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A 58-year-old agricultural worker from a remote Western province farming community in Saudi Arabia presented with a 2-year history of right plantar foot soft tissue mass. According to the patient, the swelling had gradually increased in size over a few years, but it was painless and thus had not restricted him from continuing to farm until the lesion started to affect mobility. An MRI, microbiology and histopathology reported a rare infectious agent- Actinomyces spp, otherwise referred to as Madura foot. Three-dimensional CT aided in a preoperative surgical plan which included mass excision/debulking for this challenging lesion. Full eradication was not possible, and the patient required prolonged anti-infective therapy (>6 months) along with close surveillance to map resolution of infective symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

A 68-year-old man with a slow-growing lesion in the distal medial band of the plantar fascia of the left foot is presented. Clinical photographs, ultrasound and magnetic resonance images, histologic results, and immunochemical staining are disclosed. This case study presentation aims to highlight the importance of including angioleiomyoma in the differential diagnosis of plantar foot soft-tissue masses.

Disorders of the foot and ankle are some of the most frequent ones affecting the musculoskeletal system and have a great impact on patients' quality of life. Accurate diagnosis is an important clinical challenge because of the complex anatomy and function of the foot, that make it difficult to locate the source of the pain by routine clinical examination. In the study of foot pathology, anatomical imaging (radiography, magnetic resonance imaging [MRI], ultrasound and computed tomography [CT]) and functional imaging (bone scan, positron emission tomography [PET] and MRI) techniques have been used. Hybrid imaging combines the advantages of morphological and functional studies in a synergistic way, helping the clinician manage complex problems. In this article we delve into the anatomy and biomechanics of the foot and ankle and describe the potential indications for the current hybrid techniques available for the study of foot and ankle disease., (Copyright © 2017 Elsevier España, S.L.U. y SEMNIM. All rights reserved.)

Aim: The purpose of this study was to evaluate the treatment of plantar skin lesions by excision and rotation skin flap closure with reference to patient satisfaction; patient reported outcomes and complication rates., Method: A retrospective audit of 54 consecutive patients who had undergone plantar lesion excision with rotation skin flap between May 2011 and November 2015 under the care of experienced consultant podiatric surgeons. A total of 36 patients were included in this study, 16 were lost to follow up, 2 patients were excluded due to non-related pathology. Outcomes were reviewed retrospectively via data extracted from PASCOM-10. This included the MOXFQ and also the PSQ-10 patient satisfaction questionnaire. Data extracted was analysed., Results: The mean MOXFQ scores improved across the three domains. Walking/standing improved from 68.75 (SD: 17.62) pre-operative to 41.38 (SD: 32.94) post-operative. Pain improved from 63.47 (SD: 19.41) pre-operative to 36.53 (SD: 25.51) post-operative and social interaction improved from 53.88 (SD: 20.33) pre-operative to 29.13 (SD: 26.56) post-operative. Similarly, the PSQ-10 scores have shown positive outcomes where 88.9% out of the cohort felt that their aims of surgery had been met., Conclusion: This audit has demonstrated that the Schrudde flap is an effective and alternative safe surgical procedure for the treatment of intractable plantar keratosis and viral warts., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Epidermoid inclusion cysts, infundibular cysts, and retention cysts are dense, well-encapsulated benign soft tissue lesions that develop after a portion of the epidermis has become implanted in the dermis on a follicular surface such as the scalp, face, or trunk. However, on acral surfaces such as the palms and soles, these cysts present <10% of the time. Typically, these lesions will not progress to sizes >5 cm. However, a rare subtype of epidermal cysts known as giant epidermal cysts tends to be much larger. Unlike epidermal inclusion cysts, giant cysts lack a central punctum, present on areas of thick skin lacking hair follicles, and affect an older patient population. Because of their large size and unique characteristics, few cases of giant epidermal cysts localized to the foot have been reported. We present a case report of a 57-year-old male with a rapidly growing, large, ulcerated, atypical epidermal inclusion cyst that had developed on the medial aspect of his hallux with underlying osseous changes. In this particular case, the location, overlying skin changes, and rapid growth of the lesion raised suspicion for malignancy. In the present report, we discuss the unusual features of this particular cyst and the etiologies, treatment course, and short-term outcomes regarding this unique tumor., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Acral melanoma (AM) is a rare subtype of cutaneous malignant melanoma found on acral skin, primarily on the soles of the feet. Although rare, it is the most common subtype of melanoma found in patients of African or Asian ethnicity and has a poor prognosis, often because of the more advanced stage of presentation at diagnosis. In the second of this two-part series, we review the clinical presentation, histopathology, diagnosis and management of AM. Clinically, AM presents as a variegated lesion with blue-black pigment and irregular borders on acral skin. A parallel-ridge pattern is a very specific dermoscopic finding for AM. The differential diagnoses of AM include acral naevus, pyoderma gangrenosum, pyogenic granuloma, verrucous carcinoma and peripheral neuropathy-induced foot ulcers. If there is a clinical suspicion of AM, an excisional biopsy should be taken. Once diagnosis is confirmed by histology, surgical excision is the standard treatment. Overall, dermoscopy and histopathology are key tools in the diagnosis of AM. A greater emphasis on melanoma screening and awareness is essential in minority populations to improve survival outcomes in AM., (© 2017 British Association of Dermatologists.)

