Karl Saltrick

Peroneal tendon tears: A retrospective review

Tears of the peroneal tendons are not uncommon but remain an underappreciated source of chronic lateral ankle pain. The purpose of this study was to identify the typical patient profile and nature of the injury, to analyze the course of treatment, and to determine the prevalence of complications seen with surgical repair. Forty patients with chronic pain over the peroneal tendons from the Foot and Ankle Institute at the Western Pennsylvania Hospital underwent peroneal tendon repair. During a 3-year period, a retrospective review was performed by evaluating medical records, surgical reports, and radiographs. The average patient age was 42 years (range, 13 to 64 years). The most common cause was an ankle sprain or other traumatic injury (58%). Peroneus brevis tears (35 patients; 88%), peroneus longus tears (5 patients; 13%), combined peroneus brevis and longus tears (15 patients; 37%), low-lying peroneus muscle belly (13 patients; 33%), lateral ankle ligamentous disruptions (13 patients; 33%), and peroneal subluxation (8 patients; 20%) were identified during surgery. The average follow-up was 13 months (range, 9 to 40 months). Ninety-eight percent of the patients were able to return to full activities without pain at final follow-up. The minor complication rate (transient symptoms) was 20%. Clinically significant (major) complications (continued symptoms or revisionary surgery) occurred in 10% of patients. This study indicates that lateral ankle ligamentous incompetence, combined peroneal brevis and longus tears, and low-lying peroneus muscle belly commonly coexist in patients with peroneal tendon injuries. Appropriate surgical intervention of peroneal tendon tears and their coexisting pathology yields successful and predictable results with few clinically significant complications.

Predislocation syndrome: A review and retrospective analysis of eight patients

Predislocation syndrome is defined as an either an acute, subacute, or chronic inflammatory process involving the lesser metatarsophalangealjoints. If left untreated, this process can lead to plantarplate and capsular attenuation and metatarsophalangeal joint instability. A retrospective analysis were performed on eight patients who were treated with a flexor tendon transfer for this condition. A subjective analysis and chart review were performed to determine the final outcome of these patients. All patients had a chief complaint of a painful second metatarsophalangeal joint with seven of eight patients having an associated hallux valgus deformity. Excellent results were achieved in six patients. Residual stiffness was the primary complaint of two patients following surgery, suggesting that metatarsophalangeal joint stiffness may be a potential problem after flexor digitorum longus tendon transfers. However, we concluded that the flexor digitorum longus tendon transfer remains an excellent procedure for second toe instability and late-stage predislocation syndrome. A literature review describing the epidemiology, symptom complex, physical findings, radiographic signs and therapies used to manage predislocation syndrome were also discussed.

The Effect of Hindfoot Realignment in Triple Arthrodesis

UNLABELLED Triple arthrodesis is a useful form of surgical intervention for repair of advanced hindfoot deformity. Crucial to the success of triple arthrodesis is achievement of a suitable alignment of the hindfoot in relation to the leg and forefoot. A number of radiographic measurements can be used to describe the resultant alignment of the foot and, in this article, we present the results of a review of a series of 28 triple arthrodeses, in 24 patients, followed for a median duration of 19 (range 12 to 38) months. The results of this investigation showed clinically and statistically significant improvements in the anteroposterior talocalcaneal angle and talo-first metatarsal angles, and the lateral talo-first metatarsal angle; and triple arthrodesis realigned the hindfoot primarily by means of transverse plane movement of the talus over the calcaneus, and sagittal plane realignment occurred primarily by means of reduction of the downward pitch of the talus rather than by means of elevation of the pitch of the calcaneus. Only 1 (1.19% of fusion sites, 3.57% of cases, 4.17% of patients) symptomatic nonunion was observed. Correlation analyses showed that a normal (35 degrees to 50 degrees ) preoperative lateral talocalcaneal angle was moderately inversely correlated, and a normal (< or = 21 degrees ) preoperative lateral talar declination angle was strongly positively correlated, with none to mild postoperative pain. Based on these findings, we concluded that triple arthrodesis satisfactorily realigned the hindfoot and reduced pain in patients with advanced arthrosis. LEVEL OF CLINICAL EVIDENCE 4.

