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Rapid learning curve with telehealth; a clinical audit at the time of ‘flattening the infection curve’ during the coronavirus (SARS Cov-2) pandemic

by Angela M Evans, PhD, FFPM RCPS (Glasg)

The Foot and Ankle Online Journal 13 (3): 7

The current coronavirus pandemic has necessitated rapid and substantial changes to clinical practice in all areas of healthcare to protect patients, healthcare professionals, and administrative staff. Whilst telehealth per se, is not new, it is new for podiatry. Consulting online is still consulting, and it is important that in the flurry to connect a platform, adapt camera angles, audio and lighting, that the ‘basics’, i.e. consent, privacy, clinical records, and sound diagnoses-based plans, remain intact.

Keywords: telehealth, coronavirus, Covid-19

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0007

1 – Discipline of Podiatry, College of Science, Health and Engineering, La Trobe University, Victoria 3086, Australia
* – Corresponding author:

It is known that telehealth services may be as effective as face-to-face interventions [1], and that telehealth has the potential to address many of the key challenges to providing healthcare in a country like Australia, with its substantial land area and widely dispersed population [2], and yet e-health to address allied health needs of people living in rural and remote Australia, appears unrealised [3]. The internet has also opened new opportunities in health care, from remote diabetes glycaemia monitoring, to smart sensors for diabetic foot ulcers, and medical device integration [4].

History-taking is (almost) everything with telehealth

Thorough history taking is always the primary information source of consultations, with an estimated 80% of information relevant to the clinical encounter may be derived from gaining a good history (5). Telehealth may further enhance the importance of history taking, given that some physical cues and the opportunity for direct clinical examination are diminished. This is fundamental to all clinical consulting, and the message here, is to spend time on an initial history, with a purposeful, methodical and reasoned manner, active listening, and simultaneously build online rapport with patients, who will be variably familiar with screen-based communication. Using a basic SOAP structured history method, it is helpful to summarise the consult verbally with patients, and ensure that all SOA-Plans are complete, understood, and shared decisions.

Whilst instrumentation treatment is not availed using telehealth, do not underestimate a patient’s capacity to imitate your on-screen methods, e.g. apply a basic taping for heel pain. Similarly, coached self-examining and provocation tests are very feasible, e.g. percussion of posterior tibial nerve at medial ankle, palpation of lateral ankle ligaments, range of motion. It is useful to demonstrate, as well as verbally guide. Foot posture, lower limb stance positions, gait and footwear, are all easily visible. In my paediatric patients, there is always a parent to assist with balance and strength tests, as well as gait-based neuromotor assessments. Exercises can be demonstrated, and then watched to fine-tune the imitation as needed. More specific details can be accessed from the listed resources.


Patients of all ages to be very appreciative of availing telehealth as safe access to clinical care, and everyone has been immensely cooperative, punctual, and engaged with this novel consultation experience. Postage of items to patients reduces physical contact. If sending any form of insole or foot orthoses, an emailed/SMS photo/tracing of the sock-liner (and shoe size) enables trim-to-fit, prior to post/delivery.

Given the necessary physical distancing, it is even more important to provide clear guidelines as to what is expected, what is acceptable, and what is not (e.g. ingrown nail resection will be sore initially, should subside over 24 hours, should not have increased pain, redness, or purulence). It is also important for communication access (email, phone, follow up telehealth appointments) to be provided, as people are often anxious amid this pandemic. As always, if there are doubts or suspicions, arrange to check-in after a few days, this can be very important as the following case illustrates.

Case synopsis

Day 2 of telehealth, and 12-month review of a 14.5 year-old girl with an intellectual disability, with her mother. A patient since age seven years, with very flatfeet, which were painful before use of prefabricated foot orthoses and better shoes. She had been schooling at home, barefoot consistently, and complaining of heel pain for the last month, limiting walking. Generally, an active girl, participating in Special Olympics soccer, and swimming.

Listen: the girl described heel pain most of the time, not liking to walk at all, and finding shoes and orthoses uncomfortable (previously relieving foot pain).

Think: what is probable here? Too old for apophysitis, less active with school at home, unusual location for juvenile arthritis symptoms, possibly plantar strain given flatfeet and increased barefoot time, verruca unlikely given pain when non-weight-bearing (although worse with weight-bearing).

Look: location is plantar-mid heel pad, nil to see re: redness/swelling, the mother was asked to compare left/right for temperature (assessed as same); mother said skin ‘drier/harder’ – mother was asked to squeeze skin area – not provoked, tender adjacent), asked for close up photo re: skin striations.

Listen further: the child was asked more about the pain and responses included: it hurts at night, is mild when wakes up in the morning, it hurts to touch, and it hurts to wear shoes

List diagnostic probabilities for heel pain presentation – the main suspicion was infection, given constant pain and location, with the main concerns being osteomyelitis, sepsis, and bone tumor. Whilst one of the least frequent etiologies of pediatric heel pain, it is crucial that abnormal and unusual clinical patterns are recognized. The following ‘diary’ outlines

  • Day 1: advised to see the GP regarding pain, suggest blood tests, imaging, medication
  • Day 2: the GP prescribed antibiotics (five-day course, bd); x-rays nil, sonography detected ‘fluid area adjacent to, and larger than, the painful site’
  • Day 10: the mother called as the child was no better; advised to return to GP regarding blood tests, medication review, further imaging (e.g. MRI)
  • Day 12: GP prescribed another antibiotic (7-day course, qd)
  • Day 17: follow-up via phone, and the mother reported the child as ‘grumpy’, the heel less red, pain static; advised to return to GP (offered to liaise with GP; acknowledging that GPs are also adapting to pandemic circumstances)
  • Day 20: follow-up via phone as agreed, had seen GP who ordered another sonographic scan, with review in three days. Mother reported that the child’s foot-leg appeared more ‘swollen’ and pain remained, child ‘out of sorts’; mother concerned (and me). Discussed and advised mother to take child to children’s hospital outpatient department; provided a letter summarizing presentation and main clinical concerns, i.e., cellulitis, osteomyelitis, sepsis.
  • Day 21: Mother sent a text, thanking for referral and letter. Blood tests normal, awaiting MRI. Significantly, L foot/leg now cool to touch, hence complex pain also now considered.
  • Day 23 (today): phoned to follow-up with mother; awaiting results of MRI, and specialist appointment. Foot infection, and complex pain are current medical considerations.
  • This is clearly an unusual presentation, and one not to dismiss. The main diagnostic information was provided with the history taking via telemedicine, reducing likelihood of more usual conditions, and increasing clinical suspicion of more serious factors. The circumstances amid the novel coronavirus pandemic, coupled with a stoic child with communication limitations, required diligent follow up.


This audit has shown that whilst patient numbers have diminished, the usual range of presentations has continued. Of the 49 patients seen in the three weeks of reduced consulting hours, 32 were telehealth consultations, and 17 were direct clinical consultations. Using telehealth, effectively enabled 29/49 patients to stay at home, and observe the Australian Government’s physical distancing advice. The 17 telehealth consultations which then required direct clinical consultations, were mostly adult patients with foot pain (12/17). Telehealth consultations were dominated by painful presentations (18/32), followed by pediatric reviews and follow up (11/32). The pediatric list (age range 2 – 16 years) included: musculoskeletal and elite sports, hypermobility (hypotonia), intellectual disability, developmental delay, Marfan syndrome, LHONs (mitochondrial disorder), CRPS (complex pain), ingrown nails, heel infection. Adult presentations (age range 16 to 71 years) have been mostly musculoskeletal, neurological, diabetes, foot pain (see Table 1).

Whilst telehealth has been enabling, it has been far from ‘business as usual’ (see Table). Overall, my case-load has dropped to less than 50%, admittedly, facilitated by encouraging non-essential visits to be deferred. My decision has been to physically see patients, only if they will be worse off without doing so, e.g. infections, pain. In this extraordinary time of a novel virus, it is important to be aware for Covid-19 foot signs; it may not be a common chilblain:

Given this novel experience, and that of my patients, telehealth has been invaluable, and enabled good consultation with patients of all ages, presenting with a wide range of conditions, and requiring podiatry care during this globally unprecedented time. I suspect that telehealth will remain part of clinical practice post this coronavirus pandemic.


  1. Speyer R, Denman D, Wilkes-Gillan S, Chen Y, Bogaardt H, Kim J, Heckathorn D, Cordier R: Effects of telehealth by allied health professionals and nurses in rural and remote areas: A systematic review and meta-analysis. J Rehabil Med 2018, 50:225–235.
  2. Bradford NK, Caffery LJ, Smith AC: Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health 2016, 16:4268.
  3. Iacono T, Stagg K, Pearce N, Chambers AH: A scoping review of Australian allied health research in ehealth. BMC Health Services Research 2016:1–8.
  4. Basatneh R, Najafi B, Armstrong DG: Health Sensors, Smart Home Devices, and the Internet of Medical Things: An Opportunity for Dramatic Improvement in Care for the Lower Extremity Complications of Diabetes. J Diabetes Sci Technol 2018, 12:577–586.
  5. Paley L, Zornitski T, Cohen J, Friedman J, Kozak N, Schattner A: Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Arch Intern Med., 2011, 171:1394–1396.

Further Resources

  1. Blog link:
  2. Australian Podiatry Association telehealth-podiatry:
  3. Royal Australian College of General Practitioner telehealth guidelines:
 ID no. Age Gender With parent Old/New Visit purpose Assessment Diagnosis Action Attend clinic Comments
  years M/F/O Y/N O/N Review Foot Ok Review Y/N  (specific to ID)
          complaint Shoes Pain Refer  
            Gait condition postage  
ave 19.4 12 – M 22 – Y 4 – New Paed review – 8 Msk – 16 (* 13) Review 1m – 14 Y – 3
min 2 20 – F 28 – Old Pain – 18 JH/S – 9 Review 6-12m – 12 N – 29
max 71 Referred – 3 NDIS – 4 Footwear – 9
Follow up – 3 Dev delay – 5 Exercises – 19
0 – 5 6 Marfan – 1  Refer – 1
6 – 10 7 LHONs – 1  Postage – 6
11 – 15 4  17 paed CVA – 1 Orthoses (9):
16 – 30 6   CRPS – 1 prefabricated – 7 Patient total – 49
31 – 50 5   *RA – 1 bespoke – 2 Telehealth consults – 32
51 – 70 3   *Rural – 1 Clinical (2 paed) – 17
>70 1  15 adult elite sport – 3 . Diabetes risk – 1
Infection – 1 . Msk/orthotic/pain – 12
. Ingrown nails – 4
* adults

Table 1 Summary of 49 consultations, 1-24, April 2020. Telehealth consultations comprised 32/49 patient cases. Abbreviations: Msk – musculoskeletal, JH/S – joint hypermobility/syndrome (painful), NDIS – National Disability Insurance Scheme funded, Dev delay – developmental delay, Marfan – Marfan syndrome, LHONs – Leber’s Hereditary Optical Neuropathy, CVA – cerebrovascular accident or ‘stroke’, CRPS – complex regional pain syndrome, RA – rheumatoid arthritis.


Limb salvage for calcaneal osteomyelitis with pin to bar external fixation 

by Aaron Chokan, DPM, FACFAS1; Les P. Niehaus, DPM, FACFAS2; Joseph Albright, DPM, AACFAS3; David Bishop, DPM, AACFAS3; Frederick Garland, DPM3

The Foot and Ankle Online Journal 13 (3): 6

The prevalence of heel ulcers is as high as 18% in hospitalized patients. Due to lack of underlying muscle, protective fat pad, and constant pressure, poor tissue perfusion to the area inhibits healing. Concomitant comorbidities such as diabetes, neuropathy, and peripheral arterial disease provide added challenges to limb salvage. The incidence of surgical intervention in a diabetic patient with foot ulcers is 97%, with 71% going on to some form of amputation. Our study includes 10 patients with underlying calcaneal osteomyelitis who were treated with partial calcanectomy with primary flap closure and offloading pin to bar external fixation. Primary closure was achieved in 100% of patients with an average time of 106 days (ranging from 43 to 205 days), with no pin tract infections, revisional bone debridement, or subsequent BKA/AKA. Average follow-up time was 20.9 months (ranging 12 to 45 months).  Partial calcanectomy with offloading pin to bar fixation allows for cost-effective fixation, accelerated healing, and a satisfying functional result in true limb salvage cases.

Keywords: Limb salvage, calcaneal osteomyelitis, external fixation, infection

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0006

1- Ohio Foot & Ankle Center, Stow, OH
2- Alliance Foot and Ankle Center, Alliance, OH
3- Aultman Alliance Community Hospital, PGY-3, Alliance, OH

Pressure ulcers to the heel are recognizably difficult to treat due to their anatomic location, and the prevalence of heel ulcers is as high as 18% in hospitalized patients [1]. The plantar and posterior aspects of the calcaneus are constant areas of pressure in both the sedentary or standing position. The lack of underlying muscle and common atrophy of its protective fat pad hinders tissue perfusion to the area. The associated diagnoses including diabetes, neuropathy, and arterial disease inhibits normal healing. Calcaneal ulcers are also accompanied by higher costs and have proven to be two to three times less likely to heal in comparison to forefoot ulcers [2]. Many of these patients are quickly consulted for a below knee amputation as a definitive treatment. Patients are able to use a prosthesis for a quick return to function, however, a BKA amputation increases energy expenditure by 25% and 33% of BKA amputees do not survive beyond two years [3,4].

Calcaneal osteomyelitis can be classified based on route of infection. The Waldvogel  classification includes hematogenous, direct or contiguous, and chronic osteomyelitis [5-7].  Hematogenous osteomyelitis results in bacteria disseminated into the bloodstream emanating from an identifiable focus of infection or developing during transient bacteremia unrelated to infection. Direct or contiguous osteomyelitis is caused by spread from adjacent sources or contact between bacteria and tissue and may be traumatically or surgically induced. Chronic osteomyelitis is the result of the coexistence of infected, nonviable tissues and an ineffective host response [8]. The attempt of preserving the calcaneus is beneficial for functionality but is much more difficult to fully eradicate the infection. The utilization of a static external fixator frame enables both stabilization and immobilization to achieve complete offloading through the final maturation stage of wound healing. The SALSAstand has been introduced for this purpose and its construct prevents any unwanted tension on skin edges as well as pressure-induced ischemia due to weight bearing [9].

Excluding case studies, there is lack of literature evaluating the combination of partial calcanectomy with primary closure and external fixation. Our study aims to provide a reproducible surgical approach to the treatment of heel ulcers with underlying calcaneal osteomyelitis. Partial calcanectomy with primary flap closure and offloading pin to bar external fixation allows for cost-effective fixation, accelerated healing, and a satisfying functional result in true limb salvage cases.