Aims: Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up., Patients and Methods: We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70)., Results: The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) - Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS)., Conclusion: The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190-6., (©2018 The British Editorial Society of Bone & Joint Surgery.)

Purpose: Here, we report our experience in treating painful plantar fibromas with percutaneous cryoablation., Methods: We retrospectively identified patients with symptomatic plantar fibromas who underwent percutaneous ultrasound-guided cryoablation between June 2014 and June 2015. In total, four patients (two male, two female) with five plantar fibromas undergoing a total of seven ablation procedures were identified. Each procedure was performed under general anesthesia using a single freeze-thaw cycle. The electronic medical record, procedure reports, and pain scores from a brief pain inventory administered before and after treatment were reviewed. Average and worst pain in 24 h, and time to peak symptom improvement post-procedure were compared. Complications were reviewed using the SIR classification., Results: Five plantar fibromas were treated (mean size 2.2 ± 1.6 cm). Four of five lesions were present for more than 6 years, and 1/5 was present for less than 1 year. Surgical excision was previously performed on 3/5 lesions, all with short-term recurrence. Mean worst pain score in 24 h and average pain score in 24 h (scale of 10) at initial evaluation were 7.1 ± 1.8 and 5.8 ± 1.9, reduced after cryoablation to 0.8 ± 0.8 and 0.4 ± 0.6, respectively. Average time to symptom improvement was 2.8 ± 0.98 weeks (range 2-4 weeks). All patients reported improved ambulation and weight-bearing, and complete cessation of pain medication after treatment. The improvement was sustained on follow-up at 12 months. No major complications occurred. Minor complications occurred in 3/5 patients., Conclusions: Early experience with percutaneous ultrasound-guided cryoablation to treat painful plantar fibromas suggests that it is a safe and effective treatment option, with early and near-complete symptom improvement.

Introduction: Plantar hyperkeratosis, such as corns and calluses, is common in older people and associated with pain, mobility impairment, and functional limitations. It usually develops on the palms, knees, or soles of feet, especially under the heels or balls. There are several treatment methods for plantar hyperkeratosis, such as salicylic acid plaster and scalpel debridement, and conservative modalities, such as using a shoe insert and properly fitting shoes., Methods: We present an effective method of reconstructing the wound after corn excision using a split-thickness sole skin graft (STSSG). We harvested the skin graft from the arch of the sole using the dermatome with a skin thickness of 14/1000th inches., Results: Because the split-thickness skin graft, harvested from the sole arch near the distal sole, is much thicker than the split-thickness skin graft from the thigh, it is more resistant to weight and friction. The healed wound with STSSG coverage over the distal sole was intact, and the donor site over the sole arch had healed without complication during the outpatient follow-up, 3 months after surgery., Conclusions: The recovery time of STSSG for corn excision is shorter than that with traditional treatment. Therefore, STSSG can be a reliable alternative treatment for recurrent palmoplantar hyperkeratosis.

