Midfoot Fusion Using Superconstructs for the Charcot Foot: Current Techniques and Complications.

Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM).

BACKGROUND: The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. METHODS: A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. RESULTS: There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18-75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125). Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred. CONCLUSIONS: Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

Correction to: Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

An amendment to this paper has been published and can be accessed via the original article.

Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

BACKGROUND: Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). METHODS: This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. RESULTS: In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). CONCLUSIONS: The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698-Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1.

A pilot observational study on magnesium and calcium imbalance in elderly patients with acute aortic dissection.

BACKGROUND: Magnesium (Mg) and calcium (Ca) are the principal essential elements involved in endothelial cell homeostasis. Extracellular changes in the levels of either alter endothelial contraction and dilatation. Consequently Mg and Ca imbalance is associated with a high risk of endothelial dysfunction, the main process observed during acute aortic dissection (AAD); in this clinical condition, which mainly affects elderly men, smooth muscle cell alterations lead to intimal tears, creating a false new lumen in the media of the aorta. AAD patients have a high risk of mortality as a result of late diagnosis because often it is not distinguished from other cardiovascular diseases. We investigated Mg and Ca total circulating levels and the associated pro-inflammatory mediators in elderly AAD patients, to gain further information on the pathophysiology of this disorder, with a view to suggesting newer and earlier potential biomarkers of AAD. RESULTS: Total circulating Mg and Ca levels were both lower in AAD patients than controls (p < 0.0001). Using Ca as cut-off, 90% of AAD patients with low Ca (<8.4 mg/dL) came into the type A classification of AAD. Stratifying AAD according to this cut-off, Mg was lower in patients with lower total Ca. Compared to controls, both type A and B AAD patients had higher levels of all the pro-coagulant and pro-inflammatory mediators analyzed, including sP-sel, D-dimer, TNF-α, IL-6, and CRP (p < 0.05). Dividing types A and B using the Stanford classification, no significant differences were found (p > 0.05) The levels of both ICAM-1 and EN-1 were lower in AAD than in a control group (p < 0.0001 and p < 0.05 respectively). CONCLUSIONS: These findings suggest that low Mg and Ca in AAD elderly patients may contribute to altering normal endothelial physiology and also concur in changing the normal concentrations of different mediators involved in vasodilatation and constriction, associated with AAD onset and severity.

Pantalar arthrodesis for post-traumatic arthritis and diabetic neuroarthropathy of the ankle and hindfoot.

BACKGROUND: Pantalar arthrodesis is an important salvage option for stabilizing the hindfoot and salvaging the limb following trauma or collapse. This report evaluates the healing rates and complications which occur in diabetics and post-traumatic patients. MATERIALS AND METHODS: Twenty patients presenting with post-traumatic arthritis of the ankle-hindfoot (twelve) or with Type II or Type IIIA Charcot arthropathy (eight) were managed with a pantalar fusion. Followup averaged 46 months. Patients were evaluated using the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Short Musculoskeletal Function Assessment (SMFA) and the Visual Analog Pain Scale (VAS). RESULTS: There were no amputations in either group. Casting averaged 14.9 weeks, full weightbearing was achieved at 25.1 weeks and time to union averaged 44.1 weeks. Average age was 56.3 yrs. and BMI averaged 34.2. Fourteen patients (70%) had their surgery performed in multiple stages. Acceptable outcomes were noted for all patients for the SF-36, AOFAS and SMFA scores. VAS scores averaged 2.2. There were ten complications (50%); four patients (two in each group) required additional surgery. CONCLUSIONS: Pantalar arthrodesis is a reasonable salvage option for patients with severe post traumatic arthropathy and neuropathic arthropathy. Patients should be informed of the increased risks as well as the long periods of postoperative immobilization and nonweightbearing. We believe a pantalar arthrodesis can produce acceptable outcomes regardless of the cause of disability, with a staged or single approach, and whether the surgery is performed with plates and screws or an intramedullary device.

Formula milk feeding does not increase the release of the inflammatory marker calprotectin, compared to human milk.