Patients and Methods

Patients diagnosed with osteomyelitis of the calcaneus were treated with radical resection of the calcaneus with primarily closure and with utilization of SALSAstand pin to bar external fixation. All patients were treated by a single surgical attending from January 2016 to May 2019.  The inclusion criteria included patients with type 1 or 2 diabetes mellitus, those with at least a Wagner stage 3 ulceration to the heel, patients who had been diagnosed with osteomyelitis of the calcaneus with MRI advanced imaging or white blood labelled indium scans if patient was unable to have MRI, over 20% involvement of the calcaneus, and a minimum follow up of 6 months after achievement of primarily closure.

In our experience these patients had multiple co-morbidities requiring a multi-specialty medical approach. Consults for infectious disease, cardiology, vascular, endocrinology, anesthesiology, physical therapy and internal medicine were used for safety and to increase efficacy of the operative procedure.  Additionally, patient demographics were examined.

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Figure 1 A – Plantar lateral wound probing directly to calcaneus. B – Posterosuperior Flap from achilles area rotated plantarly. C – Sutured flap over deficit, knots tied outside flap.

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Figure 2 Planned resection of calcaneus with section taken. 0.5 cm margin using MRI guided resection.

Risk factors included obesity, hemoglobin A1C, peripheral vascular disease, history of tobacco use, and end stage renal disease. Other significant findings evaluated included history of attempted surgical treatment, number of operations required, and number of re-hospitalizations following the initial procedure.

Surgical Technique

The patients were placed under general anesthesia and were initially placed in the prone position. Thigh tourniquets were used unless a patient had recently undergone vascular intervention. A combination of two incisional approaches were utilized based on the location of the heel ulcer. Straight elliptical excisions for plantar wounds and a posterosuperior flap for posterior calcaneal ulcers (Figure 1). Full-thickness incisions were created with meticulous dissection to not harm the skin flaps. Once the flap was freed from attachments and the primary wound excised, the Achilles tendon was completely resected at its insertion. Utilizing a large saw, the calcaneus was resected from proximal superior to distal inferior in an oblique fashion (Figure 2).

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Figure 3 SALSAstand method for offloading. Two half pins into tibia and two half pins into midfoot.

A margin of 0.5 cm of bone was resected from the involved bone via diagnostic advanced imaging. All the rough edges of bone were then smoothed down. Portions of the bone were sent to both microbiology and pathology. A combination of 2-0 Prolene vertical mattress technique and staples were utilized to ensure closure.

After proper closure of the flap, tourniquets were deflated and then the patient was flipped to supine position with care to prevent shearing forces or pressure on the flap. A pin to bar external fixation frame was then applied to the leg for offloading of the posterior flap. In safe zone 4, just distal to the midshaft of the tibia, using a parallel guide and clamp, two 5-0 half pins were placed into the tibial crest [10]. Two 45 degree elbows were placed in the tibial clamp and 2 bar frames were then extended toward the level of the forefoot and the heel.  Two more 5-0 half pins were then inserted medially and laterally separately into the navicular and the cuboid to help construct the offloading frame. Fluoroscopy was employed to ensure placement. Pin to bar mechanism was then utilized to connect the two bars from the elbow to the midfoot pins as well as a large offloading “U” frame that went posterior around the heel (Figure 3). The “U” frame kept the patient from externally rotating the leg and forcing any pressure on the calcaneal flap. All the pin sites were covered with xeroform and dry dressing was applied to the leg.

All patients were still placed on intravenous antibiotics for 6 week depending on microbiology results. All patients were kept non-weight bearing to the operative leg until closure of the surgical wound. After complete healing, the external fixation device was removed and the patient was casted for custom solid AFO.


A total of 12 patients were identified. Two patients were excluded due to one inadequate follow-up and one patient who was deceased before adequate follow-up, leaving 10 patients that met the inclusion criteria. Of those who met the inclusion criteria, 30% (3/10) were active tobacco smokers, 50% (5/10) were diagnosed with ESRD, 70% (7/10) had a history of PVD, previous surgical intervention occurred in 90% (9/10),  average BMI among the 10 patients was 31 and average hemoglobin A1C was 7.5%.  Demographic and medical history is seen in Table 1.

Patient Characteristics Median or no. (percentage)
Patient Age 64
Male 7
Female 3
BMI 31.3
HbA1C 7.6
Diabetes Mellitus 10 (100%)
ESRD 5 (50%)
PVD 7 (70%)
Current Tobacco Use 3 (30%)
Previous Surgical Intervention 9 (90%)
Follow up (months)
Mean 15.9
Range 7 to 42

Table 1 Patient Demographics (N=10).

Complication n
Dehiscence 3 (30%)
Flap necrosis 2 (20%)
Recurrent ulcer 2 (20%)

Table 2 Complications.

Wound Size 6.4 x 5.6 cm (35.8 cm2)
Average duration of wound 38 weeks (4 to 204)
Calcaneus resection size 122 cm3
Time to healing 106 days (43 to 205)
Time in external fixation 41 days (15 to 77)

Table 3 Pre and post operative results.

Mean wound size preoperatively was 6.4 cm x 5.6 cm (35.8 cm2), mean size of calcaneal bone resected was 6.6 cm x 4.9 cm x 3.6 cm (116.4 cm3). Average time to primary closure was 106 days (ranging 43 to 205 days), average days in external fixation devices was 41 days (ranging 15 to 77 days), and number of operating room visits following initial procedure was 1.5 visits (ranging from 1 to 3 visits). Complications encountered included partial wound dehiscence in 3/10 patients, flap necrosis in 2/10 patients, and re-ulceration in 2/10 patients.

Re-ulceration occurred at an average of 5 weeks post op (ranging 4 weeks to 6 weeks). Due to complications, subsequent adjunctive grafting occurred in 6 patients to aid in healing and 2 patients required rehospitalization. No pin tract infection, revisional bone debridement, or subsequent BKA/AKA was observed. Average follow up time was 20.9 months (ranging 12 to 45 months).


A similar study by Akkurt, et al, utilized MRI guided debridement with application of Ilizarov external fixation for patients with pedal ulcers and concomitant calcaneal osteomyelitis.[11] The mean size of calcaneal osteomyelitis was 8.73 cm3 (range 3–18 cm3) and the authors advocated for a preoperative MRI-guided resection plus a maximum 0.5 cm of resection in depth as far as healthy osseous tissue was sufficient in all patients.  The authors recommendations is the same guideline we utilized for our resection. The wounds healed in 18 of the 23 patients (78%), partial recovery occurred and subsequent flap operation was performed in three patients (13%), and below-the-knee amputation was performed in two patients (9%). Pin tract infections were the most common complication seen in 16 patients (69.5%).[11]  Our study showed complete healing in 100% of patients with no below-knee-amputations or pin tract infection as a result. Pin tract infection was a common complication possibly due to the complexity of the frames in the study by Akkurt, et al.[11] We hypothesize utilizing a four half-pin fixation construct decreases the chance for pin tract infection and subsequent amputation. There is less chance of loosening and pistoning without smooth wire fixation. Bollinger, et al., performed partial calcanectomies and evaluated the functional status of their patients. Thirteen of the 22 patients had confirmed osteomyelitis. Eighteen patients were available for follow-up. Twelve had delayed wound healing that required either a split thickness skin graft or serial debridements.  Nine patients had diabetes and all had delayed wound healing with an average follow up time of 27 months. They found that ulcers larger than 7 cm would not allow for a tension-free closure. They also recommended casting in plantar flexion for a minimum of 4 weeks post-operative. This study resulted in 100%  satisfaction rates of its subjects. However over 50% had delayed wound healing with the need of additional surgical treatment [12]. Our experience saw similar results in delayed healing with subsequent grafting at 60%. A combination of biologics and split thickness skin grafts were utilized depending on size of surgical wound. With our average wound size of 35.8 cm2, we found that even with larger deficits, utilizing a rotational flap allowed for tension free initial closure of skin.

Vac therapy is also a conservative option to attempt and close these long standing ulcers. However, the frequency of dressing changes, time needed, and prolonged non-weight bearing make the negative pressure therapy a very involved task. Nather et al., looked at wound vac therapy for diabetic foot wounds in 11 patients and administered VAC therapy for an average of 23.3 ± 10.3 days.  Initial wound sizes ranged from 6.9 to 124.0 cm2 and post therapy had an average reduction of 10.1 cm2 with an average reduction of 24.9%, which was not statistically significant [13]. The use of wound vac therapy alone in diabetics cost an average of $13,262 for a 12 week therapy course [14]. Conservative treatment through vac therapy, debridements, and serial grafting increases both cost to patient and chance of infection. Our patient population only required 1.5 visits to the OR after the initial procedure where at least one of the visits involved was to remove the external fixation device. The average healing time after calcanectomy and primary closure was about 15 weeks where the average duration of the wound being present was 38 weeks. This procedure allows for complete eradication of infected bone and tissue, properly offloading, and primary tissue healing for practical and functional results.

Dalla Paola, et al., used a combination of the treatments discussed. They enrolled 18 consecutive patients with large heel ulcers complicated by osteomyelitis. Treatment was performed in a two-step manner, first including MRI guided resection of  the infected calcaneus, application of circular external fixator, and negative pressure wound therapy  with dermal substitute. The second stage included application of split thickness skin graft over the wound. Complete healing was achieved in all patients with mean time of 69+/- 64 days. Total time for maintenance of the circular frame was 78.2 +/- 31.5 days [15]. Another surgical alternative is the use of myofascial flaps to cover soft tissue deficits in the heel. The robust nature of the muscle belly aids in bone healing and increased antibiotic deliverance to the site of infection. Abductor hallucis, reverse sural artery, and saphenous flaps are all viable options depending on the size of muscle needed for coverage. However, these surgical procedures are technically demanding and require attentive wound care. Increased risk of flap breakdown may be attributed to the high pressure area they weren’t designed for.  Flap rejection is cited from 5% to 25% while diabetics have an increased rate of necrosis at 32% [16].


  1. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implica- tions for the future. Adv Skin Wound Care 2001; 14:208-15.
  2. Jacobs TS, Kerstein MD. Is there a difference in outcome of heel ulcers in diabetic patients and non-diabetic patients? Wounds 2000; 12(4):96-101.
  3. Cuccurullo, Sara J. Physical Medicine and Rehabilitation Board Review. 2nd ed. New York: Demos Medical, 2010.
  4. Pinzur MS. Amputation level selection in the diabetic foot. Clin Orthop. 1993; 296:68-70
  5. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (first of three parts) N Engl J Med. 1970 Jan 22;282(4):198–206.
  6. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (Second of Three Parts) N Engl J Med. 1970 Jan 29;282(5):260–266.
  7. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (Third of Three Parts) N Engl J Med. 1970 Feb 5;282(6):316–22.
  8. Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often? Postgrad Med J. 2000 Aug; 76(898):479-83.
  9. Clark J, Mills JL, Armstrong DG. A method of external fixation to offload and protect the foot following reconstruction in high-risk patients: the SALSAstand. Eplasty. 2009;9:e21. Published 2009 Jun 4.
  10. Cooper P, Polysois V, Zgonis T. External Fixators Of The Foot And Ankle. Wolters Kluwer Health, Chapter 2. Published 2015.
  11. Akkurta MO, Ismail  D, Öznur A. Partial  calcanectomy  and Ilizarov external fixation may reduce amputation need in severe diabetic calcaneal ulcers. Diabetic Foot Ankle, 2017 8(1), 1264699
  12. Bollinger M, Thordarson DB. Partial calcanectomy: an alternative to below knee amputation. Foot Ankle Int. 2002;23(10):927-932.
  13. Nather A, Chionh SB, Han YY, Chan PL, Nambiar A. Effectiveness of Vacuum-assisted Closure (VAC) Therapy in the Healing of Chronic Diabetic Foot Ulcers. Ann Acad Med Singapore.  2010;39:353–8
  14. Driver V, Blume P. Evaluation of Wound Care and Health-Care Use Costs in Patients with Diabetic Foot Ulcers Treated with Negative Pressure Wound Therapy versus Advanced Moist Wound Therapy. Journal of the American Podiatric Medical Association: 2014;104(2):147-153.
  15. Dalla Paola L, Brocco E, Ceccacci T, Ninkovic S, Sorgentone S, Marinescu MG, Volpe A. Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation. Foot Ankle Int 30:1065–1070, 2009.
  16. Germann G. Invited discussion: the simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps. Plast Reconstr Surg 2003; 111:761–2.

Intraosseous ganglion of the third metatarsal: A case report

by Bryn Rowe DPM PGY21*, Jeffrey Christensen DPM FACFAS2, Daniel Lowinger DPM FACFAS3

The Foot and Ankle Online Journal 13 (3): 5

Intraosseous ganglia are benign, non-neoplastic lesions of bones that are histologically similar to their soft tissue equivalents. They most often occur in the femoral head, proximal tibia, and carpal bones. A 70-year-old female presented with a complaint of pain to the right dorsal forefoot. The patient was diagnosed with a third metatarsal intraosseous ganglion based on multiple imaging modalities and confirmed by histopathology. A case report and review of the literature is presented.

Keywords: bone cyst, ganglion, subchondral cyst, geode

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0005

1 – Swedish Medical Center Resident – Swedish Medical Center, Seattle, WA, PGY-2
2 – Attending Physician – Swedish Medical Center, Seattle, WA
3 – Attending Physician – Swedish Medical Center, Seattle, WA
* – Corresponding author-

Intraosseous ganglia are benign cystic lesions that typically occur in long bones. These lesions should be an included differential for any cystic osteolytic lesion seen in the foot or ankle. Intraosseous ganglia can be painful and have the potential to cause pathologic fractures. The standard treatment includes curettage with bone grafting, with or without internal fixation.

The etiology of intraosseous ganglion is unknown and multiple theories exist. They are most widely accepted to be primary lesions and may arise de novo with no imaging or pathological evidence of degenerative process in neighboring joints [1]. Differential diagnoses for intraosseous ganglia include any well circumscribed cystic lesion with marginal sclerosis located in the subchondral bone adjacent to a joint, such as a subchondral bone cyst, giant cell tumor, enchondroma, chondrosarcoma/blastoma, Brodie’s abscess, and fibrous dysplasia among others [3]. Intraosseous ganglia can be differentiated from other potential diagnoses based on the age of the patient as well as characteristics seen on radiographs and other imaging modalities. Diagnosis, however, can only be confirmed by histopathological analysis.

