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The authors report a case of longitudinal tendon tears of the peroneus longus and brevis in the presence of tophaceous gouty infiltration. There are a limited number of reports discussing similar processes affecting various tendons throughout the body. There has been 1 prior case of peroneal tendon involvement affecting only the peroneus brevis. A 35-year-old man presented with a 4-year history of left-sided lateral ankle pain, redness, and swelling. The patient described the 'attacks' as occurring off and on, with a recent increase in frequency. The symptoms were relieved with indomethacin, colchicine, and narcotic analgesics. Upon clinical evaluation, there was a cavus foot type with moderate calcaneal varus. Peroneal subluxation was elicited with resisted eversion. An MRI evaluation revealed longitudinal tears of both peroneal tendons. During surgical repair, a chalky-white substance resembling gouty tophi was present within both tendon tears. The tendons were remodeled and repaired. The patient had an uneventful postoperative course with nearly completed resolution of his symptoms at 1-year follow-up. The patient was referred to his primary care physician for further evaluation and long-term control of elevated uric acid levels. [ABSTRACT FROM AUTHOR]

As the incidence of diabetic foot ulcers (DFU) increases, better treatments that improve healing should reduce complications of these ulcers including infections and amputations. We conducted a randomized controlled trial comparing outcomes between a novel purified reconstituted bilayer membrane (PRBM) to the standard of care (SOC) in the treatment of non-healing DFUs. This study included 105 patients who were randomized to either of two treatment groups (n = 54 PRBM; n = 51 SOC) in the intent to treat (ITT) group and 80 who completed the study per protocol (PP) (n = 47 PRBM; n = 33 SOC). The primary endpoint was the percentage of wounds closed after 12 weeks. Secondary outcomes included percent area reduction, time to healing, quality of life, and cost to closure. The DFUs that had been treated with PRBM healed at a higher rate than those treated with SOC (ITT: 83% vs. 45%, p = 0.00004, PP: 92% vs. 67%, p = 0.005). Wounds treated with PRBM also healed significantly faster than those treated with SOC with a mean of 42 versus 62 days for SOC (p = 0.00074) and achieved a mean wound area reduction within 12 weeks of 94% versus 51% for SOC (p = 0.0023). There were no adverse events or serious adverse events that were related to either the PRBM or the SOC. In comparison to the SOC, DFUs healed faster when treated with PRBM. Thus, the use of this PRBM is an effective option for the treatment of chronic DFUs., (© 2024 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The relationship between pain/disability and angular deviation of the hallux valgus (HV), and the impact of orthotic use, laterality, and pain variability on treatment outcomes remain unclear. This was explored in post hoc analyses of a placebo-controlled trial of abobotulinumtoxinA (aboBoNT-A; Dysport®) for HV-associated pain (NCT03569098). The primary endpoint was not met in this study (change from baseline Numeric Pain Rating Scale [NPRS] score vs placebo at week 8); however, there was a greater reduction from baseline in mean NPRS score at week 12 with aboBoNT-A 500U versus placebo (p = .06). Adults with painful HV without surgery were randomized (1:1:1) to aboBoNT-A 300U, aboBoNT-A 500U, or placebo. NPRS was completed for 7 days before baseline and weeks 4, 8, and 12. Over-the-counter orthoses were permitted. Participants (N = 186) had a mean [standard deviation, SD] age of 48.2 [13.1] years, 18% (33/186) used orthotics, and 67% (124/186) had bilateral HV. No associations between baseline pain severity and angular deviation were identified. Participants with high pain variability at baseline (SD > 2) had a poorer response to aboBoNT-A treatment than those with less variability. In conclusion, no relationship between HV-related pain/disability and angular deviation was observed. PLAIN LANGUAGE SUMMARY: A bunion (medical term: hallux valgus) is a common adult foot problem in which the big toe points inward toward the other toes, and this can be painful. How much the big toe points inward (how deformed the foot is) has been linked to the amount of pain the patient experiences. A better understanding of this foot deformity and bunion pain will help doctors and patients to make the right treatment decisions. A study was completed looking at how injections of a type of botulinum toxin (abobotulinumtoxinA) into specific muscles in the foot may help to reduce bunion pain in patients without surgery. This subsequent analysis of the study data looked at the amount of foot deformity in patients, the bunion pain they experienced, and which factors affected how well abobotulinumtoxinA worked to reduce bunion pain. The results of this study showed that the amount of foot deformity was not linked to the level of bunion pain. When deciding the best treatment option to relieve bunion pain, it is important that doctors not only consider how deformed the foot is, but also other important factors such as foot pain levels., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

