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The Masquelet technique was first performed in 1986. It is a 2-stage procedure for healing of substantial bone defects, with or without the presence of infection. In the former situation, a thorough debridement of the infected site is necessary to achieve a clean cavity. A cement block is fashioned to fit into the entire defect to act as a spacer that maintains the space for grafting and reconstruction and induces a synovial-like membrane. The induced membrane avoids resorption of the bone graft and secretes growth factors, including vascular and osteoinductive factors, to promote revascularization of the graft. The membrane has an inner part that is a synovial-like epithelium and an outer part composed of fibroblasts, myofibroblasts, and collagen. It is richly vascularized. After a period of 6 to 8 weeks, the spacer is removed by incising the induced membrane that has formed. Copious bone graft, usually autologous and obtained from the iliac crest or by other means, is placed into the defect that is now lined by the induced membrane. The membrane is closed over the graft. This article describes a young patient who started on the correct path for a Masquelet procedure only to have it turn in the wrong direction. However, the problem was not recognized until 8 years after the initial injury. The situation was corrected by performing the final stage of the procedure as it was originally described.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Literature trends indicate a generally lower rate of reoperation and revision associated with the fixed-bearing two-component design implant compared to the mobile-bearing three-component design for total ankle arthroplasty (TAA). Coronal deformity is also linked to poorer outcomes following TAA. The aim of this study was to assess the impact of intra-articular coronal deformity (non-concentric ankle arthritis) on both fixed and mobile implant designs. We hypothesized that non-concentric ankle arthritis and mobile bearings would be associated with a higher early revision rate. Methods: This IRB approved retrospectivelreviewed 202 patients who underwent TAA with either mobile-bearing or fixed-bearing implants between 2007 and 2018. Patients who underwent TAA from 2007 to 2013 received the mobile-bearing implant, while those who underwent TAA after November 2012 received the fixed-bearing implant. Age, gender, ASA score, smoking status, BMI and eciology of the arthritis were reported from patients' record. Preoperative weight bearing x-ray were assessed for COFAS classification and intra-articular deformity. Non-concentric ankles were defined by a talar tilt angle greater than 4 degrees. The primary outcome was the rate of revision and reoperation within three years following the index procedure. Revision was defined as implants removal or exchange. Reoperation was defined as any additional surgery post-index surgery. The data underwent normality testing with the Shapiro-Wilk test, and comparisons were made via Kruskal-Wallis test and Chi square test. A p-value threshold of 0.05 or below was deemed significant. Results: All groups were not statistically different for age, gender, ASA score, BMI, and smoking status. Of the 76 patients who received a mobile-bearing implant, 33 had non-concentric arthritis, and 43 had concentric arthritis. Of the 126 patients who received a fixed-bearing implant, 61 had non-concentric arthritis, and 65 had concentric arthritis. In the mobile-bearing group, 8 patients underwent revision and 9 underwent reoperation. In the fixed-bearing group, 4 patients underwent revision and 10 underwent reoperation. In the non-concentric group revision rate was significantly higher (p< 0.05) for the mobile-bearing implant (15.2%) compared to the fixed-bearing implant (0%) . In the concentric group, no significant difference in revision rates between the fixed-bearing (6.2%) and mobile-bearing designs (7%) was observed. Reoperation rates were similar across all groups. Conclusion: The study suggested that the use of mobile-bearing implants in patients with non-concentric arthritis is associated with a significantly higher revision rate compared to fixed-bearing implants. In patients with concentric arthritis, there was no significant difference in revision rates between the two implant designs. Additionally, the study found no significant difference in the reoperation rates across all groups. Preoperative intra-articular deformity seems to be a predictor of early revision rate after total ankle arthroplasty.