Intraosseous ganglia appear as well-defined lytic lesions with marginal sclerosis on radiographs. They can regularly be distinguished as they often do not often exhibit calcifications, cortical expansion, or cortical destruction. They can be unilocular or multilocular. Magnetic resonance imaging (MRI) of these lesions shows low intensity signal in T1 and high intensity signal in T2. Computed Tomography (CT) imaging is useful to determine intra articular involvement or pathologic fracture not easily identified on radiographs [7].

Conservative treatment includes non-operative observation and symptom relief. Sclerosing injections have been performed however their effectiveness have not been reported in literature. The gold standard treatment is surgical curettage of the cyst and surrounding zone of sclerosis with or without bone grafting. The deficit is often packed with bone cement, autograft, or allograft either with or without internal fixation [5]. Pathologic fracture is a reported complication caused by these lesions. Arthroscopy has also been performed but is more commonly done in the wrist. There are no current studies comparing the outcomes between arthroscopy versus open curettage. Recurrence rate for intraosseous ganglion after surgical curettage is around 6.1%, however there is a variable overall reported recurrence rates ranging from 7-43% in the literature [8]. The recurrence is thought to not necessarily be from inadequate excision but rather from connective tissue metaplasia after surgery [1].

Grossly, intact cysts are round or oval in shape and appear opalescent and blue-grey in color. The walls of the cyst do not contain any epithelial or synovial lining but are rich in collagenous fibers. The unroofed cyst is made up of a largely fibrous membrane containing mucinous material. Acid mucopolysaccharide storage within the cyst leads to the myxoid degeneration seen within the ganglion wall [2]. Intraosseous and extraosseous ganglion are indistinguishable histologically. The diagnosis is confirmed by histopathological analysis.

Intraosseous ganglia are benign, non-neoplastic lesions of bones that are histologically similar to their soft tissue equivalents. They most often occur in the femoral head, proximal tibia, and carpal bones. A 70-year-old female presented with a complaint of pain to the right dorsal forefoot. The patient was diagnosed with a third metatarsal intraosseous ganglion based on multiple imaging modalities and confirmed by histopathology. A review of the literature found only one reported case of an intraosseous ganglion in the third metatarsal and two other reports occurring in the first metatarsal [2, 6]. She was treated operatively by curettage with bone allograft with no recurrence at one year follow-up. Of note, the patient’s postoperative course was complicated by delayed consolidation of the bone allograft with subsequent malunion of the third metatarsal base with dorsal angulation.

Figure 1-3 AP, MO, and lateral radiographs of the right foot with subtle marginal sclerosis noted to the base of the third metatarsal.

Case Report

The patient is a 70-year-old female who presented with chief complaint of pain with activity on the central and dorsal aspect of her right foot. The pain had been present for two years with gradual onset. There was no history of trauma. Of note, the patient also complained of first metatarsal phalangeal joint pain with a progressively worsening bunion deformity causing shoe irritation. On physical exam there was a moderate hallux valgus deformity and mild tenderness to palpation of the dorsal aspect of the 3rd metatarsal base. Radiographs of the right foot demonstrated a long 1st metatarsal, mild narrowing of the 1st metatarsophalangeal joint, and slight increase of the 1st and 2nd intermetatarsal angle.

Figure 4 Sagittal T2-weighted MR imaging with high signal intensity in the base of the third metatarsal extending distally within the metatarsal shaft.

There was a subtle discrete radiolucent area in the base of 3rd metatarsal accompanied by marginal sclerosis laterally and proximally, most pronounced on the medial oblique view (Figures 1-3).

An MRI was ordered to further assess the irregular sclerotic area as well as to rule out potential stress fracture or arthropathy. T2-weighted MR images demonstrated high intraosseous signal intensity in the proximal third metatarsal base extending to the articular surface of the third tarsometatarsal joint as well as marrow edema extending distally in the metatarsal shaft (Figure 4). The area measured 1.8 x 1.1 cm. There was no cortical irregularity, calcification, or periosteal reaction. A CT scan demonstrated a unilocular mixed lytic and lucent intramedullary lesion at the proximal aspect of the third metatarsal with no visualized tarsometatarsal joint involvement (Figs. 5-6).

Operative Technique

The patient was placed under general anesthesia in a supine position. A linear incision was made over the third tarsometatarsal joint after the position of the bone lesion was triangulated with fluoroscopy. Sharp dissection was carried down to the extensor tendons which were retracted. The periosteum over the base of the third metatarsal was incised longitudinally and reflected medially and laterally. A dorsal rectangular shaped window was created in the cortex of the base of the third metatarsal (Figure 7).

Figures 5-6 Sagittal and coronal CT imaging demonstrating the third metatarsal lesion with intact cortex present at the 3rd metatarsal-cuneiform joint with no apparent intraarticular extension.

Figure 7 Intraoperative image of the third metatarsal base after the dorsal cortical window was removed, revealing a soft gray mass and cystic cavity.

A well-encapsulated gelatinous gray tissue mass was visualized in the marrow cavity and excised completely with a curette. There was no apparent intra-articular involvement or extension in the tarsometatarsal joint noted. The cortical wall was curetted and bone allograft was packed into the deficit. The cortical window was press fit into the graft and positioned in its original position. The graft was not fixated as it was stable after positioning. The gross pathology report described the mass as a 1.6 x 0.8 x 0.7 cm disrupted pale, tan-red cyst, containing mucoid material. The final diagnosis was benign intraosseous ganglion.


Intraosseous ganglions are benign non-neoplastic bone lesions that are histologically similar to their soft tissue homologues. They are most commonly found in the epiphyseal-metaphyseal area of long bones with higher occurrences in the medial malleolus, femoral head, and carpal bones. There are few case reports in literature describing intraosseous ganglia of metatarsals, with only one case being reported in the third metatarsal and two additional cases reported in the first metatarsal [1,6]. This may be due to underreporting and confusing nomenclature leading to this lesion being named under a different pathologic entity. Peak incidence for both males and females in the fourth or fifth decade. They infrequently occur in skeletally immature individuals or the elderly, although cases have been reported in the literature [5]. Communication with surrounding joints and extension into the soft tissues are frequently reported, however, there are variable occurrence rates in literature due to differences in which imaging modality was used. In a study of patients with confirmed intraosseous ganglia, there was soft tissue extension present in 38% and intra-articular involvement present in 17% of the 29 patients who underwent MRI [7]. These lesions were evaluated using T1-weighted, T2-weighted, and short tau inversion recovery (STIR) sequences. In a similar study of 17 patients, there was 24% soft tissue extensions present. The authors also noted that among their patients, 12% had associated osteoarthritis and 18% had pathological fracture [4]. Preventing potential pathologic fracture in patients with intraosseous ganglion is an important rationale for surgical treatment

Although benign and uncommon, intraosseous ganglia should be considered in the potential diagnosis of any bony subchondral cystic lesion in the foot or ankle. Without proper clinical observation and potential treatment, intraosseous ganglia have the potential to cause significant pain, cause pathologic fracture, and exhibit secondary pathological effects by displacing surrounding soft tissues. Ideally curettage with grafting would be performed for both treatment and diagnostic purposes.


  1. Feldman F, Johnston A. Intraosseous ganglion. Am J Roentgenol Radium Ther Nucl Med. 1973;118(2):328-43.
  2. Helwig, U., Lang, S., Baczynski, M., & Windhager, R. (1994) The intraosseous ganglion. Archives of Orthopaedic and Trauma Surgery, 114: 14-17
  3. Murff, R. & Ashry, H. (1994) Intraosseous ganglia of the foot. The Journal of Foot and Ankle Surgery, 33 (4): 396-401.
  4. Sakamoto, A., Oda, Y., & Iwamoto, Y. (2013) Intraosseous ganglia: a series of 17 treated cases. Biomed Research International, 2013, Article ID 462730, 4 pages,
  5. Sedeek, S., Choudry, Q., & Garg, S. (2014) Intraosseous ganglion of the distal tibia: clinical, radiological, and operative management. Case Reports in Orthopedics, 2015, Article ID 759257, 4 pages,
  6. Wakabayashi, I., Okada, K., Hashimkoto, M., & Sageshima, M. (1999) Intraosseous ganglion of the metatarsal bone. Journal of Computer Assisted Tomography, 23 (5): 727-729. doi: 10.1097/00004728199909000-00017
  7. Williams, H., Davies, A., Allen, G., Evans, N., & Mangham, D. (2004) Imaging features of intraosseous ganglia: a report of 45 cases. European Radiology, 14: 1761-1769
  8. Yu, K., Shao, X., Tian, D., Bai, J., Zhang, B., & Zhang, Y. (2016) Therapeutic effect of bone cement injection in the treatment of intraosseous ganglion of the carpal bones. Experimental and Therapeutic Medicine, 12: 1537-1541


Emphysematous osteomyelitis of the foot: A case report

by Igor Dukarevich, DPM1*; Victoria Chirman, DPM2; Mahin Siddiqui, DPM3

The Foot and Ankle Online Journal 13 (3): 4

Emphysematous osteomyelitis is a rare life-threatening infection requiring early recognition and immediate surgical intervention. The condition is usually caused by anaerobes, gram negative rods, or is polymicrobial. It presents in immunocompromised hosts with comorbidities such as diabetes mellitus, thalassemia major, sickle cell disease, alcohol abuse, and exogenous immunosuppression. This infection can be either of contiguous or hematogenous spread, and has been previously reported in both the axial and the appendicular skeleton. Intraosseous gas is frequently overlooked on plain radiographs but is easily diagnosed by CT scan. We describe a case of direct extension emphysematous osteomyelitis involving the foot of a 52-year-old male with poorly controlled diabetes mellitus type 2. We emphasize the need for a high index of suspicion, early diagnosis via CT scan, and immediate surgical intervention. We also underscore the utility of the Symes amputation, used in our case as an alternative to transtibial amputation for diabetic limb salvage.

Keywords: emphysematous, foot, gas, intraosseous, osteomyelitis

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0004

1 – Podiatry Residency Director, Loretto Hospital, 645 S Central Ave, Chicago, IL 60644
2 – Podiatry Resident, Loretto Hospital, 645 S Central Ave, Chicago, IL 60644
3 – Podiatry Resident, Loretto Hospital, 645 S Central Ave, Chicago, IL 60644
* – Corresponding author:

Emphysematous osteomyelitis is a rarely-reported condition, previously not described in the podiatric literature.  It was first noted by Ram PC, et al., in 1981, when a CT scan demonstrated gas within the medullary cavity of the involved bone [1]. In their case series, all plain radiographs were negative and there was no clinical suspicion of the severity of the infection until a CT scan was obtained. The CT scan findings significantly changed the management of the patients.

Since the initial report, the majority of the cases described have been limited to the axial skeleton with suspected hematogenous spread [2]. A hand-full of cases have been described in the appendicular skeleton, both of contiguous and hematogenous extension, with emphysematous osteomyelitis presenting in the femur, the tibia, and the foot. In the majority of the reported cases, the patients have multiple comorbidities including diabetes mellitus, use of immunosuppressive medication, malignancy, alcohol abuse, thalassemia major, or sickle cell disease [2-4]. In many cases, the X-rays were negative for soft tissue gas and the diagnosis was made only with prompt CT imaging [1].  We report a case of contiguous spread emphysematous osteomyelitis in the foot, emphasizing the need for a high-index of suspicion, prompt advanced imaging, and aggressive treatment for this rare but life-threatening condition.

Case Report

A 52-year-old African American male, with a past medical history of polysubstance abuse, poorly controlled diabetes mellitus type 2, iron deficient anemia, seizure disorder, peripheral neuropathy, history of chronic ulcerations, had underwent treatment in our facility from 12/2018 through 01/2019 for emphysematous osteomyelitis of the right foot.  The patient presented to the emergency department on December 6, 2018 with a chief complaint of right foot pain and swelling.

Figure 1 Clinical appearance.

He previously underwent a partial right first ray amputation at a different hospital in 08/2018, with delayed healing of the surgical wound.  The patient was unable to provide a detailed history of his condition at the time of the admission. The patient had no known drug allergies. Family history was non-contributory. Review of systems was unremarkable, with exception of the chief complaint.

On examination, the patient was noted to be a well-nourished, well-developed male in no apparent distress. The vital signs were stable, with the exception of a low-grade fever at 99.4 degrees Fahrenheit and a pulse of 126 bpm.  Significant findings on the physical exam included moderate edema and erythema to the right foot. A partially healed amputation site of the first ray of the right foot was appreciated with a necrotic ulceration on the dorsum of the foot probing directly to bone and tendinous structures. Mild serous drainage was noted from the wound, but no obvious fluctuance, purulence, or soft tissue crepitus was appreciated (Figure 1).  Pedal pulses were faintly palpable bilaterally with capillary refill times less than four seconds to the remaining digits of the right foot. Neurologically, light touch and sharp/dull sensation was diminished distal to the mid-leg level of bilateral lower extremities.

Radiographs of the right foot were obtained and were suggestive of osteomyelitis of the second metatarsal base, however no evidence of significant osseous destruction or soft tissue gas was noted. Vascular calcifications were appreciated. (Figure 2). Significant neutrophilic leukocytosis was noted with WBC at 14.4. Blood cultures were positive for Strep. Pyogenes.  Lactic acid was 2.1.

Figure 2 Radiographs of the right foot, suggestive of osteomyelitis of the second metatarsal base.

Figure 3 CT of foot, showing small foci of subcutaneous gas were also noted in the tissues.

The last HbA1C was 13.7%. Albumin was 1.4. Deep wound cultures were obtained at the time of admission. The patient was started on IV fluids and Vancomycin and transferred to the hospital loor for further evaluation and management. Infectious disease and a podiatry consult was requested.

Infectious disease and podiatry recommended the addition of piperacillin/tazobactam and metronidazole to broaden the antibiotic coverage. A CT scan of the right foot was obtained. The CT scan demonstrated multiple foci of intraosseous gas in the midfoot including navicular, cuboid and cuneiform bones, as well as the bases of second, third, fourth, fifth metatarsals. Small foci of subcutaneous gas were also noted in the tissues (Figure 3). The findings were consistent with the “pumice stone” pattern previously reported by Small JE, et al., and diagnostic for emphysematous osteomyelitis.

Given the findings, an emergent incision and drainage of the right foot with a guillotine amputation at the Chopart level was performed. Clearance fragments were obtained from the distal talus and the calcaneus. Following surgical intervention, the patient continued to improve with resolution of leukocytosis and fever. Blood cultures were negative.  Wound culture results revealed growth of Staphylococcus Aureus, Klebsiella, Enterobacter Aerogenes, and Streptococcus Pyogenes Group A. Empiric antibiotic therapy was narrowed to clindamycin and penicillin, per sensitivity report and infectious disease recommendations.

