Category Archives: Uncategorized

Spring 2018

Issue 11 (1), 2018


Effects of a foot orthosis custom-made to reinforce the lateral longitudinal arch on three-dimensional foot kinematics
by Shintarou Kudo, Yasuhiko Hatanaka, Toshihiro Inuzuka


Conservative surgical management in an extreme diabetic foot case
by JM García-Sánchez, A Ruiz-Valls, A Sánchez-García, A Pérez-García


Choice of surgical treatment for patients with arthrosis of the ankle joint
by Kirill S. Mikhaylov, Vladimir G. Emelyanov, Alexandr Yu Kochish, Aleksandr A. Bulatov


A rare presentation of posterior compartment abscess in a diabetic patient: A case study
by Anthony Romano DPM/PGYIII, Kaitlyn L. Ward DPM/PGYIII, Byron Hutchinson, DPM FACFAS


A new technique using cruciate incisions for treating macrodactyly toe: Case report and review of the literature
by Mohammed Taifour Suliman MD FRCS


Cuboid navicular tarsal coalition: Presentation and evaluation with emphasis on magnetic resonance imaging appearance
by Angela Chang BS, Carly A. Lockard MS, Márcio B. Ferrari MD, Thomas O. Clanton MD, Charles P. Ho MD PhD


Eccrine syringofibroadenoma: A case report with dermatoscopic findings
by Mary A. Mooney MD and Myron A. Bodman DPM

Eccrine syringofibroadenoma: A case report with dermatoscopic findings

by Mary A. Mooney MD1* and Myron A. Bodman DPM1

The Foot and Ankle Online Journal 11 (1): 7

Eccrine syringofibroadenoma is a rare, benign adnexal lesion derived from cells of the acrosyringium of eccrine sweat glands.  This lesion has multiple clinical manifestations, including a reactive form, occurring in a pre-existing inflammatory or neoplastic dermatosis. Our case represents the typical presentation of the reactive form of eccrine syringofibroadenoma, including the dermoscopic appearance of the lesion.

Keywords: Eccrine syringofibroadenoma, dermoscopy, glomerular vessels, nummular eczema

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0007

1 – College of Podiatric Medicine, Kent State University, 6000 Rockside Woods Blvd, Independence, OH 44131
* – Corresponding author: mmooney9@kent.edu


Pedal dermatological disorders are commonly limited to superficial fungal, viral and bacterial infections, pressure induced and genetic hyperkeratotic disorders, psoriasis and eczemas. Pedal neoplastic disease is much less common. There is a characteristic diagnostic delay of pedal neoplasms that can be attributed to the behavior of both patients and physicians. Patients may pay less attention to lower extremity problems, while in the primary care office the lower extremity physical examination may have a low priority. Physicians must also be aware of this complication of chronic dermatosis.

Case Report

A 62-year-old female presented with a 12-year history of intermittent nummular eczema on the right heel.  Treatment with triamcinolone 0.5% ointment had provided some relief (patient stated 20% improvement) but the lesion remained.  The patient wanted to know the diagnosis and accepted the risks and benefits of a punch biopsy.

The medical history was significant for epilepsy, treated with Dilantin. Physical examination demonstrated an erythematous hyperkeratotic plaque with fissures on the right heel measuring 1.5 cm. in diameter (Figure 1).  Dermoscopy examination with polarized light revealed enlarged irregular dermal vascular structures and opaque hyperkeratosis consistent with cutaneous neoplasia (Figure 2).

A 2-mm punch biopsy was performed and the specimen was sent for analysis.  The pathology diagnosis was reported as syringofibroadenoma. The patient was referred for a possible wide excision of the lesion.

Figure 1 Scaly plaque over lateral aspect of the right heel pad.

Figure 2 Dermoscopy image with polarized light detects glomerular dermal vessels partially obscured by opaque hyperkeratosis.

Figure 3 Thin anastomosing cords of epithelial cells surrounded by fibrovascular stroma (H&E x 10).

Discussion  

Eccrine syringofibroadenoma (ESFA) is a rare, benign  neoplasm of the acrosyringium of eccrine sweat glands, first described by Mascaro in 1963 [1].    ESFA has multiple clinical presentations. These were classified by Starink into four subtypes [2].  French added a fifth subtype, reactive [3]. The current classification system is: 1) solitary ESFA, non-hereditary, 2) multiple ESFA in hidrotic ectodermal dysplasia (Schöpf syndrome), 3) multiple ESFA without cutaneous findings (eccrine syringofibroadenomatosis), 4) nonfamilial unilateral linear ESFA (nevoid), and 5) reactive ESFA associated with inflammatory or neoplastic dermatoses [3].

This lesion typically presents in adult individuals, usually over the age of 40.  It frequently appears in the distal extremities. The reactive form is present in patients with inflammatory or neoplastic lesions, or in patients with peripheral neuropathy [4].  In these cases, eccrine syringofibroadenoma may arise in response to repetitive damage with subsequent repair of eccrine ducts [3]. The exact nature of the lesion, however, is not completely understood.  It may be hyperplastic, hamartomatous, or neoplastic[2]. Although ESFA typically has a benign course, it has been reported as a precursor to squamous cell carcinoma and pseudocarcinomatous hyperplasia [5, 6].  Malignant transformation of ESFA is rare, but has also been reported [7]. In these cases, it can be difficult to determine if the EFSA was the primary lesion, with a carcinoma developing within it, or if the EFSA developed in response to a previously existing cancer.

Clinically, ESFA presents as a slow growing, exophytic lesion with a verrucous or spongy, moist mosaic, or erythematous scaly plaque appearance [8].  The lesions may be solitary or multiple. It is frequently located on the extremities, with multiple case reports involving the foot and ankle, although other parts of the body such as the hand, wrist, finger, and lip, can be involved [2].

The dermoscopy image detected vascular structures consistent with glomerular vessels.  The structural pattern of vessels in dermoscopy play a critical role in the diagnosis of non-pigmented skin lesions [9].  Glomerular vessels are large-caliber reddish dots formed by tortuous capillaries curled up into a ball, resembling the glomerular apparatus of the kidneys and have been observed in a variety of neoplasms including Bowen’s disease, eccrine poroma, basal cell carcinoma, Merkel cell carcinoma as well as actinic keratoses and stasis dermatitis but have not been previously reported in ESFA [9].

The histologic appearance of the lesion demonstrates thin, anastomosing strands of epithelial cells, which can appear as cords, surrounded by a fibrovascular stroma. These strands are contiguous with the epidermis [8].  Eccrine syringofibroadenoma stains positive with epithelial membrane antigen and carcinoembryonic antigen[8]. In spite of the highly variable clinical presentation, the histologic appearance of ESFA is uniform for the different subtypes [3].  

Differential diagnosis may include prurigo nodularis, granulomatous dermatitis, fungal and bacterial infections, eccrine poroma, reticulated seborrheic keratosis, lichen sclerosis, and fibroepithelioma of Pinkus and amelanotic melanoma [8, 9].

Our patient represented a case of reactive eccrine syringofibroadenoma.  The patient had a 12-year history of intermittent nummular eczema on the right heel with only a partial response to topical steroids.  This type of clinical history is similar to other reported cases of reactive EFSA. Histologically, the lesion demonstrated the typical appearance of EFSA, with thin anastomosing cords of epithelial cells surrounded by fibrovascular stroma contiguous with the epidermis.  There were no signs of atypia or malignant transformation (Figure 3).

Our patient was referred for wide excision of the lesion to a plastic surgeon and to a dermatologist for a full body examination to search for additional lesions. Wide excision has been the mainstay of treatment [10], although cryotherapy [11], radiation [12], and carbon dioxide laser [13] are alternatives.  For early lesions, close observation and follow up may be an alternative to complete excision, especially if complete excision is difficult due to the size or location of the lesion [10]. The patient was lost to follow-up.

Acknowledgement

We would like to acknowledge the assistance of Ashfaq A. Marghoob MD, Director of Clinical Dermatology at Memorial Sloan Kettering Cancer Center, New York, for his help in interpreting the dermoscopy image

This case was written with the approval of the Kent State University Institutional Review Board.

References

  1. Mascaro JM. Considerations on fibro-epithelial tumors. Exocrine syringofibroadenoma. Ann Dermatol Syphiligr (Paris) 1963;90:143-53.
  2. Starink TM. Eccrine syringofibroadenoma: multiple lesions representing a new cutaneous marker of the Schöpf syndrome, and solitary nonhereditary tumors. J Am Acad Dermatol 1997;36(4):569-76.
  3. French LE. Reactive eccrine syringofibroadenoma: an emerging subtype. Dermatology 1997;195(4):309-10.
  4. Sirikham T, Rojhirunsakool S, Vachiramon V. Reactive Eccrine Syringofibroadenoma Associated with Neuropathy, Venous Stasis, and Diabetic Foot Ulcer. Case Rep Dermatol 2016;8(2):124-9.   
  5. Bjarke T, Ternesten-Bratel A, Hedblad M, Rausing A. Carcinoma and eccrine syringofibroadenoma: a report of five cases. J Cutan Pathol 2003;30(6):382-92.
  6. Kacerovska D, Nemcova J, Michal M, Kazakov DV. Eccrine syringofibroadenoma associated with well-differentiated squamous cell carcinoma. Am J Dermatopathol 2008;30(6):572-4.
  7. Katane M, Akiyama M, Ohnishi T, Watanabe S, Matsuo I. Carcinomatous transformation of eccrine syringofibroadenoma. J Cutan Pathol 2003;30(3):211-4.
  8. Lowell DL, Salvo NL, Weily WJ, Swiatek M, Sahli H. Multiple Eccrine Syringofibroadenoma of Mascaro of the Lower Extremity. J Am Podiatr Med Assoc 2016;106(6):433-8.
  9. Tiwary AK, Firdous J, Mishra DK, Chaudhary SS. A case report of reactive solitary eccrine syringofibroadenoma. Indian Dermatol Online J 2017;8(1):35-8.
  10. Cho E, Lee JD, Cho SH. A case of reactive eccrine syringofibroadenoma. Ann Dermatol 2011;23(1):70-2.
  11. Ozkaya DB, Su O, Bahalı AG, Topukçu B, Dizman D, Tosuner Z, et al. Solitary Eccrine Syringofibroadenoma and Successful Treatment with Cryotherapy. J Am Podiatr Med Assoc 2016;106(3):237-8.
  12. Morganti AG, Martone FR, Macchia G, Carbone A, Massi G, De Ninno M, et al. Eccrine syringofibroadenoma radiation treatment of an unusual presentation. Dermatol Ther 2010;23 Suppl 1:S20-3.
  13. Athanasiadis GI, Bobos M, Pfab F, Athanasiou E, Athanasiadis IE. Eccrine syringofibroadenoma treated with carbon dioxide laser. Clin Exp Dermatol 2009;34(2):261-3.

Cuboid navicular tarsal coalition: Presentation and evaluation with emphasis on magnetic resonance imaging appearance

by Angela Chang BS1, Carly A. Lockard MS1, Márcio B. Ferrari MD1, Thomas O. Clanton MD1,2, Charles P. Ho MD PhD1,*

The Foot and Ankle Online Journal 11 (1): 6

Tarsal coalition is an uncommon condition that is often overlooked in the adult population. The potential sequelae of untreated tarsal coalition include changes in gait mechanics, flattening of the longitudinal arch and degenerative changes in the hindfoot joints. Tarsal coalition should be considered as a possible diagnosis in the active younger patient who presents with frequent hindfoot pain and ankle sprains. Our report presents a case of an incidental finding of an asymptomatic cuboid-navicular tarsal coalition in a patient who presented with persistent Achilles tendinosis and reviews the available literature regarding this condition.

Keywords: cubonavicular tarsal coalition, cuboid-navicular coalition, tarsal coalition, Achilles tendinosis, MRI

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0006

1 – Steadman Philippon Research Institute, Vail, Colorado, USA
2 – The Steadman Clinic, Vail, Colorado, USA
* – Corresponding author: charles.ho@sprivail.org


Tarsal coalition, thought to have first been described in the literature in 1877 [1], is an anatomical anomaly in which a fibrous, cartilaginous, or osseous coalition forms between two or more tarsal bones [2]. This condition occurs in less than 1% of the general population [3]. Approximately 48% of tarsal coalitions are talocalcaneal, 44% are calcaneonavicular, and the remaining 8% occur in other tarsal joints [3,4]. It has been suggested that tarsal coalition occurs during embryonic development due to failure of mesenchymal differentiation and segmentation, and may be genetic in etiology [5,6]. Tarsal coalition is found in association with pes planus, hindfoot rigidity and peroneal spastic flatfoot [7-9].

Imaging evaluation of suspected tarsal coalition should begin with anteroposterior (AP), 45-degree internal oblique, and lateral foot radiographs with the AP and lateral taken weight bearing [10].  These three views are typically sufficient for diagnosis of calcaneonavicular and talonavicular coalition. On radiographs, calcaneonavicular coalition is best visualized on a 45-degree internal oblique, and can present as an “anteater nose sign” on the lateral view [10]. Talocalcaneal coalitions may be difficult to visualize directly due to the complex orientation of the subtalar joint, but are associated with secondary signs such as talar beaking, narrowing of the posterior subtalar joint with poor visualization of the middle facets, rounding of the lateral talar process, and “C sign” created by bone bridging between the talar dome and sustentaculum tali [10].

Additional computerized tomography (CT) and magnetic resonance imaging (MRI) are recommended to visualize the size, location and extent of joint involvement more accurately [11-13]. CT should be reconstructed in both the coronal and axial planes. Non-osseous coalitions may appear as joint space narrowing and marginal reactive bone changes [10]. MRI in the coronal and sagittal planes is recommended to allow differentiation between osseous, cartilaginous, and fibrous bridges [10].

