Ryan Donegan

Charcot Neuroarthropathy of the Foot and Ankle: Diagnosis and Management Strategies

This article reviews current literature discussing the etiology, pathophysiology, diagnosis and imaging, and conservative and surgical treatment of Charcot osteoarthropathy. The treatment of Charcot osteoarthropathy with concurrent osteomyelitis is also discussed.

Isolated dislocation of the posterior tibial tendon in an amateur snowboarder: a case report.

Isolated dislocation of the posterior tibial tendon is an uncommon pathologic entity that typically occurs in the setting of acute trauma. The diagnosis remains challenging and is often delayed second to the rarity of the injury and symptoms similar to that of medial ankle sprains and other routinely diagnosed injuries about the ankle. The factors that predispose this tendon to dislocation include a hypoplastic retromalleolar groove, flexor retinaculum insufficiency, chronic repetitive trauma, and a structural abnormality from a previous medial malleolar fracture, or a combination thereof. Dislocation has also been cited as a complication of multiple local steroid injections and tarsal tunnel release. The mechanism of injury appears to involve forced dorsiflexion and eversion of the ankle when the posterior tibial tendon is contracted. Most cases do not respond well to conservative treatment and will require surgery to restore function and eliminate symptoms. We report a case of posterior tibial tendon dislocation related to a snowboarding injury and offer our technique for surgical correction.

The Role of Plastic Surgery for Soft Tissue Coverage of the Diabetic Foot and Ankle

The goal of wound healing is to obtain the best closure through the least morbid means. In the surgical treatment of the diabetic foot and ankle, the reconstructive foot and ankle surgeon is tasked with the challenge of repairing a variety of tissue defects. The decision for wound closure depends on the location of the wound and host factors. In order of increasing complexity, the clinician should consider the reconstruction decision ladder algorithm. Wound evaluation coupled with the knowledge of various closure techniques and their indications will arm the surgeon with the tools for a successful closure.

Charcot foot and ankle with osteomyelitis.

This paper presents a review of the current literature discussing topics of Charcot osteoarthropathy, osteomyelitis, diagnosing osteomyelitis, antibiotic management of osteomyelitis, and treatment strategies for management of Charcot osteoarthropathy with concurrent osteomyelitis.

Anatomic Repair of Plantar Plate With Flexor Tendon Sheath Reinforcement: Case Series.

Plantar plate pathology has gained considerable attention in recent time, and with this increased awareness multiple treatments have been proposed. There have been no comparison studies between these treatments. The authors feel a direct approach for anatomic repair allows for plantar plate repair and tightening to desired tension, without any plantar prominences or potentially irritating hardware. In addition if the plantar plate is found to be attenuated or there is a lack of residual tissue, the described imbrication utilizing the flexor digitorum longus sheath, which is not possible with hardware or newest instrumentation, allows for a robust repair. The presented case series provides results from consecutive patients treated with proposed concurrent plantar and dorsal incisions, providing proof of concept and viability of novel technique. Levels of Evidence: Level V: Case series

An overview of factors maximizing successful split-thickness skin grafting in diabetic wounds

Open wounds, from ulcerations or slow healing, are one of the comorbidities in diabetic patients that can lead to amputation. Therefore, an optimal way to close and heal wounds quickly in diabetic patients is required. Split-thickness skin grafts (STSG) offer a quick method of wound closure for diabetic patients. This article review will look at causes of failure in STSG, and ways to optimize success.

Factors Maximizing Skin Flaps and Grafts for Diabetic Wound Coverage

Diabetes mellitus has a global impact and accounts for 46% of the 162,000 hospital admissions for foot ulcers annually. The pathophysiological mechanisms underlying diabetic foot disease are multifactorial and include neuropathy, infection, immunopathy, and ischemia. The author discusses general reconstruction, general principles for success in flaps and grafts, optimizing of patients, biomechanics, immune system, vascular disease and reperfusion, physiologic considerations in flap perfusion, intraoperative care and flap technique, tissue management (biofilm, bacteria, inflammation), various flaps, and nonsurgical management. Accurate diagnosis of the underlying cause of lower extremity ulceration is essential for successful treatment.