Figure 4 Radiographs after Chopart level amputation.

Arterial doppler studies of the lower extremities confirmed no significant peripheral arterial disease of the right lower extremity with biphasic waveforms throughout. Follow-up radiographs and CT scan demonstrated no proximal spread of emphysematous osteomyelitis (Figure 4). Pathology analysis of the resected foot displayed skin and subcutaneous tissue showing necrosis and gangrene; bone with underlying acute and chronic osteomyelitis. Clearance fragments from the distal talus and calcaneus were negative for osteomyelitis.

In the subsequent days revision of the amputation and delayed primary closure was performed. Due to fair right lower extremity arterial perfusion, a decision was made to attempt distal limb salvage with a Syme’s amputation, as opposed to a below-the-knee amputation. A Syme’s amputation was performed per standard technique and the patient tolerated the procedure well (Figure 5). The remaining hospitalization course was uneventful and the amputation flap was healing well. The patient was discharged to an extended care facility. The patient missed his first two postoperative appointments and was seen in the outpatient clinic for follow-up about one month after the surgery.  The patient was noted to have partial dehiscence and necrosis of the lateral one-third of the incision with the remainder of the incision healing well. The patient was readmitted for IV antibiotic therapy, vascular evaluation, and debridement.   An angiogram of the right lower extremity confirmed no significant disease in the bilateral common internal and external iliac arteries and there was noted to be a two-vessel runoff to the foot without any significant disease. The patient underwent further debridement and wound care. The patient had successful healing of the Syme’s amputation stump via secondary intention without further setbacks.

Figure 5 Radiographs after Syme’s level amputation.


Emphysematous osteomyelitis is a rare but potentially life-threatening condition [1-5]. About thirty cases have been described thus far in literature; the majority presenting with predominantly hematogenous spread in the spine, pelvis, and hip [1-5]. Only three cases have been previously described affecting the foot [2-4].

Our case of emphysematous osteomyelitis in the foot was similar in presentation to those previously reported by Mautone et al and Abdelbaki et al [3-4].  The spread of the infection was contiguous from a chronic ulceration persisting from delayed healing of a partial foot amputation. Khanduri et al reported the only case of hematogenous spread to the foot, with the source likely being a urinary tract infection [2].

As in the previously reported cases of emphysematous osteomyelitis of the foot, our patient was immunocompromised with multiple comorbidities. Clinical findings and X-rays were fairly benign and underestimated the extent of the infection. A prompt CT scan allowed for accurate diagnosis and appropriate emergent treatment. The finding of intraosseous “pumice stone” pattern of gas formation on CT scan was diagnostic for emphysematous osteomyelitis [5]. The CT scan allowed for clear visualization of the extent of the infection and helped to guide the level of the amputation.

As in other reported cases of emphysematous osteomyelitis, the infection in our case was polymicrobial. As such, empiric antibiotic therapy should be broad-spectrum and should include anaerobic coverage, with later narrowing based on culture and sensitivity results. As with gas gangrene of the soft tissues, the primary treatment for emphysematous osteomyelitis is emergent surgical debridement with amputation of all infected structures. Input and intervention from internal medicine, interventional cardiology, and infectious disease specialists is also critical in the successful management.

As with other diabetic foot infections, the long-term treatment goal should be distal limb salvage with rapid return to functional activity [7]. Previous studies have demonstrated the utility of the Syme’s amputation, with advantage of a more natural gait resulting in decreased metabolic expenditure and cardiac stress [6-7]. The literature also suggests lower morbidity and mortality rates after a Syme’s amputation in comparison to transtibial amputations [6-7]. We believe that it remains a viable alternative for limb salvage.

We describe a case of emphysematous osteomyelitis, previously not reported in the podiatric literature, managed with a Syme’s amputation. We emphasize the need for a high-index of suspicion in immunocompromised patients with long-standing post-surgical ulcerations, as well as early use of advanced imaging. The use of a CT scan helps to determine the extent of infection and the level of amputation. We also note that the Syme’s amputation remains an alternative to transtibial amputations for distal limb preservation. Severe diabetic foot infections such as emphysematous osteomyelitis, are a challenging entity, requiring prompt intervention by a multidisciplinary team to achieve a successful outcome.


  1. PC Ram, S Martinez, M Korobkin, RS Breiman, HR Gallis, JM Harrelson. CT detection of intraosseous gas: a new sign of osteomyelitis. AJR Am J Roentgenol, 137 (1981), pp. 721-723
  2. Sachin Khanduri, Meenu Singh, Aakshit Goyal, Simran Singh. Emphysematous osteomyelitis: Report of two cases and review of literature. Indian Journal of Radiology and Imaging. 2018;(1):78.
  3. Mautone M, Gray J, Naidoo P. A Case of Emphysematous Osteomyelitis of the Midfoot: Imaging Findings and Review of the Literature. Case Reports in Radiology. January 2014:1-4.
  4. Abdelbaki A, Bhatt N, Gupta N, Li S, Abdelbaki S, Kumar Y. Emphysematous osteomyelitis of the forefoot. Proceedings (Baylor University Medical Center). 2017;31(1):100-101.
  5. Small JE, Chea P, Shah N, Small KM. Diagnostic Features of Emphysematous Osteomyelitis. Curr Probl Diagn Radiol. 2018 Jun 1
  6. Pinzur MS. Amputation level selection in the diabetic foot. Clin Orthop. 1993; 296:68-70.
  7. Yu G, Meszaros A, Schinke T. Syme’s amputation: A retrospective review of 10 cases. Podiatry Institute Update, Chapter 14, Podiatry Institute, Tucker, GA, 2005, pp. 78–88.



Ankle arthrodiastasis in conjunction with treatment for acute ankle trauma

by Nunzio Misseri, DPM¹; Hayley Iosue, DPM¹; Elizabeth Sanders, DPM¹; Amber Morra, DPM¹; Mark Mendeszoon, DPM2,3

The Foot and Ankle Online Journal 13 (3): 3

Arthrodiastasis has been described as an alternative joint sparing procedure for more advanced stages of arthritis. The use of joint distraction has been gaining popularity in foot and ankle surgery, especially with regards to post-traumatic ankle arthritis. Less is known about the effects of arthrodiastasis in cases of acute ankle trauma. This case series presents four cases of intra-articular ankle trauma that were treated with arthrodiastasis using external fixation along with reduction with/without internal fixation. The external fixators were kept on for at least 6 weeks with follow-up of at least 1-2 years for each case. These cases represent high impact injuries that were destined for post-traumatic arthritis that would eventually result in a joint destructive procedure. The results were promising in all cases, by at least delaying the need for a joint fusion or replacement in one case and foregoing the need for such procedures in the other 3 cases within our follow-up period.

Keywords: Arthrodiastasis, ankle, diastasis, arthritis, trauma, post traumatic, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0003

1 – University Hospitals Regional Hospitals, Surgical Fellow
2 – University Hospitals Regional Hospitals, Fellowship Director; faculty
3 – Precision Orthopaedic Specialities Inc.

The incidence of people with post-traumatic arthritis accounts for nearly 12% of those with symptomatic lower extremity arthritis [1]. Among those with ankle joint osteoarthritis, previous trauma is the most common etiology ranging from 20% to 78% incidence [2-4]. These patients usually end up with joint destructive procedures such as joint fusion or replacement.

Arthrodiastasis is an innovative treatment for ankle arthritis to enhance ankle joint range of motion, diminish pain, and potentially delay or forego ankle joint destructive procedures. Arthrodiastasis of the ankle has been described as an alternative and/or adjunctive salvage procedure for arthritis in patients not amenable to ankle joint replacement or arthrodesis [5]. The procedure is not technically demanding for the surgeon and, long-term, can cost less than arthrodesis or arthroplasty.

Various theories exist to explain how arthrodiastasis has a positive effect on joints. A theory by Gavril Ilizarov suggests applying tension to tissues with distraction increases micro-vascularity to articular cartilage, therefore assisting in cartilage repair [6]. This tension creates a hypervascular state which increases synthesis of nutrients, proteoglycans and in turn helps stimulate chondrocyte formation [6].

Lafeber described a theory in which joint unloading with resulting fluctuations in intra-articular pressure from joint distraction along with concomitant weight bearing, the activity of chondrocytes increases which creates proteoglycans that have the ability to repair articular cartilage and stimulate pluripotent mesenchymal cells to differentiate into articular cartilage [7,8]. This concept of mechanical offloading with continuing pressure changes was shown to increase proteoglycan synthesis by 50% in osteoarthritis knee condyles undergoing arthrodiastasis [7,9]. This process also decreases the inhibition of proteoglycan synthesis by mononuclear inflammatory cells, decreases production of catabolic cytokines and provides increased nutrition delivery to chondrocytes [7].

Both theories predicate the notion that osteoarthritic ankle cartilage is capable of regeneration. Arthrodiastasis has been used over the years with chronic osteoarthritis of the ankle with good results. A review by Dr. Rodriguez-Merchan published in 2017 looked at 14 articles that included patients with end stage osteoarthritis undergoing ankle joint distraction. A total of 249 patients were included in this review with follow up ranging from 1-12 years. Overall 73-91% of patients had good results within their follow up and 6.2-44% of patients ended up with either a joint fusion or replacement [10]. This review serves as a good foundation on the results of ankle joint arthrodiastasis in chronic cases of osteoarthritis, however little is known on its effects during its application in acute trauma. We present a series of acute ankle trauma in which we employ external fixation for arthrodiastasis. In these cases studies, each patient suffered from an intra articular ankle fracture. In the acute setting, the fractures were reduced and an external fixator was applied. Ankle joint diastasis of 5-10mm was applied to the ankle joint utilizing the external fixator. The external fixators were left in place for six to eight weeks.

Case 1

A 30 year-old male sustained an open bimalleolar fracture while operating his horse-drawn lawn mower. Upon presentation to the emergency department, he was evaluated and subsequently taken to the operating room for wound washout, flap closure, application of a delta frame for stability with percutaneous kirschner wire fixation to the medial malleolus. Once the soft tissue envelope was stable nine days later, open reduction and internal fixation was performed. The same delta frame remained intact and the ankle joint was distracted in an attempt to preclude ankle arthritic changes. The frame remained in place for six weeks allowing for ankle joint arthrodiastasis during this time. The patient was seen in the office 1.5 years after surgery and was clinically doing well. He is ambulating without orthoses and able to perform his daily activities without issues. Radiographic images revealed a healed fracture with the ankle mortise in good alignment, without signs of degenerative arthritis.


Figure 1 Open bimalleolar fracture of a 21-year-old Amish male sustained while operating a horse-drawn lawn mower. Case 1.


Figure 2 Post-operative radiographs status-post wound washout and closure, open bimalleolar fracture reduction, percutaneous fixation, application of delta frame. Status-post bimalleolar fracture open reduction and internal fixation, syndesmotic repair, and re-application of delta frame to obtain arthrodiastasis at the ankle joint.


Figure 3 Six weeks status-post bimalleolar fracture open reduction and internal fixation, postoperative day 0 of delta frame removal.

Case 2

A 56-year-old female presented after a motor vehicle accident where she sustained a right closed comminuted talar fracture. Radiographs and a CT scan revealed a Hawkins type IV talus fracture. She was subsequently taken to the operating room after full evaluation in the emergency department. Closed reduction was attempted with a calcaneal pin but was not possible. Therefore, a lateral sinus tarsi approach incision was made from the tip of the fibula extending dorsally over the 4th metatarsal to expose the talus. The talus was reduced and fixed percutaneously with Kirschner wires and a delta frame was applied.

Eleven days later, after the soft tissue envelope improved, she was taken back to the operating room for subtalar and talonavicular joint arthrodesis in an attempt to maintain blood supply to the talus. The deltoid ligament was repaired and a modified Brostrom augmentation was performed. A ring external fixator was placed to achieve stability as well as arthrodiastasis at the ankle joint. The external fixator was removed two months postoperatively. Minor medial ankle arthritis was noted on postoperative radiographic images which worsened over the years. Two years postoperatively the patient is contemplating joint destructive procedures.


Figure 4 Radiographs and CAT scan of a Hawkins type IV severely comminuted talus fracture. Case 2.


Figure 5 Intraoperative findings of a severely comminuted talus fracture. Postoperative clinical photos and radiographs of open reduction and external fixation of a comminuted talus fracture, stabilization with percutaneous Kirschner wires and circular external fixator.

Case 3

A 34-year-old male patient was admitted from an outside hospital two days after a trauma where a car he was repairing fell on his left lower limb. He was noted to have a closed dislocated fracture of the left talus, Hawkins type III, and displaced medial malleolus fracture. Closed reduction and splinting was performed at the previous hospital. After full evaluation at our facility, open reduction of the talus and closed reduction of the medial malleolus was performed followed by the application of a ring external fixator. After adequate reduction, approximately a half centimeter of distraction of the ankle joint was produced. This frame was left in place for four months. Following frame removal, the patient continued physical and functional treatment aimed at strengthening the tibial and foot muscles and was encouraged to increase range of motion of the ankle. The patient was able to return to his normal daily activities and return to work. At his two year follow-up he has not needed to go on to further joint destructive procedures and continues to be able to perform his activities of daily living without issue.


Figure 6 Radiographs on admission. Case 3.


Figure 7 Radiographs following Ilizarov frame application and during treatment.


Figure 8 Radiographs following Ilizarov frame removal 80 days status-post reduction and external fixation of talus fracture.

Case 4

A 15-year-old male patient who presented with chief complaint of right foot and ankle injury sustained after a fall while riding a BMX bike. The patient did have a history of a previous talus fracture 3 years prior to this presentation which was treated non-surgically. Radiographic images revealed a Hawkins type III talar neck fracture which was confirmed and evaluated on CT scan. The patient underwent open reduction with internal fixation of the talus fracture with two cannulated screws from posterior to anterior and application of an external fixation with approximately 6-mm of joint distraction.

The external fixator was removed after 6 weeks and the patient was gradually transitioned from a walking boot and into well-supportive sneakers while undergoing physical therapy. He was able to return to his daily activities, sports and BMX bike. The patient was seen in the office 1.5 years after surgery without any clinical or radiographic signs of post traumatic arthritis.


Figure 9 Preoperative radiographs and CT scan images; post operative radiographs pre and post removal of external fixation.