Calprotectin is a protein released into stools, used as a marker of inflammation in inflammatory bowel diseases. We tested the hypothesis that cow's milk protein in formula milk may increase the intestinal release of calprotectin, as a consequence of a subclinical inflammatory reaction. At 12 weeks of age, we measured fecal calprotectin by an immunoenzyme assay (Calprest, Eurospital, Trieste, Italy), in 38 exclusively breastfed and in 32 exclusively formula-fed infants. Fecal calprotectin levels were not different in the two groups (p = 0.09), although a trend to higher values in infants with colic, or with family history of allergies was noted. This suggest that, in general, formula milk does not promote activation of an intestinal inflammatory reaction, compared to human milk, although a subclinical activation of the inflammatory response in infants at risk for allergic diseases may be present.

Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. Surgical technique.

BACKGROUND: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique. METHODS: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction. RESULTS: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure. CONCLUSIONS: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.

Lasso stitch with peroneal retinaculoplasty for repair of fractured os peroneum: a report of two cases.

UNLABELLED: Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon. LEVEL OF EVIDENCE: Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.

Surgical repair of acute and chronic tibialis anterior tendon ruptures.

BACKGROUND: Rupture of the tibialis anterior tendon is an uncommon disorder that can cause a substantial functional deficit as a result of loss of ankle dorsiflexion strength. We are not aware of any reports on a large clinical series of patients undergoing surgical repair of this injury. METHODS: Nineteen tibialis anterior tendon ruptures were surgically repaired in eighteen patients ranging in age from twenty-one to seventy-eight years. Early repair was performed for one traumatic and seven atraumatic ruptures three days to six weeks after the injury. Delayed reconstruction was performed for two traumatic and nine atraumatic ruptures that had been present for seven weeks to five years. Direct tendon repair was possible for four of the early repairs and three of the delayed reconstructions. An interpositional autogenous tendon graft was used for four early repairs and eight delayed reconstructions. Patients were reassessed clinically and with the American Orthopaedic Foot and Ankle Society hindfoot score at an average of 53.3 months after surgery. RESULTS: The average hindfoot score improved significantly from 55.5 points preoperatively to 93.6 points postoperatively. The surgical results did not appear to vary according to patient age, sex, or medical comorbidity. Complications requiring a second surgical procedure occurred in three patients. Recovery of functional dorsiflexion and improvement in gait was noted in eighteen of the nineteen cases. Ankle dorsiflexion strength was graded clinically as 5/5 in fifteen of the nineteen cases. Three patients regained 4/5 ankle dorsiflexion strength, and one patient had 3/5 strength with a poor clinical result. CONCLUSIONS: Surgical restoration of the function of the tibialis anterior muscle can be beneficial regardless of age, sex, medical comorbidity, or delay in diagnosis. Early surgical treatment may be less complicated than delayed treatment, and an intercalated free tendon graft and/or gastrocnemius recession may be necessary to achieve an appropriately tensioned and balanced repair.

Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy.

BACKGROUND: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique. METHODS: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction. RESULTS: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure. CONCLUSIONS: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.

Another case of cystic fibrosis complicated by meconium ileus associated with Hirschsprung's disease: a rare and important association.

We are reporting the case of a neonate which died on 16th day of life due to a fatal evolution of a rare association of cystic fibrosis and Hirschsprung's disease.

First Report of Bud Rot of Canary Island Date Palm Caused by Phytophthora palmivora in Italy.