Background: The conventional procedure of the sural neuro-fasciocutaneous flap enables the supply of blood and venous drainage by increasing the width of the adipofascial tissue and preserving tiny venous return routes. Moreover, skin graft is a common method for donor site closure, which may lead to some complications and influence the aesthetic appearance. We report modifications for a distally based sural neuro-fasciocutaneous perforator flap and a relaying flap for donor site closure without skin graft., Methods: Twelve patients undergoing the modified flap for foot and ankle reconstruction were included in this study between 2014 and 2016. A peroneal-based perforator, a superficial vein, and the vascular axis of the sural nerve were included in the pedicle. A Z-shape skin incision was performed to explore the perforator vessels and a relaying island perforator flap was used to close the donor site., Results: All flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 15 cm. The diameter width of the pedicle ranged from 1.0 to 2.0 cm. A relaying perforator island flap was used in 10 cases for donor site closure and no skin graft was performed. There were no serious donor site complications. All patients were satisfied with the aesthetic outcome postoperatively at the final follow-up., Conclusions: The distally based sural neuro-fasciocutaneous perforator flap is considered a reliable method for foot and ankle reconstruction. The modification for flap pedicle and donor site closure method without skin graft should be recommended., (Copyright © 2017. Published by Elsevier Ltd.)

We here report the case of a16-year old patient, with no particular past medical history, presenting, with skin swelling at the level of the forefoot evolving for 02 years, at the Department of Dermatology. Clinical examination showed hard budding cutaneous mass painless on palpation covering the 2 nd , the 3 rd and the 4 th , right toes, measuring 4 cm in large diameter. The remainder of the clinical examination was normal, without adenopathies. Skin biopsy was performed at the level of the tumor and histological examination showed carcinoma in situ. Surgical treatment was recommended. Bowen's disease is a relatively rare squamous intraepithelial carcinoma in situ. It mainly affects adults at any age, with predominance in women. The diagnosis is suspected on the basis of clinical examination, but it is confirmed by the anatomo-pathological examination.

Background: Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery. The purpose of this article is to report the authors' experience with the use of the medial plantar artery perforator flap for reconstruction of defects of the foot sole in three different regions: heel, middle foot sole, and plantar forefoot., Methods: From January of 2003 to May of 2016, 28 patients (13 male and 15 female patients) with an average age of 54 years (range, 12 to 84 years) underwent reconstruction with 28 medial plantar artery perforator flaps. Twenty-six flaps were harvested as pedicle perforator flaps and two as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (four cases), and forefoot (four cases). The causes of reconstruction were tumors in 18 patients, decubitus in eight patients, and trauma in two patients., Results: The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results., Conclusion: The medial plantar artery perforator flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region., Clinical Question/level of Evidence: Therapeutic, IV.

This article is a comprehensive review of the current utilizations of ultrasound in the treatment of orthopedic conditions of the foot and ankle. It reviews the diagnostic and interventional applications to commonly encountered lower-extremity ailments, including plantar fasciosis, tendinosis, and peripheral nerve disorders. It also outlines minimally invasive ultrasound-guided procedures and emerging therapies as alternatives to current treatments. These emerging therapies can be used to assist surgeons and provide options for patients needing intervention. Techniques such as hydrodissection, injection, aspiration, tenotomy, and fasciotomy are discussed, giving readers insight into different treatment modalities and options to help manage their patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To evaluate the short-term effectiveness of talonavicular arthrodesis for Müller-Weiss disease., Methods: Between May 2013 and February 2015, 13 patients with Müller-Weiss disease were treated with talonavicular arthrodesis. There were 11 females and 2 males with an average age of 59 years (range, 42-67 years). The disease duration was 8-20 years (mean, 13 years). According to Maceira stage, there were 7 cases of stage Ⅲ, 6 cases of stage Ⅳ. The foot longitudinal arch height measured on weight-bearing X-ray films was (43.1±1.8) mm; the Meary angle and talocalcaneal angle measured on lateral X-ray films were (-2.8±2.3)° and (5.8±2.4)°, respectively; the calcaneal valgus angle measured on Saltzman position X-ray films was (-2.0±0.7)°. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 43.5±12.4, and visual analogue scale (VAS) score was 7.3±1.5., Results: All the patients were followed up 14-39 months (mean, 20 months). The symptoms of foot pain and intermittent claudication disappeared in all patients. All cases achieved bony union, the fusion time was 12-16 weeks (mean, 13 weeks). There was no complications such as wound infection, skin necrosis, or internal fixator broken. At last follow-up, the foot longitudinal arch height, Meary angle, talocalcaneal angle, and calcaneal valgus angle were (52.5±2.2) mm, (1.3±2.2)°, (16.5±3.7)°, and (0.4±0.7)°, respectively; the AOFAS score and VAS score were 83.8±9.1 and 1.0±0.4, respectively; all were significantly improved when compared with preoperative ones ( P <0.05)., Conclusion: If the subtalar and calcaneocuboid joints are relatively healthy, talonavicular arthrodesis may be a reliable and effective surgical option for Müller-Weiss disease that is resistant to conservative treatment.