Acute ankle arthrodiastasis with concomitant ankle fracture, open reduction with internal and/or external fixation, should be considered in an attempt to preclude post-traumatic ankle arthritis. This becomes more crucial in cases of intra-articular ankle trauma, where the rate of post-traumatic arthritis increases. With arthrodiastasis, the changes in hydrostatic pressure provide an environment for chondrocyte repair and regeneration thus decreasing the chances for post-traumatic arthritis and the potential need for a joint fusion or replacement. The combination of mechanical offloading along with the microangiogenesis that is produced with increased tension to the soft tissue structures have shown to aid this process of repair.

Vito, et al., distracted 65 arthritic ankles using the Ilizarov frame for 6 weeks with distraction of 5-10 mm [11]. The patients had marked reduction in pain at 12 months for all patients except two: those two went on to arthrodesis. Valburg, et al., reported an average of two years pain relief following three months of arthrodiastasis with an Ilizarov frame [12]. Ploegmakers, et al., assessed the use of arthrodiastasis in 22 patients and reported 73% of the patients had significant improvement at seven years [13]. Although these series were not in the acute setting, one can assess the benefit these series showed with arthrodiastasis of the ankle joint.

This case series showcased four different cases of intra-articular ankle trauma where ankle diastasis was employed as part of the fixation in the acute setting. Successful outcomes were noted in three patients thus far at one to two years of follow up. One of the patients will require a joint fusion or replacement after 2 years. With the widening list of indications for arthrodiastasis, we believe there are benefits of using joint distraction in acute intra-articular trauma to either forgo or delay post-traumatic arthritis. This review serves as a foundation to pursue further indications for arthrodiastasis, however it does have limitations. The sample size is small at this time due to lack of extended follow-up. The follow-up time period listed for these four cases is 1-2 years. The results may prove to be different in the future with extended follow-up, however ankle joint diastasis remains a viable option in patients with intra-articular trauma to possibly reduce or delay the need for arthrodesis in the future


  1. Thomas AC, Hubbard-Turner J, Wikstrum EA, Palmieri-Smith RM. Epidemiology of Posttraumatic Arthritis. Journal of Athletic Training. 2017;52(6):491-496.
  2. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006;20(10):739–744.
  3. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-46.13.
  4. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009; 467(7):1800-1806.
  5. Labovitz, J. The Role of Arthrodiastasis in Salvaging Arthritic Ankle. Foot & Ankle Specialist. 2010; 3(4):201-204.
  6. Ilizarov GA. Transosseous Osteosynthesis. Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue, Chapter 11, Non-operative Correction of Foot Deformities. 547-581. Springer-Verlag, Heidelberg, 1992.
  7. Lafeber FP, Intema F, van Roermund PM, et al. Unloading joints to treat osteoarthritis, including joint distraction. Curr Opin Rheum. 2006. 18:519 – 525.
  8. Vito G, et al. Point-Counterpoint: Is Arthrodiastasis A Viable Option For Ankle Arthrosis. Podiatry Today. 2008;21(10).
  9. Kluesner AJ, Wukich DK. Ankle Arthrodiastasis. Clin Podiatr Med Surg. 2009 Apr;26(2):227-44.
  10. Rodriguez-Merchan EC. Joint Distraction in Advanced Osteoarthritis of the Ankle. Arch Bone Jt Surg. 2017;5(4):208-212.
  11. Vito G, Pacheco F, Southerland C, Rodriguez E, Thompson S. A New Solution for the Arthritic Ankle. Podiatry Today. 2005. 18(12):36-43.
  12. Van Valburg AA, van Roermund PM, Marijnissen AC, van Melkebeek J, Lammens J, Verbout AJ, Lafeber FP, Bijlsma JW. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage. 1999 Sep;7(5):474-9.
  13. Ploegmakers JJ, et al. Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Osteoarthritis Cartilage. 2005;13(7):582-588


Rare, non-displaced, sagittal plane fractures of the navicular body: A report of two cases

by Rachelle Randall, DPM1*, Lawrence M. Fallat, DPM, FACFAS2

The Foot and Ankle Online Journal 13 (3): 2

Cases of non-displaced, sagittal plane fractures of the navicular are most commonly seen as stress fractures. Previous literature suggests that the mechanism of injury of most high impact falls have shown significant dislocation of the navicular counterparts or comminution to other structures of the foot. We present two rare cases of high impact injury creating sagittal plane fractures through the navicular body without any dislocation of the navicular or trauma to any surrounding structures. Two patients had similar high impact falls and mechanisms of injury leading to mirrored navicular fracture patterns. Surgical correction was performed in both patients. At three months postoperative both patients were clinically pain free in normal shoe gear, and radiographically healed. At one year postoperative both patients had maintained correction and had returned to full activity prior to injury, pain free. Both of these cases resulted from falls with a longitudinal compression force and an axial loading mechanism, generating these non-displaced, sagittal, navicular body fractures. Due to the avascularity of the body of the navicular and age of the patients, surgical correction of the fracture site was performed to help prevent non-union, avascular necrosis, displacement and future arthritic changes. Both patients had favorable surgical outcomes. There is a need to denote this mechanism of injury and corresponding fracture pattern within the current literature.

Keywords: bone, fall, foot, mechanism, midfoot, stress, trauma

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0002

1 – Resident, Postgraduate Year 2 – Beaumont Health Wayne, Podiatric Foot and Ankle Surgical Residency, Beaumont Hospital Wayne, Wayne, MI 48184, USA
2 – Director – Beaumont Health Wayne, Podiatric Foot and Ankle Surgical Residency, Beaumont Hospital Wayne, Wayne, MI 48184, USA
* – Corresponding author:

Isolated fractures of the navicular bone are rare [1]. The navicular plays an essential role in the medial longitudinal arch and the stability of the midfoot structure as the keystone [2]. Loss of the height or alignment of the keystone can result in loss of 90% or greater of complex hindfoot motion [3]. Classification systems have been derived for fractures of the navicular and corresponding midfoot. Sangeorzan, et al., [4] classified displaced, intra-articular fractures of the tarsal navicular, while Watson-Jones [5] classified multiple navicular fracture patterns including the stress fracture. Though there have been classifications of fracture patterns, the discussion of the mechanism of action and injury is rarely researched and cited. Main and Jowett [6] were the first authors to describe multiple potential mechanisms of action of the navicular fracture. Rymaszewski and Robb [1] in 1976, proposed one revisional mechanism in a later case report and finally, Rockett and Brage [7] in 1997 assessed navicular fractures on Computerized Tomography reviewing five different fracture patterns and proposed another potential mechanism of injury not previously discussed in the literature.

Figure 1 Preoperative radiograph of right foot in Patient 1.

Main and Jowett is still the most cited and well recognized classification system of navicular fracture mechanisms. This classification system was based solely on assessment of radiographic appearance of midtarsal fractures. It was developed by considering the direction of the fracture, the disruption of joints and malalignment of the foot. As stated by Main et al. tarsal navicular body fractures result from axial loading forces that occur frequently when falling from a height. The longitudinal compression forces on the talus lead to compression of the navicular into the cuneiforms, and the navicular to absorb the shock of impact [6].

We present two cases of high impact injury causing sagittal plane fractures through the navicular body, without dislocation of the navicular or surrounding structures.

Figure 2 Eight weeks postoperative radiograph of right foot in Patient 1.

Our case report reveals fracture patterns that appear consistent with stress fractures [8] while the mechanism of action correlates to dislocated, comminuted, corresponding fracture patterns. This mechanism of injury and corresponding fracture pattern has yet to be recognized in the current literature or described in any classification system.

Case Report 1

A 17-year-old male, with no significant past medical history, was treated from 08/2017 to 06/2019. He first presented to the emergency department after a bike riding accident. The patient reported he was 10-15 feet in the air doing a bike trick when he fell and landed directly on his right foot. He stated that he landed with his foot being pointed downward (plantarflexed) and landing on the ball of his foot. The patient admitted to continuing to ride his bike for 20 minutes after initial injury until the pain became too severe. On physical exam the patient had midfoot edema but no ecchymosis or visible deformity present.

Plain radiographs were taken revealing a non-displaced, fracture in the sagittal plane through the body of the navicular. No comminution or dislocation was noted (Figure 1). The patient had surgery three weeks from the initial injury date. He was placed on the operating table in the supine position with an ankle tourniquet inflated. After IV sedation and local anesthesia, the fracture site was reduced percutaneously with a point-to-point clamp and a guide wire was placed across the fracture site from medial to lateral. Guide wire alignment and fracture reduction were then assessed with fluoroscopy imaging intra-operatively. Next, a small stab incision was made on the medial aspect of the navicular and a single 4.0 mm cannulated, cancellous, partially threaded screw was placed across the fracture site. The skin was closed with 3-0 nylon suture.

The patient was placed in a CAM boot to remain non-weight bearing with use of crutches. The sutures were removed at four weeks and the patient was permitted partial weight-bearing in a CAM boot at this time. He was seen again at eight weeks with zero out of ten pain. The radiographs revealed bony callus with cortical healing across the fracture site (Figure 2). The patient was advised to continue use of the CAM boot for two more weeks and then transition into normal shoe gear. The patient started his wrestling season at ten weeks post-operatively, and he was pain free. The patient was seen at three months postoperatively and had been ambulating in supportive shoe gear without pain and participating in wrestling and snow-boarding. The patient was evaluated again 12 months from initial surgery date and remained actively participating in sports and daily activities pain free.

Case Report 2

The second patient was a 26-year-old female, with no significant past medical history, treated from 10/2017 to 05/2019. She presented to our office after being referred from an orthopedic surgeon one week after her initial injury. The patient stated that she fell down a flight of stairs and landed on the ball of her left foot. On physical exam she had no apparent deformity, but localized edema at the midfoot. Plain radiographs showed a complete, non-displaced, sagittal plane fracture through the body of the navicular (Figure 3).

Surgery was performed one week after the initial injury date. She was placed on the operating table in the supine position with an ankle tourniquet inflated. After IV sedation and local anesthesia, the fracture site was reduced percutaneously and stabilized with a point-to-point clamp. Two guide wires were placed from medial to lateral, percutaneously, crossing the fracture site. A small stab incision was then made medially and two 4.0 mm cannulated, partially threaded screws were placed across the fracture site. Fluoroscopy imaging was performed intra-operatively confirming reduction of the fracture site and alignment of the screws. The skin was closed with 3-0 nylon.

The patient was placed in a CAM boot to remain non-weight bearing with use of crutches. Sutures were removed at four weeks postoperatively and the patient was permitted to partial weight-bear in CAM boot at this time. The patient was seen at eight weeks with two out of ten pain. The radiographs revealed bony callus and healing across the fracture site (Figure 4). She was advised to slowly transition out of the CAM boot over the following two weeks. The patient was evaluated again at three months postoperatively and she was playing with her kids pain free at this time. The patient was seen again at 12 months postoperatively and she continued to remain asymptomatic and ambulating in normal shoe gear and full activity.

Figure 3 Preoperative radiograph of left foot in Patient 2.


These isolated fracture patterns with associated mechanisms of action are rarely cited in literature. Cases of non-displaced, sagittal plane fractures are most commonly seen as stress fractures. Most high impact falls have shown significant dislocation of the navicular counterparts or surrounding structures [9]. Although both cases resulted from high energy falls with longitudinal compression and an axial loading mechanism, they exhibited non-displaced, sagittal, navicular body fractures, without dislocation or comminution. This fracture pattern and corresponding mechanism of injury does not fit into any previously cited case.

Figure 4 Eight weeks postoperative radiograph of left foot in Patient 2.

Main and Jowett [6] go into great detail when discussing mechanism, classification and treatment of midtarsal joint injuries. They divided the midtarsal injuries into five major categories when assessing mechanism and fracture pattern. The two navicular injuries presented do not fit into any current classification of mechanism of injury and corresponding fracture pattern. The study by Rocket and Brage [7] most closely correlates to our findings. In their 4th patient, the radiograph revealed what appeared to be a non-comminuted, sagittal plane fracture through the body of the navicular. After computed tomography was performed they found a corresponding large plantar fragment suggestive of comminution. It is also important to note the patient had multiple calcaneal fractures from the corresponding injury as well. As Sangeorzan, et al., classified all of their fracture patterns as displaced fractures of the navicular, our fractures only revealed a sagittal plane fracture without dislocation or comminution [4]. The majority of high impact navicular fractures are associated with either dislocation of navicular components or multiple bone injuries of the foot.

Isolated fractures through the body of the navicular lack significant blood flow [10] and frequently require internal fixation to ensure higher healing probabilities. Due to the avascularity of the body of the navicular [3] and young age of patients, it was appropriate to have surgical correction of the fracture site to help prevent non-union, avascular necrosis and future displacement or arthritic changes. Due to the lack of dislocation and ease of fracture site approximation, the ability to reduce and fixate these fractures percutaneously was both imperative and beneficial. Both patients having suffered high impact falls with minor osseous injury, had excellent surgical outcomes.

We propose the concept that there is potentially another mechanism of injury with corresponding fracture patterns, not previously cited in literature. The foot is accepting forces in an axial loading mechanism while the navicular is able to completely absorb the forces of the impact due to the talus and corresponding cuneiforms compressing at equal energies. These cases resulted from longitudinal compressive forces through the foot without any dislocation and allowing solely the navicular bone to absorb their impact.


  1. Rymaszewski, L. A., & Robb, J. E. Mechanism of fracture-dislocation of the navicular: brief report. The Journal of bone and joint surgery. British volume, 70(3), 492-492, 1988.
  2. Nyska, M., Margulies, J. Y., Barbarawi, M., Mutchler, W., Dekel, S., & Segal, D. Fractures of the body of the tarsal navicular bone: case reports and literature review. The Journal of trauma, 29(10), 1448-145, 1989.
  3. Buckley R, Sands A, AO Surgery Reference,
  4. Sangeorzan, B. J., Benirschke, S. K., Mosca, V. E. A., Mayo, K. A., & Hansen, J. S. Displaced intra-articular fractures of the tarsal navicular. The Journal of bone and joint surgery. American volume, 71(10), 1504-1510, 1989.
  5. Watson-Jones, Reginald. Fractures and Joint Injuries. Baltimore, The Williams and Wilkins Co. Ed. 4, Vol. II, p. 900, 1955.
  6. Main, B. J., & Jowett, R. L. Injuries of the midtarsal joint. The Journal of bone and joint surgery. British volume, 57(1), 89-97, 1975.
  7. Rockett, M. S., & Brage, M. E. Navicular body fractures: computerized tomography findings and mechanism of injury. The Journal of foot and ankle surgery, 36(3), 185-191, 1997.
  8. Mallee, W. H., Weel, H., van Dijk, C. N., van Tulder, M. W., Kerkhoffs, G. M., & Lin, C. W. C. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med, 49(6), 370-376, 2015.
  9. Mathesul, A. A., Sonawane, D. V., & Chouhan, V. K. Isolated tarsal navicular fracture dislocation: a case report. Foot & ankle specialist, 5(3), 185-187, 2012.
  10. Torg, J. S., Pavlov, H., Cooley, L. H., Bryant, M. H., Arnoczky, S. P., Bergfeld, J., & Hunter, L. Y. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. JBJS, 64(5), 700-712, 1982.