Case Report

A 23-year-old man began experiencing heel pain three years prior to presentation at our office. His past medical history was negative for diabetes mellitus, traumatic or chronic foot and ankle injuries, or rheumatologic disease. Three years prior to presentation at our clinic the patient experienced acute onset of left heel pain focused around the medial aspect of the distal Achilles following a high-elevation mountain hike. This pain improved with eccentric calf exercises and gentle stretching. However, another alpine hiking activity one year later resulted in onset of pain in the right heel, which did not improve satisfactorily with conservative treatment including gel heel inserts, calf raises and inversion-eversion exercises. The patient began to experience chronic recurrent bilateral distal Achilles pain that varied between 0 and 9 points on a 10-point scale. The patient did not experience any other midfoot or hindfoot pain. The pain was exacerbated with running and improved with rest and diclofenac 1% gel (Voltaren Topical). Four days prior to presentation at our clinic the patient underwent a right hip arthroscopy for femoroacetabular impingement, including labral repair and acetabular and femoral osteochondroplasty.

Upon physical exam, the patient was wearing a hip brace and limited to 20 pounds of flatfoot weight-bearing on the right and therefore standing alignment could not be assessed. Bilaterally there was swelling but no tenderness to palpation along the Achilles tendon at the insertion, over the lateral calcaneal ridge, or over the lateral or medial aspect of the tendon. Heel raises were not performed due to his postoperative right hip arthroscopy status. Range of motion of the right ankle with knee straight showed dorsiflexion to 0°, plantarflexion to 40°, inversion to 15°, eversion to 10°, adduction of 15°, and abduction of 10°.  Left ankle dorsiflexion with the knee bent was to 10°.  Range of motion was equal bilaterally. The patient had 5/5 manually-tested plantarflexion strength bilaterally.

Bilateral calcaneal lateral and axial radiographs were obtained.  There was no evidence of Haglund’s deformity, calcifications, or fracture. Sagittal, coronal and axial magnetic resonance images of both ankles were also obtained.

On MRI of the right ankle, mild longitudinal thickening of the Achilles tendon with increased signal and tendinosis of the distal tendon was visualized. No focal tear defect or retraction was identified. A mild retrocalcaneal bursitis was noted. The cuboid-navicular tarsal coalition was identified on the MRI.  The coalition appeared as an osseous prominence of the cuboid-navicular junction, with prominent narrowing of the cuboid-navicular bone junction, and sclerosis, irregularity, thinning, slight pitting, and appearance of interdigitation of the bone margins at the junction. These characteristics are visible both on sagittal (SAG) and coronal non-fat-suppression (COR non-FS) and fat-suppression (FS) images. (Figures 1 and 2). Surrounding bone showed poorly defined increased signal compatible with stress-related edema; this increased signal is most apparent on the FS images (Figures 1b and 2b).   Stress-related change and edema were also visualized in the surrounding soft tissue; this increased signal is most apparent on the FS images (Figures 1b and 2b). The cuboid-navicular tarsal coalition appearance, with the narrowing of the bone junction and appearance of bone margin interdigitation and thinning but lack of complete cortical and trabecular bone continuity and marrow bridge, is typical of a soft tissue fibro-cartilaginous coalition or mixed osseous/soft tissue coalition.

Figure 1 Sagittal proton density-weighted turbo spin echo non-fat-suppressed (A) and fat-suppressed (B) magnetic resonance image showing coalition (arrow). Severe narrowing of the cuboid-navicular junction is seen with opposing bone margin irregularity, sclerosis, appearance of interdigitation thinning and pitting. Bone and surrounding soft tissue increased signal and stress-related edema are more apparent and prominent on the fat-suppressed image.

Figure 2 Coronal proton density-weighted turbo spin echo non-fat-suppressed (A) and fat-suppressed (B) magnetic resonance image showing coalition (arrow). Severe narrowing of the cuboid-navicular junction is seen with opposing bone margin irregularity, sclerosis, appearance of interdigitation thinning and pitting. Bone and surrounding soft tissue increased signal and stress-related edema are more apparent and prominent on the fat-suppressed image.

On the left side there were similar signs of Achilles tendinosis and retrocalcaneal bursitis. No tarsal coalition was present on the left side. The patient was made aware of the incidental finding and the potential for the coalition to become symptomatic in the future. The patient deferred treatment of the coalition and elected to manage the Achilles tendinosis conservatively.

Discussion

Calcaneonavicular and talocalcaneal tarsal coalitions are extensively reported in the literature. However, a much smaller number of cuboid-navicular cases have been reported, with varying symptoms at presentation.  Current literature suggests that this type of coalition is often asymptomatic, with exacerbation of pain and/or peroneal spastic flatfoot only with increased activity [14]. Del Sel and Grand reported the diagnosis of bilateral cuboid-navicular coalitions in a 45-year-old patient who underwent radiographic examination due to trauma to both feet [15].  Chu et al. also reported an incidental finding of a cuboid-navicular coalition upon CT evaluation in a 35-year-old patient following a comminuted pilon fracture [16].

In addition to reports on asymptomatic coalitions, several authors have reported symptomatic coalitions, with symptoms including dorsal and midfoot pain and decreased range of motion [13,14,17,18]. Awan et al. reported a case on a 17 year old patient with chronic unremitting pain at rest that was exacerbated during sports-related activities [14]. Feliu reported a case in which the only symptom was two years of intermittent pain in the dorsum of the foot with otherwise normal findings upon physical exam, while Johnson et al. reported a case on a patient with fixed pes planus deformity presented with midfoot pain associated with a decrease in subtalar and transverse tarsal joint motion [18,3].  

The patient age at the time of diagnosis varies from 9 [17] to 45 [15] years old. We found a comparable number of studies reporting male [3,14,15,18,19] and female [4,16,17,20] patients. However, the reported time from the beginning of the symptoms to the diagnosis ranged from two weeks [19]  to several years [3,13,17]. Delayed diagnosis of cuboid-navicular coalitions is often reported in the literature due to missed coalition on radiographic exam. Routine images often show minimal changes with an absence of secondary signs that are seen with other tarsal coalitions and findings specific to cuboid-navicular coalitions [14].

A high level of suspicion must be present in order to correctly diagnose cuboid-navicular coalition, as the only radiographic finding may be an abnormal relationship between the posterior medial cuboid and plantar lateral navicular [14]. Cuboid-navicular coalition does not cause talar beaking, so the absence of the talar beak sign cannot be used to exclude the presence of this type of coalition [14]. Although some case studies reported successful diagnosis using radiographs, [18,19,21] several authors reported negative radiographic findings [3,4].

Fibrocartilaginous and bony forms of cuboid-navicular coalition exist and MRI can be useful in distinguishing between them [3,13,14,16,17]. MRI findings in the context of a bony coalition include a continuous marrow across the coalition bridge [10]. MRI may be superior to CT for the diagnosis of fibrous coalitions as the MRI allows better differentiation between bony and fibrous changes [10]. Furthermore, MRI proton density fat-suppressed (PD FS), T2-weighted fat-suppressed (T2 FS), and short T-1 inversion recovery (STIR) images allow visualization of reactive edema [10]. Different stages of coalition ossification may exist in a single patient. For example, Del Sel and Grand and Piqueres et al. reported cases of bilateral cuboid-navicular coalition, with an osseous coalition on one side and a cartilaginous coalition on the contralateral side [15,21].

The treatment for symptomatic cuboid-navicular coalition varies from conservative [14,18] to surgical treatment [3,13,17,20]. Awan et al reported successful treatment using physical therapy, although the reported follow-up was only 3 months [14]. Several authors have reported their surgical treatment outcomes, with generally good results. Johnson et al. reported failure of conservative treatment including short leg cast immobilization, ultimately progressing to surgical treatment, with the resection of the osseous bar. This was performed through a single lateral curvilinear incision from the inferior aspect of the lateral malleolus to the distal medial aspect of the navicular [3]. Piqueres et al also reported good results following surgical treatment, with 1 year follow-up, and return to previous sports participation with no recurrence of pain [21]. During surgical treatment the resected bone surfaces may be separated using bone wax [4], adipose tissue [13], or the extensor digitorum brevis muscle [17] to avoid coalition recurrence. However, Hounshell  reported that donor site morbidity and recipient instability can occur with the use of wax or muscle belly as the interposition spacer and suggested the use of an acellular human dermal regenerative tissue matrix as an acceptable alternative since it was associated with good stability and no regeneration of the bone bar [20]. To our knowledge, the largest surgically-treated case series reported is from Sarage et al., which included four patients aged 15 to 35 years with fibrous coalition who were surgically treated with coalition resection and adipose tissue interposition with good results [13].

Conclusion

The purpose of this case study is to present the radiographic and MRI findings in a patient with asymptomatic cuboid-navicular coalition in the context of symptomatic Achilles tendinosis. MRI is an important diagnostic component of the evaluation of tarsal coalition, especially in the less commonly affected tarsal bones.

Funding declaration

No funding was received for this work.

Conflict of interest declaration

All authors: Steadman Philippon Research Institute Research Support from: Smith & Nephew Endoscopy, Arthrex, Siemens Medical Solutions, USA, Ossur Americas, Vail Valley Medical Center.

Charles P. Ho: Steadman Philippon Research Institute (Research Advisory Committee), Rotation Medical (Consultant).

Thomas O. Clanton: Arthrex, Inc. (Consultant/speaker fees, and royalties and in-kind donations of surgical supplies for research), Stryker, Inc. (Consultant/speaker fees and royalties), Steadman Philippon Research Institute (Research Advisory Committee).

References

  1. Moraleda L, Gantsoudes GD, Mubarak SJ. C Sign: Talocalcaneal coalition or flatfoot deformity? J Pediatr Orthop 2014;34:814–9.
  2. Kulik SA, Jr., Clanton TO. Tarsal coalition. Foot Ankle Int 1996;17(5):286-96.
  3. Johnson TR, Mizel MS, Temple T. Cuboid-navicular tarsal coalition — presentation and treatment: A case report and review of the literature. Foot Ankle Int 2005;26(3):264-6.
  4. Kamiya T, Watanabe K, Teramoto A, Yamashita T. Cuboid-navicular tarsal coalition in an adolescent female athlete: A case report. JBJS Case Connect, 2015 Nov 11; 5 (4): e93.
  5. Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br 1974;56b(3):520-6.
  6. Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: A clinical and anatomic study. Foot Ankle 1986;6(6):273-88.
  7. Anderson RJ. The presence of an astragalo-scaphoid bone in man. J Anat Physiol 1880;14(Pt 4):452-5.
  8. Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg Br 1948;30-B(4):624-34.
  9. Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg 1927;15:75-88.
  10. Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics 2000;20(2):321-32; quiz 526-7, 32.
  11. Lawrence DA, Rolen MF, Haims AH, Zayour Z, Moukaddam HA. Tarsal coalitions: Radiographic, CT, and MR imaging findings. HSS J 2014;10(2):153-66.
  12. Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int 2006;27(12):1163-9.
  13. Sarage AL, Gambardella GV, Fullem B, Saxena A, Caminear DS. Cuboid-navicular tarsal coalition: Report of a small case series with description of a surgical approach for resection. J Foot Ankle Surg 2012;51(6):783-6.
  14. Graham JA, Awan O. The rare cuboid-navicular coalition presenting as chronic foot pain. Case Rep Radiol 2015:1-4.
  15. Del Sel JM, Grand NE. Cubo-navicular synostosis; a rare tarsal anomaly. J Bone Joint Surg Br 1959;41-b(1):149.
  16. Chu JS, Underriner T, Yegorov A. A rare case of cubonavicular coalition. Radiol Case Rep.
  17. Prado MP, Mendes AA, Olivi R, Amodio DT. Cuboid-navicular tarsal coalition. Rev Bras Ortop 2010;45(5):497-9.
  18. Feliu EC. Cubonavicular synostosis. A case report. Acta Orthop Belg 1991;57(3):306-8.
  19. Waugh W. Partial cubonavicular coalition as a cause of peroneal spastic flat foot. J Bone Joint Surg Br 1957;39-b(3):520-3.
  20. Hounshell CR. Regenerative tissue matrix as an interpositional spacer following excision of a cuboid-navicular tarsal coalition: A case study. J Foot Ankle Surg 2011;50(2):241-4.
  21. Piqueres X, de Zabala S, Torrens C, Marin M. Cubonavicular coalition: A case report and literature review. Clin Orthop Relat Res 2002(396):112-4.

A new technique using cruciate incisions for treating macrodactyly toe: Case report and review of the literature

by Mohammed Taifour Suliman MD FRCS

The Foot and Ankle Online Journal 11 (1): 5

This report is a case of macrodactyly of the second and fourth toes of a young girl using  bilateral cruciate incisions the procedure details described and similar procedures discussed highlighting the differences and advantages of our procedure. The final outcome is shown and we reviewed the literature as well.

Keywords: macrodactyly, gigantism, toes, cruciate

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0005

1 – Department of Plastic Surgery, King Fahad Hospital; Tabuk, Kingdom Saudi Arabia.
* – Corresponding author: mtaifour1@yahoo.com


Macrodactyly or gigantism of the toes is a rare congenital anomaly [1-3]. There are two types of the condition: first is the true macrodactyly which is always congenital, and there is the pseudo macrodactyly which occurs in partial gigantism, von Recklinghausen’s disease, Ollier’s disease, Maffucci’s syndrome, Klippel-Trenaunay-Weber syndrome and congenital lymphedema [2]. Temtamy further divided true macrodactyly into two types (a) macrodactyly simplex congenita in which the digit is bigger at birth and grows in proportion (the static type) and (b) progressive lipomatous macrodystrophy in which the digit is bigger at birth, but the subsequent growth is greater and out of proportion [2]. Diagnosis is obvious and can be reached even in utero [1].