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.

Comparing Magnetic Resonance Imaging and High-Resolution Dynamic Ultrasonography for Diagnosis of Plantar Plate Pathology: A Case Series

Abstract Plantar plate pathology has gained noticeable attention in recent years as an etiology of lesser metatarsophalangeal joint pain. The heightened clinical awareness has led to the need for more effective diagnostic imaging accuracy. Numerous reports have established the accuracy of both magnetic resonance imaging and ultrasonography for the diagnosis of plantar plate pathology. However, no conclusions have been made regarding which is the superior imaging modality. The present study reports a case series directly comparing high‐resolution dynamic ultrasonography and magnetic resonance imaging. A multicenter retrospective comparison of magnetic resonance imaging versus high‐resolution dynamic ultrasonography to evaluate plantar plate pathology with surgical confirmation was conducted. The sensitivity, specificity, and positive and negative predictive values for magnetic resonance imaging were 60%, 100%, 100%, and 33%, respectively. The overall diagnostic accuracy compared with the intraoperative findings was 66%. The sensitivity, specificity, and positive and negative predictive values for high‐resolution dynamic ultrasound imaging were 100%, 100%, 100%, and 100%, respectively. The overall diagnostic accuracy compared with the intraoperative findings was 100%. The p value using Fishers exact test for magnetic resonance imaging and high‐resolution dynamic ultrasonography was p = .45, a difference that was not statistically significant. High‐resolution dynamic ultrasonography had greater accuracy than magnetic resonance imaging in diagnosing lesser metatarsophalangeal joint plantar plate pathology, although the difference was not statistically significant. The present case series suggests that high‐resolution dynamic ultrasonography can be considered an equally accurate imaging modality for plantar plate pathology at a potential cost savings compared with magnetic resonance imaging. Therefore, high‐resolution dynamic ultrasonography warrants further investigation in a prospective study. &NA; Level of Clinical Evidence: 4

Functional Results and Patient Satisfaction of First Metatarsophalangeal Joint Arthrodesis Using Dual Crossed Screw Fixation

Abstract A total of 262 feet in 228 consecutive patients underwent first metatarsophalangeal joint (MPJ) fusion; thus, the present study is the largest single‐surgeon patient series reported. The inclusion criteria included severe painful deformity of the first MPJ due to osteoarthritis, rheumatoid arthritis, or gouty arthritis and stage 3 or 4 hallux rigidus. The exclusion criteria were revision surgery of the first MPJ, fixation other than with dual crossed screws, and a postoperative follow‐up period of <3 months. Fusion of the first MPJ was fixated with dual‐crossed 3.0‐mm screws. The office follow‐up period was ≥3 months postoperatively and the survey follow‐up period was ≥6 months postoperatively. The mean duration to radiographic evidence of arthrodesis was 7.00 ± 2.33 weeks, and 252 of the feet (96.18%) achieved successful arthrodesis. The mean postoperative office follow‐up duration was 30.43 ± 6.59 weeks. The mean modified American College of Foot and Ankle Surgeons scale score was 51.2 ± 3.28 of maximum possible of 68 points. The mean subjective score was 37.1 ± 2.5 (maximum possible of 50 points), and the mean objective score was 14.5 ± 1.7 (maximum possible of 18 points). Furthermore, 200 patients (87.72%) reported that they had little to no pain, 187 (82.02%) reported they either mostly liked the appearance of their toe or liked it very much, and 173 (75.88%) reported that they could wear any type of shoe most or all the time after the operation. Of the respondents, 207 (90.79%) stated they would have the surgery repeated, and 197 (86.40%) would recommend the surgery to a family member or friend. &NA; Level of Clinical Evidence: 3