Canary Island date palm (Phoenix canariensis hort. ex Chabaud) is planted as an ornamental in Mediterranean climatic regions of the world. From 2004 to 2006, withering of the spear leaf was observed on screenhouse-grown potted plants of this palm in Sicily (Italy). The first symptom was a dark brown rot that extended from the petiole base of the spear to the adjacent youngest leaves and killed the bud. Dissection of plants revealed a foul-smelling internal rot. After the bud died, external older leaves remained green for months. As much as 10% of plants in a single nursery were affected. A Phytophthora species was consistently isolated from symptomatic plants on BNPRAH selective medium (4). Single zoospore isolates were obtained from the colonies. The species isolated was identified as Phytophthora palmivora (E. J. Butler) E. J. Butler on the basis of morphological and cultural characteristics (3). On V8 juice agar, the isolates produced elliptical to ovoid, papillate sporangia (33 to 77 × 22 to 38 µm) with a mean length/breadth ratio of 1.8. Sporangia were caducous with a short pedicel (mean pedicel length = 5 µm) and had a conspicuous basal plug. All isolates were heterothallic and produced amphigynous antheridia, oogonia, and oospores when paired with reference isolates of P. nicotianae and P. palmivora of the A2 mating type. The oogonium wall was smooth. Identification was confirmed by electrophoresis of mycelial proteins in polyacrylamide slab gels (1). The electrophoretic patterns of total mycelial proteins and four isozymes (alkaline phosphatase, esterase, glucose-6-phosphate dehydrogenase, and malate dehydrogenase of the isolates) from Phoenix canariensis were identical to those of P. palmivora reference isolates, including four Italian ones, two from pittosporum and olive, respectively, and two (IMI 390579 and 390580) from Grevillea spp. Phoenix canariensis isolates were clearly distinct from those of other heterothallic papillate species including P. capsici, P. citrophthora, P. katsurae, P. nicotianae, and P. tropicalis. Pathogenicity of one isolate from Phoenix canariensis (IMI 395345) was tested on 10 2-year-old potted Canary Island date palm plants. An aqueous 105 zoospores per ml suspension (200 µl) was pipetted onto unwounded petiole bases of the three youngest central leaves of each plant. Sterile water was pipetted onto 10 control plants. All plants were incubated in 100% humidity at 24°C for 48 h and maintained in a greenhouse at 20 to 28°C. Within 3 weeks after inoculation, inoculated plants developed symptoms identical to those observed on plants with natural infections. Control plants remained healthy. P. palmivora was reisolated from symptomatic plants. Phytophthora bud rot is a common palm disease worldwide and Phoenix canariensis is reported as a host (2). To our knowledge, this is the first report of Phytophthora bud rot on Phoenix canariensis in Italy. References: (1) S. O. Cacciola et al. EPPO Bull. 20:47, 1990. (2) M. L. Elliot et al., eds. Compendium of Ornamental Palm Diseases and Disorders. The American Phytopathological Society, St. Paul, MN, 2004. (3) D. C. Erwin and O. K. Ribeiro. Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul, MN, 1996. (4) H. Masago et al. Phytopathology, 67:425, 1977.

Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment.

BACKGROUND: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. METHOD: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. RESULTS: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. CONCLUSIONS: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

Surgical treatment of the hallux rigidus.

Numerous surgical procedures are available for the treatment of hallux rigidus. The choice of a particular one depends on the severity of the disease, patient activity level, and expectations about the surgery. Cheilectomy is recommended for early disease and may be associated with an osteotomy of the proximal phalanx. For active patients who have severe hallux rigidus, arthrodesis and biologic interposition arthroplasties have shown good results. Keller arthroplasty is reserved for low demand patients; prosthetic replacements are not recommended at this time.

Outcome of surgical treatment of tarsal tunnel syndrome.

One hundred and eight ankles in 72 patients were evaluated from July 1986 to July 1997 with clinical findings and positive electrodiagnostic studies of tarsal tunnel syndrome. Clinical data included physical findings, subjective complaints, duration of symptoms, trauma history, steroid injections, nonsteroidal use and workman's compensation involvement. Associated medical conditions included diabetes, back pain and arthritis. Sixty-two patients underwent tarsal tunnel release, with 13 of them bilateral. There were 44 females and 18 males, 35 right feet and 40 left feet. The average age was 49 years. Preoperative symptom duration was 31 months. Average length of follow-up was 58 months. Average time for return to usual activity was nine months. All patients had at least a 12-month follow-up, and compared with both (Maryland Foot Score) MFS and AOFAS postoperative scores. Preoperative MFS scores obtained prior to 1994, were 61/100 (average), and postoperative MFS scores were 80/100 (average). Postoperative AOFAS scores were 80/100 (average). Patients with symptoms less than one year had postoperative MFS/AOFAS scores significantly higher than those with symptoms greater than one year. The most common surgical findings included arterial vascular leashes indenting the nerve and scarring about the nerve. Varicosities and space occupying lesions were present also. The outcome of surgery was not affected by the presence or absence of trauma. Patients with tarsal tunnel syndrome warrant surgery when significant symptoms do not respond to conservative management. Meticulous surgical technique must be followed. Improvement in foot scores is predictable even when a discrete space-occupying lesion is not present and when symptoms have been present for periods of greater than one year.