Treatment is surgical and aims at size reduction and shortening of the toe with preservation of the cosmetic appearance and comfortable shoe fitting [5,6,8].

Case report

A 22 year-old female presented to our clinic with macrodactyly of the 2nd and 4th toes of her right foot (Figure 1). She has had her right 3rd toe amputated previously in another hospital. Following all the appropriate and routine preoperative measures she was taken to the operating room and under general anesthesia and a thigh tourniquet the plan for debulking and shortening of the affected toes were carried out as shown in Figure 2. First the two circumferential incisions were planned to carefully preserve the digital neurovascular bundles. Then the skin between these incisions was excised leaving behind the vessels intact. Next, two v-shaped incisions were made on the plantar and dorsal aspects of the toe to join the circumferential wound rim proximally. This was repeated with two inverted v-shaped incisions joining the rim from the distal axis (Figure 2).

Figure 1 The right foot showing megadactyly of the second and fourth toes. The scar of the site of amputated middle toe is clear.

Then all the skin and deep tissue within the v–shaped incisions were excised to debulk the enlarged toe and through the same wound, a segment of the affected middle phalanx excised. Finally, the wound was closed in a cruciate fashion with a K-wire insertion to maintain the digit in a rectus position. At a two-year postoperative follow-up, the result was satisfactory with the toes shortened, debulked and the nails preserved [Figure 3]. With no recurrence the patient is happy having no problems wearing her shoes comfortably and painting her nails.

Figure 2 Depicting the cruciate incision on the dorsum of the enlarged toe.

Discussion

Macrodactyly is a rare congenital anomaly with no known etiology [1,2]. Affected individuals experience difficulties in fitting shoes and are embarrassed by the unsightly cosmetic appearance of the enlarged digit [4, 5].

Surgery offers the best solution to this problem and many procedures have been described, all aiming at size reduction and shortening of the affected digit with preservation of the nail in most of the recent procedure [4-10].

The technique we described here meets the three objectives mentioned above with good final functional and cosmetic results (Figure 3).

Figure 3 Final results three months postoperatively showing the foot from dorsal view (a) , and planter view (b). With good results with the nail preserved.

Fatemi et al described similar technique for the hand , but in two children where they included the distal joint to arrest bone growth[10]. We did not perform an arthrodesis as our patient is an adult and no further bone growth is expected. The main difference between our method and that of Fatemi et al is that we added two v-shaped incisions proximal to the circumferential wound and further two inverted v-shaped incisions distally (Figure 2). This facilitates debulking of the enlarged toe and at the same time allowed us for easy resection of the bone. Fatemi used only the circumferential incision which we think is suitable in their cases as there was less tissue to debulk [10].

Other methods for nail preservation were described but not without complications. The Tsuge procedure preserves the nail but some patients reported a skin bump on the dorsal aspect of the digit [6]. Free nail graft was also tried but the graft survival was compromised by the poor fatty bed, devascularized nail graft, and long term discomfort at the nail [6-8].  Transfer as described by Dautel and others produce good cosmetic results but due to the rigid nail plate, the interphalangeal joint was stiff [9]. We think our method adds a new option for the surgeon in dealing with this problem, its main advantages over other described nail preserving procedures is that the v- and inverted v-shaped incisions facilitates debulking of the affected digit and at the same time allow bone resection.

References

  1. Khanna N, Gupta S, Khanna S, Tripathi F. Macrodactyly. Hand. 1975;7(3):215-22.
  2. Minguella J, Cusi V. Macrodactyly of the hands and feet. Int Orthop. 1992;16(3):245-9.
  3. Yüksel A, Yagmur H, Kural BS. Prenatal diagnosis of isolated macrodactyly. Ultrasound Obstet Gynecol. 2009;33(3):360-2.
  4. Hop MJ, Van der biezen JJ. Ray reduction of the foot in the treatment of macrodactyly and review of the literature. J Foot Ankle Surg. 2011;50(4):434-8.
  5. Ahn JH, Choy WS, Kim HY, Lee SK, Lee SH. Treatment of macrodactyly in the adult foot: a case report. Foot Ankle Int. 2008;29(12):1253-7.
  6. Morrell NT, Fitzpatrick J, Szalay EA. The use of the Tsuge procedure for pedal macrodactyly: relevance in pediatric orthopedics. J Pediatr Orthop B. 2014;23(3):260-5.
  7. Sabapathy SR, Roberts JO, Regan PJ, Ramaswamy CN. Pedal macrodactyly treated by digital shortening and free nail graft; a report of two cases. Br J Plast Surg. 1990;43(1):116-9.
  8. Uemura T, Kazuki K, Okada M, Egi T, Takaoka K. A case of toe macrodactyly treated by application of a vascularised nail graft. Br J Plast Surg. 2005;58(7):1020-4.
  9. Dautel G, Vialaneix J, Faivre S. Island nail transfer in the treatment of macrodactyly of the great toe: a case report. J Foot Ankle Surg. 2004;43(2):113-8.
  10. Fatemi MJ, Forootan SK, Pooli AH. Segmental excision of the distal phalanx with sparing of neurovascular bundle in macrodactyly: a report of two cases. J Plast Reconstr Aesthet Surg. 2010;63(3):565-7.

A rare presentation of posterior compartment abscess in a diabetic patient: A case study

by Anthony Romano DPM/PGYIII1, Kaitlyn L. Ward DPM/PGYIII1,  Byron Hutchinson, DPM FACFAS1*

The Foot and Ankle Online Journal 11 (1): 4

This case outlines the management of a 61-year-old undiagnosed diabetic female who presented to the emergency department with signs and symptoms consistent with an acute Achilles rupture. The patient was referred to the foot and ankle clinic for routine management. Due to inconsistent clinical findings and progressive worsening of status in clinical exam, additional tests were ordered which revealed a 11.4 cm abscess in the posterior compartment of the right leg and an intact Achilles tendon. The patient underwent a staged incision and drainage with removal of all nonviable tissue resulting in a 4 cm x 1.4 cm defect. She underwent negative pressure wound VAC therapy resulting in full closure of the wound. This treatment led to resolution of the infection, limb salvage and preserved limb functionality.

Keywords: leg abscess, diabetes mellitus, Achilles tendon rupture, infection

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0004

1 – Franciscan Foot & Ankle Institute, Federal Way, WA
* – Corresponding author: byronhutchinson@chifranciscan.org


We present a unique case in which an undiagnosed diabetic patient presented to the emergency department with symptomatology and history consistent with an acute Achilles tendon rupture. Despite having no constitutional symptoms, the patient was found to have a large abscess of the posterior compartment of the right lower leg.

This case report describes the diagnostic tests, surgical intervention and wound care techniques that eventually led to resolution of the infection and preserved limb functionality. It also draws attention to the fact that uncontrolled diabetes has the propensity to allow for large-scale infections in patients that have no open wounds or obvious sources of infection.

Diabetes mellitus (DM) presents a wide variety of systemic complications for affected patients. Of interest to this case is the diabetic individual’s reduced ability to mount an immune response, thereby masking the constitutional signs and symptoms of infection (fever, tachycardia, hypotension and tachypnea) [1]. In the previously undiagnosed patient, this abnormal presentation may delay and/or prevent proper diagnosis and treatment. The primary mechanism of immunosuppression is due to the altered structure and function of the diabetic polymorphonuclear cells, monocytes and macrophages compared to non diabetics [2,3]. The diabetic patient is also at an increased risk for infection as certain microorganisms become more virulent in a high glucose environment [4]. Microorganisms also demonstrate an increased adherence to diabetic cells as compared to non diabetic cells [5,6]. For this reason, physicians caring for diabetics need to have a high index of suspicion for possible infection even if vital signs and lab results remain within normal ranges, or if no clear source of infection is apparent [1,6].  

Case Report

A 61-year-old Caucasian female presented to the emergency department due to increasing right calf pain, tenderness, swelling and inability to bear weight. Per the emergency department physician’s notes, the patient reported stepping out of an RV when she heard a pop and felt like her Achilles tendon was “overstretched”. She was not able to plantarflex on initial exam. No other injuries were reported. She denied fever, chills, nausea or vomiting. Vital signs were as follows: Blood pressure (BP) 158/75, Pulse 114, Temperature (Temp.) 36 °C (96.8 °F), Respiration rate (RR) 16 bpm, blood oxygen saturation (SpO2) 95%.

Pertinent past medical history included obesity and hypertension. She reported prior hand ganglion cyst excision, temporomandibular joint surgery and tonsillectomy. Her family medical history was remarkable for maternal diabetes and maternal aortic valve disease. She was a former smoker (1 pack/day, quit 5 years prior) and consumed 1-2 alcoholic beverages a month.

The review of systems upon arrival in the emergency department was negative. No abnormal integumentary findings were noted, specifically rash or erythema. Physical exam was positive for calf tenderness with palpation. A positive Thompson test was also documented. Vascular status was intact. Radiographs were ordered and revealed no bony abnormality or evidence of acute fracture (Figures 1a and b). The patient was diagnosed with an acute right Achilles tendon rupture and subsequently discharged. She was given a prescription of Vicodin and Ibuprofen and instructed to follow up with podiatry within a week.

Figure 1a and b Lateral (a) and AP (b) radiographs obtained in emergency room at initial presentation revealed no bony abnormality or evidence of acute fracture.

The patient followed up as instructed two days later at the foot and ankle clinic.  She stated that she developed a blister to her right posterior heel and noticed redness to her right calf. She rated her pain as 10/10. She denied nausea, fever, vomiting, chills and diarrhea. Vital signs were as follows: BP 155/89, Pulse 89, Temp. 36.7 °C (98.1 °F), RR 16, SpO2 96%.

On physical exam, she was neurovascularly intact. Significant global non-pitting edema was noted to the right ankle. A superficial bulla was noted to right posterior heel with serous drainage. Erythema was also present involving the posterior leg and foot. The musculoskeletal exam was positive for extreme guarding to right lower extremity. There was a negative Thompson’s test, in contrast to what the emergency department provider had documented. There was suspicion for infection; however, no obvious portal of entry was evident.

The patient’s diagnosis was then modified to acute right Achilles tendon rupture with cellulitis. The cellulitis was thought to have stemmed from the bulla secondary to traumatic edema. The patient was placed in a CAM boot, instructed to perform daily dressing changes to the bulla and to return to clinic in two days for re-evaluation. A venous duplex was ordered and reported as negative for deep vein thrombosis. An MRI was also ordered at that time due to suspicion of infection.

Figure 2 Sagittal sections from MRI revealed 114 mm large posterior compartment abscess. Intact Achilles tendon demonstrated (a-c). Axial bilateral T2 MRI showing the fluid collection in the right posterior compartment (d).

The patient returned to the podiatry clinic two days later. She stated she had been compliant with non-weight bearing and dressing changes. She reported a perceived increase in posterior heel edema. Her vitals were as follows: BP 163/89, Pulse 94, Temp. 36.3 °C (97.4 °F), Resp. 15, SpO2 95%.  

Upon repeat clinical exam, the patient remained neurovascularly intact and extreme tenderness along the posterior lower leg was noted. Erythema and edema had worsened. Redness extended from her heel to the knee, both anterior and posteriorly. Expressible purulence was noted from the bulla which had increased in size and spread to her lateral heel. The posterior heel at the Achilles insertion site was enlarged and there was noticeable fluctuance, indicating an underlying abscess.

A CBC was ordered and revealed a WBC count of 17,700 with a left shift. Although the patient had no previous diagnosis of DM, her fasting glucose was 268 mg/dL with an HbA1C of 10.5%.  ESR was 105 and CRP was 23.7. Cultures were taken from the purulent bulla and revealed methicillin resistant staphylococcus aureus bacteria.

The patient was admitted to the hospital and started on IV Vancomycin. The previously ordered MRI revealed an 11.4 cm fluid collection present in the posterior compartment of the leg (Figure 2a-d). The Achilles tendon was fully intact with no signs of rupture (Figure 2c).

The patient was consented for an incision and drainage of the purulent bulla in the operating room to be performed the following day. The incision and drainage was performed with the patient in the prone position. After an appropriate sterile prep was achieved, attention was directed to the bulla at the Achilles tendon insertion on the posterior aspect of the right heel where a stab incision was made (Figure 3). The stab incision was extended proximally until purulent drainage ceased at the level of the mid-calf.

Approximately, 75 cc of purulent drainage was evacuated from the leg. Three liters of normal saline was used for irrigation of the leg. Upon completion of the procedure, major muscular and tendinous structures, namely the Achilles tendon, were noted to be viable. The infection was confined to the posterior compartment only. The macerated, non-viable skin where the original bulla had been located was excised leaving an approximately 4 cm x 1.4 cm void over the Achilles tendon insertion [Figure 4]. The wound was reapproximated using a combination of retention sutures and a vessel loop to reduce tension to the area (Figure 4). The wound was then packed and covered with a sterile dressing. Daily packing changes were performed with a repeat washout of the leg performed 72 hours later.

Figure 3 Purulent drainage from the bulla on the posterior leg upon stab incision.

Figure 4 Postoperative clinical appearance, demonstrating the extent of the incision required to ensure complete evacuation of the purulence. Vessel loop employed in a crisscross fashion in order to relieve tension. Note void with exposed Achilles tendon.