Cuboplasty: A novel approach to management of traumatic cuboid fracture with impeding peroneal tendon imposition

by Vikram A. Bala, DPM1,4; Gregory A. Foote, DPM1,4; Morgan E. Garcia, DPM1,5; and Jason A. Piraino, DPM, MS1,2,3

The Foot and Ankle Online Journal 13 (3): 1

This study describes a minimally invasive operative technique commonly described for vertebral compression fractures. This was applied to a rare presentation of cuboid injury with peroneal tendon entrapment. A chart review was performed of a 35-year-old male following an all-terrain vehicle accident. The patient was subject to a dorsiflexion/inversion crush injury to the left foot. Initial radiographs from an outside facility were inconclusive for osseous abnormality. Upon presentation to the clinic, radiographs were concerning for compression fracture of the cuboid. An MRI revealed a comminuted fracture of the cuboid with entrapment of the peroneus longus tendon. The patient underwent peroneus longus tendoscopy in conjunction with percutaneous balloon kyphoplasty for reduction of the fracture and the interposed peroneal tendon. The cuboid fracture was then stabilized using injectable calcium sulfate bone cement. The patient experienced a timely return to function with significant pain improvement quantified by AOFAS scores obtained in the postoperative period. This study demonstrates the utilization of an innovative, minimally invasive operative technique in the foot and ankle. Through use of various imaging modalities and a novel procedure, the patient returned to previous levels of function. This unique practice offers advancement of current treatment methods.

Keywords: cuboplasty, inflatable bone tamp, cuboid Fracture, peroneal entrapment, tenogram, tendoscopy

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0001

1 – Department of Orthopedics, Division of Foot and Ankle Surgery
2 – Associate Professor
3 – Chief of Foot and Ankle Surgery
4 – PGY-3 Podiatry Resident
5 – PGY-2 Podiatry Resident. University of Florida College Of Medicine- Jacksonville, University of Florida Health- Jacksonville

A trend toward the development of minimally invasive surgical techniques has gained momentum in recent years as benefits include equivalent outcomes with expedited recovery times and decreased risk of wound complications. Since its inception in 1945, minimally invasive surgical techniques have continued to grow in popularity, with rapidly expanding applications in a multitude of surgical specialties. One minimally invasive procedure that has become more prevalent of late is the kyphoplasty, initially described as the use of a percutaneously placed inflatable bone tamp (IBT) for intraosseous vertebral fracture reduction under fluoroscopic guidance. Since being developed for use in 1998, the technique’s application has expanded to orthopedic surgery for use in the extremities to now include tibial plateau and plafond, talar dome, distal radius and calcaneal fractures [1,2]. Through introduction of an arthroscopic cannula, the IBT or balloon is used to reduce peri- and intra-articular fractures. Fracture segments are then stabilized using an injectable bone graft substitute or bone cement, which has been shown to have equivalent outcomes as traditional fracture reduction and internal fixation [1-4]. The placement of fast-setting calcium phosphate cement into fresh orthopedic fracture sites has been proven to provide decreased subjective pain levels and allow earlier mobilization [2]. Additionally, other authors have demonstrated that calcium phosphate cements are superior to traditional bone graft, or no bone graft, with respect to preventing fracture subsidence [1-3]. Heim, et al., first described the successful treatment of an isolated cuboid compression fracture utilizing this technique [5].

A novel surgical approach was utilized in this case report to manage a comminuted cuboid compression fracture with peroneus longus tendon entrapment due to concerns regarding wound healing and the patient’s need for expedited recovery. Peroneal longus tendoscopy was utilized to view the interposed tendon in conjunction with percutaneous IBT for intraosseous fracture reduction under fluoroscopic guidance, followed by fracture segment stabilization using injectable calcium sulfate bone cement. Adequate reduction of the cuboid fracture was confirmed along with near anatomic course of the peroneus longus tendon via intraoperative tenogram.

Case Report

A 35 year-old male presented to the Ambulatory Care Clinic after initially being treated in a community hospital Emergency Department for a left foot injury stemming from an all-terrain vehicle (ATV) accident. The patient reported he was riding at approximately 15-mph when he struck a tree root and the vehicle began to roll over. While attempting to stabilize the vehicle, the patient’s left foot was pinned beneath the ATV as it overturned, resulting in a dorsiflexion-inversion injury. The patient was unrestrained, there was no loss of consciousness at the scene and no other concomitant injury. The patient reported hearing a “pop” at the time of injury, followed by immediate pain and swelling to the left mid- and hindfoot. Initial radiographs on the day of injury were reported as negative for acute fracture or osseous abnormality. The patient was subsequently discharged and was made non-weight bearing in a compressive wrap with instructions on rest, nonsteroidal anti-inflammatory medication and outpatient follow-up in the podiatric clinic.

Upon presentation to the office, new radiographs revealed a subtle radiolucency within the body of the cuboid with associated diastasis of the calcaneal-cuboid joint, concerning fracture-subluxation (Figure 1). On clinical examination, the skin was intact and the patient was neurovascularly intact to the left foot. There was localized edema of the lateral mid- and hindfoot with tenderness upon palpation of cuboid, calcaneal-cuboid joint (CCJ), and along the course of peroneal tendons. An MRI was obtained, which confirmed a comminuted fracture of the cuboid with entrapment of the peroneus longus tendon between the fragments, a chronic partial tear of the ATFL and stenosing tenosynovitis of both peroneal tendons posterior to the distal aspect of the fibula (Figure 2).

The patient had a past medical history significant for hyperlipidemia, asthma, hypertension and was employed as a roofer by trade, being the sole provider for his family.

He was also noted to be a current pack per day smoker with a 7.5 pack-year history. Due to his medical history, current smoking status, and need for limited downtime, it was determined that the patient would benefit from a minimally invasive approach to limit the risk associated with wound complications and to provide an expedited return to function. The patient was scheduled for surgical intervention consisting of cuboid kyphoplasty and peroneus longus tendoscopy.

Figure 1 Initial anterior-posterior radiograph revealing subtle radiolucency in cuboid, and calcaneo-cuboid joint diastasis.

On the day of surgery, the patient received a preoperative popliteal and saphenous nerve block by the anesthesia team. The patient was placed supine on a radiolucent flat-top operating room table. A 2.7mm arthroscope was used for peroneal tendoscopy (Smith and Nephew Inc., Andover, MA). The tendon sheath was accessed via a small incision just distal to the lateral malleolus.

Figure 2 Axial MRI film revealing diffuse cuboid comminution and interposed peroneus longus tendon.

Tendoscopy revealed mild fraying along the course the peroneus longus tendon without rupture. Iodine contrast medium (Visipaque, General Electric Healthcare Inc, Princeton, NJ) was then injected distally into the tendon sheath to track the course of the entrapped peroneus longus tendon through the fractured cuboid fragments. Attention was then drawn to the lateral aspect of the midfoot where, under the guidance of C-arm fluoroscopy, a small incision was made at the dorsal/lateral aspect of the cuboid. The trocar/cannula was then placed under fluoroscopy through a stab incision overlying the central fracture fragment.

Figure 3 Initial medial-oblique radiograph revealing subtle radiolucency in cuboid and CCJ diastasis.

Figure 4 Initial lateral radiograph revealing subtle radiolucency in cuboid and CCJ diastasis.

Figure 5 Procedure clinical image; From left to right: Cannula, IBT, hemostat holding reduction of PL tendon prior to IBT inflation.

Figure 6 Intraoperative fluoroscopy demonstrating bone tamp inflation and reduction of fracture fragments.

Figure 7 Intraoperative fluoroscopy of bone cement placement.

Figure 8 Intraoperative tenogram revealing course of reduced peroneus longus tendon within peroneal groove.

A 1.5cm long tunnel was then drilled through the cannula with a 3.5mm drill. Two additional trocars were placed through portals utilizing a similar technique on the medial and proximal margins of the cuboid to ensure no extravasation of the bone graft substitute and also to guide the IBT during inflation. A fourth and final trocar was placed centrally over the dorsal aspect of the cuboid (Figure 3). The kyphoplasty balloon (Kyphon, Medtronic Inc, Memphis, TN) was inserted through the pre-drilled tunnel and inflated to 200 psi (Figure 4). Fracture reduction was confirmed under live fluoroscopy. This step was repeated in a second location, lateral and slightly inferior to the first position.

Following reduction, the balloon was deflated and five milliliters of flowable calcium phosphate bone graft substitute (NoriaN, Depuy-Synthes Inc, West Chester PA) were injected through the cannula into the void left in the cuboid as fracture fixation (Figure 5).

Final fluoroscopy confirmed adequate reduction of the fracture with no extravasation of the flowable bone graft substitute into the calcaneal-cuboid or lateral tarsometatarsal joint. Finally, attention was directed to the plantar aspect of the cuboid, where tenogram was repeated, which revealed the peroneus longus tendon coursing plantarly to the cuboid, representing restoration of normal anatomy. All instrumentation was removed from the surgical sites, the incisions were copiously irrigated with normal sterile saline and sutured closed with No. 3-0 nylon in portal stitch fashion. The patient was placed into a CAM boot and was instructed to remain non-weight bearing to the left foot with crutch assist for 10 to 14 days.

Once evaluated postoperatively in the office, the patient was then transitioned to weightbearing as tolerated in a CAM walker with crutch assist at two weeks postoperatively once sutures were removed. At four weeks, the patient was referred to physical therapy with focus on increasing strength and function of the affected peroneus longus muscle. Radiographs revealed interval placement of injectable calcium phosphate bone cement within the cuboid with adequate anatomical reduction of fracture. (Figures 7 and 8). The patient was able to gradually progress weight bearing as directed by physical therapy and return to full duty at six weeks postoperatively.

Final postoperative radiographs were taken at a 16-week follow up visit, which revealed the maintained position of the bone cement along with adequate alignment of the calcaneocuboid joint and anatomic cortical restoration of the cuboid (Figure 9 and 10). At both six and 12-month postoperative visits, there was notable improvement seen in both the American Orthopedic Foot and Ankle Society (AOFAS) midfoot and lower extremity functional scores in comparison to preoperative values (Figure 11 and 12).

Figure 9 A: Anterior-posterior radiograph obtained 4-weeks postoperative with adequate restoration of CCJ. B: Medial-oblique radiograph obtained 4-weeks postoperative with anatomic restoration of cuboid and calcaneocuboid Joint.

Figure 10 Lateral radiograph obtained 4-weeks postoperatively anatomic restoration of cuboid and calcaneocuboid joint.

Figure 11 A: Anterior-posterior radiograph obtained 16-weeks postoperatively with improved cortical alignment to cuboid along with preservation of the calcaneocuboid joint. B: Medial-oblique radiograph obtained 16-weeks postoperatively with improved cortical alignment to cuboid along with preservation of the calcaneocuboid joint.

Figure 12 Lateral radiograph obtained 16-weeks postoperatively with maintained position of the bone cement spacer along with calcaneocuboid Joint alignment.

The patient was noted to have minimal pain after his six month follow-up visit and was able to fully return to pre-injury levels of activity and function. Most recently, the patient was noted to be completely pain free upon final one-year postoperative visit.


In a typical skeletally mature foot, the cuboid bone articulates with the calcaneus, lateral cuneiform, fourth and fifth metatarsal, making it an integral contributor to the stability of the lateral column.

The restoration of the lateral column is the goal in reduction of cuboid fractures and is essential to maintain the motion and function of the foot [6]. Various fracture patterns of cuboid injury exist, ranging from avulsion, transverse and oblique body fractures, to more extensive comminuted-crush injuries commonly described as a nutcracker fracture [7]. Surgical techniques to reduce such fractures include percutaneous pinning using Kirschner wires or screws, spanning external fixator, or open reduction and internal fixation from least to most invasive. Due to the high energy associated with this injury, there is a high incidence of soft tissue insult, thus the least invasive technique is most often preferred. Percutaneous pinning and cannulated screws, however, are only possible in the presence of stable, non-comminuted fracture fragments to allow for adequate purchase to hold fixation, while external fixation is often complicated with superficial or pin-site infections. Open reduction-internal fixation with or without the addition of bone graft may be a viable option if the soft tissues are amenable but only lend itself as a viable option in non-comminuted, fairly simple fracture patterns.

Techniques used for high-energy crush injuries with a high-degree of comminution, such as spinal compression fractures and tibial plateau fractures, can be translated to the small bones of the foot. The outcomes of kyphoplasty in the spine have been shown to be quite effective with success rates as high as 95% in significant pain relief following the procedure [1]. For intra-articular fractures of the extremities, use of an IBT followed by an injectable calcium sulfate bone cement was shown to be effective in maintaining articular reductions in a good or adequate manner at 12-weeks postoperatively [2]. Complications in kyphoplasty patients have also remained relatively low with only up to 10% of patients experiencing extrusion of bone cement [8]. By utilizing the IBT for the presenting cuboid fracture in this instance allowed for minimally invasive means for adequate reduction for the fracture fragments.

The current case report describes percutaneous balloon reduction of the cuboid and entrapped Peroneal tendons, followed by internal fixation of the fracture segments by backfilling of the defect with an injectable calcium sulfate bone cement. In a meta-analysis, authors found the infection rates were significantly lower in fractures managed with calcium phosphate bone cement than in controls who were managed with no bone graft substitute [3]. Other authors have demonstrated that the use of calcium phosphate cements is superior to traditional bone graft or no bone graft in regard to preventing fracture subsidence and allow for less pain and earlier mobilization due to its fast setting nature and lack of need for union [3,4,9]. The compressive strength of calcium sulfate bone cement has been reported as 55 megapascals, equivalent to the strength of intact cancellous bone, essentially eliminating the need and potential complications associated with the use of allograft [3,9,10].

Peroneus longus tenogram used in conjunction with cuboid fracture management has not been previously described in literature. The utility of Peroneal tenography has been demonstrated in identifying the prevalence of Peroneal tendon impingement in patients with lateral pain following calcaneal fractures [11]. Additionally, several authors have shown the efficacy of tenography in diagnosing various tendon and ligament abnormalities in the ankle to successfully dictate appropriate therapy [12].