AbobotulinumtoxinA (aboBoNT-A, Dysport® [Ipsen, Paris, France]) inhibits acetylcholine release at the neuromuscular junction and may modulate pain signaling in hallux valgus (HV). This randomized study (NCT03569098) included a double-blind phase (aboBoNT-A 300U, 500U or placebo injections into forefoot muscles) and an open-label aboBoNT-A treatment period in participants with an HV diagnosis and no HV surgery. The primary endpoint was change from baseline in numeric pain rating scale (NPRS) score at week 8. Secondary endpoints included change in NPRS (other time points) and proportion of participants with ≥20% reduction from baseline NPRS (responders). Post-hoc analyses assessed number of days in a 7-day evaluation period that participants spent in a lower pain state than at baseline. Participants received aboBoNT-A 300U (n = 63), 500U (n = 60) or placebo (n = 63). Superiority to placebo was not observed with either aboBoNT-A dose at week 8, thus the primary endpoint was unmet. At week 12, a trend toward efficacy was observed with aboBoNT-A 500U versus placebo and the proportion of participants with ≥20% reduction from baseline NPRS was greater with aboBoNT-A 500U versus placebo (p = .006). Participants in the aboBoNT-A 500U group spent more days with lower NPRS than their lowest baseline score, and with NPRS ≥2 points lower than their mean baseline NPRS at weeks 8 and 12 versus placebo (all p < .05; post-hoc). AboBoNT-A was well tolerated. Although the primary endpoint was unmet, other endpoints showed a nominal advantage for aboBoNT versus placebo for treatment of HV-related pain, particularly at week 12. Further clinical evaluation is needed to establish whether botulinum toxins represent a viable non-operative treatment option for HV-associated pain. PLAIN LANGUAGE SUMMARY: Hallux valgus is the medical name for a bunion, a foot deformity that can worsen over time. Patients with bunions experience pain and walking can become difficult, which can affect their quality of life. Foot support aids (e.g., braces, splints and inserts) are available, but surgery is the standard treatment. This study looked at how injections of a specific type of botulinum toxin, called abobotulinumtoxinA or "aboBoNT-A", into the foot may help to reduce pain in patients with bunions. The study included 186 patients aged 18 to 75 years who had not had surgery on their bunion. The researchers looked at how well the injections worked using scales that measure the pain levels the patient experienced. The main outcome was whether patients who had aboBoNT-A injections had less pain after 8 weeks than they did before treatment. The study included patients who were injected with saltwater (no treatment) to check that any treatment effect was real. Researchers also looked at the results after 12 weeks, as well as how many patients had less pain after treatment than before and how many days in a given week patients experienced less pain after treatment than they did before. There was no reduction in pain levels with aboBoNT-A injections after 8 weeks compared with no treatment. However, the other study outcomes suggested that aboBoNT-A resulted in a small benefit compared with no treatment, especially after 12 weeks. Further medical research is needed to establish whether botulinum toxins represent an alternative treatment to surgery for the pain associated with bunions., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity., Competing Interests: Discloser Relative to this article, there are no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Diabetic foot infections continue to be a major challenge for health care delivery systems. Following encouraging results from a pilot study using a novel purified reconstituted bilayer matrix (PRBM) to treat chronic diabetic foot ulcers (DFUs), we designed a prospective, multi-centre randomised trial comparing outcomes of PRBM at 12 weeks compared with a standard of care (SOC) using a collagen alginate dressing. The primary endpoint was percentage of wounds closed after 12 weeks. Secondary outcomes included assessments of complications, healing time, quality of life, and cost to closure. Forty patients were included in an intent-to-treat (ITT) and per-protocol (PP) analysis, with 39 completing the study protocol (n = 19 PRBM, n = 20 SOC). Wounds treated with PRBM were significantly more likely to close than wounds treated with SOC (ITT: 85% vs 30%, P = .0004, PP: 94% vs 30% P = .00008), healed significantly faster (mean 37 days vs 67 days for SOC, P = .002), and achieved a mean wound area reduction within 12 weeks of 96% vs 8.9% for SOC. No adverse events (AEs) directly related to PRBM treatment were reported. Mean PRBM cost of healing was $1731. Use of PRBM was safe and effective for treatment of chronic DFUs., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