At the second wash-out, all purulence was noted to be absent and all muscular and tendinous structures remained viable. Partial primary closure was performed at the proximal aspect of the incision. The distal portion could not be closed. A vessel loop in a crisscross fashion was again employed to assist with reapproximation. Vacuum assisted closure therapy of the wound (wound VAC) was then initiated over the exposed Achilles tendon and along the incision. The patient’s WBC normalized three days postoperatively. The patient was medically managed for her undiagnosed diabetes.

Figure 5 Granulation tissue beginning to cover exposed Achilles tendon.

Figure 6 Clinical appearance 26 months postoperatively: Complete granularization and re-epithelialization over posterior wound.

Wound VAC changes were performed every other day while the patient was hospitalized. Upon discharge from the hospital, the patient received daily infusions of intravenous (IV) vancomycin for two weeks and all dressing changes were performed by enterostomal therapists. Although the infection had been eradicated, the challenge of keeping the exposed Achilles tendon viable for limb functionality remained.

Results

Over the next several weeks, the patient remained non-weightbearing and continued wound VAC therapy. At four weeks postoperatively, granulation tissue began to form over the tendon (Figure 5). The tendon appeared viable throughout the entire process; however, there was noticeable contracture during this period of non-weight bearing. The patient continued this course with regular wound VAC and dressing changes at a wound care center. At approximately four months postoperatively, complete granulation over the Achilles tendon and skin re-epithelialization was noted. No additional surgical intervention was needed.

Upon complete closure of the wound, the patient began physical therapy to regain ankle range of motion, strength and stability. After eight weeks of therapy, she was able to attain adequate ankle dorsiflexion. She remains completely healed with a functional limb 26 months post initial presentation (Figure 6).

Discussion

To our knowledge this is the first case report of deep posterior leg compartment infection in an undiagnosed diabetic patient initially misdiagnosed as an Achilles tendon rupture. On initial presentation to the emergency department and initial follow-up at the podiatry clinic, the patient’s large infection was masked due to the fact she was diabetic, albeit undiagnosed. She did not exhibit any constitutional symptoms of infection including fever, tachycardia, hypotension, or tachypnea. Additionally, there was no obvious portal of entry for the infection at the time of presentation.

In this case, there were key steps that ultimately led to limb salvage. The first was made by the emergency department physician by stressing the importance of prompt follow-up at the foot and ankle clinic for immediate management. The second key step was the foot and ankle physician performing the repeat physical exam from presentation to the emergency department. The negative repeat Thompson test led the provider to consider a broader differential diagnosis (Achilles tendon rupture with cellulitis vs deep vein thrombosis vs infection). Additional tests were then ordered to help narrow the differential even though the patient wasn’t demonstrating any constitutional signs of infection.

The two day follow up period as ordered by the foot and ankle specialist facilitated a prompt diagnosis and admission to the hospital immediately after review of the newly ordered labs and imaging. The timely diagnosis, admission, and incision and drainage ensured that the infection did not spread to other compartments or render the Achilles tendon nonviable.

Following initial management, additional steps were also taken to ensure full future functionality of the limb. The repeat incision and drainage allowed appropriate assessment of the infected structures prior to definite closure to ensure limb viability. The decision to maintain daily infusions of IV antibiotics for two weeks postoperatively prevented recurrence and non-weight bearing status allowed for appropriate granulation tissue to form over the tissue void and exposed tendon. Alternative wound care products which may have resulted in faster would closure were unavailable due to the patient’s insurance. Despite this limitation, wound VAC therapy was successful at gaining full would closure.

The final step which ensured limb viability and functionality was the referral to physical therapy in order to address the acquired equinus contracture. This referral was purposefully delayed until full would closure was achieved as early mobilization may have resulted in wound opening, and compromised healing, ultimately prolonging the course of treatment.

In conclusion, diabetic infections present unique challenges; however, when the proper precautions are taken limb salvage can be achieved.

References

  1. Geerlings SE and Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 1999 Dec;26(3-4):259-265.
  2. Tater D, Tepaut B, Bercovici JP, Youinou P. Polymorphonuclear cell derangements in type 1 diabetes. Horm Metab Res 1987;19:642-647.
  3. Moutschen MP, Scheen AJ and Lefebvre PJ. Impaired immune responses in diabetes mellitus: analysis of the factors and mechanisms involved in relevance to the increased susceptibility of diabetic patients to specific infections. Diabetes Metab 1992;18:187-201.
  4. Hostetter MK. Perspectives in diabetes. Handicaps to host defense. Effects of hyperglycemia on C3 and Candida albicans. Diabetes 1990;29:271-275.
  5. Andersen B, Goldsmith GH and Spagnuolo PJ. Neutrophil adhesive dysfunction in diabetes mellitus; the role of cellular and plasma factors. J Lab Clin Med 1988;111:275-285.
  6. Geerlings SE, Brouwer EC, Gaastra W, Verhoef J and Hoepelman AI. The effect of glucose and pH on uropathogenic and non-uropathogenic escherichia coli: studies using urine from diabetics and non-diabetics. J Med Microbiol 1999;48:535-539.
  7. Deresinski S. Infections in the diabetic patient: strategies for the clinician. Infect Dis Rep 1995;1:1-12.

Choice of surgical treatment for patients with arthrosis of the ankle joint

by Kirill S. Mikhaylov1, Vladimir G. Emelyanov2, Alexandr Yu Kochish3, Aleksandr A. Bulatov4

The Foot and Ankle Online Journal 11 (1): 3

The purpose of this study was to justify the algorithm of rational choice of surgical treatment in patients with arthrosis of the ankle joint, based on a comparative analysis of risk factors for poor results after surgery involving ankle fusion and ankle arthroplasty. We evaluated the efficiency of ankle fusion (63 patients) and ankle joint replacement (71 patients). All patients were divided into 2 groups – prospective (6, 12 and 24 months) and retrospective (3, 5, 7 and 10 years). The results were evaluated with the help of a visual analogue scale (VAS) and the 100-point AOFAS scale; we also performed X-ray examinations. The longest follow-up period was 10 years. We found that the desirable angles of ankle fusion ranging from 900– 950 could reduce the chance of the rapid progression of arthritis in the joints of the middle part of the foot. For ankle joint replacement we identified a significant risk factor for the most frequent complication, which was aseptic instability of the implant components. From the results of our analysis we suggest an algorithm of surgical treatment in patients with terminal stage arthrosis of the ankle joint.

Keywords: ankle joint, arthrosis of the ankle joint, ankle arthroplasty, ankle fusion, risk factors of poor treatment outcomes

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0003

1 – Cand. Sci (Med), researcher, Vreden Russian Research Institute of Traumatology and Orthopaedics, Saint Petersburg, Russia.
2 – Cand. Sci (Med), head of traumatology and orthopaedics department № 19, Vreden Russian Research Institute of Traumatology and Orthopaedics.
3 – Dr. Sci. (Med), Professor, deputy director for research and academic affairs, Vreden Russian Research Institute of Traumatology and Orthopaedics.
4 – Cand. Sci (Med), Vreden Russian Research Institute of Traumatology and Orthopaedics, department № 19.
* – Corresponding author: web2@mail.ru


The improvement of methods of surgical treatment for patients with late stages of deforming arthrosis of the ankle joint is one of the priority goals of modern traumatology and orthopaedics [1,2]. Currently, patients with the specified pathology undergo two main types of surgery: the first is ankle joint arthrodesis which has been used since the beginning of surgical orthopedics and the second is total ankle replacement (TAR) which has been used in clinical practice since the 1970s [3,4] and quickly became an accepted method. According to the literature both specified methods of surgical treatment have advantages and disadvantages and also show different results in the present day compared with the past. Therefore the choice of one of these methods presents certain difficulties. Indications and contraindications for performing either of these surgeries are discussed in the following articles [5-9].

Surgeries of each type are quite often followed by complications and pathological states that substantially worsen the result of treatment in both the short and long term. In particular, after ankle joint fusion patients often develop degenerate and dystrophic changes in joints of the middle part of the foot and in addition, compensatory loads of the overlying large joints of the lower extremity lead to increased development of a pain syndrome [7]. Operations involving TAR increase the risk of future development of a number of pathological states such as destruction of the established prosthesis designs, aseptic instability of their components and a deep periprosthesis infection [10-12]. Therefore, introduction of TAR surgeries has been approached cautiously in clinical practice around the world. Indeed, according to the German register of operations, arthrodesis of the ankle joint is carried out approximately 3 times more often than its endoprosthesis replacement; the number of annually established endoprostheses of the ankle joint is about 1300 [13].

On the other hand, the relevant literature also has suggestions from some orthopaedists to greatly expand the indications for arthroplasty of the ankle joint [14,15]. In particular, there are publications describing operations with the angles of varus or valgus deformities in this joint over 20° [16-18], at the site of tumoral damage of the tibia or talus [19], at defects of a talus [20] and also at the fracture of an earlier arthrodesis of the ankle joint [21-23].

The analysis of literature on this subject has convinced us that the comparative efficiency of operations of an ankle fusion and TAR, especially regarding long-term performance, and also risk factors of the development of a number of pathological states, are insufficiently studied and need to be further investigated. Here, we have discussed the choice of a method of surgical treatment for patients with late stages of deforming arthrosis of the ankle joint based on the analysis of significant risk factors of unsatisfactory outcomes. The investigation of the practical importance of the above unresolved questions was one of the purposes of this study.

In addition, we attempted to justify an algorithm for the choice of a surgical treatment of patients with late stages of deforming ankle joint arthrosis, on the basis of a comparative analysis of risk factors for unsatisfactory outcomes after ankle fusion and TAR.

Materials and Methods

We performed an analysis of the most common noninfectious complications and unsatisfactory outcomes of treatment after these 2 surgeries to detect significant risk factors in 2 clinical groups of patients during the period from 2003 to 2014. The first of these groups (63 patients) underwent biarticulated arthrodesis of the talocrural and subtalar joints using the interlocked intramedullary nail. The second group (71 patients) underwent TAR using 3 implants of the third generation: Mobility (DePuy) 27, Hintegra (NewDeal) 37, and STAR (Waldemar Link) 7. Gender and age characteristics of patients of the 2 specified clinical groups are provided in Tables 1 for comparison.

Group Ave age (years) Sex Total
М F
1 53,8±5,8 30 (47,6%) 33 (52,4%) 63 (100%)
2 48,1±4,2 29 (40,9%) 42 (59,1%) 71 (100%)

Table 1 Age and sex of patients of the first clinical group.

Radiological examination was used to diagnose the deforming arthrosis of the talocrural and subtalar joints for all 63 patients of the first clinical group and was based on the classification of Kellgren et al [24]. At the same time we established that 7 (11.1%) patients had stage II with expressed pain syndrome, 31 (49.2%) patients had stage III and 25 (39.7%) patients had stage IV. Among patients of the second group, 15 (21,1%) patients had stage II, 41 (57,8%) patients had stage III and 15 (21,1%) patients had stage IV of arthrosis of the ankle joint.

Of note, the reasons for the deforming ankle joint arthrosis in patients of both clinical groups, including injuries and disease were similar, both in aetiology, and in share ratios; therefore correct comparisons could be made.

Taking into account how the results of the surgeries were assessed and the availability of information for unsatisfactory outcomes, patients of the first and second groups were allocated to 2 prospective (49 and 31 patients) and 2 retrospective (14 and 40 patients) subgroups. The corresponding examinations of patients in the prospective subgroups were conducted at 6, 12 and 24 months, and in the retrospective subgroups  after 3, 5, 7 and 10 years after treatment. For all patients, we carried out an objective and radiological inspection of the feet including an X-ray analysis with the necessary projections and patients also completed scores for VAS and AOFAS. Of note, all patients included in the research underwent surgery in the clinic by one team of surgeons in order to avoid differences in the result of treatment due to different operational techniques and equipment.

Results

In the prospective subgroup of the first clinical group 2 years after surgery for a biarticular arthrodesis of the ankle joint and subtalar joints, also AOFAS (less than 50 points) was recorded 9 (18.4%) the unsatisfactory results of the carried out treatment on scales VAS (more than 6 points). At the same time, for 3 patients unsatisfactory results were caused in the 12 months after treatment by an unsuccessful arthrodesis in the talocrural and subtalar joints that necessitated carrying out repeated arthrodesis. Also, 6 other patients with poor clinical and functional outcomes of treatment have been associated with a 2-year period of postoperative osteoarthritis in the joints of the middle part of the foot, accompanied by severe pain syndrome and dysfunction of the feet which had undergone surgery.

Additionally, the analysis of the angles of ankylosis of the ankle joint in the sagittal plane showed that 4 of these 6 patients had a pathological condition; this angle ranged from 101° to 105°, which is confirmed by the radiographs in Figure 1. The other 2 patients with this pathology showed that the corners angles of ankylosis of the ankle joint ranged from 96°–100° and had angles of 90°–95°; these unsatisfactory outcomes were not noted until 2 years after surgical treatment (Table 2).

Figure 1 The ankylosis of an ankle joint at an angle of 101°; arthrosis of joints of the middle part of the foot in an 82-year-old patient with pain syndrome (7 points on a scale VAS), 2 years after surgery.

The studied parameters Fusion angle The average for the group
90–95 96–100 101–105
VAS 2.5±0.4 2.6±0.3 2.8±0.3 2.6±0.3
AOFAS 77±3.5 75±3.6 70±3.6 74±3.5
Numbers of patients 7 (15.2%) 28 (60.9%) 11 (23.9%) 46 (100%)

Table 2 Outcomes in patients of the first clinical group 2 years after surgery, indicating the fusion angle.

