Background: Midfoot osteotomy is often used in the surgical treatment of foot deformities. The percutaneous Gigli saw osteotomy (PGSO) technique has many advantages compared with known osteotomy techniques. We aimed to show the efficacy and reliability of the PGSO technique in the midfoot of fresh frozen cadavers without using an image intensifier.
Methods: Four mini-incisions were performed on the dorsomedial, dorsolateral, plantar medial, and plantar lateral regions of the midfoot. Subperiosteal tunnels were then opened with a thin bone elevator, and the four incisions were combined with each other. The Gigli saw was tied to suture material and passed through the tunnels. The PGSO was performed in the midfoot of 12 feet of the cadaver specimens without using an image intensifier. Cadaver specimens were dissected, and injured structures were noted.
Results: The mean ± SD (range) cadaver age was 81.16 ± 10.38 years (65–93 years) and weight was 60.86 ± 12.39 kg (49.8–81.6 kg). All of the osteotomies were adequate as planned in the cuboid-cuneiform level and all of them were complete osteotomy .Incomplete osteotomy was not observed in any cadaver specimens. In one specimen, a complete injury of the peroneal tendons (peroneus longus and brevis) was detected. In another specimen, an incomplete tibialis anterior tendon injury was detected. There was no iatrogenic neurovascular injury in the specimens.
Conclusions: The PGSO technique is recommended for use even by inexperienced surgeons owing to its minimal risk of soft-tissue injury, provision of a complete osteotomy line, and easy application with limited incisions.
Background: Nail thickening is a poor prognostic factor in onychomycosis. Mechanical reduction by micromotor nail grinding is an alternative treatment for onychomycosis. However, this treatment introduces a large amount of infected nail dust particles into the air and can adversely affect other patients and health-care providers. The innovative recirculating airflow safety cabinet (ASC) was developed to prevent the spread of these generated infected nail dust particles. The aim of this study was to determine the efficacy of the ASC in patients with onychomycosis or traumatic onychodystrophy.
Methods: The ASC was used during the nail-grinding process in 50 patients, including 36 onychomycosis patients and 14 traumatic onychodystrophy patients. For each patient, five Sabouraud dextrose agar plates with chloramphenicol were positioned within the working space of the ASC, and the other five plates were positioned near the area of air exit after the carbon filters within the cabinet. A total of 500 plates were incubated at 25°C and evaluated every 7 days. The results of fungal cultures were analyzed.
Results: In the traumatic onychodystrophy group, all fungal cultures of nail dust particles from both before and after filtration from the ASC were negative in all 14 patients. In the onychomycosis group, 52 fungal cultures (28.9%) from nail particles within the ASC working area tested positive; however, the results of fungal cultures of nail dust particles after filtration were all negative.
Conclusions: The newly developed ASC was found to be effective for preventing the spread of infected nail dust particles generated by micromotor nail grinding to mechanically reduce nail thickness in patients with onychomycosis.
Background: Foot dimension information is important both for footwear design and clinical applications. In recent years, noncontact three-dimensional (3-D) foot digitizers/scanners have become popular because they are noninvasive and are valid and reliable for most of the measures. Some of them also offer automated calculations of basic foot dimensions. We aimed to determine test-retest reliability, objectivity, and concurrent validity of the Tiger full-foot 3-D scanner and the relationship between manual measures of the medial longitudinal arch of the foot and alternative parameters obtained automatically by the scanner.
Methods: Intraclass correlation coefficients and minimal detectable change values were used to assess the reliability and objectivity of the scanner. Concurrent validity and the relationships between the arch height measures were determined by the Pearson correlation coefficient and the limits of agreement between the scanner and the caliper method.
Results: The relative and absolute agreement between the repeated measurements obtained by the scanner show excellent reliability and objectivity of linear measures and only good to nearly good test-retest reliability and objectivity of arch height. Correlations between the values obtained by the scanner and the caliper were generally higher in linear measures (rp ≥ 0.929). The representativeness of state of bony architecture by the soft-tissue margin of the medial foot arch demonstrates the lowest correlation among the measurements (rp ≤ 0.526).
Conclusions: The Tiger full-foot 3-D scanner offers excellent reliability and objectivity in linear measures, which correspond to those obtained by the caliper method. However, values obtained by both methods should not be used interchangeably. The arch height measure is less accurate, which could limit its use in some clinical applications. Orthotists and related professions probably appreciate the scanner more than other specialists.
Background: Historically recalcitrant to treatment, infection of the nail unit is a pervasive clinical condition affecting approximately 10% to 20% of the US population; patients present with both cosmetic symptomatology and pain, with subsequent dystrophic morphology. To date, the presumptive infectious etiologies include classically reported fungal dermatophytes, nondermatophyte molds, and yeasts. Until now, the prevalence and potential contribution of bacteria to the clinical course of dystrophic nails had been relatively overlooked, if not dismissed. Previously, diagnosis had largely been made by means of clinical presentation, although microscopic examinations (potassium hydroxide) of nail scrapings to identify fungal agents and, more recently, panel-specific polymerase chain reaction assays have been used to elucidate causative infectious agents. Each of these tools suffers from test-specific limitations.