Background: Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region., Methods: From August 2012 to February 2015, a total of 13 patients - nine males and four females - received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n = 9), diabetes (n = 3), and malignancy (n = 1). The mean age was 43.07 years, which ranged between 19-70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups., Results: All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08 ± 2.96 mm) was significantly lower compared with ALT (25.21 ± 3.16 mm) and TDAP (29.88 ± 1.55 mm) groups (p < 0.01)., Conclusions: The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.

Plantar fibromatosis, also known as Morbus Ledderhose, is a well known and frequently encountered disorder of the planta pedis. When conservative treatment fails, surgical therapy with complete resection is the therapeutical procedure of choice. Soft tissue sarcoma is a heterogeneous and rare malignant disease of the musculoskeletal system with over 50 histopathological subtypes which can potentially arise in any localization but is most commonly found at the extremities. Here, we report the case of an epithelioid sarcoma of the sole of the foot which was initially and repeatedly clinically and histopathologically misinterpreted as plantar fibromatosis, receiving insufficient resection and subsequently ending in amputation of the lower leg., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring., Methods: Forty-four patients (mean age, 29.2 years; range, 13-54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided into two groups by the method of osteosynthesis: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography., Results: The AOFAS midfoot and visual analog scale scores of both groups were improved at the last postoperative follow-up. The time to return to social activities was 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p=0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group., Conclusion: The tension band wiring technique could be another treatment choice of osteosynthesis for fixation of the accessory navicular bone., Level of Evidence: Level III, Retrospective Case Control Study., (Copyright © 2016 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Interdigital neuroma (IN), otherwise known as Morton's neuroma, is a common cause of metatarsalgia presenting to the elective foot and ankle clinic. Surgical excision of the IN in patients who fail to respond to nonoperative measures is considered to be the gold standard of care in many centers. The Royal College of Pathologists UK recommend that all excised interdigital Morton's neuromas are sent for formal histopathological analysis. We present a study correlating clinical and radiological diagnosis with histopathologic appearances of IN following surgical excision, and question if routine histopathological analysis is warranted., Methods: A retrospective study was carried out in a single center. Ninety-six operative records were reviewed to identify all the cases of IN surgically resected between January 2007 and July 2016. The histopathology result of the resected IN specimen, that had a clinical and radiological diagnosis of IN, was analyzed., Results: A total of 85 patients met the inclusion criteria and were included in the final analysis. We found that 100% of patients with a clinical, radiographic, and intraoperative diagnosis of a Morton's neuroma had a histopathological report confirming a Morton's interdigital neuroma., Conclusion: In our single-surgeon series, histopathologic diagnosis is in complete agreement with clinical and radiological diagnosis. We therefore recommend that routine histopathological analysis of IN is not necessary, saving resources and providing a cost benefit. Histopathologic examination should be reserved only in cases where intraoperative findings do not concur with clinical and radiological features., Levels of Evidence: Level IV: Case series.