In the analysis of the end result of treatment in the retrospective subgroup of the first clinical group, we found that 5 years after surgery of a biarticular arthrodesis the average scores for VAS and AOFAS were worse (R <0.05) for patients with the angle of an ankylosis of 101°–105°, in comparison with patients for whom this corner ranged from 90°–95°.

The analysis of treatment outcomes showed that in all circumstances the best clinical functional results for patients of the first clinical group were achieved with ankle joint ankylosis corners in the sagittal plane from 90°–95°, and the corresponding corners with values within 101°–105° were in fact significant risk factors for unsatisfactory treatment outcomes (Table 3).

Angle VAS AOFAS
Bad

7–10

Satisfactory

5–6

Good

2–4

Bad

1–50

Satisfactory

51–74

Good

75–100

90– 95 6 (13%) 1 (2,3%) 2 (4,3%) 5 (10,9%)
96–100 2 (4.3%) 24(52.2%) 2 (4.3%) 2 (4.3%) 24(52.2%) 2(4.3%)
101– 105 2 (4.3%) 7(15.2%) 2 (4.3%) 4 (8.7%) 7 (15.2%)
Total 4 (8.7%) 37(80.4%) 5(10.9%) 6 (13%) 33(71.7%) 7(15.2%)

Table 3 Qualitative index for 2-year treatment results using the AOFAS and VAS scales depending on the angle of fusion.

For patients of the second clinical group, the most frequent reason for unsatisfactory treatment results from 6 months until 10 years post-surgery was an aseptic instability of components of the installed ankle joint endoprostheses. Therefore, special attention was paid in our work to the detection of significant risk factors of this emerging pathological state. We found that in the prospective subgroup of patients radiological signs of instability of the established designs were observed 2 years after the surgery in 6 (19.4%) of 31 patients under clinical supervision. However, the presence of a severe pain syndrome and essential decrease in functionality which necessitated carrying out a repeat operation (fusion) was reported only by one (3.2%) patient of the prospective subgroup.

Figure 2 The result 5 years after total ankle replacement (left side) in a 42-year-old patient with use of a Hintera implant (NewDeal): a) radiological signs of instability of an endoprosthesis: the slight shift backwards of a tibial component and a sagging of a talus component due to decreased height of a talus; b) satisfactory functional result: 3 points on a VAS and 69 points on the AOFAS.

In the retrospective subgroup from 3 to 10 years after treatment radiological signs of instability of components of ankle joint endoprostheses of were recorded for 16 (40%) of 40 observed patients. In addition, using scores of VAS and AOFAS, patients with this complication had worse average values of these indicators (R <0.01), than other patients of the subgroup. However, the revised procedures including removal of unstable implants with the subsequent biarticulate fusion of the ankle and subtalar joints were only carried out by interlocking intramedullary nails in 7 (43.8%) of 16 patients, as the other 9 patients preferred to keep the established endoprostheses. It should be particularly noted that these 9 patients had only radiological signs of instability of the endoprosthetic components without their essential migration regarding bone bed, and they had a satisfactory functional result of treatment.

An example of a satisfactory functional result can be observed (Figure 2) 5 years after TAR with the presence of radiological signs of instability of the established construction. However, it is necessary to note that the patient did not demand a high functional load from the operated ankle joint.

Special attention in our research was paid to the detection of risk factors for developing aseptic instability of endoprostheses of the ankle joint. A search was carried out concerning 2 groups of the factors noted in the relevant literature [4,15,17,22,25,26,27,28]. The first group of risk factors included various deformations of the bones forming the ankle joint. The second group included the age of patients, the related physical activity, and also functional loads of the operated joints as significant factors. It should be noted that such analyses were carried out separately in the prospective subgroup (31 patients) and in the retrospective subgroup (40 patients). The results are presented in Tables 4 and 5.

Anamnesis Age of patients, years Total
20–39 40–54
Change of a distal metaphysis of tibia 3 (50%) 3 (50%)
Fracture of ankle bones 1 (16,7%) 1 (16,7%)
Fracture of a collision bone 1 (16,7%) 1 (16,7%)
Deforming ankle joint arthrosis 1 (16,7%) 1 (16,7%)
Total 1 (16,7%) 5 (83,3%) 6 (100%)

Table 4 The anamnesis and age of patients who had aseptic instability of ankle joint endoprostheses 2 years after surgery.

Anamnesis Age of patients, years Total
20–39 40–54 55 and older
Change of a distal metaphysis of tibia 3 (18,8%) 3 (18,8%)
Fracture of ankle bones 2 (12,5%) 2 (12,5%) 4 (25%)
Fracture of a collision bone 6 (37,5%) 6 (37,5%)
Deforming ankle joint arthrosis 1 (6,3%) 1 (6,3%) 1(6,3%) 3 (18,7%)
Total 3 (18,8%) 12 (75%) 1(6,3%) 16 (100%)

Table 5 The anamnesis and age of patients who had aseptic instability of ankle joint endoprostheses from 3 to 7 years after surgery.

The analysis showed that the risk of aseptic instability of endoprosthesis components of the ankle joint during all periods of observation was clearly associated with previous fractures of the bones forming the joint. As can be seen from Tables 3 and 4, such fractures occurred in 5 of 6 patients with this pathological condition in the prospective sub-group and in 13 of 16 patients in the retrospective subgroup. In addition, we observed that the vast majority of these states (21 of 22 or 95.5%) occurred in patients under the age of 55 years. The proportion of patients with aseptic instability of the implant in the subgroup of patients younger than 55 years was 34.4% (21 of 61) and in the subgroup of 55 years and older only 10% (1 of 10). It should also be noted that in 19 (86.4%) of the 22 cases of aseptic instability of endoprosthesis components, these patients performed activities involving high functional loads on the ankle joint in the postoperative period.

Analysis of the models installed as ankle joint implants in patients diagnosed with aseptic instability of the implant did not reveal any significant advantages for any 1 of the 3 used structures. Studied implants of the third generation have a similar clinical effectiveness with respect to the development of the discussed pathological conditions.

The analysis revealed the following significant risk factors of aseptic instability of endoprosthesis components of the ankle joint: previous fractures of bones forming the joint, an age of up to 55 years, and a high functional load on the operated joints in the postoperative period.

The results of our study and related data of specialized scientific publications helped to substantiate and propose the algorithm for choosing a rational method of surgical treatment of patients with terminal stages of deforming arthrosis of the ankle joint. The algorithm involves the separation of diagnostic procedures in 2 stages and in sequence, as shown in the diagram (Figure 3).

Figure 3 The algorithm for choosing the method of surgical treatment of patients with terminal stages of deforming arthrosis of the ankle joint.

At the beginning of the patient examination, we performed an assessment of the current stage of deforming arthrosis of the ankle joint. These data, along with the severity of pain, are crucial to the choice between conservative or surgical treatment of such patients. Particular attention should be given to the severity of the deformity. It is known that gross deformation of bones forming the ankle joint, in particular varus or valgus angles greater than 10°, practically excludes the possibility of adequately installing the endoprosthesis components and does not predict a long and successful outcome. Therefore, patients with these gross deformities of the ankle joint should be encouraged to undergo fusion of the affected joints.

Other patients with no such deformations can be considered as candidates for surgery involving endoprostheses of the ankle joint. However, it is advisable to assess the presence of risk factors for the development of pathological conditions that cause poor outcomes of surgical treatment such as aseptic instability of the endoprosthesis components. These factors, according to the proposed algorithm (Figure 3), should be evaluated at the second stage of selecting a rational method of surgical treatment. Among the risk factors for this pathology the age of the patients is very important. Therefore, it is recommended initially to divide all patients into 2 age groups: under 55 years and older (Figure 3).

When evaluating the older age group, patient history of bone fractures of the ankle joint should be specifically assessed. The surgery for replacement of the ankle joint is only recommended for patients without an identified history of fractures, and if there is such a history it is expedient to look for arthrosis of the affected joints. In the group aged under 55 years, the selection method for surgery should be generally performed in accordance with the same principles as that of the older patient group. However, the assessment of risk factors for the development of instability of installed implants needs to be performed more fully and carefully.

Therefore, within the presented algorithm (Figure 3). we propose initially to allocate the patients under the age of 55 years into 2 subgroups depending on the presence or absence of a history of fractures of the ankle joint. In the presence of such fractures, it is advisable to offer the patients arthrosis ankle joint. In their absence it is also important to rate their level of anticipated physical activity and consequently, possible future functional load on the operated joints. High physical load on the joints was defined in our studies as one of the important risk factors of aseptic instability of the endoprosthesis components of the ankle joint. Therefore, patients with high demands for future functional loads on the affected joints should be made aware that fusion of the ankle joint has a more reliable positive long-term outcome. In cases of expected moderate physical activity of the treated joints, arthroplasty of the ankle joint can be recommended even at a young age.

Discussion

We have analysed unsatisfactory results of surgical treatment of patients with terminal stages of deforming arthrosis of the ankle joint, and found a number of risk factors for their development. These factors were different and specific for each of the 2 main types of surgery. In our view, these factors can and should be considered primarily at the stage of diagnosis and while determining the severity of pathological changes in the affected ankle joint. This is important both for preoperative planning and during surgery involving fusion or TAR.

The most clinically significant pathology observed a year or more after arthroplasty of the ankle joint is aseptic instability of components of the installed implants. According to authors from other countries, the proportion of patients with this pathological condition varies from 3% to 13.7% in the first 5 years after surgery and from 16% to 32% in the period from 5 to 10 years after the treatment [26,29,30]. In our observations, the proportion of patients with radiographic signs of instability of the endoprosthesis components was 19.4% after 2 years and 40% after 3 to 10 years. However, severe clinical symptoms arising from this condition and requiring repeat surgery were observed much less frequently: 3.2% after 2 years and 17.5% in the later periods of observation. It should be noted that the proportion of patients with aseptic instability of the implants in our study were slightly higher because patients purposely went to a clinic, where endoprosthesis treatment for the ankle joint was undertaken. In addition, patients without this pathology did not always agree to be tested over a long-term period after surgical treatment. In a retrospective sub-group of patients (40 observations) analysis of cases of aseptic instability of the endoprosthesis components of the ankle joint showed that the greatest number of them (and accordingly the highest percentage of the number of patients) was recorded 3 years (5 cases or 17.2%) and 5 years (10 cases or 43.5%) after the operations were performed. After 7 years of observations, these figures decreased (about 1 case of 8 or 12.5%) and when 3 patients were examined after 10 years, signs of this pathological condition were absent.

Among the risk factors for the development of the aseptic instability and, consequently, unsatisfactory outcomes for ankle joint replacement, the proposed algorithm first took into account the severity of deformities in the affected ankle joint. In the literature a direct link between the development of aseptic instability of endoprostheses of the ankle joint and deformations of the articular surfaces of the tibia and talus, and also varus or valgus deviations of more than 100 have been reported [8,15,18,27,28]. In addition, many orthopaedists have reported a higher incidence of this pathology among people of a young age [4,22,25] and also in patients with increased functional load on the previously operated ankle joint, related to high physical activity [26,29]. These findings of other authors were fully confirmed in our study, in particular as illustrated by the data given in Tables 3 and 4. Therefore, all of these risk factors were considered significant and included in the algorithm.

In addition, our study identified opportunities to prevent some of the complications and pathological conditions that lead to poor results of surgical treatment, because of certain requirements during the 2 types of operations. In particular, we found that during surgery for ankle joint arthrodesis the aim should be to form an ankylosis with an angle in the sagittal plane of 90°–95°. If this is achieved, it is possible to prevent the rapid development of deforming arthrosis in the joints of the middle part of the foot, which often leads to decreased function and severe pain in the late postoperative period.

The algorithm presented in the present article is based on results of our own research and data from relevant literature. We have considered significant risk factors of the most frequent pathological states arising after surgeries of fusion and TAR and resulting in poor outcomes. At the same time we have shown that the desirable angles of an ankylosis of the ankle joint in the sagittal plane varying from 90°–95° can reduce the probability of rapid progression of arthrosis in joints of the middle part of the foot. For TAR surgery significant risk factors of development of the most frequent reason of unsatisfactory results of treatment (aseptic instability of the components of the installed designs) were revealed. If these are present, the algorithm assumes refusal of Total Ankle Replacement in favour of the more reliable surgery of ankle joint fusion. However, TAR can be indicated for patients aged 55 years and older and without anamnesis of fractures of the bones forming the ankle joint, and also for younger patients corresponding to these criteria but not expecting high loads on the operated joints.

We hope that practical use of the presented algorithm for selection of a method of surgical treatment will promote the prevention of a number of the pathological states predetermining the poor results of surgeries of both discussed types and will help to improve the outcomes of expeditious treatment.