This study assesses the impact of a processed microvascular tissue (PMVT) allograft on wound closure and healing in a prospective, single-blinded, multi-centre, randomised controlled clinical trial of 100 subjects with Wagner Grade 1 and 2 chronic neuropathic diabetic foot ulcerations. In addition to standard wound care, including standardised offloading, the treatment arm received PMVT while the control arm received a collagen alginate dressing. The primary endpoint was complete wound closure at 12 weeks. Secondary endpoints assessed on all subjects were percent wound area reduction, time to healing, and local neuropathy. Novel exploratory sub-studies were conducted for wound area perfusion and changes in regional neuropathy. Weekly application of PMVT resulted in increased complete wound closure at 12 weeks (74% vs 38%; P = .0003), greater percent wound area reduction from weeks four through 12 (76% vs 24%; P = .009), decreased time to healing (54 days vs 64 days; P = .009), and improved local neuropathy (118% vs 11%; P = .028) compared with the control arm. Enhanced perfusion and improved regional neuropathy were demonstrated in the sub-studies. In conclusion, this study demonstrated increased complete healing with PMVT and supports its use in treating non-healing DFUs. The observed benefit of PMVT on the exploratory regional neuropathy and perfusion endpoints warrants further study., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Diabetic foot ulcers (DFUs) are at risk for detrimental complications even with current, standard of care (SOC) treatments. The primary objective of this randomised controlled trial was to compare a unique resorbable glass microfiber matrix (Mirragen; Advanced Wound Matrix [BBGFM]; ETS Wound Care, Rolla, Missouri) compared with a standard of care group (SOC, collagen alginate dressing) at 12 weeks. Both groups received standard diabetic foot care including glucose monitoring, weekly debridements when needed and an offloading device. The primary endpoint was proportion of full-thickness, non-infected, non-ischaemic wounds healed at 12 weeks, with secondary endpoints including percent area reduction (PAR) and changes in Semmes-Weinstein monofilament testing. The result illustrated in the intent-to-treat analysis at 12 weeks showed that 70% (14/20) of the BBGFM-treated DFUs healed compared with 25% (5/20) treated with SOC alone (adjusted P = .006). Mean PAR at 12 weeks was 79% in the BBGFM group compared with 37% in the SOC group (adjusted P = .027). Mean change in neuropathic score between baseline and up to 12 weeks of treatment was 2.0 in the BBGFM group compared with -0.6 in the SOC group where positive improvement in scores are better (adjusted P = .008). The mean number of BBGFM applications was 6.0. In conclusion, adding BBGFM to SOC significantly improved wound healing with no adverse events related to treatment compared with SOC alone., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

It is important to identify the level of the deformity or deformities. It is important to get the limb as close to anatomic alignment as possible. Many levels and multiple procedures may be involved with this reconstruction., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Pathologic affects from a cavus foot deformity range from flexible subtle to rigid severe deformities and are related to many pathologic conditions of the foot and ankle. Understanding the underlying deformity and the deforming force is essential in treating the cavus ankle and foot. Every deformity is different and unique to a given patient; therefore, surgical plans should be modified to each patient., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Woringer-Kolopp disease is a rare variant of mycosis fungoides, a type of cutaneous T-cell lymphoma. Described is a case of a small annular plaque on the foot diagnosed histologically as Woringer-Kolopp disease and treated successfully with topical and intralesional steroids. In addition, a brief review of the literature and treatment options is provided.