Subtalar joint arthrodesis

Forty patients (12 men and 28 women) treated with isolated subtalar joint arthrodesis were retrospectively reviewed. The average patient age was 50 years (range, 21-76 years). Preoperative diagnoses included posterior tibial tendon dysfunction, post-traumatic arthritis, nontraumatic arthritis, and subtalar joint middle facet coalition. The average follow-up was 15 months (range, 12-74 months). Subjective postoperative questionnaire results were classified as satisfied (n = 32), satisfied but with reservations (n = 4), or dissatisfied (n = 4). Eighty-three percent of the patients (n = 33) stated that they would undergo the procedure again. Minor complications (those that resolved with nonoperative treatment) occurred in 55% of the patients. However, the major complication rate was only 12.5%. This study showed no statistical correlation between the preoperative diagnosis and the postoperative outcome. Our results also suggested that the prevalence of complications is slightly higher than in previous reports. Isolated subtalar joint arthrodesis is an effective treatment for pain and deformity of the rearfoot.

A Retrospective Analysis of Anterior Calcaneal Osteotomy with Allogenic Bone Graft

Anterior calcaneal osteotomy (ACO) with extension bone graft is commonly employed in the treatment of symptomatic supple, hypermobile flatfoot in adolescent as well as adult (>or= 18 years of age) patients. Although autogenous bone graft has been considered the gold standard, allogenic bone is widely used for this procedure because it is readily available, requires no additional procedure for procurement and has incorporation rates similar to autogenous bone graft. There is increasing agreement among surgeons that the union rates with allograft bone are comparable with that observed with autograft bone when used in the ACO. We reviewed the medical records of 51 consecutive patients who had undergone 53 ACO with allogenic bone graft for the repair of flatfoot deformity in an effort to further evaluate outcomes associated with the use of allogenic bone graft. All of the patients had at least 12 months of follow-up. The mean time to graft incorporation was 9.10 +/- 1.54 weeks for adolescents and 9.81 +/- 2.13 weeks for adults (P = .0149), The incidence of graft incorporation (bone union) was 100% and 90% (P = .1391) in the adolescent and adult groups, respectively. Complications included lateral column pain, sinus tarsitis, nonunion, calcaneocuboid capsulitis, complex regional pain syndrome, incisional dehiscence, and sural neuritis; and all of the complications occurred in the adult group. The results support the understanding that ACO with allogenic bone graft is a reasonable alternative to autograft bone graft in the treatment of flexible flatfoot in adolescent and adult patients.

Basal Cell Carcinoma of the Nail Unit: A Case Report

Basal cell carcinomas (BCC) of the foot are rare. A review of the English literature found only 23 cases of BCC reported in the foot, none of which involved the nail unit. The nail unit, which is composed of the nail bed and nail-folds, is an exceedingly atypical site for basal cell carcinomas. A case of BCC of the proximal nail fold of the hallux which was treated with Mohs Micrographic Surgery (MMS) is presented. 16–21

Utilization of autogenous corticocancellous bone graft from the distal tibia for reconstructive surgery of the foot and ankle

Procurement of corticocancellous autogenous bone graft from any donor site is not without potential complications. Increased postoperative morbidity, fracture at the donor site, an additional surgical procedure, increased operative time, excessive blood loss, hematoma, and increased relative cost are all factors that must be considered, regardless of donor site. The authors have been using the distal tibia as a source of corticocancellous bone since 1988. A review of 16 patients with distal tibial bone grafts at our institution has demonstrated this area to be readily available and effective with limited morbidity. The distal tibial metaphyseal area has been found to be an excellent source of corticocancellous bone for grafting in reconstructive foot and ankle surgery.

Traumatic Dislocation of the First Metatarsophalangeal Joint with Tibial Sesamoid Fracture A Case Report of a Type III B Dislocation

We present a case report about traumatic dislocation of the first metatarsophalangeal joint and patterns of injury. We are unaware of previous reports in the literature describing this unusual variant.

A Diagnosis of Marginal Zone Lymphoma Following Surgical Correction of Hallux Abductovalgus: A Case Report

UNLABELLED Marginal zone lymphoma is a neoplasm affecting the lymphatic system, including the bone marrow, thymus, spleen, and lymph nodes. This type of non-Hodgkins lymphoma affects B cells and is estimated to comprise between 5% and 17% of all non-Hodgkins diseases. The incidence of finding any neoplasm within the foot and ankle has been estimated to be only 2.0% to 3.5% of all patients. However, despite the low incidence of cancer found within the foot and ankle, the clinician must be mindful that the possibility does exist and should thus consider surgically excised soft tissue and bone for pathological evaluation. A case report of marginal zone lymphoma, incidentally diagnosed through hallux valgus surgery, is presented. LEVEL OF CLINICAL EVIDENCE 4.

Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study

ABSTRACT Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case‐control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.