In this case report AOFAS Midfoot and Lower Extremity functional outcome scores were collected preoperatively, and were repeated at six and 12 months postoperatively.

Preoperative Score 6 months Postoperative Score 12 months Postoperative Score
AOFAS Midfoot 53 82 100
LEFS 26/80= 32.5% 44/80= 55% 80/80=100%

Table 1 AOFAS and LEFS Functional Outcome Scores, taken preoperatively and at six and twelve months

AOFAS scores revealed significant increases at both the six and 12-month marks postoperatively, with scores of 82 and 100 respectively, when compared to the preoperative score of 53. The LEFS scale revealed similar results with significant increases at six and 12-month followup (55%, 100%) when considered in comparison to the preoperative value (Table 1).

Sequential radiographs taken immediately postoperatively, and again at four and 16 weeks postoperatively revealed maintenance of the internal fixation via the injectable calcium phosphate bone cement. Adequate anatomic restoration of both the calcaneocuboid joint and the cortical alignment of the plantar and lateral surfaces of the cuboid including the peroneal sulcus were also noted. On final, 16-week radiographs, there was no notable migration of the bone cement spacer, which remained confined within the cortices of the cuboid bone. Fracture fragments were noted to be stable as well, and appear to have achieved union when compared to preoperative films.

Overall, this application of percutaneous balloon reduction with use of calcium phosphate bone cement and use of tenography for management of a comminuted cuboid fracture is a viable and reproducible alternative to previously described techniques for these types of injuries. Expected risk and complication rates in our application of “Cuboplasty” should be less than or equal to those previously described for spinal kyphoplasty due to lack of proximity to vital neurovascular structures. Using an injectable calcium sulfate bone cement as opposed to bone grafting, the time to healing is expected to decrease as compared to the traditional approach due to lack of need for biologic graft incorporation. Overall, injectable calcium sulfate bone cement proves to be an acceptable method of fixation for fracture comminution or impacted articular surfaces in various crush injuries, and in conjunction with a percutaneous reduction, this technique will allow patients to return to activity in a timely manner. Peroneus longus tenography was vital to confirm the reduction of the tendon along its natural anatomic course through the peroneal groove, which was unable to be visualized via standard intraoperative fluoroscopy. This technique allows for a percutaneous reduction of a severely comminuted cuboid fracture with restoration of the lateral column and reduction of the entrapped peroneus longus tendon while preserving the soft tissue envelope. To our knowledge, this is the second instance of this type of surgical technique described in the foot and ankle literature. We believe future studies are warranted to determine the efficacy and the long-term results of this procedure.


This case report demonstrates the successful utilization of an innovative, minimally invasive operative technique in the foot and ankle, previously described only once before [5]. Through use of various imaging modalities in conjunction with a novel surgical procedure, this technique allowed a patient with a complex pathology, complicated by firm medical and social restrictions, to return to previous levels of function in a pain-free and timely manner. This unique practice offers advancement of current treatment methods.


  1. Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine. 26:1511-5, 2001.
  2. Heiney JP, Redfern RE, Wanjiku S. “Subjective and novel
    objective radiographic evaluation of inflatable bone tamp treatment of articular calcaneus, tibial plateau, tibial pilon and distal radius fractures.” Injury 44.8 (2013): 1127-1134.
  3. Bajammal SS, Zlowodzki M, Lelwica A, et al. The use of calcium phosphate bone cement in fracture treatment. A meta-analysis of randomized trials. J Bone Joint Surg Am 2008;90(June (6)):1186-96.
  4. Cassidy C, Jupiter JB, Cohen M, et al. Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. J Bone Joint Surg 2003;85-A(November (11)):2127-37.
  5. Heim, KA, Sullivan C, Parekh S. “Cuboid Reduction and Fixation Using a Kyphoplasty Balloon: A Case Report.” Foot & Ankle International, vol. 29, no. 11, 2008, pp. 1154–1157.,
  6. Sangeorzan BJ, Swiontkowski MF. Displaced fractures of the cuboid. J Bone Joint Sur. Br. 72:276-8, 1990.
  7. Borrelli Jr J, De S, VanPelt M. “Fracture of the cuboid.” JAAOS-Journal of the American Academy of Orthopaedic Surgeons 20.7 (2012): 472-477.
  8. Pateder, DB, Khanna, AJ, Lieberman, IH. Vertebroplasty and kyphoplasty for the management of osteoporotic vertebral compression fractures. Orthop Clin North Am. 38:409-18, 2007.
  9. Keating JF, Hajducka CL, Harper J. Minimal internal fixation and calcium-phosphate cement in the treatment of fractures of the tibial plateau. A pilot study. J Bone Joint Surg Br 2003;85(January (1)):68-73.
  10. Rohl L, Larsen E, Linde F, et al.,: Tensile and compressive properties of cancellous bone. J Biomech 1991, 24:1143-1149.
  11. Chen W, Xicheng L, Yiangliang S, et al. “Peroneal Tenography to Evaluate Lateral Hindfoot Pain after Calcaneal Fracture.” Foot & Ankle International, vol. 32, no. 8, 2011, pp. 789–795.
  12. Jaffee NW, Gilula LA, Wissman RD, et al. Diagnostic and Therapeutic Ankle Tenography Outcomes and Complications. Am J Roentgenology. 2001; 176: 365-371.
  13. Monteagudo M, Maceira E, and Martinez de Albornoz P. “Foot and ankle tendoscopies: current concepts review.” EFORT open reviews 1.12 (2016): 440-447. https:/dx.doi/org/10.1302/2058-5241.160028
  14. Ochsner JL. “Minimally invasive surgical procedures.” The Ochsner Journal 2.3
    (2000): 135-136.


Bilateral distal fibula stress fractures in late pregnancy: A case report

by C. Wek1, I. Pilkington1*, J. Compson1, R. Ahluwalia1

The Foot and Ankle Online Journal 13 (2): 9

In this case report we describe an unusual case of bilateral distal fibula stress fractures during late pregnancy. The predisposing and precipitating factors for development of stress fractures were examined, and an evaluation of the impact of pregnancy related factors were completed. Our patient presented at 32 weeks of her pregnancy when the stress fractures developed and was evaluated both in the Emergency Department and orthopaedic outpatient clinic. She was diagnosed with bilateral distal fibula stress fractures which were managed conservatively due to their stable nature and monitored until union.

Keywords: stress fractures, fibula stress fractures, pregnancy, bilateral

ISSN 1941-6806
doi: 10.3827/faoj.2020.1302.0009

1 – Trauma and Orthopaedic Surgery Department, Kings College Hospital, London, UK
* – Corresponding author:

Stress fractures are caused by repetitive cyclical loading of bone. They are often caused by a sudden increase in exercise, smoking, glucocorticoid intake, alcohol abuse, or by metabolic and hormonal imbalances. Stress fractures during pregnancy are rare. Studies have reported that pregnant females with macrosomic infants, an increase in activity, or a vaginal delivery may run a higher risk of stress fractures

Case Report

A 42-year old lady who was 1-month postpartum was referred by her general practitioner to the orthopedic outpatient clinic with bilateral ankle pain. She reported that a month before delivery (at 32 weeks), she developed severe pain in her left ankle. This was then followed by the same pain experienced in her right ankle. The pain was over her lateral malleolus and she attended her local Emergency Department. She underwent clinical and radiological assessment but no cause for the pain was visualized on x-rays. She did not have any co-morbidities and there was no history of smoking or excessive alcohol intake.

On examination she had bilateral pes planus with valgus heels. She had a full range of movement and there was no neurovascular deficit. The repeat x-rays obtained in the clinic at 8 weeks demonstrated stress fractures of the distal fibula at the level of the syndesmosis of both ankles. There was no suggestion of osteoporosis or osteopenia.

The fractures were nondisplaced and the patient was managed conservatively with bilateral “aircast” boots. At week 4, the fractures had healed clinically and radiologically (Figure 1) and she was able to remove the boots. She was given medial arch supports for her pes planus deformity.

C:\Users\kingsepr\Downloads\Ankle XR2 - Left.jpg

Figure 1 Right and left ankle fractures.


Stress fractures were first described by Aristotle in 200 BC and initially recorded in the literature as a syndrome of painful swollen feet in Prussian soldiers by Breithaupt in 1855, as described by Bucholz, et al. [1]. These are fractures that occur in normal bone when it is subjected to abnormal or uncommon stresses which are in the form of repetitive loading. In repetitive loading, there is an imbalance between bone resorption and formation which engenders a resorption-dominated accelerated remodeling process that reduces the strength of bone. Stress fractures can occur in any bone in the body and a study of 320 athletes by Matheson, et al., found that the most common bones affected were the tibia (49.1%) and the fibula (6.6%) with bilateral stress fractures in 16.6% of cases [2].

During pregnancy numerous hormonal, anatomical and physiological changes occur. As a result, neuromechanical adaptations to gait, postural parameters and sensory feedback gradually occur throughout. Weight gained during pregnancy may impact the ability to maintain balance which leads to an increase in stresses at the ankle. A biomechanical study by Ogamba, et al., evaluated the changes in gait with an anteriorly added mass [3]. In this study, a kinematic analysis was performed on healthy female volunteers with a pseudopregnancy sac with a gradual increase in weight. This study found that the volunteers modified their gait biomechanics and this resulted in kinematic changes in the lower limb which increased joint stresses and may contribute to musculoskeletal pain.

Metabolic and hormonal imbalances may also confer an increased risk to fracture and the entity of pregnancy-associated osteoporosis has been described in the literature. A review article by Kovacs, et al., suggested that genetics were a contributing factor such that deficiency of calcitonin or its receptor and elevated levels of parathyroid hormone-related protein enhance osteoclastic activation resulting in a local reduction of bone mineral density.

Our patient had a bilateral pes planus deformity which may also have contributed to the development of a stress fracture. A biomechanical study by Takebe, et al., found that with the ankle in a neutral position the fibula receives between 6.4 – 17.2% of the load applied to the lower extremity [4]. Cheng, et al., reported a stress fracture of the distal fibula occurring in a patient with pes planus deformity and suggested that this may be due to increased loading of the fibula due to lateralization of the load axis during weight bearing [5]. These factors combined with the biomechanical changes seen in pregnancy may account for the development of a stress fracture.

In 1948, Burrows divided stress fractures of the distal fibula into two groups: the first involving young male athletes with fractures 5-6cm proximal to the tip of the lateral malleolus and the second involving middle-aged females with fractures occurring 3-4cm proximal to the tip of the distal fibula [6]. This study also suggested that radiographic findings were often not evident until 3 weeks post injury. Tavakkolizadeh, et al., described bilateral distal fibula stress fractures in a 38-year old lady and suggested that these injuries were more likely to occur in cancellous bone in the second group of patients as previously described by Burrows [7]. The majority of stress fractures may be treated conservatively with splinting in the form of an aircast boot which provides support during ambulation. In this case arch supports were also utilized for the underlying pes planus deformity.


Stress fractures in pregnancy are very rare and to date there have been no reports of bilateral distal fibula fractures occurring in late pregnancy. The hormonal and physiological changes that occur during pregnancy may result in increased joint contact stresses, transient osteoporosis and ligamentous laxity. These changes may predispose individuals to stress fractures.

There is always a hesitancy to expose pregnant patients to radiation, however localized joint pain should be investigated as this may be attributed to a stress fracture. These injuries are inherently stable as the bone is under compression so they may be managed conservatively without any adverse effects.


  1. Bucholz RW, et al. Rockwood and Green’s Fractures in Adults. LWW; Seventh edition (December 29, 2009). ISBN-10: 1605476773
  2. Matheson GO, Clement DB, Mckenzie DC, et al. (1987). Stress fractures in athletes: A study of 320 cases. The American Journal of Sports Medicine, 15(1), 46–58.
  3. Ogamba MI, et al. Changes in Gait with Anteriorly Added Mass: A Pregnancy Simulation Study. J Appl Biomech. 2016 Mar 8
  4. Takebe K, Nakagawa A, Minami H, et al. Role of fibula in weight bearing. Clin Orthop 1984;184:289.
  5. Cheng Y, et al. Stress fracture of the distal fibula in flatfoot patients: case report. Int J Clin Exp Med. 2015 Apr 15;8(4):6303-7
  6. Burrows JH. Fatigue fractures of the fibula. J Bone Joint Surg 1948; 30B:266–79.
  7. Tavakkolizadeh A, Klinke M, Davies MS. Bilateral distal fibular stress fractures. Foot and Ankle Surgery 11 (2005) 171–173.


Surgical technique tip: Using reaming systems for joint surface preparation for first metatarsophalangeal joint arthrodesis

by Stephen A. Mariash, DPM1*, Sarah L. Hatton, CST2

The Foot and Ankle Online Journal 13 (2): 8

Various techniques have been described for joint preparation when performing a first metatarsophalangeal joint arthrodesis. These include power saw resection of the cartilage and subchondral bone, curettage, rongeur, osteotome, and power joint reamers. The reaming systems have the advantage of maintaining the convexity of the first metatarsal head and the concavity of the base of the proximal phalanx of the hallux. Unfortunately, these systems have been the target of criticism in that they can be quite aggressive leading to overzealous bone resection causing excessive shortening and possible fractures, especially in the presence of osteopenic bone. We present a technique tip which will offer the surgeon more control of the power instrumentation and subsequently less risk of intraoperative complications.

Keywords: first metatarsophalangeal joint, joint preparation, reaming, arthrodesis, fusion

ISSN 1941-6806
doi: 10.3827/faoj.2020.1302.0008

1 – St. Cloud Orthopedics, Sartell, MN, USA
2 – St. Cloud Hospital, St. Cloud MN, USA

* – Corresponding author:

Arthrodesis of the first metatarsophalangeal (MTP) joint is a procedure that is utilized successfully for the treatment of various pathologies involving the hallux. These include arthrosis of the first MTP joint, severe hallux valgus deformities, hallux rigidus, hallux varus, neuromuscular disorders, and as a salvage procedure for failed first MTP joint procedures [1,2]. As with any arthrodesis procedure, the success relies on proper joint preparation and satisfactory fixation in adequate alignment. Maintaining the convexity of the head of the first metatarsal and concavity of the base of the proximal phalanx of the hallux yields several advantages. Shortening of the first ray is minimized compared to power saw resection of the cartilage and subchondral bone. In addition, surface area of the opposing osseous surfaces is maximized. Moreover, the convex and concave surfaces of the first metatarsal head and base of the proximal phalanx respectively allow the surgeon to “dial-in” the alignment of the proposed arthrodesis in all three body planes prior to final fixation.