Aseptically processed dehydrated human amnion and chorion allograft (dHACA) (AmnioBand) has shown great promise in the treatment of recalcitrant diabetic foot ulcers (DFUs) when compared with standard wound care but has not yet been compared to any other tissue forms used in treating DFUs. The hypothesis was to conduct a randomized controlled trial in which dHACA was compared to one of the earliest and most commonly accepted tissue-engineered skin substitutes (TESS) (Apligraf) in the treatment of nonhealing DFUs over a period of 12 weeks to assess the superiority of healing., Methods: Following a 2-week screening period during which subjects with DFUs were treated with collagen alginate dressing, 60 subjects were randomized at 5 sites to receive either dHACA or TESS applied weekly, with weekly follow-up for up to 12 weeks., Results: The mean time to heal within 6-week time period for the dHACA group was 24 days (95% CI, 18.9-29.2) versus 39 days (95% CI, 36.4-41.9) for the TESS group; the mean time to heal at 12 weeks was 32 days (95% CI, 22.3-41.0) for dHACA-treated wounds versus 63 days (95% CI, 54.1-72.6) for TESS-treated wounds. The proportion of wounds healed at study completion (12 weeks) was 90% (27/30) for the dHACA group versus 40% (12/30) for the TESS group. The mean product cost for the dHACA group was significantly lower than that for the TESS group [dHACA: $2,200 (median: $1,300); TESS: $7,900 (median: $6,500)]. The mean wastage (%) at 12 weeks was also significantly lower for the dHACA group than that for the TESS group (36% vs 95%)., Conclusions: It was concluded that aseptically processed dHACA heals diabetic foot wounds more reliably, statistically significantly faster than and at significantly lower cost than TESS., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The purpose of this article is to examine complications in patients who underwent bone grafting from the calcaneus between December 2001 and June 2010. This retrospective, single-practice study included 247 procedures in 242 patients, including 200 (82.64%) female and 42 (17.36%) male patients, ranging in age from 13 to 89 (median 49) years. Overall, the incidence of experiencing any form of complication was 2.43% (6 of 247); these included 5 (2.02%) feet that displayed donor site sural neuritis and 1 (0.41) that displayed a painful, hypertrophic scar at the donor site. The only statistically significant risk factor associated with the development of a calcaneal donor site complication was white race (being African American was protective). These findings indicate that procurement of autogenous bone graft from the calcaneus, as described in this report, is safe and dependable with a low incidence of complications, and irritation of the sural nerve is the most common complication associated with the procedure. Further clinical and long-term follow-up studies controlling for confounding variables need to be performed to fully determine the overall safety and efficacy of this procedure., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Amnion and chorion allografts have shown great promise in healing diabetic foot ulcers (DFUs). Results from an interim analysis of 40 patients have demonstrated the accelerated healing ability of a novel aseptically processed, dehydrated human amnion and chorion allograft (dHACA). The goal of this study was to report on the full trial results of 80 patients where dHACA was compared with standard of care (SOC) in achieving wound closure in non-healing DFUs. After a 2-week screening period, during which patients with DFUs were unsuccessfully treated with SOC, patients were randomised to either SOC alone or SOC with dHACA applied weekly for up to 12 weeks. At 12 weeks, 85% (34/40) of the dHACA-treated DFUs healed, compared with 33% (13/40) treated with SOC alone. Mean time to heal within 12 weeks was significantly faster for the dHACA- treated group compared with SOC, 37 days vs 67 days in the SOC group (P = .000006). Mean number of grafts used per healed wound during the same time period was 4.0, and mean cost of the tissue to heal a DFU was $1771. The authors concluded that aseptically processed dHACA heals DFUs significantly faster than SOC at 12 weeks., (© 2018 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Aseptically processed human reticular acellular dermal matrix (HR-ADM) has been previously shown to improve wound closure in 40 diabetic patients with non-healing foot ulcers. The study was extended to 40 additional patients (80 in total) to validate and extend the original findings. The entire cohort of 80 patients underwent appropriate offloading and standard of care (SOC) during a 2-week screening period and, after meeting eligibility criteria, were randomised to receive weekly applications of HR-ADM plus SOC or SOC alone for up to 12 weeks. The primary outcome was the proportion of wounds closed at 6 weeks. Sixty-eight percent (27/40) in the HR-ADM group were completely healed at 6 weeks compared with 15% (6/40) in the SOC group. The proportions of wounds healed at 12 weeks were 80% (34/40) and 30% (12/40), respectively. The mean time to heal within 12 weeks was 38 days for the HR-ADM group and 72 days for the SOC group. There was no incidence of increased adverse or serious adverse events between groups or any graft-related adverse events. The mean and median HR-ADM product costs at 12 weeks were $1200 and $680, respectively. HR-ADM is clinically superior to SOC, is cost effective relative to other comparable treatment modalities, and is an efficacious treatment for chronic non-healing diabetic foot ulcers., (© 2018 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Subtalar joint arthrodesis is a procedure used in posttraumatic arthritis, osteoarthritis, tarsal coalition management, posterior tibial tendon dysfunction, and inflammatory arthropathies, and can be used in deformity correction. The goals of the procedure are to eliminate pain, improve function, restore stability, and realign the hind foot. The procedure has high patient satisfaction with low complications while preserving motion in adjacent tarsal joints. Joint preparation is important and time should be spent preparing the joint for successful arthrodesis and the fixation construct needs to be done well and effectively to provide a solid Arbeitsgemeinschaft für Osteosynthesefragen (AO) construct for good results., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Acellular dermal matrices can successfully heal wounds. This study's goal was to compare clinical outcomes of a novel, open-structure human reticular acellular dermis matrix (HR-ADM) to facilitate wound closure in non-healing diabetic foot ulcers (DFUs) versus DFUs treated with standard of care (SOC). Following a 2-week screening period in which DFUs were treated with offloading and moist wound care, patients were randomised to either SOC alone or HR-ADM plus SOC applied weekly for up to 12 weeks. At 6 weeks, the primary outcome time, 65% of the HR-ADM-treated DFUs healed (13/20) compared with 5% (1/20) of DFUs that received SOC alone. At 12 weeks, the proportions of DFUs healed were 80% and 20%, respectively. Mean time to heal within 12 weeks was 40 days for the HR-ADM group compared with 77 days for the SOC group. There was no incidence of increased adverse or serious adverse events between groups or any adverse events related to the graft. Mean and median graft costs to closure per healed wound in the HR-ADM group were $1475 and $963, respectively. Weekly application of HR-ADM is an effective intervention for promoting closure of non-healing DFUs., (© 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Acellular matrices have been successfully used to heal indolent diabetic foot ulcers (DFUs). These tissues include allogenic dermis as well as xenograft dermis, pericardium, and small intestine submucosa. While all of these tissues show promise for healing DFUs, dermal-derived matrices have shown considerable potential., Materials and Methods: The authors retrospectively reviewed healing in patients with DFUs that failed the standard of care (SOC) treatment from a previous prospective randomized, controlled trial (RCT). That trial compared the efficacy of human reticular acellular dermal matrices (HR-ADMs) with the SOC. Of the 16 out of 20 patients who did not heal in the SOC group, 12 were eligible for crossover treatment with the HR-ADM. The authors studied the rate of complete healing in that specific cohort after 12 weeks of crossover treatment., Results: Of the 12 patients who were eligible for the HR-ADM, 10 (83%) achieved complete wound healing, with a mean healing time of 21 days to closure. The corresponding wound area reduction was from 1.7 cm2 to 0.6 cm2. The mean product cost to closure was $800/patient., Conclusion: This study further demonstrates the effectiveness of the HR-ADM in facilitating the closure of nonhealing DFUs refractory to SOC.