Background: BRCA1-Associated-Protein 1 (BAP1) is a dynamic tumor suppressor which, when mutated, has been associated with an increased risk of uveal melanoma, cutaneous melanoma, mesothelioma, and several other cancers. Germline BAP1 mutations have been extensively studied, where they have been found to cause hereditary cancer susceptibility. However, their sporadic counterparts, tumors that display a loss of BAP1 expression due to somatically arising mutations in the BAP1 gene, remain a poorly described entity., Case Presentation: Here we present the case of a 49-year-old female who presented with an asymptomatic dome-shaped pink papule on the dorsal foot which was found on biopsy to be deficient in the BAP1 tumor suppressor. While the patient's family history did not suggest the presence of a familial cancer syndrome, germline genetic testing was performed and was negative. The patient underwent surgical excision of this sporadically appearing "BAPoma" by Mohs surgery., Conclusions: Given the relatively banal clinical appearance of these dome-shaped neoplasms, sporadic BAPomas may often be overlooked by clinicians and dermatologists. In addition to providing a representative case, here we also provide a synopsis of the current understanding of these neoplasms, both in terms of the histopathological features, as well as the molecular mechanisms underlying BAP1 function and its ability to prevent tumorigenesis.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Intraosseous epidermal inclusion cysts (IEpC) are benign bone tumors that often present in the phalanges of the fingers, but rarely are seen in the lower extremity. These tumors often present following surgery, and have a similar clinical and radiographic presentation to osteomyelitis. The lack of defining characteristics makes preoperative diagnosis of these tumors very difficult. It is crucial to differentiate these tumors from malignant lesions with similar presentation. This case study presents our treatment of this osseous tumor and reviews the available literature describing this condition., Levels of Evidence: Level V: Case report.

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept., (© 2017 Wiley Periodicals, Inc.)

Background: Reconstruction of foot defects following oncologic resection is a crucial element in the treatment of soft tissue malignancy of the foot., Objective: The present study aimed to comprehensively evaluate outcomes of oncologic foot reconstruction using free perforator flaps., Methods: Outcomes of patients with soft tissue malignancy of the foot who underwent reconstruction using a free perforator flap following ablative surgery were reviewed, and perioperative and delayed complications (secondary debulking operation and flap instability) were documented. The Foot Function Index (FFI) questionnaire was surveyed to assess functional status., Results: Overall, 72 patients were analyzed, with a median follow-up period of 28 months. Malignant melanoma was a predominant etiology. Three kinds of perforator flaps were used, with the thoracodorsal artery perforator flap being the most common. Flaps with skin dimensions matching the defect size were inset and the thickness of the flaps was controlled with primary defatting. Flap re-exploration was conducted in 11 (15.2%) cases and total flap loss occurred in 3 (4.2%) cases. Delayed complications developed in an additional 12 cases, therefore 23 (31.9%) cases required a return to the operating room. The average FFI score was 8.86 at postoperative month 36, on average (range 11-128 months). All respondents reported being independently ambulatory and had minimal difficulty in their daily lives. Reconstruction of defects on weight-bearing regions showed a significantly higher FFI score than that on nonweight-bearing regions (mean 11.96 vs. 4.79, p = 0.029), although the scores remained very low for both instances., Conclusions: Oncologic foot defects can be reliably reconstructed using well-contoured free perforator flaps with minimal functional morbidity.

The use of structural autografts from the iliac crest for reconstruction of bony defects in the hand and foot was described by Wilson and Lance in 1965. However, very few series of this technique are published and long-term results are unknown. We present a single-institution series of 23 patients with a mean follow-up of 92 months. We also describe a novel modification of this technique using the anterior superior iliac spine for reconstruction of the adjacent joint. Failure rate was 13% at mean of 17.3 months. All patients had a firm grip in the hand and walked without support. Bony fusion was achieved in all cases regardless of the type of fixation used. The use of ASIS for joint reconstruction was successful, particularly in low-demand joints. We encountered 1 case of instability and progressive stiffness in weight-bearing joints. This is a reliable method of reconstructing bony defects in the hand or foot following tumor resections.

Traditional transmetatarsal amputations are a reliable level of amputation. However, amputations at the Lisfranc level have met with limited success owing to improper biomechanics resulting from tendon imbalance, ultimately leading to foot deformity positions and an unstable soft tissue envelope with ensuing skin breakdown, infection, and below-the-knee amputation. We describe proper tendon rebalancing that results in improved biomechanics and a more reliable and stable amputation at the more proximal Lisfranc level., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Giant-cell tumor of the tendon sheath (GCT-TS) is an uncommon occurrence for a foot and ankle surgeon. However, there is a need to recognize the symptoms of typical and atypical presentations of this pathology. These benign neoplasms are recognized clinically as a soft-tissue mass that is usually painless and palpable. The foot and ankle account for only 3% to 5% of all GCT-TS in the body, with most being located in the hand. Giant cell tumor in the tendon sheath occurring in the foot and ankle is usually encountered on the lateral ankle and dorsum of the foot, occupying the extensor tendons. Additionally, it is commonly misdiagnosed clinically. This case study illustrates how early use of magnetic resonance imaging decreased patient morbidity with early recognition and excision of GCT-TS.