References

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  5. Jordan RW, Chahal GS, Chapman A. Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review. Adv Orthop. 2014;2014:986285. doi: 10.1155/2014/986285. Epub 2014 Aug 21. Review. PubMed PMID: 25215242; PubMed Central PMCID: PMC4158286.
  6. Koryshkov N.A., Larionov S.V., Murashova N.A., Sobolev K.A. ANESTHESIA IN SURGERIES ON THE FOOT AND ANKLE (REVIEW).  Traumatology and Orthopedics of Russia. 2012;(3):118-126. (In Russ.) DOI:10.21823/2311-2905-2012–3-118-126
  7. Chou LB, Coughlin MT, Hansen S Jr, Haskell A, Lundeen G, Saltzman CL, Mann RA. Osteoarthritis of the ankle: the role of arthroplasty. J Am Acad Orthop Surg. 2008 May;16(5):249-59. PubMed PMID: 18460685.
  8. Glazebrook MA, Arsenault K, Dunbar M. Evidence-based classification of complications in total ankle arthroplasty. Foot Ankle Int. 2009 Oct;30(10):945-9. doi: 10.3113/FAI.2009.0945. Review. PubMed PMID: 19796587.
  9. Jiang JJ, Schipper ON, Whyte N, Koh JL, Toolan BC. Comparison of perioperative complications and hospitalization outcomes after ankle arthrodesis versus total ankle arthroplasty from 2002 to 2011. Foot Ankle Int. 2015 Apr;36(4):360-8. doi:  10.1177/1071100714558511. Epub 2014 Oct 30. PubMed PMID: 25358807.
  10. Borkosky SL, Mankovecky M, Prissel M, Roukis TS. Polyarticular sepsis originating from a prior total ankle replacement. Clin Podiatr Med Surg. 2013 Jan;30(1):97-100. doi: 10.1016/j.cpm.2012.08.007. Epub 2012 Sep 26. Review. PubMed PMID: 23164442.
  11. Schipper ON, Haddad SL, Pytel P, Zhou Y. Histological Analysis of Early Osteolysis in Total Ankle Arthroplasty. Foot Ankle Int. 2017 Apr;38(4):351-359. doi: 10.1177/1071100716682333. Epub 2016 Dec 1. PubMed PMID: 28367690.
  12. Lee AY, Ha AS, Petscavage JM, Chew FS. Total ankle arthroplasty: a radiographic outcome study. AJR Am J Roentgenol. 2013 Jun;200(6):1310-6. doi: 10.2214/AJR.12.9649. PubMed PMID: 23701070.
  13. Kostuj T, Preis M, Walther M, Aghayev E, Krummenauer F, Röder C. [German Total Ankle Replacement Register of the German Foot and Ankle Society (D. A. F.) – presentation of design and reliability of the data as well as first results]. Z Orthop Unfall. 2014 Oct;152(5):446-54. doi: 10.1055/s-0034-1382933. Epub 2014 Oct 14. German. PubMed PMID: 25313699.
  14. Bibbo C. Controversies in total ankle replacement. Clin Podiatr Med Surg. 2013 Jan;30(1):21-34. doi: 10.1016/j.cpm.2012.08.003. Epub 2012 Oct 6. Review. PubMed  PMID: 23164437.
  15. Coetzee JC. Surgical strategies: lateral ligament reconstruction as part of the management of varus ankle deformity with ankle replacement. Foot Ankle Int. 2010 Mar;31(3):267-74. doi: 10.3113/FAI.2010.0267. PubMed PMID: 20230710.
  16. Schuberth JM, Christensen JC, Seidenstricker CL. Total Ankle Replacement with Severe Valgus Deformity: Technique and Surgical Strategy. J Foot Ankle Surg. 2017 Mar 3. pii: S1067-2516(17)30030-3. doi: 10.1053/j.jfas.2017.01.030. [Epub ahead of print] PubMed PMID: 28268144.
  17. Hobson SA, Karantana A, Dhar S. Total ankle replacement in patients with significant pre-operative deformity of the hindfoot. J Bone Joint Surg Br. 2009 Apr;91(4):481-6. doi: 10.1302/0301-620X.91B4.20855. PubMed PMID: 19336808.
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Conservative surgical management in an extreme diabetic foot case

by JM García-Sánchez1, A Ruiz-Valls1, A Sánchez-García1, A Pérez-García1

The Foot and Ankle Online Journal 11 (1): 2

Diabetes mellitus is one of the most prevalent diseases worldwide and an important cause of morbidity and mortality. Of relevance, due to its complicated management, morbidity and cost associated, is the diabetic foot. Here we present a case of a 51 year-old male diagnosed with  long-standing decompensated Diabetes mellitus with a 2 year history of a foot ulcer. After debridement of the ulcer, preservation of the bony structure was achieved by covering it with a fillet flap. The therapeutic management in patients with advanced diabetic foot should be individualized based on patient characteristics. Oftentimes, conservative amputations entail the need of complex surgical techniques, however, it allows the patient to retain their independence and an improved quality of life.

Keywords: diabetic foot, ulcer,  diabetes mellitus, fillet flap

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0002

1 – Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitari i Politèctnic la Fe, Valencia, Spain.
* – Corresponding author: alejruvall@gmail.com


Diabetes mellitus (DM) is one of the most common diseases worldwide with a global prevalence of 8.5%, and increasing every year. Sustained hyperglycemia derives in numerous complications, mostly caused by macro and microangiopathy [1], of special importance are Diabetic Foot Ulcers (DFUs).

Diabetic Foot Ulcers represent an important healthcare issue due to the elevated morbidity, complexity of its management and elevated costs associated with this disease [2]. DFUs have a global prevalence of 6.3% and have a higher prevalence in DM type 2 and male patients [3]. Neuropathy is the most important risk factor for the development of DFUs. Moreover, the addition of different factors such as the of loss of skin integrity, existence of foot deformities (Hallux Valgus, Charcot’s arthropathy, etc.), and peripheral vascular disease ultimately lead to the formation of DFUs [4].  

The course of healing the DFU is arduous due to the impaired cicatrization and granulation processes in these patients, which is frequently complicated with superimposed infections.  Some cases, especially when osteomyelitis is present, require limb amputation as the sole therapeutic option. However, it is imperative to remain as conservative as possible, since amputations suppose a great psychological and functional impact that can pose a decrease in quality of life.

Here we present a case of a patient with a complicated DFU that was managed with conservative surgical treatment without undergoing amputation.

Case Report

A 51 year old male was first evaluated in the outpatient setting for a 1-year history of a DFU on the right foot. His medical history included a atrial fibrillation, dyslipidemia, hypertension, and a poorly controlled insulin-dependent DM with development of retinopathy, nephropathy and cardiac disease. The patient was also an active smoker with over 30 years of smoking history. A transmetatarsal amputation from the 2nd to the 5th toes on the right foot was previously carried out in a different hospital due to inadequate healing of a DFU. The surgical wound was complicated with a dehiscence, which remained as an ulcer that impeded the patient from ambulating.

The physical examination showed a lateral subluxation of the first metatarsophalangeal joint, an ulcer on the amputation stump, with granulation on the base and no inflammatory signs, proliferative signs, dermatosclerosis or hyperpigmentation of the skin edges (Figure 1). Additionally, the patient presented signs of chronic venous insufficiency, hence the induration hindered lower limb distal pulse examination. Plantar protective sensation was severely diminished.

An MRI was performed, which showed findings suggestive of osteomyelitis of the remnants of the 3rd, 4th and 5th toe, the anterior portion of the cuboid bone, and the navicular bone of the right foot. These findings were later confirmed with a gamma scan. The CTA scan showed bilateral permeability of the aortoiliac, femoropopliteal, and distal infrapopliteal trunks.

Given these findings a new surgical approach was conducted, with resection of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone (Figure 2), a fillet flap from the hallucis and the plantar skin was performed to provide coverage of the cutaneous defect (Figure 3).

The pathology report indicated the presence of a verrucous squamous cell carcinoma. However, no infiltrative component was seen in the specimen and the margins were disease free.

Figure 1 A 51 year old male with a lateral luxation of the metatarsophalangeal joint of the hallucis (Left). Ulcer presence on the amputation stump (Right). Frontal (Left) and plantar (Right) view.

Figure 2 Surgical excision of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone.

The postoperative course was uneventful with a favorable healing towards the resolution of the surgical wound, which was supported by a tight glucose control and a smoking cessation program. Two months after the intervention the patient has a healthy-appearing stump that allows ambulation (Figure 4).

Figure 3 Foot defect after resection (Left). Coverage with a fillet flap from the hallucis and the plantar skin (Right).

Figure 4 Postoperative result two months after the intervention. Frontal (Left) and posterior (Right) view.

Discussion

Complicated diabetic foot poses a risk of amputation and early mortality in diabetic patients. With a 10-fold increase in amputation rate of the lower limb for diabetic patients, according to WHO. Furthermore, the mortality rate is also increased 3-fold within a year of the amputation compared to non-amputated diabetic patients [6].

The course of DFUs is usually difficult owing to a deficient granulation and cicatrization, and commonly complicated with superimposed infections. DFUs that persist over time can sometimes lead to malignant transformation; most frequently squamous cell carcinoma [5]. All of these result in wide surgical excisions and, sometimes inevitably amputations.

There are different amputation levels of the lower limb, those that result in above-the-ankle amputation are considered major amputations, and those that spare the ankle are defined as minor amputations [7]. Regarding amputation-related-mortality, Evans et al, showed a mortality of 20% in the 2-year follow-up after a minor amputation compared to the 52% seen in patients who underwent a major amputation [8].

Numerous studies support the need to be as surgically conservative as possible, with limb conservation procedures, since energetic output is increased progressively as an amputation becomes more proximal [9]. Moreover, several patients present with several comorbidities, as in the case presented, and are non-candidates for rehabilitation after major amputations. Hence, preservation of the majority of the limb with partial minor amputations can result in an improved functional status [10]. Likewise, minor amputations may confer the possibility to ambulate for short distances without the need of prosthesis, allowing the patient to perform many daily-living activities, and thus, having a major impact on quality of life [8].  In some cases, in order to achieve minor amputations, the complexity of the surgical techniques is considerably higher and are often unconventional procedures that surgeons might not be familiarized with. In the case presented, due to patient conditions, impaired sensibility, presence of osteomyelitis, and the condition of the foot soft tissues, initially the decision was to perform a major amputation. Nevertheless, the scarce possibilities for adaptation to a prosthetic device and ambulation after amputation, a more conservative approach was planned. Therefore, preservation of the non-osteomyelitic bone and coverage of the skin defect with an adipocutaneous fillet flap from the hallux and the plantar surface provided a stable coverage without any added morbidity.

The fillet flap is well described in the literature as an alternative for large defects that require coverage without sacrificing the length of the extremity [11].  It provides superb mechanical stability plus an added quasi-normal sensitivity to the stump. Additionally, utilizing plantar tissue also provides an excellent, and long-lasting, surface for the stump [12].

Conclusion

Diabetic patients with DFUs should undergo individualized treatment based on their characteristics. In certain cases, a more conservative amputation, despite being more technically challenging, allows the patient to have a better quality of life as well as more independence.

Conflict of interest declaration

No conflict of interest to disclose.

References

  1. Pérez NF, Pérez CV, Llanes JA. Las amputaciones de dedos abiertas y cerradas: su evolución en el pie diabético. Rev Cuba Angiol Cir Vasc. 2010;11(1):89–100.
  2. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017 Mar;49(2):106–16.
  3. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS One. 2015;10(5):e0124446.
  4. Allen L, Powell-Cope G, Mbah A, Bulat T, Njoh E. A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers. Ostomy Wound Manage. 2017 Jun;63(6):30–3.
  5. Scatena A, Zampa V, Fanelli G, Iacopi E, Piaggesi A. A Metastatic Squamous Cell Carcinoma in a Diabetic Foot: Case Report. Int J Low Extrem Wounds. 2016 Jun;15(2):155–7.
  6. Hoffstad O, Mitra N, Walsh J, Margolis DJ. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care. 2015 Oct;38(10):1852–7.
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  8. Evans KK, Attinger CE, Al-Attar A, Salgado C, Chu CK, Mardini S, et al. The importance of limb preservation in the diabetic population. J Diabetes Complications. 2011 Jul;25(4):227–31.
  9. Czerniecki JM, Morgenroth DC. Metabolic energy expenditure of ambulation in lower extremity amputees: what have we learned and what are the next steps? Disabil Rehabil. 2017 Jan 16;39(2):143–51.
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  11. Chung S-R, Wong KL, Cheah AEJ. The lateral lesser toe fillet flap for diabetic foot soft tissue closure: surgical technique and case report. Diabetic Foot Ankle. 2014 Jan;5(1):25732.
  12. Janssen D, Adolfsson T, Mani M, Rodriguez-Lorenzo A. Use of a pedicled fillet foot flap for knee preservation in severe lower extremity trauma: A case report and literature review. Case Rep Plast Surg Hand Surg. 2015 Dec 23;2(3–4):73–6.

Effects of a foot orthosis custom-made to reinforce the lateral longitudinal arch on three-dimensional foot kinematics

by Shintarou Kudo1, Yasuhiko Hatanaka2, Toshihiro Inuzuka3

The Foot and Ankle Online Journal 11 (1): 1

There is extensive evidence of the benefits of a foot orthosis; however, it is dependent on the skill and experience of the clinician. The purpose of this study was to clarify the effects on 3D foot kinematics of a custom-made foot orthosis (CMFO) which reinforced the lateral longitudinal arch, without subjective assessments. All eighteen feet of nine normal volunteers who had a flat-foot deformity were included in this study. The CMFO was designed according to each participant’s foot shape using high-density polyethylene for the medial CMFO. The lateral part of the CMFO was then designed to cover the lateral longitudinal arch using polypropylene and was made to fit the medial CMFO. The full CMFO was defined as the medial CMFO together with the lateral CMFO. Eleven reflective skin markers were mounted over the anatomical landmarks of the foot and foot motion during the forward lunge without stride were recorded using eight infrared cameras; the spatial coordinates of those markers were then calculated. Differences between the three conditions: without CMFO, with medial CMFO and with full CMFO in displacement of all markers, were then calculated during the forward lunge. Medial movements of the third metatarsal base, and the medial and posterior top of the calcaneus with the full CMFO were significantly smaller than those with the medial CMFO. Therefore, the full CMFO which reinforced the lateral longitudinal arch could cause reduced movement of the rear-foot indicated by the calcaneus during the forward lunge. Our CMFOs demonstrate that changing the stiffness of the lateral part of the CMFO could reduce rear-foot motion in the medial direction without any form change. This might help with the manufacture of an appropriate CMFO without subjective assessment.