Background: Allogeneic grafts derived from amnion/chorion are known to be efficacious in healing chronic diabetic foot ulcerations (DFUs). The goal of this study was to compare aseptically processed dehydrated human amnion and chorion allograft (dHACA) versus standard of care (SOC) in facilitating wound closure in nonhealing DFUs., Methods: Patients with DFUs treated with SOC (off-loading, appropriate debridement, and moist wound care) after a 2-week screening period were randomized to either SOC or wound-size-specific dHACA (AmnioBand, Musculoskeletal Transplant Foundation, Edison, N.J.) applied weekly for up to 12 weeks plus SOC. Primary endpoint was the percentage of wounds healed at 6 weeks between groups., Results: At 6 weeks, 70% (14/20) of the dHACA-treated DFUs healed compared with 15% (3/20) treated with SOC alone. Furthermore, at 12 weeks, 85% (17/20) of the DFUs in the dHACA group healed compared with 25% (5/20) in the SOC group, with a corresponding mean time to heal of 36 and 70 days, respectively. At 12 weeks, the mean number of grafts used per healed wound for the dHACA group was 3.8 (median 3.0), and mean cost of the tissue to heal a DFU was $1400. The mean wastage at 12 weeks was 40%. One adverse event and 1 serious adverse event occurred in the dHACA group; neither was graft related. Three adverse events and 1 serious adverse event occurred in the SOC group., Conclusion: Aseptically processed dHACA heals diabetic foot wounds significantly faster than SOC at 6 and 12 weeks with minimal graft wastage.

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis., Methods: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline., Results: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed., Conclusions: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Osteobiological agents are a welcome addition to the surgeon’s armamentarium. These products should always be thought of as a complement to good surgical principles and construct. As history has shown, nothing outperforms the osteogenic properties of autograft bone. Even if allograft is procured for use, an attempt should be made to combine it with autograft if possible, given the primary indexprocedure in which it will be used. Structural support from corticocancellous autografts is also greater than allografts, which lose mechanical strength during the sterilization and preservation process. Bone fillers without structural support should be used only when there are other means of cortical contact. The ability of the human skeletal system to repair itself is amazing. Osseous healing relieson a complicated series of intrinsic and extrinsic factors. Some of these factors include a stable fixation construct, nutritional status, good surgical technique, and good decision making. Autogenous bone graft remains the gold standard, and the presence of native growth factors and osteogenic cells is mandatory to repair these deformities. When this microenvironment is disruptive, nonunion may result.Understanding the mechanisms of bony healing contributes to the available osteobiologics, which give the foot and ankle surgeon additional tools to enhance the reparative process of bony defects and the ability of the foot to restore itself., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Treatment of midfoot injuries is surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, whereas more unstable injuries typically need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration for surgery. The importance of treating midfoot injuries adequately is shown in how the midfoot is needed for function with weight bearing and its relationship between the front and the back of the foot. It is also important to ensure that the patient is able to ambulate with a reasonably normal gait., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The clinical presentation of adult flatfoot can range from a flexible deformity with normal joint integrity to a rigid, arthritic flat foot. Debate still exists regarding the surgical management of stage II deformities, especially in the presence of medial column instability. This article reviews and discusses various surgical options for the correction of stage II flatfoot reconstructive procedures. The authors discuss their opinion that is not always necessary to transfer the flexor digitorum longus tendon to provide relief and stability in this patient population. The anatomy, diagnosis, and current treatments of flexible flatfoot deformity are discussed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The Lapidus procedure affords correction of a multitude of first ray pathologic entities. When reconstructing the first ray using the Lapidus procedure, the relocation of the first metatarsal over the sesamoid bones with frontal plane rotation should be considered one of the key components. In the present technical report, we have described a bunion correction with emphasis on sesamoid reduction through indirect frontal plane manipulation. Our technique, borne from applied basic anatomy of the first metatarsophalangeal joint, uses intact soft tissues about the first metatarsophalangeal joint to reduce subluxed or dislocated sesamoids., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