A narrative integrative review on the evidence for hoof trimming found 16 articles on efficacy, frequency, and associations with behavior and physiologic parameters. Review of these studies revealed (1) hoof trimming is associated with behavior and physiologic changes; (2) increasing the frequency of hoof trimming seems to decrease the incidence of hoof lesions; (3) there is limited research to support any particular technique; and (4) descriptions of the hoof trimming techniques used is inadequate in most articles. To increase scientific support for hoof trimming practices, current knowledge gaps in technique, timing, and frequency of hoof trimming need to be addressed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and purpose - Patient-reported outcome measures (PROMs) are increasingly used to evaluate results in orthopedic surgery. To enhance good responsiveness with a PROM, the minimally important change (MIC) should be established. MIC reflects the smallest measured change in score that is perceived as being relevant by the patients. We assessed MIC for the Self-reported Foot and Ankle Score (SEFAS) used in Swedish national registries. Patients and methods - Patients with forefoot disorders (n = 83) or hindfoot/ankle disorders (n = 80) completed the SEFAS before surgery and 6 months after surgery. At 6 months also, a patient global assessment (PGA) scale-as external criterion-was completed. Measurement error was expressed as the standard error of a single determination. MIC was calculated by (1) median change scores in improved patients on the PGA scale, and (2) the best cutoff point (BCP) and area under the curve (AUC) using analysis of receiver operating characteristic curves (ROCs). Results - The change in mean summary score was the same, 9 (SD 9), in patients with forefoot disorders and in patients with hindfoot/ankle disorders. MIC for SEFAS in the total sample was 5 score points (IQR: 2-8) and the measurement error was 2.4. BCP was 5 and AUC was 0.8 (95% CI: 0.7-0.9). Interpretation - As previously shown, SEFAS has good responsiveness. The score change in SEFAS 6 months after surgery should exceed 5 score points in both forefoot patients and hindfoot/ankle patients to be considered as being clinically relevant.

Background: The results of operative treatments for symptomatic accessory navicular are debatable. In some cases, recurrent pain may develop after the Kidner procedure. The purpose of this study is to review the reasons for recurrent pain after the Kidner procedure and to suggest possible options for revision surgery., Methods: We reviewed the clinical and radiological outcomes in 9 patients who underwent revision surgery for recurrent pain after the Kidner procedure. During the revision surgery, the tibialis posterior tendon was reattached to the navicular either by advancing the tendon in 4 patients or by lengthening the tendon in another 4 patients. In the other 1 patient, the flexor digitorum longus tendon was transferred. Surgeries for the accompanying deformities were performed simultaneously in all patients. The results were evaluated using the American Orthopaedic Foot and Ankle Society ankle-hindfoot score and a visual analog scale. The mean follow-up was 2.3 years (range, 1 to 5 years)., Results: The mean American Orthopedic Foot and Ankle Society ankle-hindfoot score improved from 71.25 to 81.50 in the advancement group, and 71.75 to 90.00 in the lengthening group. The mean visual analog scale improved from 7.75 to 4.25 in the advancement group and from 7.50 to 1.75 in the lengthening group., Conclusions: Recurrent pain after the Kidner procedure was associated with pes planovalgus or hindfoot valgus deformity. In revision surgery, correction of the associated deformities and reattachment of the tibialis posterior tendon after lengthening may need to be considered., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Intravascular papillary endothelial hyperplasia (IPEH)/Masson's pseudoangiosarcoma is a rare (orphan) disease of the forefoot that has not yet been described in Europe. The pathoanatomic examination of a young patient with a vague interdigital space-consuming lesion revealed a intravascular papillary endothelial hyperplasia/Masson's pseudoangiosarcoma. The intravascular papillary endothelial hyperplasia can be mainly detected in the upper limbs as well as cervically. Heretofore, the intravascular papillary endothelial hyperplasia has only been described in Japan and the USA. For Europe, our case report is the first description of the clinical course of IPEH.