Methods: Molecular-age medicine now includes DNA-based tools to universally assess any microbe or pathogen with a known DNA sequence. This affords clinicians with rapid DNA sequencing technologies at their disposal. These sequencing-based diagnostic tools confer the accuracy of DNA-level certainty, and concurrently obviate cultivation or microbial phenotypical biases.
Results: Using DNA sequencing-based diagnostics, the results in this article document the first identification and quantification of significant bacterial, rather than mycotic, pathogens to the clinical manifestation of dystrophic nails.
Conclusions: In direct opposition to the prevailing and presumptive mycotic-based causes, the results in this article invoke questions about the very basis for our current standards of care, including effective treatment regimens.
Heel decubitus ulcerations are relatively common occurrences that can be limb threatening. There are many options to treat these ulcerations, ranging from conservative wound care to serial debridement with flap reconstruction. However, not all patients are good candidates for major reconstructive surgery. In this case, we present a 46-year-old man who failed 3 months of conservative wound care after sustaining a heel decubitus ulcer because of immobilization from a motor vehicle accident. The ulceration was treated with sharp excision of the wound with calcaneal decorticalization and use of negative-pressure wound therapy to use the localized bone marrow within the wound bed. The patient went on to heal within 3 months of operative intervention and remains healed greater than 1 year postoperatively. This technique provided the ability to use localized bone marrow to assist in wound healing without the operative morbidity of a reconstructive procedure.
As the number and complexity of operative techniques taught at U.S. podiatric medicine and surgical residencies (PMSR) with the added credential in reconstructive rearfoot and ankle (RRA) surgery has continued to increase, so to has the use of intraoperative fluoroscopy. The purpose of the present prospective observational pilot study was to quantify and compare the shallow dose equivalent (SDE), deep dose equivalent (DDE), and lens of the eye dose equivalent (LDE) exposures for podiatric medicine and surgery residents at a single PMSR-RRA over 12 consecutive months. Shallow-dose equivalent, DDE, and LDE exposures (in millirems) were measured using Landauer Luxel dosimeters from July of 2018 to July of 2019. Dosimeters were exchanged monthly, and mean monthly/annual SDE, DDE, and LDE exposures were calculated and compared. Overall, residents averaged 19 operative cases per month and 222 per year. More than half (53%) required intraoperative fluoroscopy, for which a mini C-arm was used in most cases. Monthly SDE, DDE, and LDE exposures averaged 7.3, 9.3, and 7.0 mrem, respectively; whereas annual SDE, DDE, and LDE exposures averaged 87.3, 112, and 84 mrem, respectively. No significant monthly (P = 1.0, P = .70, and P = .74) or annual (P = .67, P = .67, and P = .33) differences were identified between residents. The annual SDE, DDE, and LDE for residents at a single PMSR-RRA were well below the recommended dose limits of 50,000 mrem/year (SDE), 5,000 mrem/year (DDE), and 15,000 mrem/year (LDE) set by the National Council on Radiation Protection. However, given that the stochastic effects from low levels of ionizing radiation are cumulative, not well studied long-term, and relate both to the degree and duration of exposure, mini-C arm fluoroscopy, radiation tracking, and use of personal protective equipment provide simple means for residents to reduce any long-term potential for risk.
Background: Historically, Kirschner wires have been used for fixation of the interphalangeal joints of the toe. They are still the most popular form of fixation, likely due to training patterns, ease of use, and decreased cost. Recently, numerous medullary fixation devices have become available, including medullary screws.
Methods: After performing various forms of fixation for the correction of toe deformities, the authors have developed a new pilot hole technique for screw fixation advancing on the previously described pilot hole technique for Kirschner wire fixation.
Results: The authors have found this method to provide intraoperative confidence that improper hardware placement has not occurred.
Conclusions: The pilot hole technique described in this paper is a safe and effective technique that may be employed by surgeons using screw fixation for the treatment of hammertoe deformities. The technique reduces the possibility of surgeon error and helps to ensure that the screw is properly placed within the phalanges when properly employed.
Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.
Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.
Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0).
Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.
One of the challenges after central ray resection is a large soft-tissue defect. Many authors have reported the use of external fixators as a means of narrowing the forefoot. Ours is the first article to report an interesting case using widely available and inexpensive tools such as Kirschner and cerclage wires as an external fixation means of narrowing the forefoot after a complete second-ray resection and extensive soft-tissue debridement for a severe diabetic foot ulcer. This simple yet inexpensive technique is easy to perform for any foot and ankle surgeon at any hospital or surgical center.
Plantar vein thrombosis (PVT) is an atypical cause of plantar heel pain and is seldom reported in the literature. We present a unique, rare case report of a patient exhibiting plantar heel and medial arch pain caused by thrombosis in the plantar medial branch of the posterior tibial vein. The diagnosis was made by means of magnetic resonance imaging, showing lobulated hypointensity in the medial plantar vein, consistent with a PVT. In this article, we provide an overview of the clinical signs of PVT, which is most commonly plantar heel pain. Furthermore, we discuss ultrasound and magnetic resonance imaging as diagnostic modalities, and conservative treatment options, including anti-inflammatory medications, anticoagulation therapy, and compression therapy. As with other types of venous thromboembolism, this condition must also be diagnosed without delay to avoid potential complications.