We present a technique for split peroneous brevis lateral ankle stabilization using an interference screw as the fixation device. The interference screw provided stable fixation by way of physiologic tension and restored lateral ankle instability while preserving the range of motion in the surrounding joints., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical management of the pediatric forefoot often brings challenges to the foot and ankle surgeon. It requires a thorough understanding of the pathologic abnormality and underlying causes involved, which include the contributing genetic conditions. Albeit most of the deformities carry a rare level of incidence, they do however have a significant level of psychological component and stress on the pediatric patient. The goals of managing those pathologic abnormalities are ultimately to improve function while achieving a cosmetically acceptable outcome. The common forefoot pathologic abnormalities in the pediatric population are reviewed with an added focus toward management of forefoot trauma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Lisfranc joint dislocation secondary to Charcot arthropathy is a debilitating condition that often leads to ulceration and infection. After conservative treatment, such as bracing and appropriate shoe wear fail, the only option might be amputation. However, we have seen good clinical outcomes from applying a plate to the plantar (tension) side of the medial midfoot. In our retrospective study, 24 consecutive patients (25 feet) from April 1999 through July 2004 underwent Charcot reconstruction for Lisfranc dislocation. Clinical and radiographic follow-up examinations were performed every 3 weeks during the postoperative course. Union was achieved in 24 (96%) of the 25 feet. The average time to ambulation was 11.68 (range 7 to 20) weeks for the 24 patients. The average follow-up period was 38.0 (range 17 to 64) months. The union and interval to ambulation rates showed that a plate applied to the plantar aspect of the medial midfoot provides a strong, sturdy construct for arthrodesis and ambulation., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

When total ankle arthroplasty fails, few good options are available for salvage. We report a case of total ankle arthroplasty displacement after trauma. The injury was initially repaired with an anterior ankle arthrodesis plate for ankle fusion. On the follow-up radiographs taken during the fourth postoperative week, internal fixation failure was noted. A second revision was undertaken, using a femoral locking plate to obtain tibiotalocalcaneal fusion. We present this case as an alternative method for developing a stable construct in revising total ankle take down., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Casting is an important part of the postoperative treatment in foot and ankle surgery. Applying a split plaster cast allows for swelling while maintaining surgical correction and alignment. Resecting approximately a 1-in. portion of the plaster cast dorsally and anteriorly maintains stable structural support of the cast while relieving the pressure caused by swelling. We describe a technique for applying a plaster below the knee cast, with a univalve dorsal split, to provide support, while allowing for edema and access to anterior postoperative dressings., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Total ankle joint replacement (TAR) has been offered as an alternative to ankle joint arthrodesis since the 1970s. TAR offers the benefit of perseveration of joint motion, with potential decreased occurrence of adjacent joint degeneration, and a more expedient path to weight bearing. Since their introduction, TAR devices have undergone a variety of modifications, specifically in regards to the number and type of components used., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In the present case report, we describe the surgical repair of a complete laceration of the anterior tibial tendon using acellular human dermal tissue matrix. A 17-year-old, elite league hockey player was injured in the locker room when a teammate still clad in ice skates stepped on his bare left foot. After evaluation at a local emergency department, the patient presented to our office the next day for additional evaluation. It was determined that surgery would be performed using acellular tissue graft augmentation, followed by physical therapy. Within 7 weeks of the injury, the athlete returned to his original level of activity. At 3 years of follow-up, he was playing Division 1 hockey at the university level. We believe that augmentation of the tendon repair with the grafting material enhanced the tendon tensile strength and promoted ingrowth through vascular channels. This, combined with the patient's dedication to physical therapy, led to excellent recovery in less time than anticipated., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The authors describe a technique in which two 5.5-mm pins are inserted from the posterior aspect of the calcaneus and advanced anteriorly on a slightly convergent vector. The 2 points of fixation, with a 5/8 ring, provide a "steering wheel" effect allowing for leverage and control of the hindfoot and ankle. The construct also allows for offloading of the posterior calcaneus., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Herein, we illustrate an operative technique to attain limb salvage after a failed intramedullary nail in the diabetic Charcot neuropathic patient. The use of the blade plate, or T-plate, in combination with external fixation, fastened into the body of the calcaneus allows for greater bone capture. Our experience has shown that this provides for a stable, long-lasting construct., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