Background: Subclinical spread of in situ melanoma occurs at a wide frequency, ranging from 12% to 71%., Objective: To identify clinical factors associated with subclinical spread of in situ melanoma., Methods: We used a retrospective, cross-sectional study of 674 consecutive in situ melanomas to examine 627 patients treated with Mohs surgery and melanoma antigen recognized by T cells 1 immunostaining. The presence of subclinical spread was correlated with clinical characteristics. Univariate and multivariate logistic regression analyses were performed to generate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: Both univariate and multivariate analyses demonstrated significantly increased odds for subclinical spread of in situ melanomas when they were located on the head or neck, at acral sites, or on the pretibial leg (OR 1.97, 95% CI 1.41-3.40); in persons with a history of prior treatment (OR 2.77, 95% CI 1.74-4.420); melanomas of preoperative size >1 cm (OR 1.74, 95% CI 1.23-2.46, P = .002); or in persons ≥60 years old (OR 1.47, 95% CI 1.01-2.13, P = .042). A count prediction model demonstrated that the risk for subclinical spread increased with the number of clinical risk factors., Limitation: We used a single-site, retrospective study design., Conclusion: Clarifying the risk factors for subclinical spread might help to refine triage of in situ melanomas to the appropriate surgical techniques for margin assessment prior to reconstruction., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Os vesalianum is a rare accessory bone located proximal to the base of the fifth metatarsal in the peroneus brevis tendon. It is a radiographic diagnosis and mostly an asymptomatic incidental finding with a reported prevalence of 0.1% to 0.9%. Only 11 symptomatic cases have been described in the literature. Surgical therapy has been reported with good outcome in adults, whereas recurrence may follow excision during skeletal growth. We report a case of a 19-year-old girl with chronic weightbearing pain proximal to the base of the fifth metatarsal of her left foot. She first experienced exacerbated pain on increased loading when she started professional training as a shop assistant. Because several months of nonsurgical therapy failed, the decision was made to surgically excise the accessory bone from the peroneus brevis tendon via a longitudinal incision and a simple tendon-to-tendon reconstruction. Postoperative treatment consisted of using a walker to avoid weightbearing for 6 weeks, followed by a gradual return to full weightbearing as tolerated. At final follow-up, the patient was fully asymptomatic and was able to return to work. Citing this case, this article discusses differential diagnoses and treatment options for os vesalianum.

Background: Various methods of midfoot and hindfoot arthrodesis for treating symptomatic Müller-Weiss disease (MWD) have been reported in the literature. In this study, we present the results of a previously unreported method of treatment using a calcaneal osteotomy incorporating a wedge and lateral translation., Methods: Thirteen patients (14 feet) with MWD were treated with a calcaneal osteotomy and retrospectively reviewed. These included 7 females and 6 males, with an average age of 56 years (33-79 years), and an average symptoms duration of 10.6 years (1-16 years). The disease was staged according to Maceira, which included 5 feet in stage II, 4 feet in stage III, 4 feet in stage IV, and 1 foot in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients' satisfaction rate of the surgery were evaluated at an average of 3.7 years (range, 1-8.5 years) following surgery., Results: The final follow-up visit showed satisfactory outcomes, with VAS score reducing from the preoperative 8 (7-9) to postoperative 2 (0-4), whereas the AOFAS score improved from the preoperative 29 (20-44) to the postoperative 79 (70-88). The patient's subjective ratings showed excellent results in 4 feet, good results in 8 feet, and fair outcomes in 2 feet. The hindfoot range of motion remained unchanged, as did the extent of the navicular complex arthritis, and no patient required an arthrodesis since surgery., Conclusion: A calcaneal osteotomy can be used as an alternative treatment option for selected MWD patients regardless of the radiologic stage of the disease., Level of Evidence: Level IV, retrospective case series.

MR imaging has an important role in the evaluation of the postoperative foot and ankle. In this article, a variety of operative techniques and postoperative findings in the foot and ankle are described, including tendon and ligament reconstruction, as well as the treatment of tarsal coalition and Morton neuroma. The role of MR imaging in the assessment of complications of foot and ankle surgery is also detailed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery., Methods: Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery., Results: For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist's care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual's higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one's practice based on experience, practice environment, and/or specialty interest., Conclusions: These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice., Clinical Relevance: These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.