Keywords: custom made foot orthosis, lateral longitudinal arch, flat foot

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0001

1 – Department of Physical therapy, Morinomiya University of Medical Sciences Osaka, Japan
2 – Department of Physiotherapy, Suzuka University of Medical Science, Suzuka-City, Japan
3 – Sports Orthotic Laboratory
* – Corresponding author: shintarou.iimt@gmail.com


The foot is made up of the seven tarsal bones, five metatarsals, and fourteen phalanges. The human foot has three arches: the medial longitudinal arch, the lateral longitudinal arch, and the transverse arch, and these play three important roles. The first is to buffer the impact force during the loading response. Second is maintenance of the stability and support of the lower limb, and third is assistance in forward propulsion during locomotion. Dysfunction of the three arches of the foot leads to excessive mechanical stress on the lower limbs. Flat-foot deformity, which is defined as decreased height of the medial longitudinal arch with excessive foot pronation, has been linked to various conditions including medial tibial stress syndrome [1-3], anterior knee pain syndrome [4], Achilles tendinopathy [5, 6], and plantar fasciitis [7, 8].

Foot orthoses (FOs) are frequently-prescribed interventions for flat-foot deformity [9-11]. FOs generally aim to realign skeletal structures, alter movement patterns of the lower extremity during gait and most importantly, reduce symptoms associated with lower limb conditions [11,12]. Custom-made foot orthoses (CMFOs) are widely known as one of the conservative treatments for overuse injuries [13].

Several researchers have investigated the effects of CMFOs in producing positive clinical outcomes [14-17]. Previous studies have shown that CMFOs influence the biomechanics of the lower limb [10, 18-23]. In foot kinematics, many studies have shown that FOs which aim to support the medial longitudinal arch reduce the pronation of the foot [24, 25]. McLean, et al, reported that a 6-week intervention using semi-rigid CMFOs led to a significant decrease in maximum eversion angle and velocity of the rear-foot [26]. Moreover, a significant decrease in the maximum ankle inversion moment and angular impulse during the loading phase and impact peak has been reported with the use of a semi-rigid CMFO [26]. Kido, et al, assessed the effects of insoles which raised the medial longitudinal arch by 10 mm with an inner wedge for flat-foot deformity using subject-based three-dimensional (3D) computed tomography (CT) models [27]. They reported that therapeutic insoles significantly suppressed the eversion of the talocalcaneal joint. CMFOs for flat-foot deformity cause increased activity of the tibialis anterior and decreased activity of the peroneus longus during the contact phase of gait and increased activity of the tibialis posterior and decreased activity of the peroneus longus during midstance and propulsion phase [28]. A review by Landorf, et al, concluded that the CMFO is one of the effective interventions for heel pain [29].

Many types of CMFO are aimed at supporting the medial longitudinal arch, although the foot arch consists of three arches. Kudo, et al, reported that it is important for the 3D foot kinematics of the foot in flat-foot deformity to be maintained, not only with regard to the medial longitudinal arch but also the lateral longitudinal arch [30]. There is a great deal of evidence supporting the benefits of a foot orthosis; however, it is dependent on the skill and the experience of the clinicians, and it is unclear how the material and form used influence foot kinematics and lower limb kinetics. In the clinical setting, foot conditions during motion are assessed by motion observation which is not a quantitative assessment. Thus, the most important assessment used in the manufacture of foot orthoses lack an objective focus, and it is necessary to individually mold and paste the orthosis. Consequently there is a requirement to provide foot orthoses based on foot biomechanics without subjective assessments. The purpose of this study was to clarify the effects on 3D foot kinematics of CMFOs which reinforce the lateral longitudinal arch without subjective assessments.

Methods

All eighteen feet of nine volunteers (age; 20.6 ± 0.7 years, height; 162.6 ± 8.1 cm, weight; 54.7 ± 6.9 kg, male/female; 2/7) with flat-foot deformity were included in this study. Subjects did not have any pain of the lower limb, nor any pain history. The flat-foot deformity was defined as a score of more than five points on the Foot Posture Index version six (FPI-6) [31].  Ethical approval was obtained from the Morinomiya University of Medical Sciences and informed consent was obtained from all participants.

The foot shape was modeled using a foot impression box at the bench setting. A plaster foot model was created based on the foot impression, and the CMFO molded from the plaster foot model using high density polyethylene for the medial part of the CMFO (Figure 1-a). The lateral part of the CMFO which covered the heel and cuboid was created using polypropylene (Figure 1-b) and was made according to the medial CMFO. The full CMFO was defined as the medial CMFO mounted on the lateral CMFO.

Reflective skin markers were mounted over eleven anatomical landmarks which were the 1st, 2nd, and 5th metatarsal heads (MTH) and the 1st, 3rd, and 5th metatarsal bases (MTB), the navicular (NAV), the cuboid (CUB), and the medial, lateral and posterior top of the calcaneus (CALM, CALL, CALP). Foot motions during the forward lunge without stride were recorded using eight infrared cameras (VICON vero, VICON, Oxford, UK) at 100 Hz, and the spatial coordinates of the markers were calculated, while ground reaction forces were captured using two AMTI force plates at 1,000 Hz (BP600900, Advanced Mechanical Technology Inc., Watertown, MA, USA).

Figure 1 Picture of the CMFO. a: Medial CMFO b:Lateral CMFO c: Medial view of the medial CMFO d: Lateral view of the medial CMFO. The CMFO according own plaster foot model using the high density polyethylene as the medial CMFO (a,c,d). And the lateral part of the CMFO which was covered on the heel and cuboid using the polypropylene were made according to the full CMFO (b).

Figure 2 Forward range of motion. A: Starting position of the forward lunge involved standing upright with measurement foot stance one step forward. B: Whole plantar surface in contact with floor and the body weight was loaded on the forefoot.

Vicon Nexus software was used to reconstruct the three-dimensional coordinates of each marker during motion. Cut-off frequency was 10 Hz using a Butterworth digital filter. The starting position of the forward lunge involved standing upright in a stance with the measurement foot one step forward (Figure 2). The entire plantar surface was maintained in contact with the floor and approximately 70–80 percent of the body weight was loaded on the forefoot. Subjects were instructed to complete the forward lunge within 1 second or less, and they were allowed enough time to practice. Five repetitions of the forward lunge were performed.

Each marker was tracked from the starting position to the forefoot weight-loading position in which the lower leg was maximally-inclined forward and the displacement of each marker was calculated. The differences in the displacement of each marker among the three conditions of without CMFO, medial CMFO and full CMFO were analyzed using the Freedman test and the post-hoc Bonferroni test. Statistical analyses were performed using SPSS ver24 (IBM Corp., Armonk, NY, USA), and significance was set at P < 0.05.

Results

The three-dimensional movement of the markers is shown in Tables 1, 2, and 3. In the mediolateral direction (Table 1), all markers moved medially during the forward lunge, and almost all markers, with the exception of MTH5, showed a significant difference among the three conditions. Movements of the foot markers with the medial and full CMFO were smaller than those without the CMFO. Moreover, movements of MTB3, CALM, and CALP with the full CMFO were significantly smaller than those with the medial CMFO.

In the anteroposterior direction (Table 2), all markers moved forward during the forward lunge. Movements of the MTH2, MTB1, CUB, NAV, CALL and CALP markers were significantly different among the three conditions. Movements of the MTB1, CUB and NAV markers with the medial CMFO were significantly smaller than those without the CMFO, while the forward movement of the NAV with full CMFO was also smaller than that without the CMFO. The movements of the MTB1, CALL and CALM markers with the full CMFO were larger than those with the medial CMFO.

In the vertical direction (Table 3), all markers except the CALP, which was elevated, were reduced during the forward lunge. Movements of most of the markers except the MTH5, MTB5 and CALL were significantly different among the three conditions. The movements of the MTH2, MTB3 and CUB with the full CMFO were significantly larger than those without the CMFO. Movements of the CALM and NAV with full CMFO were significantly smaller than those without the CMFO. Movements of the MTH1, MTH2, MTB3, MTB1 and CUB with the full CMFO were significantly larger than those with the medial CMFO.

Without CMFO Medial CMFO Full CMFO p-value
MTH1 4.41 ( 3.09 5.66 ) 3.24 ( 2.10 4.94 ) † 2.59 ( 2.38 4.05 ) † <0.01
MTH5 2.69 ( 1.75 3.85 ) 2.08 ( 1.63 3.19 ) 2.18 ( 1.66 2.76 ) 0.31
MTH2 3.53 ( 1.87 4.25 ) 2.45 ( 1.43 3.62 ) † 2.30 ( 1.42 3.27 ) † <0.01
MTB3 4.32 ( 3.08 6.23 ) 3.69 ( 2.28 4.78 ) † 3.27 ( 1.90 3.78 ) † †† <0.001
MTB5 4.51 ( 2.88 6.19 ) 3.40 ( 2.27 5.00 ) † 3.26 ( 2.01 4.43 ) † <0.001
MTB1 4.88 ( 3.66 6.33 ) 3.79 ( 2.52 5.36 ) † 3.24 ( 2.03 4.26 ) † <0.001
CUB 3.73 ( 3.17 5.98 ) 2.92 ( 2.37 3.79 ) † 2.97 ( 1.67 3.61 ) † <0.01
NAV 5.64 ( 4.80 6.44 ) 4.60 ( 3.44 6.37 ) 4.37 ( 3.57 6.00 ) † <0.05
CALM 5.33 ( 3.99 6.72 ) 3.64 ( 2.60 5.50 ) † 2.76 ( 1.91 4.43 ) † †† <0.001
CALL 5.06 ( 4.65 6.91 ) 3.52 ( 2.99 4.00 ) † 3.15 ( 2.30 4.65 ) † <0.01
CALP 6.11 ( 4.42 7.33 ) 3.74 ( 2.63 6.33 ) † 2.63 ( 1.99 4.75 ) † †† <0.001

Table 1  The medial movement of the each makers [mm]. †:difference between without CMFO ††: difference between medial CMFO.

Without CMFO Medial CMFO Full CMFO p-value
MTH1 1.43 ( 1.14 2.91 ) 1.25 ( 1.02 1.99 ) 1.53 ( 1.03 2.05 ) 0.06
MTH5 1.17 ( 0.85 1.25 ) 0.94 ( 0.68 1.34 ) 0.79 ( 0.58 1.17 ) 0.21
MTH2 1.40 ( 1.06 2.35 ) 1.30 ( 1.02 1.69 ) 1.46 ( 0.70 1.94 ) <0.05
MTB3 4.44 ( 2.93 5.14 ) 3.06 ( 2.44 4.78 ) 4.16 ( 2.81 5.39 ) 0.06
MTB5 1.44 ( 1.09 2.57 ) 1.88 ( 0.81 2.64 ) 1.39 ( 0.88 1.96 ) 0.22
MTB1 4.32 ( 3.46 6.14 ) 3.74 ( 3.15 5.21 ) † 4.54 ( 3.50 6.52 ) †† <0.05
CUB 4.98 ( 4.06 7.42 ) 4.36 ( 3.55 6.48 ) † 4.94 ( 3.85 7.39 ) <0.01
NAV 5.56 ( 4.17 5.91 ) 4.19 ( 3.21 6.13 ) † 4.64 ( 3.47 6.10 ) † <0.05
CALM 5.70 ( 4.48 7.13 ) 4.60 ( 3.82 6.90 ) 5.75 ( 4.11 7.01 ) 0.14
CALL 3.86 ( 2.74 5.36 ) 3.38 ( 2.11 4.58 ) 4.56 ( 2.50 6.29 ) †† <0.05
CALP 3.76 ( 3.26 5.24 ) 3.27 ( 2.88 4.71 ) 4.11 ( 3.47 4.98 ) †† <0.05

Table 2 The forward movement of the each makers [mm]. †:difference between without CMFO ††: difference between medial CMFO.

Without CMFO Medial CMFO Full CMFO p-value
MTH1 2.65 ( 2.02 3.75 ) 2.30 ( 1.56 2.97 ) † 2.89 ( 2.31 3.41 ) †† <0.01
MTH5 1.23 ( 1.02 2.04 ) 1.23 ( 1.01 1.62 ) 1.28 ( 1.06 1.91 ) 0.57
MTH2 1.30 ( 1.00 1.73 ) 1.24 ( 0.76 1.46 ) 1.61 ( 1.28 2.03 ) † †† <0.05
MTB3 3.00 ( 2.48 3.99 ) 3.46 ( 2.79 3.98 ) 4.05 ( 3.25 4.97 ) † †† <0.001
MTB5 2.33 ( 1.87 3.15 ) 2.21 ( 1.47 2.92 ) 2.38 ( 1.50 2.70 ) 0.18
MTB1 3.75 ( 3.00 5.18 ) 3.48 ( 2.68 4.44 ) 4.09 ( 3.57 5.02 ) †† <0.01
CUB 3.35 ( 2.44 4.17 ) 4.21 ( 2.16 4.98 ) 4.33 ( 3.34 5.51 ) † †† <0.001
NAV 7.29 ( 5.43 10.21 ) 6.24 ( 4.59 8.65 ) † 6.69 ( 4.91 7.87 ) † <0.05
CALM 3.29 ( 2.43 4.94 ) 2.12 ( 1.49 3.22 ) † 2.18 ( 1.66 3.07 ) † <0.01
CALL 3.12 ( 2.39 4.59 ) 2.53 ( 1.80 3.45 ) 2.70 ( 2.28 4.98 ) 0.63
CALP 9.59 ( 7.59 12.05 ) 7.78 ( 6.82 10.36 ) † 10.02 ( 7.62 12.78 ) † †† <0.05

Table 3 The vertical movement of the each makers [mm]. †:difference between without CMFO ††: difference between medial CMFO.