End-stage ankle arthritis is a debilitating condition that leads to pain and swelling in the ankle joint, with symptoms aggravated by standing and ambulation. Ankle arthritis commonly results from a history of trauma, or a series of recurrent injuries to the ankle. However, it may develop from other causes such as uneven loading of the ankle joint caused by an alignment deformity or from inflammatory arthritis such as rheumatoid arthritis, gout, or secondary to a serious joint infection. Patients with severe ankle arthritis often have limited ankle motion with an antalgic gait., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Accurate early diagnosis with adequate reduction and maintenance of anatomic alignment of the dislocation or fracture within the Lisfranc joint complex have been found to be the key to successful outcomes regarding this injury. Because of the anatomic variations, the thin soft tissue envelop, and the abundance of ligamentous and capsular structures in the region, repair of these injuries can be a challenge. The classification systems used to describe these injuries aid in describing the mechanism of injury or displacement type present, which may aid in determining what treatment modality can provide the best outcome., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The goal of a tibiotalocalcaneal arthrodesis is to create a pain-free, stable hindfoot and ankle. Although a reserved procedure, it is useful when simultaneous ankle and subtalar joint pathology exists. Numerous complications have been reported after tibiotalocalcaneal arthrodesis, most importantly nonunion. Locking plates have proved to be a more stable construct than alternative forms of arthrodesis. In the inverted positions, the hybrid plating of the femoral locking plate structurally aligns with the anatomy of the hindfoot. This provides an anatomically sound construct, while allowing for both locking and lag screw insertion. We describe a new technique using a 4.5-mm condylar plate for tibiotalocalcaneal arthrodesis., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

This is a retrospective, multicenter study examining the long-term results for the treatment of end-stage hallux rigidus using 3 different surgical procedures. A total of 158 subjects (105 females and 53 males) were included in the present study. They had undergone 1 of the following surgical procedures: arthrodesis, hemi-implant, or resectional arthroplasty. The long-term results for the subjective assessment of pain, function, and alignment, as well as objective radiographic and physical findings, were examined. The median interval to postoperative follow-up for the 3 procedure groups was 159 weeks. No statistically significant difference was found in age or the number of subjects included in the 3 treatment groups (p = .11 and p = .16, respectively). The body mass index was significantly different statistically among the 3 treatment groups, with the hemi-implant group representing a smaller body mass index compared with the other procedures (p = .007). No statistically significant difference was found in the subjective outcomes among the 3 treatment groups using the American College of Foot and Ankle Surgeons' First Metatarsophalangeal Joint and First Ray Scoring Scale (patient questionnaire) or the modified Hallux Metatarsophalangeal-Interphalangeal Scale of the American Orthopedic Foot and Ankle Society (p = .64 and p = .14, respectively). Furthermore, the correlation coefficient between the 2 subjective scoring scales was 0.78, statistically significant and reflecting a moderate to high correlation (p < .001). The results of the radiographic and clinical evaluation revealed that metatarsalgia was the most common finding for the arthrodesis group (9.8%), bony overgrowth into the joint for the hemi-implant group (28.3%), and floating hallux for the resectional arthroplasty group (30.9%). The results of our study suggest that all 3 surgical procedures are viable options for the treatment of end-stage hallux rigidus., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Historically, a variety of fixation techniques for calcaneal osteotomies have been used. The prevention of postoperative sequelae, including delayed or nonunion of the osteotomy sites and minimization of soft tissue damage, is always a primary consideration for foot and ankle surgeons. The present report describes a fixation technique for a double calcaneal osteotomy that entails use of a single screw that functions as both a positional tool, as well as a compressive fixation device. This technique provides compressive and positional qualities and decreases the amount of soft tissue disruption to the surgical site., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

A prospective investigation of the effects on the medial and lateral neurovascular structures of the rearfoot after percutaneous posterior calcaneal displacement osteotomy was performed using 20 below the knee fresh frozen cadaver specimens. This anatomic study aimed to examine the medial and lateral neurovascular structures to determine whether they were jeopardized during execution of the osteotomy. After completion of the osteotomy, the medial plantar, lateral plantar, medial calcaneal, sural, and posterior tibial neurovascular structures, along with their respective branches, were inspected for iatrogenic injury. Our findings demonstrated that the percutaneous, subperiosteal osteotomy minimized trauma to the local soft tissue envelope and protected the adjacent neurovascular structures. Because no iatrogenic injury was observed in the cadaveric specimens, we postulated that percutaneous calcaneal displacement osteotomy is a safe, predictable, and advantageous alternative compared with open techniques for osteotomy and could result in reduced postoperative complications. The results of this investigation remain to be confirmed in the clinical setting., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