Category: Bunion; Other Introduction/Purpose: Hallux Valgus correction with Minimally Invasive Surgery (MIS) is a popular procedure due to its potential advantages such as shorter operative time and quicker recovery than open surgery. Third-generation Minimally Invasive Chevron Akin (MICA) osteotomy has shown excellent clinical and radiological outcomes. The optimal fixation criteria are 3-point fixation (medial cortex, lateral cortex, and the lateral half of the 1st metatarsal head) for the proximal screws and 2-point fixation (medial cortex and central position in the 1st metatarsal head) for the distal one. To address the steep learning curve of the free hand technique, we describe a new guided trajectory system for third-generation MICA to increase precision and reduce the risk of suboptimal K-wire or screw placement. Early radiological outcomes and complications were reported. Methods: From April 2022 to January 2023, 13 consecutive MICAs were performed on 11 female patients (bilateral in 2 patients) with an average age of 61 by a single fellowship-trained foot and ankle orthopaedic surgeon who developed the device. These were the 13 first cases performed with the new device. Preoperative and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA) and tibial sesamoid position (TSP) were measured in all patients using weight-bearing radiographs. Also evaluated in the postoperative radiographs were the number of cortical purchase of the screws and their position in the metatarsal head. Additionally, any difficulties or intraoperative complications and operative time were reported. All parameters were analysed with the one-tailed non-parametric Wilcoxon test. Results: All the radiographic parameters improved significantly. The median IMA improved from 14.5 degrees (interquartile range [IQR]: 11.5-16) to 5 degrees (IQR: 4.0-6.0) (p < 0.005). The median HVA also decreased from 27.5 degrees (IQR: 25.3-34.5) to 7.0 degrees (IQR: 4.0-8.5) (p < 0.005). The median DMAA fell from 15.5 degrees (IQR: 13.3-19.3) to 6.0 degrees (IQR: 6.0-8.0) (p < 0.005). The median TSP was 2 (IQR: 2-3) pre-operatively and 0 (IQR : 0-1) (p < 0.005) post-operatively. All the proximal screws for Chevron osteotomy had 3-point fixation and the distal anti-rotation screws had 2-point fixation No intraoperative complications were reported. The mean operative time was 52 (SD:10,4) minutes. Conclusion: Our study demonstrates the successful use of a guided trajectory system for minimally invasive bunion correction with optimal screw placement, good early radiological outcomes, and without extensive operating time. The absence of intraoperative complications or difficulties further confirms the efficacy of this system. Our findings suggest that the use of a guided trajectory system can potentially improve the consistency and success of third-generation MICA procedures. These results emphasize the benefits of incorporating guided trajectory systems in bunion correction surgeries and their potential to improve patient outcomes.

Category: Bunion; Other Introduction/Purpose: The Lapidus procedure (first tarsometatarsal joint (TMT1) fusion) is an established treatment for correcting hallux valgus with 1st ray hypermobility. The original Lapidus (OL) technique involves fusing the TMT1 joint and first metatarsal base to the second, while the modified Lapidus (ML) technique involves fusing only the TMT1 joint. The purpose of this study was to investigate whether the ML procedure results in an early loss of correction. Methods: This retrospective study analyzed the outcomes of 45 feet in 40 patients with hallux valgus who underwent either the ML (21 feet) or OL (24 feet) procedure between 2014 and 2022 at a single center. All fixations were performed with 3.5 cortical screws, except for 9 cases that were fixed with a plantar locking plate. Differences in the immediate postoperative (6 weeks) and postoperative (6 months) intermetatarsal angle (IMA) and hallux valgus angle (HVA) were analyzed using Mann-Whitney tests, and complications were reported. Results: The mean preoperative IMA and HVA for the OL were 15.8° ± 3.5° and 36.4° ± 9.5°, respectively, and 14.5° ± 2.3° and 33.0° ± 7.0° for the ML. The immediate postoperative IMA and HVA were similar for both procedures (7.2° ± 2.0° and 7.7° ± 4.3° for OL, 7.3° ± 2.1° and 8.5° ± 5.5° for ML). Although from 6 weeks to 6 months postoperatively, the loss of correction of the HVA did not differ between both procedures (4.2° for OL, 5,6° for ML), the IMA loss of correction was significantly higher in the ML (1.1° ± 1.4° vs 0.5° ± 1.1°) (p < 0.05). One case of delayed union was reported in the OL group, but it did not require revision. Conclusion: The study results suggest that the ML procedure does not provide the same stability as the OL procedure in the early postoperative period, as there was a significantly greater early loss of correction of the IMA at 6 months postoperatively in the ML group compared to the OL group. Although there were no differences in the loss of correction of the HVA angle (HVA), an observed loss of 5 degrees remains a concern. Further studies are necessary to better understand the indications of the modified and original procedures.

