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Minimally Invasive Surgery in Hallux Valgus and Digital Deformities

Minimally invasive surgical techniques are an alternative with potential advantages in the treatment of forefoot deformities.

Endomedullary Screw Fixation for First Metatarsophalangeal Arthrodesis

Background: The purpose of this study was to evaluate the clinical and radiological results in a group of patients who underwent first metatarsophalangeal joint arthrodesis with an endomedullary screw fixation technique (MPA-E). Methods: Between 2003 and 2009, 101 metatarsophalangeal arthrodesis were performed in 76 patients. There were 64 women and 12 men with an average age of 68 years. The indication for surgery was osteoarthritis with severe pain and functional limitation. Patients were evaluated radiologically and with the American Orthopaedic Foot & Ankle Society scoring system (AOFAS) at an average follow-up of 32 months (range, 24-92 months). Results: The success rate was 93%, with an increase of the average preoperative AOFAS from 38.5 points to 85.5 points postoperatively (P < .0001). The consolidation rate after radiological evaluation was 90.1%; there were 5 cases (5.0%) with asymptomatic nonunion and 5 cases (5.0%) with poor results because of symptomatic nonunion. Screw removal was needed in 4 feet (4.0%), and 2 feet (2.0%) had acute postoperative superficial infection. No implant cutout was observed. Conclusion: The MPA-E technique provided consistent and high functional outcomes. This valid and effective alternative should be considered as an option for hallux metatarsophalangeal arthrodesis. Level of Evidence: Level IV, retrospective case series.

Toe ulcers and early diagnosis of osteomyelitis in diabetic patients

Category: Diabetes Introduction/Purpose: Neuropathy and Peripheral arterial disease are the main causes of diabetic foot ulcers. Toes are the most frequent location. Osteomyelitis diagnosis of foot ulcers is still controversial, mainly in ulcers without bone exposure. Although MRI has 90% sensitivity and 85% specificity for osteomyelitis diagnosis, it is not usually used for early detection of bone changes, due to lack of availability and high cost. Bone biopsy puncture is considered the gold standard methodology together with microbiological and histological examinations, but it is not always available in all practices. The purpose of this study was to describe the diagnosis in forefoot ulcers found in diabetic patients using MRI and bone biopsy puncture. Methods: This is a retrospective study, a case series. Clinical records of patients with injuries limited to toes between January 2013 and December 2015 were analyzed. The inclusion criteria were: patients with Diabetes Mellitus (DM) diagnosis and with a grade 1 or 2 digital ulcer according to Wagner’s classification for at least 3 weeks, with visible bone edema in the magnetic resonance (MRI) and those with a bone biopsy performed, and with a minimum follow–up of a year. Patients with diabetic foot ulcers were evaluated by an interdisciplinary team. Laboratory standards were evaluated preoperative and during antibiotic therapy. The surgical bone biopsy was performed by a foot and ankle surgeon with experience in Diabetic foot pathologies. Microbiological and histological study was analyzed. We also recorded the demographic data and identified the patients who had received previous empiric antibiotic therapy. Statistical analysis was performed. Results: Thirty patients out of 93 patients fulfilled inclusion criteria between January 2013 and December 2015. Eleven patients had grade 1 ulcers and 19 grade 2. Twenty-two patients (73.3%) got bone biopsies with positive cultures and 14 (63,3%) had a positive pathological anatomy. Eight patients got negative cultures and pathology. Six patients that did not received empiric antibiotic therapy and 19 patients out of 24 who had received empiric antibiotics had positive cultures. Mean healing time for patients who did not had antibiotics was 4 weeks (3-12) and for the group who received empiric antibiotics was 6 weeks (4-10/) Only 4 patients out of 19 patients with Wagner II ulcers had the toe amputated. Conclusion: A precise diagnosis of the germ was obtained in 73.3% of the patients and a specific antibiotic treatment was completed. Although empiric antibiotic therapy 19 out of 24 patients had positive bone cultures and healing time was longer. Amputation index was 13%, all of them were grade 2 ulcers. There were no major amputations. We consider that in these kind of ulcers that had more than 3 weeks without healing and had no radiographic changes, MRI can show bone edema. Surgical bone biopsy should be done to begin specific antibiotic therapy and improve healing time.

Talus Bipartitus: A Rare Anatomical Variant Presenting as an Entrapment Neuropathy of the Tibial Nerve within the Tarsal Tunnel

Tarsal tunnel syndrome is an entrapment neuropathy of the tibial nerve within the tarsal tunnel that lies beneath the retinaculum on the medial side of the ankle. It is often underdiagnosed. Talus bipartitus is a rare anatomical variant; only a few cases have been described in medical literature. We report a case of a 36-year-old female with tarsal tunnel syndrome secondary to a talus bipartitus undergoing surgical treatment with good clinical outcome. To our knowledge, talus bipartitus presenting as tarsal tunnel syndrome has no previous reports. Image studies and physical examination are crucial to reach precise diagnosis.

Evans Osteotomy with Locked Plate with Wedge Block for Stage IIB Flat Foot

Category: Hindfoot Introduction/Purpose: Elongation of the lateral column is indicated only in patients who have a flexible deformity Stage 2B of flat foot. The Evans osteotomy is performed 1.5 or 2 cm from the cuboideal calcaneal joint, and in many publications is maintained by different kind of devices. Our hypothesis is that Evans osteotomy, with blocked plates with a wedge block, without the use of bone graft, maintain the correction obtained at one year after surgery. The primary objective was to evaluate the radiological results at the postoperative year of the osteotomy Secondary objectives were to evaluate the persistence of the correction obtained between the 3 months and the year of the postoperative period and to evaluate the functional outcomes with AOFAS score. Methods: We studied a total of 12 patients, 14 feet. with stage 2 B flat foot, in all cases surgery was performed by the same specialist between March of 2011 and March of 2014 in the Service of foot and ankle of our institution. Inclusion criteria were: patients with type 2B flat foot, submitted to external column elongation, with plates blocked with a 6 to 10 mm wedge block, without the use of bone grafting, minimum follow-up of 1 year. Exclusion criteria: revision of previous surgery, another type of material used for elongation of the external column, neurological sequelae. The study was performed retrospectively through clinical records database, data collection and measurements were performed by 2 second-year Foot and ankle fellow trained in the same institution. Statistical analysis was performed with the T-student test. Results: A total of 12 patients / 14 feet were evaluated during the study period, with a diagnosis of flatfoot type 2B. The average age was 57 years (32-65 years), 11 (78.5%) were female. No statistically significant difference was observed in any of the radiographic variables measured, at 3 months and at 12 months postoperatively. The preoperative AOFAS score, was 54 points. At the first year was 93 points. Consolidation was achieved at 3 months in all cases. The complications found were 2 superficial infections and 1 wound dehiscence. As a late complication, there was only 1 case of cuboidal calcaneal osteoarthritis that did not require surgical resolution. Conclusion: Evans osteotomy for elongation of the external column provides a reproducible and reliable method to restore the normal functional stability of the midfoot and hindfoot. According to the results obtained in our work, we can conclude that the blocked plates with a wedge lock manage to preserve the corrections obtained with the Evans osteotomy in patients with type IIB flat foot. There is no need of autograft with the consequent risk of comorbidities produced by a second approach to the grafting as well as the complications that could happen with the use of allografts.