical for success. Comorbidities such as increased body mass index, history of smoking, malalignment, and posttraumatic arthritis should be considered when contemplating arthroscopic ankle arthrodesis. Although total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis remains a viable alternative for management of the end-stage arthritic ankle.

An Alternative Surgical Approach to Pseudoainhum: A Case Report.

Pseudoainhum is a disorder of unknown etiology that is usually congenital and nonprogressive. One theory states it is caused by amnion band constriction in utero. These constriction bands lead, not only to a less cosmetically appealing foot, but also to long-term neurovascular compromise, resulting in amputation of the digit. The described surgical approaches have been limited within published data. The 2 procedures that have been described are either a Z-plasty or amputation, depending on the degree of the deformity. The present case report provides an alternative surgical approach to a pseudoainhum deformity of a third digit.

Use of an all-suture anchor for re-creation of the anterior talofibular ligament: a case report.

The lateral ankle ligament complex is typically injured during athletic activity caused by an inversion force on a plantar flexed foot. Numerous open surgical procedures to reconstruct the lateral ankle complex have been described. In contrast, we present a case report in which an all-suture anchor was used arthroscopically to re-create the anterior talofibular ligament in conjunction with ankle arthroscopy. A retrospective analysis of a 55-year-old male with a work-related inversion ankle sprain was performed with 14 months of follow-up. Objective and subjective assessments were obtained using range of motion measures, a strength assessment, and the Foot Function Index. An all-suture anchor was deployed through the anterolateral portal and secured in both the fibula and talus, re-creating the anterior talofibular ligament at its origin and insertion. Active range of motion physical therapy began at 2 weeks postoperatively. The patient started a neuromuscular re-education program at 5 weeks with minimal pain or discomfort. A return to full duty was achieved at 3 months postoperatively. To our knowledge, the use of an all-suture anchor has not been previously reported for lateral ankle complex re-creation. It is hoped that this approach to anterior talofibular ligament repair will decrease the incidence of complications and improve outcomes.