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.

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.

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.

Tarsal tunnel syndrome caused by an anomalous muscle.

We report the cases of six patients (seven feet) who had tarsal tunnel syndrome in association with an anomalous muscle that was located deep to the flexor retinaculum of the ankle. An accessory flexor digitorum longus muscle was present in six of the ankles and a tibiocalcaneus internus muscle, in one. All of the patients had a release of the tarsal tunnel and a neurolysis of the posterior tibial nerve and its branches in addition to a resection of the anomalous muscle. The duration of follow-up averaged forty-one months (range, twenty-eight to eighty-three months). Although the pain was reduced in four of the six patients, only one patient was completely free of symptoms at the time of the most recent follow-up examination. Four of the six patients were satisfied with the result of the operation.

Neurapraxia of the femoral nerve in a modern dancer.

We have presented a case of an acute onset femoral nerve neurapraxia in a pure modern dancer. Repeated mild stretching of the femoral nerve during an established dance routine over a period of several months is implicated as the etiology. The thigh muscles quickly weakened, but regained strength within 3 months. Electromyographic evidence of specific femoral nerve injury initially was negative, but was evident 6 weeks following injury. Overuse syndrome in dancers can cause rapid loss of strength. Other conditions such as herniated intervertebral disc, acute hemorrhage, trauma, iliopsoas rupture, and acute stretching must be ruled out. Complete recovery was the natural outcome.

Surgical treatment of lateral ankle instability syndrome.

Lateral ankle instability syndrome is defined by pain and instability caused by ligament laxity. Anterior talofibular ligament laxity, with or without calcaneofibular laxity and other abnormalities, is often present in conjunction with peroneus brevis tendon tears, abnormal ligament placement, tibialis posterior tendon tears, osteochondritis dissecans, arthritis, synovitis, loose bodies, and tarsal coalition. Surgical reconstructions were performed on 43 ankles using a split peroneus brevis tendon graft routed through osseous tunnels in the talus, fibula, and calcaneus and resutured to the reconstructed anterior talofibular and calcaneofibular ligaments. The tunnel locations, transfer routes, and tendon reinforcement were modifications based on the Elmslie procedure. Good and excellent results were achieved in 91% of the patients. Ninety-eight percent of the patients achieved stability. Followup was from 9 months to 11 years. Twenty-one patients had preoperative and intraoperative findings that required additional procedures. Thorough evaluation of patients with lateral ankle instability syndrome increases the frequency of finding associated abnormalities, which if left uncorrected, may adversely affect the outcome of surgery.

Peroneal tendon injuries.

Injuries to the peroneal tendons are common. Acute injuries of the peroneus brevis tendon include tendinitis; avulsion of the insertion with or without bone fragment, i.e., styloid fracture of the fifth metatarsal; lacerations; and acute dislocation with or without a "rim fracture." Chronic lesions include longitudinal rents in the tendon either alone or associated with other localized disease. Lesions of the peroneus longus tendon include rupture and longitudinally oriented chronic tears, perhaps with a fragmented os perineum. Treatment for these entities is discussed.

Intramedullary fixation of metatarsal fracture and nonunion. Two methods of treatment.

Fracture of a metatarsal is one of the most common fractures in the foot. The location of the fracture depends to some extent on the metatarsal involved, the activity, and the foot shape. The goal of treatment is to achieve a successful outcome and to avoid prolonged disability. This article covers patient selection, surgical technique, and postoperative care.

Fine needle aspiration cytology of silicone lymphadenopathy in a patient with an artificial joint. A case report.

Three years after replacement of the left first metatarsophalangeal joint with a silicone prosthesis, a patient noted enlargement of a left femoral lymph node. Fine needle aspiration of the node revealed a foreign body giant cell reaction to particulates morphologically compatible with silicone elastomer. This finding suggests the potential utility of fine needle aspiration in the evaluation of patients' responses to a variety of foreign materials used in prosthetic devices and as pharmaceuticals.

The Jones fracture.

The Jones fracture is a fracture that occurs 1.5 cm distal to the styloid of the fifth metatarsal. The mechanism of injury in both the acute and chronic, or stress, fracture is repetitive weightbearing and pivoting on the involved foot. Acute fractures occur equally in both sexes, generally in nonathletes, and usually in individuals older than 21. Chronic or fatigue fractures occur in individuals between 15 to 21 years of age and predominantly in male athletes. Treatment of the acute fracture in the adult may require three months in a nonweightbearing cast. Surgical intervention with intramedullary screw compression is a surgical option that should be discussed with the patient. Chronic or fatigue fractures will require intramedullary compression screw fixation or open reduction and bone grafting using corticocancellous bone graft. The treatment outcome of this fracture is usually good if postoperative rehabilitation is prescribed and followed.

The dancer's hip.

Conditions that occur in the dancer's hip fall into the following categories: poor training; conditions that occur as the result of normal use; overuse syndromes, including tendinitis and myositis; and conditions referring pain to the hip. Dancers are highly motivated and goal oriented and often suppress symptoms for long periods, making diagnosis and treatment difficult. Observing the dancer at work and understanding his art are emphasized, and a practical guide to therapy is presented. Development of proper dance technique and a proper flexibility program can decrease the incidence of injuries.