Influencia del tratamiento quirúrgico para el hallux abductus valgus en la movilidad del primer radio / Influence of surgical treatment of hallux abducto-valgus on first ray mobility

Objetivo: El objetivo principal de este trabajo es determinar la variación de movilidad pre y postquirúrgica del primer radio. Pacientes y métodos: El diseño corresponde a un estudio prospectivo de series de casos en pacientes sometidos a cirugía de hallux valgus. Se valoró en 13 pies la movilidad del primer radio con el medidor del primer radio, la flexo-extensión de la primera articulación metatarsofalángica, el ángulo de Clarke y el “Arch Index” en pedigrafías, los ángulos hallux valgus e intermetatarsal I-II en radiografías dorsoplantares en carga, y la postura general del pie mediante el “Foot Posture Index” antes y después de ser sometidos a cirugía de hallux valgus. Todo ello con un periodo de seguimiento de 6 meses. Resultados: El rango total de movilidad del primer radio pasó de 11.74 ± 1.88 mm a 6.72 ± 2.20 mm; y el de la primera articulación metatarsofalángica pasó de 79.62° ± 22.33° a 48.69° ± 18.69° tras la cirugía. Los ángulos radiográficos de hallux valgus y ángulo intermetatarsal disminuyeron una media de 19.07° ± 8.20° y 7.23° ± 2.97°, respectivamente. El ángulo de Clarke cambió de 41.31° ± 10.79° a 38.31° ± 11.00°. El “Arch Index” cambió de 0.24 ± 0.06 a 0.25 ± 0.05. Y el “Foot Posture Index” pasó de 6.70 ± 3.33 de media antes de la cirugía a 5.46 ± 3.86 tras la misma. Conclusión: En los participantes incluidos en este estudio se observó una disminución generalizada de todas las variables examinadas tras la cirugía, a excepción de los parámetros valorados en las pedigrafías, que no llegaron a presentar diferencias relevantes.(AU)

Objectives: The main aim of this work is to determine the variation of first ray mobility before and after surgery. Patients and methods: The design corresponds to a prospective case series of patients operated of hallux valgus. A total of 13 feet have been included in this study. Measurements of the first ray mobility were obtained using the first ray mobility measurer. Furthermore, we assess the flexo-extension of the first metatarsophalangeal joint. The Clarke’s angle and the Arch Index were evalued on weightbearing footprints. The hallux valgus angle and intermetatarsal I-II angle were made on weightbearing dorsal-plantar projection radiographs. And finally, the general posture of the foot was quantified using the Foot Posture Index. All this with pre and post measurements of hallux valgus surgery and with a follow-up period of 6 months. Results: The total range of motion of the first ray decreased from 11.74 ± 1.88 mm to 6.72 ± 2.20 mm; and the range of motion of the first metatarsophalangeal joint underwent from 79.62° ± 22.33° to 48.69° ± 18.69° after surgery. The hallux valgus angle and intermetatarsal I-II angle decreased by a mean of 19.07° ± 8.20° and 7.23° ± 2.97°, respectively. The Clarke’s angle changed from 41.31° ± 10.79° to 38.31° ± 11.00°. The Arch Index changed from 0.24 ± 0.06 to 0.25 ± 0.05. And the Foot Posture Index went from 6.70 ± 3.33 before surgery to 5.46 ± 3.86 after it. Conclusion: In the participants included in this study, a generalized decrease was observed in all the examined variables after surgery, except for the parameters assessed in the pedigraphs, which did not present relevant differences.(AU)

Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital.

BACKGROUND: Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS: The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS: The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION: Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Clinical outcome of a conservative approach to giant cell tumor of ankle and foot bones.

Giant cell tumor of the bone (GCTB) affecting foot and ankle is rare, and the literature available on their clinical behavior and reconstructive options is scarce. Many authors consider these sites a special subset with high rates of local recurrence. Eighteen patients with GCTB of foot and ankle were treated from (March 2014 to February 2020). Extended curettage was offered wherever feasible. Twelve patients underwent extended curettage, three underwent resection and reconstruction, one patient had ray amputation, one had below knee amputation. One patient with multifocal disease was treated conservatively with denosumab. There were 11 females and the mean age was 31.7 years. Distal tibia (11 patients) was the commonest location, followed by the first metatarsal (four patients). At a median follow up of 46 months, two patients out of the 17 operated had a local recurrence. GCTB affecting the foot and ankle have a clinical course comparable to those at other locations. They should be treated with a conservative approach, where radical resection and amputation are reserved for only the non-curettable tumors.

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.

Publishing Characteristics of Foot and Ankle Research Over a 15-Year Time Interval: A Review of The Journal of Bone & Joint Surgery from 2004 to 2018.

BACKGROUND: As the foot and ankle subspecialty continues to grow in orthopaedics, trends in published literature provide valuable insights to help understand and strengthen the field. The current study evaluates the changes in the characteristics of foot and ankle articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS-A) from 2004 to 2018. METHODS: Foot and ankle-related articles in JBJS-A from 2004 to 2018 were identified and categorized by type of study, level of evidence, number of authors, academic degree(s) of the first and last authors, male and female authorship, number of citations, number of references, region of publication, and use of patient-reported outcomes (PROs). RESULTS: A total of 336 foot and ankle articles from 2004 to 2018 were reviewed. The type of study published has changed over time, with more clinical therapeutic evidence and less case reports. The level of evidence grades, as rated by JBJS-A and objective evaluators, have increased over the past 15 years. The total number of authors per article has increased, and female authorship has increased significantly. The number of references per article has increased, and the number of citations per year has decreased. The field of foot and ankle surgery has seen an increase in global publications. CONCLUSIONS: The results of this study suggest that the foot and ankle literature that has been published in JBJS-A has continued to increase in quality and diversity over the past 15 years.

