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Osteomyelitis of the calcaneus combined with a pathologic fracture is a rare and difficult presentation for any practicing foot and ankle surgeon. Treatment for achieving an aseptic nonunion involves a variety of steps, including surgical debridement, antibiotic administration, and fracture stabilization. In this case series, we report a novel technique for the treatment of a tongue-type calcaneal fracture in the setting of chronic osteomyelitis using the Biomet JuggerLoc bone-to-bone system for fixation.
Presented here is a preliminary report of 102 patients who underwent first metatarsocuneiform joint arthrodeses performed with external fixation for the correction of hallux valgus. The advantages of using external fixation are the ability to initiate early weightbearing, predictable fusion, and removal of all of the hardware postoperatively. In the 102 patients reported here, the average time to initiation of unassisted full weightbearing was 13.1 days. The average time to fusion was 5.3 weeks, with removal of the external fixator at an average of 5.5 weeks postoperatively. There was no incidence of delayed union or nonunion. There was one case of pin-tract irritation, which resolved with appropriate pin care and a short course of oral antibiotics. External fixation is an effective alternative to traditional internal fixation techniques in metatarsocuneiform joint arthrodesis. (J Am Podiatr Med Assoc 95(4): 405–409, 2005)
Diabetic Foot Infections
Time to Change the Prognostic Concept
Patients with diabetic neuropathy are subject to ulcerations that may be complicated by infection and gangrene, with subsequent risk of amputation. It is the job of the foot specialist to identify and manage these problems early to avoid the unfortunate complication of amputation regardless of the presenting condition of the patient’s limb. We shed light on the hypothesis that suggests that infection and gangrene in a diabetic patient aggravate the degree of ischemia (microvascular, macrovascular, or both) already present enough to endanger the viability of the surrounding tissues unless urgent drainage with decompression and debridement of the necrotic sloughs is performed, with consequent reduction of tissue pressure and improvement in circulation to the area. We present cases with severe infections leading to gangrene and ischemia, which were improved following surgical management with consequent improvement in tissue viability. In these cases, we demonstrate that immediate treatment of the wound despite the delayed presentation of the patients resulted in limb salvage with much less soft-tissue loss than expected before treatment. (J Am Podiatr Med Assoc 99(5): 454–458, 2009)
Threatening Fracture of Intraosseous Lipoma Treated by Internal Fixation
Case Report and Review of the Literature
Intraosseous lipomas are rare benign bone neoplasms with an incidence of less than 0.1%; origin in the calcaneus has been reported in only a few patients. First-line treatment remains conservative, but several surgical techniques have also been described. We describe a 44-year-old woman with increasing pain in her left heel for a year and a half, who noticed swelling on the lateral side of the calcaneus. The patient underwent radiography, magnetic resonance imaging, and computed tomography of her left foot, which was suspicious for an intraosseous lipoma with a threatening calcaneal fracture. We performed a surgical procedure, curettage of the tumor, spongioplastics (by autologous bone transplant and ?-tricalcium phosphate), and internal stabilization with a calcaneal plate considering the goal of immediate postoperative weightbearing. Histologic examination confirmed an intraosseous lipoma of the calcaneus. The patient's pain was relieved immediately after surgery. Internal stabilization of the calcaneus allowed the patient to immediately fully weightbear and to return to usual daily activities. Although a benign bone tumor, intraosseous lipoma can cause many complications, such as persistent pain, decreased function, or even pathologic fracture as a result of calcaneal bone weakening. Choosing an appropriate treatment is still controversial. Conservative treatment is the first option, but for patients with severe problems and threatening fracture, surgery is necessary. Internal fixation for stabilization enables immediate postoperative weightbearing and shortens recovery time.
Posterior Bone Block for Footdrop
A Report of Two Cases
A posterior bone-block operation is one of the few treatment options in cases of paralytic footdrop. A case with a flail ankle and no bony deformity is ideal for this approach. Two cases of acquired flail ankle with equinus deformity were treated using a new modification of the bone-block technique that does not interfere with subtalar joint motion. A bone block harvested from the iliac crest was fixed at the posterior talus after partial resection of the posterior tubercle. The graft was in contact with the posterior malleolus of the tibia. Satisfactory correction was achieved, and both patients could walk without the use of external splints. (J Am Podiatr Med Assoc 97(2): 160–164, 2007)
Onychocryptosis is a common pathology treated by podiatry medical services, and in a considerable percentage, surgical procedures are required to achieve a solution. There are multiple surgical approaches for ingrown toenails, both incisional procedures and nonincisional procedures, such as chemical matrixectomies and physical matrixectomies using carbon dioxide laser. This study presents a surgical procedure for onychocryptosis using a physical matrixectomy with a 1064-nm laser applied by means of a 400-μm optical fiber and surgical removal of the posterior cauterized tissue to achieve healing by primary intention. This technique was performed on 30 patients with onychocryptosis affecting the great toe (Mozena stages I and IIa), and all of the patients were followed up postoperatively for 12 months. The patients reported minimal postoperative pain, quicker surgical postoperative healing, rapid return to activities of daily living, and minor postoperative recurrence compared with previous studies using incisional procedures and chemical matrixectomies.
Ingrown toenails are one of the most common pathologic conditions encountered in podiatric medical practice. Many methods of treatment for ingrown toenails have been used and studied, including chemical matrixectomies, surgical approaches, and CO2 laser ablation. This study is a retrospective review of a new technique that consists of resection of the involved nail matrix using a No. 15 blade and controlled cauterization using a CO2 laser. The technique was performed on 381 painful ingrown toenails, and all of the patients were followed up postoperatively for an average of 34 months. The results showed minimal pain, a low recurrence rate, rapid return to activity, and good cosmesis. (J Am Podiatr Med Assoc 95(2): 175–179, 2005)
After resection of bone or amputation, postoperative stump breakdown occurs frequently. Furthermore, the altered mechanics with ambulation are difficult to control with bracing and orthoses alone. During the past 10 years, the peroneus brevis tendon has been transferred to various locations in the foot after resection of the fifth metatarsal base in an effort to provide continued balance between the supinatory and pronatory forces needed for a steady gait. In patients who have had a peroneus brevis tendon transfer, the rate of postoperative ulceration and the need for further bony resection is minimal. Analysis of the biomechanical influences and effects of different anatomical placements of the transferred tendon reveals the importance of transfer of the peroneus brevis tendon. (J Am Podiatr Med Assoc 94(6): 594–603, 2004)