Following a Lisfranc joint injury, stable fixation of the tarsometatarsal joints is crucial to avoid deformity and posttraumatic osteoarthritis, but the ideal method of fixation remains controversial. Kirschner wire (K-wire) fixation of all involved joints with cast immobilization resulted in loss of position, and was replaced by open reduction with improved fixation using transarticular screws. However, it seems intuitive that transarticular screws will result in further damage to already traumatized joints, and this has led to plate-spanning techniques. The objective of this study was to describe the method of dorsal multiple plating without the routine use of transarticular screws, and to report on the ability of plate fixation to maintain alignment comparable to that of transarticular screw fixation in 15 patients. [Following a Lisfranc joint injury, stable fixation of the tarsometatarsal joints is crucial to avoid deformity and posttraumatic osteoarthritis, but the ideal method of fixation remains controversial. Kirschner wire (K-wire) fixation of all involved joints with cast immobilization resulted in loss of position, and was replaced by open reduction with improved fixation using transarticular screws. However, it seems intuitive that transarticular screws will result in further damage to already traumatized joints, and this has led to plate-spanning techniques. The objective of this study was to describe the method of dorsal multiple plating without the routine use of transarticular screws, and to report on the ability of plate fixation to maintain alignment comparable to that of transarticular screw fixation in 15 patients. [ Orthopedics. 2014; 37(12):815–819.]

Background: Functional hallux limitus (FHLim) refers to a limitation of hallux dorsiflexion when the first metatarsal head is under load, whereas physiologic dorsiflexion is measured in the unloaded condition. Limited excursion of the flexor hallucis longus (FHL) in the retrotalar pulley has been identified as a possible cause of FHLim. A low-lying or bulky FHL muscle belly could be the cause of this limitation. However, to date, there are no published data regarding the association between clinical and anatomical findings. The purpose of this anatomical study is to correlate the presence of FHLim and objective morphologic findings through magnetic resonance imaging (MRI). Methods: Twenty-six patients (27 feet) were included in this observational study. They were divided into 2 groups, based on positive and negative Stretch Tests. In both groups, we measured on MRI the distance from the most inferior part of the FHL muscle belly and the retrotalar pulley as well as the cross-sectional area of the muscle belly 20, 30, and 40 mm proximal to the retrotalar pulley. Results: Eighteen patients had a positive Stretch Test and 9 patients had a negative Stretch Test. The mean distance between the most inferior part of the FHL muscle belly and the retrotalar pulley was 6.0 ± 6.4 mm for the positive group and 11.8 ± 9.4 mm for the negative group (P = .039). The mean cross section of the muscle measured at 20, 30, and 40 mm from the pulley were 190 ± 90, 300 ± 112, and 395 ± 123 mm2 for the positive group and 98 ± 44, 206 ± 72, and 294 ± 61mm2 for the negative group (P values .005, .019, and .017). Conclusion: Based on these findings, we can conclude that patients with FHLim do have a low-lying FHL muscle belly causing limited excursion in the retrotalar pulley. However, the mean volume of the muscle belly was comparable in both groups, and therefore bulkiness was not found to be a contributing factor. Level of Evidence: Level III, observational study.