Discussion

Medial movements of almost all markers with both forms of the CMFO were lower than those without the CMFO, and medial movements of the rear-foot indicated by the CALM and CALP markers with the full CMFO were smaller than those with the medial CMFO. Forward movements of the midfoot with the medial CMFO were significantly lower than those without the CMFO, and vertical movements of the medial foot markers MTH1, NAV and CALM were smaller than those without the CMFO.

Moreover, vertical movement of the forefoot with the full CMFO were larger than those with the medial CMFO or without the CMFO. However, there were slight differences (approximately 1 mm) among the three conditions in the forward and vertical directions. This suggests that the full CMFO which reinforced the lateral longitudinal arch could cause reduced movement of the hindfoot indicated by the calcaneus during forward lunge.  

The lateral longitudinal arch of the foot is composed of the calcaneus, the cuboid and the fifth metatarsal. It is supported by both a static stabilizer in the form of the long plantar ligament and dynamic stabilizers of the peroneus longus, peroneus brevis and abductor digitorum minimi. Keystones of the lateral and the medial longitudinal arch are the cuboid and the navicular, respectively. The lateral longitudinal arch is stiffer than the medial longitudinal arch, and its movements are smaller. Thus, collapse of the lateral longitudinal arch is rare. However, Fukano and Fukabayashi demonstrated that angular changes of the lateral longitudinal arch are greater than those of the medial longitudinal arch during single leg landing [32]. Noh, et al, reported that soccer players with medial tibial stress syndrome have an abnormal structural deformation with a larger decrease in both the medial and the lateral longitudinal arch [3]. We previously reported that the foot kinematics of flat feet with a history of foot pain are important to forward movements of the cuboid [30]. Therefore, we hypothesized that a CMFO which reinforced the lateral longitudinal arch would improve foot kinematics for flat-foot deformity.

Both a full and a medial CMFO could reduce medial movements of the rear foot. Mechanical overloading in flat-foot deformity has been controversial, however there are some reports which describe abnormal rear-foot kinematics (e.g. excessive rear-foot eversion or increased range of rear-foot eversion), abnormal foot and ankle kinetics (e.g. elevated joint moments or abnormal loading forces) and altered physical function (e.g. altered muscle activation and timing or increased energy consumption) [33, 34]. Therefore, both the CMFOs we provided have the effects of controlling foot kinematics in flat-foot deformity.

Mills, et al, investigated the biomechanical effects of three different types of orthoses (hard, medium and soft), and they showed that the least comfortable orthosis caused a greater increase in the control/support of the frontal plane for a mobile midfoot, while the opposite was true for a non-mobile foot [35]. The frontal plane movements consisted of both medial and vertical movements. The medial CMFO decreased the vertical movements of the midfoot more than the full CMFO. Therefore, the medial CMFO is likely to be more uncomfortable than the full CMFO. However, the full CMFO could not decrease the forward movement of the cuboid, nor could it increase the medial movements of the MTB3. Cuboid movements in flat feet of the previous study showed larger forward movements and smaller medial and vertical movements than those of normal feet [30]. This indicated that the foot motion of patients with flat feet was reduced in the frontal plane. Our CMFO could not induce controlled movement of the midfoot in the frontal or sagittal plane. The reason why our full CMFO could not control cuboid motion might be due to the form of the reinforcement part of the lateral longitudinal arch of the CMFO. It was necessary that the reinforced part of the lateral longitudinal arch was expanded in both distal and medial directions. However, the CMFOs we provide demonstrate that changing the hardness of the lateral part of the CMFO could reduce rear-foot motion in the medial direction without any change in form. This might help in the manufacture of CMFOs without subjective assessment such as motion observation.

There are two limitations to this study. Firstly, we did not assess the kinematics during locomotion. There have been some studies which investigated the kinematic effects of a CMFO during shod walking. However, in these studies the researchers also manufactured the shoes, and the rigidity of the shoes also provided some support to the medial side of the foot, affecting the biomechanical effects of the CMFO. Therefore, we investigated the kinematics during the forward lunge. Future studies will investigate effects of the CMFO during locomotion. The second limitation is the definition of flat feet. In our previous study, flat feet were defined as those with more than five points of the FPI-6 values and having a history of pain in the foot and ankle which was related to the flat-foot deformity [30]. However, in this study, none of the subjects had any history of foot pain. It is difficult to define normal feet, because normal feet without a collapsed medial longitudinal arch of the foot might be injured due to overuse syndrome, and there are many feet that did not have any pain, although the medial longitudinal arch of the foot had collapsed. Therefore, it is possible that some subjects diagnosed with flat feet in this study have normal function, although a lower medial longitudinal arch was observed.

Acknowledgment

This work was supported by JSPS KAKENHI Grant Number JP15K16408.

Funding declaration

Japan Society for the Promotion of Science (JSPS); KAKENHI (Multi-year Fund); Grant-in-Aid for Young Scientists (B).

Conflict of interest declaration

No conflict of interest.

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Winter 2017

Issue 10 (4), 2017


Effects of medial and lateral orthoses on kinetics and tibiocalcaneal kinematics in male runners
by Jonathan Sinclair


The use of unidirectional porous β-tricarcium phosphate in surgery for calcaneal fractures: A report of four cases
by Shigeo Izawa, Toru Funayama, Masashi Iwasashi, Toshinori Tsukanishi, Hiroshi Kumagai, Hiroshi Noguchi, Masashi Yamazaki


Spontaneous double tendon rupture of the ankle
by Jay Kaufman DPM, Alexander Newton DPM, Payel Ghosh DPM, Zachary Ritter DPM


Dual plating technique for comminuted second metatarsal fracture in the diabetic obese patient: A case report
by Sham Persaud DPM, MS, Anthony Chesser DPM, Karl Saltrick DPM


A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report
by Rajesh Kumar Chopra, Narendran Pushpasekaran, Sathyamurthy Palanisamy, Balu Ravi

A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report

by Rajesh Kumar Chopra1, Narendran Pushpasekaran2*, Sathyamurthy Palanisamy2, Balu Ravi2

The Foot and Ankle Online Journal 10 (4): 5

Closed midfoot dislocations are not uncommon injuries. The key to good functional outcomes is stable concentric reduction by understanding the injury pattern and early intervention to maintain the biomechanics of the foot. We report on a 20-year-old male, the presentation of a complex pattern of closed traumatic dislocation of the midfoot, managed by open reduction and internal fixation with Kirschner wires for six weeks. He did not show any evidence of instability or arthritis and had a foot function index of 94% at 14 months. The unique presentation of this midfoot dislocation is the separation of naviculocuneiform and calcaneocuboid joints. An entity that requires reporting in literature as it remains unclassified and to add to the spectrum of injuries caused by the deforming forces of foot.

Keywords: foot injuries, tarsal bones, open reduction, arthritis, foot function index

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0005

1 – M.S.(Ortho), professor, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
2 – M.S.(Ortho), resident, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
* – Corresponding author: drnaren247ortho@gmail.com


Closed traumatic dislocations of the midfoot are common injuries in level 1 and 2 trauma care [1]. Apart from the common Lisfranc, Chopart and talonavicular dislocations, swivel-type dislocations of the medial column involving the talus, navicular and cuneiforms, and lateral columns involving the calcaneus and cuboid bones have rarely been reported [2-4]. The proposed injury mechanisms to cause such injuries are dorsiflexion, plantar flexion, abduction and adduction forces or a combination of them [5]. However, involvement of both columns in the form of complete disruption of the naviculocuneiform and calcaneocuboid joints has been infrequently reported in the literature. We report this complex presentation sustained following a supination-abduction force.

Case report

A 20-year-old male, presented to the emergency department after a motor vehicle collision. He sustained a supination-abduction injury in a dorsiflexed foot and developed pain, deformity and swelling in the right foot. The forefoot was depressed and supinated in relation to the hindfoot with mild contusion and skin necrosis over the talonavicular prominence. An abnormal prominence was noted dorsally and medially at the naviculocuneiform joint. (Figures 1A and B). Distal pulses, toe movements and neurological examination were normal. There were no associated injuries in the body. The patient had no medical illness or neuropathies. Radiographs of the foot and ankle showed complete dislocation between the naviculo-cuneiform and calcaneocuboid joints with disruption of the calcaneo-navicular articulation. (Figures 2A and B). This pattern of injury has not been included in any classifications  available in literature.

Figure 1 showing the deformities-step at the naviculocuneiform  junction, forefoot supinated in relation to hindfoot. Pressure necrosis is seen over the navicular site.

Figure 2 Anteroposterior and Oblique views of right foot and ankle showing dislocation of the naviculocuneiform and calcaneocuboid joints (white arrow). Chip fracture of the navicular (black arrow), the site of attachment of calcaneonavicular ligament.

Under general anaesthesia, closed reductions were attempted with the knee flexed and the ankle in 15 degree plantar flexion. The deformity was initially exaggerated and reduction attempted by traction and manipulation opposite to the deforming forces. However, incongruent reduction required an open reduction through Ollier’s approach. The dorsal midtarsal ligament, lateral and plantar cuboideonavicular ligaments were found to be ruptured. Congruent stable reduction was achieved and secured with two 2mm Kirschner wires (K-wires) stabilizing the calcaneocuboid joint and two k wires fixating the medial two cuneiforms and the navicular under image intensifier control (Figures 3A and B). The ruptured ligaments were meticulously repaired. Additional immobilisation by below knee cast and non weight bearing was maintained for 6 weeks. With the removal of the K-wires, physiotherapy, partial weight bearing, medial arch support and controlled ankle motion boot were instituted. The patient had full weight bearing and a plantigrade foot at his 4 month follow-up. The patient had a mild restriction of subtalar motion and restriction of dorsiflexion by 5 degrees. He had no clinical or radiological signs of instability or arthritis and foot function index of 94% at 14 months (Figures 4A and B).

Figure 3 AP and oblique views of the foot and ankle. The navicular, the three cuneiforms and calcaneocuboid joints are concentrically reduced and fixed with K-wires.

Figure 4 Anteroposterior and oblique views of foot and ankle at 14 months follow-up showing normal alignment of arches and no arthritis.

Discussion

Closed midfoot dislocations are not uncommon presentations in level 1 or 2 trauma centers [1]. Apart from the common complex dislocations of Lisfranc and Chopart, isolated and swivel-type fractures and dislocations involving the medial column (talus, navicular and cuneiforms) and lateral column (calcaneus and cuboid) have rarely been reported [2-4]. However, the midfoot dislocations involving the separation of naviculocuneiform and calcaneocuboid joints are rare pattern of injuries infrequently reported in the literature (Table 1).

  Report Patient details Mode of injury Pattern Treatment Follow up Outcomes
1 Q. Choudry et al in 2007 [6]. 34/ male Fall of motorized palate over foot Naviculo- cuneiform subluxation and calcaneocuboid dislocation Closed reduction and immobilization for 6 weeks 15 weeks Good
2 y. chen et al in 2012 [7]. 64/ male Run over by car cuboid, medial and intermediate cuneiform fractures with naviculo-cuneiform and calcaneocuboid dislocation Open reduction and internal fixation of fractures 6 months Good
3 y. chen et al in 2012 [7]. 59/female Car accident left navicular, medial cuneiform and calcaneal fractures with calcaneal–cuboid, navicular–cuneiform and first tarsometatarsal joint dislocations Open reduction and internal fixation 3 months Chronic pain due to calcaneo cuboid instability
4 Our patient 20/male Fall from bike Isolated calcaneal–cuboid, navicular–cuneiform dislocation Open reduction and stabilization 14 months Good

Table 1 Review of reported naviculocuneiform and calcaneocuboid disruptions.

Main and Jowett had extensively studied the mechanisms of midtarsal injuries and proposed the various deforming forces causing the midtarsal fractures and dislocations [5] (Table 2).

Deforming forces Spectrum of midfoot injuries
1 Medial Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular).
2 Longitudinal In plantar flexed foot- navicular fractures.

In dorsiflexed foot- talus fractures, dorsal navicular dislocations.

3 Lateral Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular or naviculocuneiform with intact calcaneo-cuboid).
4 Plantar Fracture-sprains, fracture- subluxations or dislocations (chopart), plantar swivel dislocations.
5 Crush Fractures of mid tarsals.

Table 2 Mechanism of midfoot injuries [5].

Our case presents an unusual and complex pattern of injury in which plantar-abduction force at the midfoot caused the injury path through naviculocuneiform joint and calcaneocuboid joints causing complete dislocation of the three cuneiforms and cuboid articulations. This extends the spectrum of injury pattern caused by abduction deforming forces.

Obtaining concentric and stable reduction is of paramount importance to restore the biomechanics of the foot and prevent debilitating arthritis [8]. The management and prognosis of such complex midtarsal injuries in the literature have not been elaborated, except for a few case reports favoring open reduction and internal fixation [9]. In our case, the patient had good outcomes treated by open reduction and Kirschner wire fixation.

Conclusion

We report this case of traumatic closed dislocation of naviculocuneiform and calcaneocuboid joints following supination abduction deforming forces. Such injuries require further reporting to understand the spectrum of midfoot injuries. Congruent and stable fixation is of paramount importance to maintain proper biomechanics of foot.

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