Surgical Technique

The first metatarsophalangeal joint is accessed in the usual fashion. Any loose bodies may be removed and osteophytic lipping over the doral, medial and lateral aspects of the first metatarsal head and base of the proximal phalanx of the hallux is resected with a rongeur.


Figure 1 The guide pin is inserted into the shaft of the first metatarsal.


Figure 2 The StrykerSystem 7 Rotary Drill. The instrument may be set in either the “drill” or “ream” mode.

A guide pin is inserted into the first metatarsal head and shaft with care taken to drive the pin down the center of the medullary canal of the first metatarsal (Figure 1). This may be verified with anterior-posterior and lateral views utilizing intraoperative fluoroscopy. The appropriate size reamer for the head of the first metatarsal is selected. The sizes vary depending upon the manufacturer, but usually range from 16 mm to 22 mm in 2 mm increments. The reamer is placed onto a rotary drill/reamer. We used a Stryker System 7 single-trigger rotary drill (Figure 2). Any system that has a separate setting for drill and ream will suffice. The device is placed in the ream position and the cartilage and subchondral bone at the head of the first metatarsal is removed (Figures 3).

image6.jpg image3.jpg

Figure 3 A-B, Cartilage and subchondral bone removed from the head of the first metatarsal.

The surgeon has more control of the power instrument in the ream setting versus the drill setting. With the ream setting, there is a lower speed and higher torque compared to the drill setting (Table 1).





DRILL 1200 41
REAM 270 157

Table 1 Specifications for the Stryker System 7 Rotary Drill.


Figure 4 Guide pin driven into the base of the proximal phalanx of the hallux.

image2.jpg image5.jpg

Figure 5 A-B, Cartilage and subchondral bone removed from the base of the proximal phalanx of the hallux.

A guidepin is then placed into the base of the proximal phalanx of the hallux (Figure 4). The pin is driven down the shaft of the medullary canal and satisfactory placement may be confirmed with anterior-posterior and lateral views utilizing intraoperative fluoroscopy.


Figure 6 The hallux is placed in the desired alignment and temporary fixation is placed using Kirschner wires.

The appropriate size reamer for the base of the proximal phalanx of the hallux is selected. This matches the size used for the head of the first metatarsal. Once again, the reamer is inserted into the rotary drill/reamer. The cartilage and subchondral bone at the base of the proximal phalanx is resected (Figure 5). The reader is encouraged to view the video demonstrating the difference between the ream and drill settings on the rotary power instrument (Video). A rongeur may be used to remove any remnants of subchondral bone.


The position of the proposed arthrodesis is finalized by placing the head of the first metatarsal and the base of the proximal phalanx of the hallux in the desired alignment [3]. This is easily achieved due to the convexity of the first metatarsal head and concavity of the base of the proximal phalanx of the hallux. It is generally agreed that the toe should be arthrodesed in approximately 10 to 15 degrees of valgus and should not touch the second toe. In addition, the toe should be in about 10 to 15 degrees of dorsiflexion relative to the weightbearing surface of the foot in the sagittal plane. Temporary fixation with Kirschner wires is performed (Figure 6) and the alignment is checked with fluoroscopy. Final fixation is achieved depending on surgeon preference [4–8].


The main advantages of the presented technique tip are intraoperative time saving, minimal resection of cartilage and subchondral bone, decreased shortening of the first ray, and the maintenance of the convexity at the head of the first metatarsal and the concavity at the base of the proximal phalanx of the hallux which allows for greater bone to bone contact area and the ability for the surgeon to “dial-in” the desired position of the proposed arthrodesis [9]. Moreover, placing the power rotary instrument in the “ream” setting, allows the surgeon to have more control of the device given the decreased speed and increased torque compared to the “drill” setting. One must still be cautious when addressing bone with cystic changes and osteopenia.


  1. Sage RA, Lam AT, Taylor DT. Retrospective analysis of first metatarsal phalangeal arthrodesis. J Foot Ankle Surg. 1997;36: 425–9; discussion 467.
  2. Donegan RJ, Blume PA. Functional Results and Patient Satisfaction of First Metatarsophalangeal Joint Arthrodesis Using Dual Crossed Screw Fixation. J Foot Ankle Surg. 2017;56: 291–297.
  3. Roukis TS. A simple technique for positioning the first metatarsophalangeal joint during arthrodesis. J Foot Ankle Surg. 2006;45: 56–57.
  4. Coughlin MJ, Abdo RV. Arthrodesis of the first metatarsophalangeal joint with Vitallium plate fixation. Foot Ankle Int. 1994;15: 18–28.
  5. Coughlin MJ. Arthrodesis of the first metatarsophalangeal joint with mini-fragment plate fixation. Orthopedics. 1990;13: 1037–1044.
  6. Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 2006;27: 869–876.
  7. Rongstad KM, Miller GJ, Vander Griend RA, Cowin D. A Biomechanical Comparison of Four Fixation Methods of First Metatarsophalangeal Joint Arthrodesis. Foot & Ankle International. 1994. Aug;15(8):415-419
  8. Herr MJ, Kile TA. First Metatarsophalangeal Joint Arthrodesis with Conical Reaming and Crossed Dual Compression Screw Fixation. Techniques in Foot and Ankle Surgery 2005; 4(2): 85-94.
  9. Kundert H-P. [Cup & cone reamers for arthrodesis of the first metatarsophalangeal joint]. Oper Orthop Traumatol. 2010;22: 431–439.


A case of stenosing peroneal tendinopathy in a fibro osseous tunnel due to a hypertrophied peroneal tubercle in the setting of a ball and socket ankle joint

by Zach T. Laidley1*, DPM, Daniel A. Lowinger2,4, DPM, FACFAS, Douglas S. Hale3, DPM, FACFAS

The Foot and Ankle Online Journal 13 (2): 7

Peroneal tendinopathy is a common pathology encountered by the foot and ankle surgeon. A hypertrophied or enlarged peroneal tubercle can be implicated in the etiology of tendinopathy. We present a case of stenosing peroneal tendinopathy due to an enlarged peroneal tubercle with concomitant ball and socket joint. Ball and socket ankle joint is a rare pathology that can present among different pathologic entities. The foot and ankle surgeon should consider the role of the peroneal tubercle in peroneal tendon disease especially in cases of complex rearfoot and ankle deformities.

Keywords: peroneal tendinopathy, ball and socket ankle joint, rearfoot coalition, lateral ankle instability, congenital foot deformity

ISSN 1941-6806
doi: 10.3827/faoj.2020.1302.0007

1 – Resident, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
2 – Attending Physician, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
3 – Residency Director, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
4 – The Polyclinic, Seattle, WA

* – Corresponding author:

Stenosing peroneal tendinopathies are relatively rare and can be associated with an enlarged peroneal tubercle [1,2]. The reported presence of a peroneal tubercle is varied but is present in 90% of specimens and enlarged in 20% [3,4]. It is located at the lateral aspect of the calcaneus and serves as a fulcrum to guide the peroneus longus underneath the cuboid [5]. It sits between the peroneus brevis and longus with the brevis superior and the longus inferior. It serves as an insertion point for the inferior peroneal retinaculum and separation point of the peroneal sheaths. With hypertrophied peroneal tubercles, the inferior peroneal retinaculum can be thickened, trapping the peroneal tendons in a dense fibrous tissue layer [1,2].

The peroneal tendons can be stenosed at the retromalleolar sulcus, at the peroneal tubercle, or inferior to the cuboid notch [1,2,6,7]. The exact etiology of an enlarged peroneal tubercle is unknown but has been theorized as either congenital or acquired. The hypertrophied peroneal tubercle has been associated with tenosynovitis and rupture of the peroneus longus tendon [8]. The enlarged tubercle can alter the stresses on the peroneal tendons, or tendons can be entrapped between the enlarged tubercle and the fibula leading to stenosing pathologies [8].

Figure 1 AP ankle radiograph, ball and socket ankle joint with enlarged peroneal tubercle.

Figure 2 (A) Coronal T2 MR image showing enlarged peroneal tubercle with peroneal tendons traveling in osseous tunnel, with surrounding tenosynovitis. (B) Coronal T1 showing enlarged peroneal tubercle.

Ball and socket ankle joint is a rare condition that can initially present as lateral ankle or peroneal tendon pathology [9]. The ball and socket ankle joint has a loss of concavity of the talar articular surface and rounding (increased concavity) of the tibial and fibular surfaces. The etiology of the deformity is controversial, with the most contested origins being embryologic malformation and adaptive deformation due to abnormal subtalar and midtarsal structural abnormalities [5,10-12]. Using arthrographic studies, Takura, et al., showed that ball and socket ankle deformity did not occur until after 5 years of age , supporting the theory that ball and socket ankle joint is an acquired deformity [13]. Others have supported the findings of Takura, stating that the ball and socket ankle joint occurs as a result of abnormal subtalar joint structure and function [5,12]. Several different orthopedic pathologies are associated with the ball and socket ankle joint, including fibular shortening or aplasia, limb length discrepancy, tarsal coalitions, and ligamentous laxity [10,11,13-15]. The nature of the deformity lends itself to increased frontal plane instability. As a result, these patients can present with chronic ankle instability or persistent lateral ankle pain [14,16].

The association between hypertrophied peroneal tubercle and peroneal tendinopathy has been extensively reported in the literature [1-3,6-8,17,18]. There are also cases of peroneal tendinopathy in the setting of ball and socket ankle joint [9]. However, to our knowledge, this is the only case report of stenosing peroneal tendinopathy due to a hypertrophied peroneal tubercle in the setting of a ball and socket ankle joint.

Case Report

A 35-year old female with past medical history significant for ligamentous laxity and chronic lower back pain presented with a 3-month history of lateral ankle pain. Symptoms initially started following an increase in activity during a vacation. She denied any recent or past inciting event or trauma to her ankle. The physical exam was most notable for significant tenderness along the course of peroneal tendons at the posterior aspect of the lateral malleolus and extending to the hindfoot. There was pain with eversion against resistance.

Figure 3 Coronal T2 (A) and sagittal T1 (B) MR images showing subtalar joint coalition.

Initial radiographs showed an osseous talocalcaneal coalition with a ball and socket ankle joint (Figure 1). There was evidence of an enlarged peroneal tubercle of the calcaneus. An MRI was subsequently obtained to assess the peroneal tendons and lateral ankle ligaments. The MRI showed an enlarged peroneal tubercle (Figure 2) and a solid osseous subtalar joint middle facet coalition extending into portions of the posterior facet with an associated hindfoot valgus (Figure 3). Severe common peroneal tendon sheath tenosynovitis with a high-grade partial thickness tear of the peroneus brevis with subluxation into the fibular calcaneal interval was noted (Figure 2 & 3). Moderate peroneus longus tendinosis was noted. The syndesmotic, anterior talofibular and calcaneofibular ligaments were intact.

Conservative treatment was attempted with an ankle brace and NSAIDs, but the patient was unable to tolerate the brace long-term. Surgical excision of hypertrophic peroneal tubercle with repair of peroneal tendons was planned.

Description of Procedure

The patient was placed in a lateral decubitus position with appropriate padding. The right foot and leg were prepped and draped, and the pneumatic tourniquet was placed. A linear longitudinal incision was made at the posterolateral aspect of the ankle over the peroneal tendon sheath extending in a curvilinear fashion distal to the peroneal tubercle. The peroneal tendon sheath was incised, exposing the peroneus longus tendon and inflamed synovial tissue.

A picture containing person, indoor, food Description automatically generated

Figure 4 Intraoperative image of peroneal tendons retracted out of the way to show enlarged peroneal tubercle.

The peroneus brevis tendon was visualized impinged between a large prominence of bone at the lateral wall of the calcaneus and the lateral malleolus (Figure 4).

The prominent bone was resected using an osteotome and mallet and smoothed using a rasp. Bone wax was applied to exposed cancellous bone. The peroneus brevis was somewhat thinner than normal diameter distal to the excised bone, but with normal appearing texture of the tendon. At the level of the peroneal tubercle, the peroneus brevis tendon was thickened, and there was a full-thickness split tear at the level of the peroneal tubercle and distal portion of the lateral malleolus, measuring approximately 3cm length. Fibrous and scar tissue within the tendon was excised, and the defect was repaired. The peroneal tendon sheath was then reapproximated, followed by closure of subcutaneous tissues and skin.

Postoperatively, the patient was non-weight bearing in orthopedic cast boot for two weeks and then allowed to transition to weight-bearing as tolerated. At the six-month follow up, the patient was doing well and reported overall satisfied with the surgery. She had successfully transitioned out of the ankle brace for ambulation and was currently undergoing a course of physical therapy. Eversion strength was intact with no crepitus with range of motion of peroneal tendons and no evidence of effusion.


Hypertrophied peroneal tubercle resulting in stenosing peroneal tendon pathology is a rare condition. This case is also unique given the osseous subtalar joint coalition and concomitant ball and socket ankle joint. The etiology of the hypertrophied peroneal tubercle is largely unknown, but is commonly associated with peroneal tendon pathology. In this case the etiology of the hypertrophied peroneal tubercle is likely secondary to congenital abnormalities. A literature review by Kocadal, et al., investigated 22 studies, including 186 ball and socket ankle joints, no study reported on the occurrence of concomitant hypertrophied peroneal tubercle [9]. To our knowledge this is the only case in the literature describing hypertrophied peroneal tubercle resulting in stenosing peroneal tendon pathology predisposed by subtalar joint coalition and an associated ball and socket ankle joint.


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  2. Burman M. Subcutaneous tear of the tendon of the peroneus longus: its relation to the giant peroneal tubercle. AMA Arch Surg. 1956; 73:216–219.
  3. Hyer C, J Dawson J, Philbin T, Berlet G, Lee T. The peroneal tubercle: Description, Classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005; 26:947–950.
  4. Palmanovich E, Laver L, Brin YS, Kotz E, Hetsroni I, Mann G, Nyska N. Peroneus longus tear and its relation to the peroneal tubercle: a review of the literature. Muscles Ligaments Tendons J. 2011; 1:153–160.
  5. Ruiz SF, Picazo MC, Canadillas BL, Garcia BE. 2002. Ball-and socket ankle joint with hypoplastic sustentaculum tali. Eur Radiol. 2002;12:S48– S50.
  6. Bruce, WD, Christoferson MR, Phillips DL. Stenosing tenosynovitis and impingement of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999; 20(7):464–467.
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  8. Taneja AK, Simeone FJ, Chang CY, Kumar V, Daley S, Bredella MA, Torriani M. Peroneal tendon abnormalities in subjects with an enlarged peroneal tubercle. Skeletal Radiol. 2013;42:1703–1709.
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