One of the most widely debated topics amongst foot and ankle surgeons is the treatment of end stage arthritis. With the advent of the newer generation of total ankle replacement (TAR), a viable option over an arthrodesis is now available for patients with end-stage ankle arthritis. When compared with an ankle arthroplasty, recent reports suggest the ankle arthrodesis has poor long-term outcomes (20 years+) and can experience short- and long-term complications. Proper training, strict patient selection, and proper implant contribute to a successful outcome. As advances continue to be made in both implant design and surgical technique, the benefits of a TAR appears to provide the foot and ankle surgeon a good alternative for the appropriate patient., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Total ankle replacement in the rheumatoid patient is a feasible and effective treatment for ankle arthritis. The benefits of ankle prosthesis are good pain relief, acceptable function, and patient satisfaction. It is a joint-sparing procedure for restoring functionality. All investigators of total ankle replacement feel that, as clinicians gain experience with the procedure and related products, difficulties and risks associated with the procedure will decline. Following an early history of failure and poor patient satisfaction, more recent results have shown promise., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Rheumatoid arthritis is an autoimmune disorder that presents in females more often than males, and may affect people belonging to any age group. This disease shows no regional or ethnic preference. Although genetic and environmental causes have been proposed, the definitive cause of immunologic susceptibility, as well as viral and bacterial infectious processes that may cause rheumatoid arthritis, have not been identified. This article discusses various reconstructive forefoot surgeries to correct rheumatoid arthritis and the perioperative care of the patients who undergo surgery, along with the radiographic and magnetic resonance imaging findings associated with the disease., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Pediatric and adolescent flexible flatfoot is a pathomechanically complex deformity. Conservative and surgical treatment is directed at realigning the foot and alleviating symptoms. When surgical intervention is considered, there are various methods and techniques that may be performed to realign the foot. The treatment goals are directed first at resolution of pain, and second at the realignment of the foot. A specific treatment algorithm does not exist, although planal dominance influences direct the surgeons when considering surgical intervention. Open physis often dictates the direction of the reconstruction. Attempts at essential joint preservation should be strongly considered in this young patient population. This article provides an overview of the common treatment pathways that highlight methods to structurally realign the pediatric and adolescent flatfoot.

Unlabelled: A review of the use of bone morphogenetic protein in 38 cases in 35 patients at high risk for bone healing complications following foot and ankle surgery was performed. Multiple relevant variables were analyzed with respect to the incidence of healing, including age; diabetes mellitus; Charcot neuroarthropathy; prior infection; type of procedure; and the use of femoral head allograft, electrical bone stimulation, and external fixation. The overall incidence of successful healing was 84.21%. A statistically significant decrease in the incidence of bone healing was observed if the patient was 50 years of age or older (P = .03), and all 16 patients younger than 50 years healed their index operation. If 60 years of age was the benchmark, a statistically significant decrease in the rate of healing was observed (P = .02). Logistic regression showed that a 10-year increase in age almost doubled the risk of not healing (odds ratio = 2.613). Furthermore, 4 (66.66%) of the 6 patients who did not heal had diabetes mellitus and were older than 60 years. This combination of risk factors was associated with a statistically significant decrease in the likelihood of bone healing (P < .01). Of the 10 cases to exhibit postoperative drainage, only 50% of these successfully healed, whereas 96% of the remaining 28 cases successfully healed (P = .0026). The results of this study demonstrate the utility of bone morphogenetic proteins in foot and ankle surgical patients at high risk for bone healing complications., Level of Clinical Evidence: 2.

The patient who has a diagnosis of diabetes mellitus, diabetic peripheral neuropathy, peripheral vascular disease and experiences an unstable ankle fracture presents as a difficult case scenario for the treating physician. In addition, patients who have diabetes mellitus, along with the presence of multiple comorbidities, have been shown to have higher complication rates than patients who do not have diabetes mellitus. This article describes a relatively safe alternative surgical percutaneous technique using external circular ring fixation in the vascularly compromised diabetic patient with an unstable ankle fracture. This novel technique decreases the risk for soft tissue complications in the high-risk diabetic patient and serves as a definitive method of fixation without the need for additional surgery. It allows the patient to have early and full weight bearing when indicated in the postoperative period.