Computer-assisted orthopedic surgery has developed dramatically during the past 2 decades. This article describes the use of intraoperative 3-dimensional computed tomography and navigation in foot and ankle surgery. Traditional imaging based on serial radiography or C-arm–based fluoroscopy does not provide simultaneous real-time 3-dimensional imaging, and thus leads to suboptimal visualization and guidance. Three-dimensional computed tomography allows for accurate intraoperative visualization of the position of bones and/or navigation implants. Such imaging and navigation helps to further reduce intraoperative complications, leads to improved surgical outcomes, and may become the gold standard in foot and ankle surgery. [ Orthopedics. 2016; 39(5):e1005–e1010.]

Optimal duration of antibiotic prophylaxis following major lower limb amputation in preventing adverse stump outcomes is controversial. We assess the epidemiology and risk factors of wound dehiscence and stump infection after mid-thigh to transmetatarsal amputations with regard to antibiotic administration. Our retrospective observational study at the Geneva University Hospital (January 1995–June 2010) includes a total of 289 amputations in 270 adult patients (199 males; median age 70years). Wound dehiscence and/or stump infection occurred in 47 (16.3 %) and 63 (21.8 %) patients with a median delay of 24 and 14days, respectively. No clinical variable was significantly associated with stump infection. Diabetes and older age (>80years) were associated with dehiscence. Importantly, transcutaneous tissue oxygen tension (TcPO2) and duration of antibiotic administration showed no association with either outcome. The duration of antibiotic administration before or after surgery does not change the epidemiology of stump complications.

We report a case of desmoplastic fibroblastoma (DF) of the foot in a 65-year-old woman. The tumor presented as a slow-growing, painless mass located in the first intermetatarsal space of the right foot. Ultrasound showed a well-circumscribed hypoechoic lesion containing hyperechoic calcifications confirmed on standard radiographs. At magnetic resonance imaging (MRI), the mass appeared isointense to the muscles on T1-weighted (T1W) images, hyperintense on proton-density-weighted fat-saturated images, and presented scattered internal hypointense foci. Post-contrast T1W spectral presaturation with inversion recovery (SPIR) images showed heterogeneous, mostly peripheral, contrast enhancement. DF must be considered in the differential diagnosis of soft-tissue calcified tumors of the foot.

BACKGROUND:Second-generation total ankle arthroplasty has been reported to have good intermediate-term results. The purpose of the present study was to report on the cause and frequency of reoperation and failure after total ankle arthroplasty and to determine demographic and clinical predictors of reoperation and failure. METHODS:Three hundred and six consecutive primary total ankle arthroplasties were performed with use of the DePuy Agility Total Ankle System between 1995 and 2001. At a mean of thirty-three months after the arthroplasty, we retrospectively reviewed the records with regard to patient age, gender, the indications for the index procedure, adjuvant procedures, the timing and frequency of reoperation, and the indications for and the type of reoperations performed. Kaplan-Meier analysis was performed to determine the rate of prosthetic survival, and Cox regression analysis was performed to determine predictors of reoperation and failure. RESULTS:Eighty-five patients (28%) underwent 127 reoperations (involving 168 procedures) after primary total ankle arthroplasty. The most common procedures at the time of reoperation were débridement of heterotopic bone (fiftyeight), correction of axial malalignment (forty), and component replacement (thirty-one). Eight patients underwent below-the-knee amputation. Age was found to be the only significant predictor of reoperation and failure after total ankle arthroplasty. The five-year survival rate with reoperation as the end point was 54%. The five-year survival rate with failure as the end point was 80% for all patients and 89% for patients who were more than fifty-four years of age. The prosthesis could not be salvaged in nine ankles (2.9%); the inability to salvage the prosthesis was most often due to loosening or infection. CONCLUSIONS:We noted a relatively high rate of reoperation after total ankle arthroplasty with this second-generation device. Younger age was found to have a negative effect on the rates of reoperation and failure. Most prostheses could be salvaged; however, the functional outcome of this procedure is uncertain. LEVEL OF EVIDENCE:Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.