Background: Ultraviolet radiation is a well-known risk factor for basal cell carcinoma (BCC). Therefore, the high incidence of BCCs in sun-exposed areas such as the head and neck is unsurprising. However, unexpectedly, BCCs on the sun-protected dorsal foot have also been reported, and tumor occurrence here suggests that other factors besides ultraviolet radiation may play a role in BCC pathogenesis. Because only few dorsal foot BCCs have been reported, data on their clinical features and management are limited., Objective: To perform an updated review of the literature on clinical characteristics and treatment of dorsal foot BCCs., Methods: We conducted a comprehensive literature review by searching the PubMed database with the key phrases "basal cell carcinoma dorsal foot," "basal cell carcinoma foot," and "basal cell carcinoma toe.", Results: We identified 20 cases of dorsal foot BCCs in the literature, 17 of which had sufficient data for analysis. Only 1 case was treated with Mohs micrographic surgery. We present 8 additional cases of dorsal foot BCCs treated with Mohs micrographic surgery., Conclusion: Basal cell carcinomas on the dorsal foot are rare, and potential risk factors include Caucasian descent and personal history of skin cancer. Mohs micrographic surgery seems to be an effective treatment option.

An intramuscular lipoma is a deep-seated, rare, benign mesenchymal tumor that arises in skeletal muscle. These soft-tissue masses are rarely reported in the foot. We describe an unusual case of an intramuscular lipoma of the flexor hallucis brevis muscle. A review of the literature revealed only one previous report of this lesion in the foot.

Although, trauma, foot deformity (pesplanovalgus), systemic diseases such as diabetes mellitus and lupus, drugs (steroids, antineoplastic) and excessive alcohol consumption have all been accused in the etiology of avascular necrosis of the tarsal bones, spontaneous avascular necrosis of the navicular bone, especially in adults, is a rare entity. In this article, we report a 50-year-old female patient with bilateral, spontaneous avascular necrosis of the navicular bone and related severe talonavicular arthrosis. Clinical and radiological findings were concordant with Müller-Weiss disease, which is a rare disease with complex idiopathic foot condition of the adult tarsal navicular bone characterized by progressive navicular fragmentation and talonavicular joint destruction. The patient was successfully treated with two-staged bilateral talonavicular arthrodesis.

Objective: Idiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults., Methods: A total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances., Results: All procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet. Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again., Conclusion: Soft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults., Level of Clinical Evidence: Level IV, Therapeutic study., (Copyright © 2016 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Verrucous carcinoma of the foot is a rare malignancy, and proper diagnosis can be delayed. Furthermore, misdiagnosis often results in delayed appropriate treatment. Herein, we present an unusual case of verrucous carcinoma of the fifth toe with bone invasion in a 63-year-old woman that was mistaken for a plantar wart for 3 years. The condition was treated by ray amputation. We emphasize the need for appropriate biopsy to achieve an accurate diagnosis.

Primary plantar hyperhidrosis is defined as excessive secretion of the sweat glands of the feet and may lead to significant limitations in private and professional lifestyle and reduction of health-related quality of life. Conservative therapy measures usually fail to provide sufficient relieve of symptoms and do not allow long-lasting elimination of hyperhidrosis. Endoscopic lumbar sympathectomy appears to be a safe and effective procedure for eliminating excessive sweating of the feet and improves quality of life of patients with severe plantar hyperhidrosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Tibiotalocalcaneal arthrodesis has recently become more popular as a form of reconstructive surgery. The precise anatomical orientation and the functional extrinsic musculature of the hindfoot are essential for a satisfactory result. Fixation of the arthrodesis is a mechanical problem. Straight and angulated nails are not anatomically or mechanically ideal. A circular arc nail can fix the tibia, the talus and the calcaneus in anatomical alignment. This is a pure "bone nail", in contrast to the "intramedullary nail," which is driven through an existing opening in long bones. The nail is driven through a circular arc-shaped opening in the bone, which results in optimal form-fit between nail and bone. A corresponding aiming device permits the precise shaping of the bone tunnel, which follows the orientation of the bone trabeculae. The instrumentation was applied in 11 cases, with the following indications: post-traumatic conditions, congenital deformities, chronic polyarthritis and diabetic Charcot arthropathy. The desired alignment of the hindfoot is not affected while the nail is being introduced. The fixation achieves primary stability thus allowing for early functional treatment.