Clinical features and outcomes in children with bone and joint infections of the ankle or foot.

BACKGROUND: The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae. METHODS: We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed. RESULTS: The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess. CONCLUSION: Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND: Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES: To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS: A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS: The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS: Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

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.

Percutaneous Techniques in Orthopedic Foot and Ankle Surgery.

This article presents the indications, contraindications, preoperative surgical planning, surgical technique, and postoperative management of some of the most common percutaneous procedures in orthopedic foot and ankle surgery. The background of each procedure also is presented, supported by the latest in published literature to educate surgeons. Such topics include percutaneous bunionectomy, lesser toe deformity and bunionette correction, calcaneal osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis.

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.

A high-profile thread with grit-blasted and acid-etched surface reduces loosening of medial column fusion bolt in instable Charcot foot.

BACKGROUND: Intramedullary fusion bolts (FB) were introduced to stabilize the medial column of the instable Charcot foot (ICF), but complications as bolt loosening or breakage are frequent. We compared the use of a standard FB and a high-profile threaded FB with a grit-blasted surface. We hypothesized that implant related complications occurred less often and osseous consolidation of fusion sites was more distinctive using the latter type of FB. METHODS: Consecutive patients suffering from an ICF were stabilized with a high-profile threaded and surface-modified FB (HTFB) (n=20) or with a standard FB (n=20) which was placed into the first ray. Additional bolts and dorsal low-profile plates were applied in every patient. In a retrospective assessment osseous consolidation of the fusion sites was analyzed at 3 month and quantified by CT scan. At 3 and 12 month longitudinal foot arch collapse and rate of bolt loosening were assessed. RESULTS: Compared to the control group, the HTFB group reached significant higher consolidation after 3 month. No dislocation and a single bolt breakage was observed in the HTFB group after the fourth month, while the control group included 3 patients with bolt dislocation at 3±1 month and 5 patients with bolt breakage at 6±1.8 month. Compared to preoperative values, the improvement of Meary's angle after one-year was significant higher in the HTFB group (23.4°±14) than in controls (11.7°±13). CONCLUSIONS: Modification of bolt design improves the stability of the medial column: A higher rate of osseous consolidation of the medial column leads to lower rate of bolt dislocation/breakage and finally to permanently erected longitudinal foot arch. Initially disappointing results following medial column stabilization with fusion bolts can be rejected by modifications of bolt design and its technical application.

Endoscopic Treatment of Symptomatic Foot and Ankle Bone Cyst with 3D Printing Application.

OBJECTIVE: To study the efficacy of arthroscopy for treating symptomatic bone cysts of the foot and ankle through the follow-up of patients and to further explore the application value of 3D printing technology in this treatment. METHODS: Twenty-one patients with symptomatic bone cysts in the foot and ankle who underwent arthroscopic surgery in our Center from March 2010 to December 2018 were enrolled, including 11 in the experimental group and 10 in the control group. For the control group, C-arm fluoroscopy was used intraoperatively to confirm the positioning of the cysts; for the experimental group, a 3D model of the lesion tissue and the 3D-printed individualized guides were prepared to assist the positioning of the cysts. Debridement of the lesion tissues was conducted under an arthroscope. Regular follow-ups were conducted. The time of establishing arthroscopic approaches and the times of intraoperative fluoroscopy between the two groups were compared. Significance was determined as P < 0.05. RESULTS: The postoperative pathology of the patients confirmed the diagnosis. No significant perioperative complications were observed in either group, and no recurrence of bone cysts was seen at the last follow-up. The VAS scores and AOFAS scores of the two groups at the last follow-up were significantly improved compared with the preoperative data, but there was no statistical difference between the two groups. All surgeries were performed by the same senior surgeon. The time taken to establish the arthroscopic approaches between the two groups was statistically significant (P < 0.001), and the times of intraoperative fluoroscopy required to establish the approach were also statistically significant (P < 0.001). The intraoperative bleeding between the two groups was statistically significant (P < 0.01). There was 1 case in each group whose postoperative CT showed insufficient bone grafting, but no increase in cavity volume was observed during the follow-up. CONCLUSION: With the assistance of the 3D printing technology for treating symptomatic bone cysts of the ankle and foot, the surgeon can design the operation preoperatively and perform the rehearsal, which would make it easier to establish the arthroscopic approach, better understand the anatomy, and make the operation smoother. This trial is registered with http://www.clinicaltrials.govNCT03152916.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Soft Tissue Reconstruction with Diabetic Foot Tissue Loss.

Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.

Bone Reconstruction in the Diabetic Foot.

Surgical bone reconstructive procedures of the foot and ankle in diabetic patients must be considered when performing evaluation of a diabetic foot for patients with preulcerative lesions and preexisting wounds. Preventive deformity correction can reduce the potential risk of ulceration, infection, and possible amputation in a patient with an at-risk foot type. It can also expedite wound healing and prevent further breakdown in a patient with lower extremity ulcerations. This article discusses different types of surgical bone reconstructive procedures as preventive and prophylactic deformity corrections to reduce osseous deformity, minimize preulcerative lesions, and increase limb-salvage rates in the compromised patient.

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.