Malignant neoplasms originating from the bones of the foot: Predilection of hematological malignancies and sex-related and ethnic disparities in amputation.

PURPOSE: Neoplasms originating from the "small bones of the lower limb and the overlapping joints" are rare but portend a serious prognosis. Current study utilizes a population-based registry in the United States to characterize the malignancies of the foot. METHODS: National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 514 patients in the Uited States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival. Chi square test was used to assess the correlation. RESULTS: Hematological malignancies constituted 14.8% of the entire cohort. Incidence of the foot neoplasms was 0.024 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific-5-year survival for the entire cohort was 73%. On multivariate analysis younger age groups, "localized" stage and extent of surgical resection were predictors of improved outcomes. A significant correlation was found between amputation with male sex and Hispanic ethnicity. CONCLUSIONS: The current study analyzes data from population-based registry reporting incidence and survival data for patients with neoplasms of the foot. Independent prognostic factors include age, stage and extent of surgical resection. Amputation was found to be associated with male sex and Hispanic ethnicity.

Augmented Spring Ligament Repair in Pes Planovalgus Reconstruction.

Patients with pes planovalgus deformity often have coexisting spring ligament pathology. A primary repair of the ligament may fail during weightbearing due to chronic degeneration of the ligamentous tissue. Augmentation with a suture tape has been suggested to strengthen the repair. Limited data exist regarding flatfoot reconstruction with augmented spring ligament repair using a suture tape. This is a review of 57 consecutive patients who had flatfoot reconstruction with concomitant spring ligament augmented repair between July 2014 and August 2017. Weightbearing radiographic parameters were obtained preoperatively and compared to radiographs at an average time of 62 ± 46.5 (range 20-220) weeks postoperative. Significant improvements were seen in the radiographic parameters evaluated. Five patients had subsequent operations including one deep infection, 2 hardware removals remote to the spring ligament augmentation, 1 ankle arthrodesis, and 1 triple arthrodesis. Concomitant spring ligament repair augmented with a suture tape was a safe procedure that contributed to radiographic correction in a consecutive series of 57 patients undergoing flatfoot deformity correction.

The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation.

BACKGROUND: Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear. PURPOSE: To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair. STUDY DESIGN: Controlled laboratory study. METHODS: Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states. RESULTS: Cutting the anterior deltoid introduced ER (+2.1°; P = .009) and eversion laxity (+6.2° of eversion; P < .001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P < .001). CONCLUSION: A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment. CLINICAL RELEVANCE: Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity.

Subchondroplasty of the Ankle and Hindfoot for Treatment of Osteochondral Lesions and Stress Fractures: Initial Imaging Experience.

Objective:To describe the imaging findings of patients treated with subchondroplasty (SCP) of the ankle and hindfoot. Materials and Methods: Eighteen patients (10 men, 8 women; age mean 43.1 years [range 20.1-67.7 years]) underwent ankle and hindfoot SCP at a single center over a 14-month period. Imaging data were reviewed retrospectively by 2 radiologists by consensus interpretation, including preoperative radiography (18), computed tomography (CT) (11), and magnetic resonance imaging (MRI) (13) and postoperative radiography (10), CT (4), and MRI (6). Follow-up imaging was acquired 1 month to 1.6 years following SCP. Results: Indications for SCP included symptomatic bone marrow lesions (BMLs) secondary to an osteochondral lesion (OCL) (16/18) or stress fracture (2/18). While focal radiodensity related to the SCP procedure was retrospectively identifiable on postoperative radiography in all except 1 case (10/11), postprocedural findings were not described by the interpreting radiologist in 6/11 cases. On CT, the average injected synthetic calcium phosphate (CaP) volume was 1.15 cm3 (SD = 0.33 cm3); mean CT attenuation of the injectate was 1220 HU (range 1058-1465 HU). In all patients who had pre- and postoperative MRI (5/18), BML size decreased on follow-up MRI. Extra-osseous extrusion of CaP was not seen on postoperative radiography, CT, or MRI. Conclusion: Physicians should be aware of the expanding preoperative indications and postoperative imaging findings of SCP, which is being performed with increasing frequency in the ankle and hindfoot.Levels of Evidence: Diagnostic, Level III: Retrospective cohort study.

Effects of Micronized Cartilage Matrix on Cartilage Repair in Osteochondral Lesions of the Talus.

BACKGROUND: The repair of osteochondral lesions remains a challenge due to its poor vascularity and limited healing potential. Micronized cartilage matrix (MCM) is dehydrated, decellularized, micronized allogeneic cartilage matrix that contains the components of native articular tissue and is hypothesized to serve as a scaffold for the formation of hyaline-like tissue. Our objective was to demonstrate in vitro that the use of MCM combined with mesenchymal stem cells (MSCs) can lead to the formation of hyaline-like cartilage tissue in a single-stage treatment model. DESIGN: In group 1 (no wash), 250 µL MCM was reconstituted in 150 µL Dulbecco's phosphate-buffered saline (DPBS) for 5 minutes. Group 2 (saline wash) included 250 µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated to remove all DPBS and reconstituted in 150 µL DPBS. Group 3 (serum wash): 250µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated and reconstituted in 150 µL fetal bovine serum. Each group was then added to 50 µL solution of MSC suspended in DPBS at a concentration of 1.2 × 106 cells/350 µL. After 3 weeks, the defects were extracted and sectioned to perform viability and histologic analyses. RESULTS: Stem cells without rehydration of the MCM showed almost no viability whereas near complete cell viability was seen after rehydration with serum or saline solution, ultimately leading to chondrogenic differentiation and adhesion to the MCM particles. CONCLUSION: We have shown in this proof-of-concept in vitro study that MCM can serve as a scaffold for the growth of cartilage tissue for the treatment of osteochondral lesions.

The Influence of Percentage Weight-Bearing on Foot Radiographs.

Introduction: Clinical decisions are often made on weight-bearing radiographs. However, it is unknown whether various weight-bearing conditions alter specific radiographic measurements. The purpose of this study was to determine whether percentage weight-bearing influences radiographic measurements of the normal foot. Methods: A prospective study with 20 healthy individuals had radiographs of the foot under 5 weight-bearing conditions (non-weight-bearing, 10% body weight, 25% body weight, 50% body weight, and 100% body weight). Measurements were made of hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), talonavicular coverage angle (TNCA), talocalcaneal angle (TCA), forefoot width, LisFranc distance, cuboid height to ground (CHG), and talo-first metatarsal angle (TMA) of each weight-bearing condition. Statistical differences of each measurement for each weight-bearing condition were determined. Results: The TNCA and TCA increased significantly, whereas the CHG decreased significantly with increased percentage body weight. There were no differences in HVA, IMA, forefoot width, LisFranc distance, and TMA with increased percentage body weight. Conclusions: This study shows an increase in TNCA and TCA, and decrease in CHG, demonstrating a flattening of the medial arch, increasing hindfoot valgus, and midfoot external rotation and abduction with increasing percentage body weight applied to a foot. Percentage weight-bearing does not change radiographs in the foot between 25% and 100% weight-bearing. The clinical relevance of this finding is that graduated postinjury or postoperative weight-bearing regimens may only be relevant if the patient is either less than or greater than 25% of body weight on their extremity. Levels of Evidence: Case Series, Level IV: Prospective.

Removable Rigid Dressings for Postoperative Management of Transtibial Amputations: A Review of Published Evidence.

Forty years of clinical experience and peer-reviewed research studies support the use of nonweight-bearing removable rigid dressings (RRDs) as an effective means of postoperative management of transtibial amputations. We reviewed the published medical evidence regarding the use of RRDs as a postoperative management strategy, culminating in an evidence-based practice recommendation. Published peer-reviewed literature on the topic was searched and classified by level of evidence based on the research design using the scale recommended by the PM&R (level I through V). The search uncovered a total of 15 articles, including 5 level I randomized controlled trials, 6 level III retrospective matched controlled trials, and 4 level V case reports. A number of benefits associated with the application of RRDs compared with soft dressings were reported across these 15 studies. These included faster healing times, reduced limb edema, preparatory contouring of the residual limb in anticipation of prosthetic use, the prevention of knee flexion contractures, and reduced external trauma to the limb. Also described were an increased probability of successful prosthetic use and pain reduction. The RRDs studied permitted regular inspection of surgical wounds with greater ease and consistency of application than traditional soft dressing approaches. Rigid dressings provide all the same benefits of RRDs except ease of wound inspection, therefore rendering them impractical for the 82% of patients receiving an amputation for ischemic disease that are at high risk of developing wound dehiscence. Weight-bearing immediate postoperative prostheses are almost exclusively reserved for use on trauma patients who usually do not show evidence of vascular or neurologic impairment. The inherent risks of falls and inconsistent pressure on the surgical wound have further restricted their use in practice to a limited patient type. The benefits of RRDs compared with soft dressings are universally recognized in the published peer-reviewed medical evidence to be superior to soft dressings. Based on the best-available current published evidence, nonweight-bearing removable rigid dressings should be considered the first treatment choice for the postoperative care of transtibial amputees to optimize outcomes with regard to reductions in injury due to falls, knee flexion contractures, edema, healing time, time to prosthetic fitting, and pain. LEVEL OF EVIDENCE: II.