Single Stage Reconstruction of Posterior Soft Tissue Ankle Defects with a Free Anterolateral Thigh Flap and Rolled Tensor Fascia Lata for Functional Tendo-Achilles Reconstruction - A Case Report and Review of the Literature

Soft tissue defects in the posterior ankle region with underlying Achilles tendon loss pose a reconstructive challenge to both Orthopaedic and Plastic surgeons. Such injuries can result in a severely debilitating sequelae for the patient, therefore reconstruction of the area must provide reliable function and durability with minimal complications and aesthetically pleasing results to enable normal foot wear. We describe the case of a twenty-seven year old male, who presented following a traumatic open rupture of the Achilles tendon and failed reverse sural artery flap. We performed a single stage composite soft tissue reconstruction with a free anterolateral thigh (ALT) flap and rolled vascularised Tensor Fascia Lata (TFL) for functional Achilles tendon reconstruction. The patient had no post-operative complications and was able to fully weight bear and dorsiflex his foot beyond ninety degrees at seven month follow-up. Whilst many options are available to reconstruct this area, we review the literature to illustrate the advantages of using this technique to achieve all of the above factors, and advocate for all foot and ankle surgeons to be aware of its use in their reconstructive repertoire.

Radiographic Evaluation of Charcot Foot Involving the Lateral Column

In the study of Charcot foot, the lateral column has been largely neglected in previous research. The purpose of the current study is to radiographically characterize the lateral column in Charcot midfoot collapse.

Acute Calcific Tendinitis of the Forefoot in Young Women- A Presentation of Two Cases

Introduction: Calcific tendinitis is an uncommon presentation in the forefoot with relatively few cases reported in the medical literature. It is commonly overlooked and should form part of a differential diagnosis when assessing patients presenting with acute pain of the forefoot localised to a single joint or tendon. We present two cases of young women involved in amateur running and martial arts respectively who presented with acute pain of their forefoot. Case Description: These 2 cases describe a 44 year old amateur female runner and 23 year old female martial arts athlete who presented with acute onset of pain affecting the dorsal aspect of their great toe interphalangeal joint and base of 1st metatarsal respectively. Both patients had tender erythematous swellings at the site of pain and difficulty weightbearing. Plain radiography revealed areas of calcification at the respective sites which was confirmed with ultrasound. Both patients underwent US guided corticosteroid injections with significant symptom improvement within 48 hours of injections and rapid return to sport. Discussion: These two cases demonstrate an atypical presentation of acute calcific tendinitis affecting the forefoot and add two more cases to the reported literature. Combining the characteristic clinical presentation of acute pain affecting a tendon or joint with a tender erythematous swelling on examination with the typical radiographic features of calcification can promptly diagnose this often misdiagnosed condition and avoid unnecessary investigations. Conservative treatment and intralesional injection with corticosteroids can lead to rapid resolution and favourable patient outcomes.

Radiation Doses to Patients Undergoing Osteosynthesis Procedures

Fractures of limbs are most frequent causes of orthopaedic interventions. Especially the older people are exposed to these because of motion disorders and osteoporosis. Most of orthopaedic surgery interventions are performed under X-rays control to achieve an optimal settings the anatomical details and also some artificial implants, if such are necessary. Because if that, X-ray units are common equipment in operational theatre where orthopaedic procedures are performed. As a rule they are mobile C-arm units, which are easy available in any time when are necessary. A consequence of every usage of X-rays an exposure to patient but also to operational medical team [1-3]. They are a number of factors affecting both the patient and staff irradiation. There are three categories: patient dependent, equipment dependent and procedure dependent factors. Patient dependent factors include: body thickness in the beam, complexity of the anatomic structure. Equipment dependent factors include: setting of dose rates in pulsed fluoro- and continuous fluoro mode, last image hold, acquisition, and virtual collimation. The main procedure related factors are: number of radiographic frames per run, collimation, fluoroscopic and radiographic acquisition modes, fluoroscopy time, wedge filter, magnification, distance of patient to image receptor (image intensifier or flat panel detector), distance between X-ray tube and patient, and tube angulations. Very important is also the experience of the operator. In case of patient, this is especially important for the procedures when the primary beam can cover the part of the trunk. Such situation has place in the procedure of osteosynthesis the femoral bone, reconstruction of head of femur and also osteosynthesis the humeral bone. Despite a relatively short time of real exposures, doses to patients undergoing these procedures can achieve quite high values: the entrance skin air kerma (here named the “dose”) over 80 mGy was also recorded. Additionally, in practice the primary X-ray beam incident on the same area patient’ body making a higher risk of radiation detriments. The paper presents collection of doses recorded for patients undergoing the procedures of osteosynthesis the femoral bone and the humeral bone during last moths in the big university clinic.

Impact of Aging on Distal Tibia Metaphysis Diameter

One of the many bone changes that occur with aging is “cortical drift”, the absorption and deposition of bone on the endosteal and periosteal side, respectively, which results in bone enlargement in some but not all metaphyses. The distal tibia is one of the most fractured sites in the body and where anatomically shaped implants are mostly used. The economic viability of these implants depends on the maintenance of bone contour throughout life. MRI sagittal ankle images from 422 patients aged 18 to 100 years were analyzed and total distal tibia diameter measured. No correlation was observed between the parameters age and distal tibia diameter (Pearson-0.099), or when individuals were separated by sex (Pearson-0.021 for men and 0.049 for women). When separated by age, patients younger and older than 60 years old had a similar average height (1.65 and 1.62 m, respectively, student’s t- test = 0). This is the first study to evaluate possible age-related distal tibia enlargement. Bone changes with age do not result in distal tibia enlargement and possibly the majority of anatomically shaped bone implants are suitable irrespective of age.

Spiculectomy and Orthonyxia for Ingrown Toenails in Patients at Risk; Prospective Observational Cohort Study

Background: Ingrown toenails (unguis incarnatus) are common in persons with Diabetes Mellitus (DM) and Peripheral Arterial Disease (PAD). Minimal invasive treatment of ingrown toenails with spiculectomy and/or orthonyxia might be a promising treatment option. Aim: The aim of this study was to evaluate the efficacy and safety of minimal invasive treatment spiculectomy and orthonyxia Design/Setting: Prospective observational cohort study in an outpatient podiatric clinic Method: Eighty-eight patients with unguis incarnatus were included. Primary outcomes were post-procedural complication rate (infection and hemorrhage), and duration of pain. Patient satisfaction during and after treatment procedure was evaluated. Results: Healing was achieved in 80/88 (90.9%) persons; non-DM group 28/32 (87.5%) vs DM group 51/56 (91.1%); median healing time (21 [14, 42] days) and median treatment time; (56 [30, 86] days) were comparable between the non-DM and the DM groups. (Sixty-four patients (72.7%) had a significant pain reduction within 0-2 days. Median reduction of the VAS score after the first treatment was 2.0 points [0.0, 6.0] (non-DM group 3.5[1.0, 6.0]; DM group 2.0[0.0, 5.0] (p=0.0117)). Forty-eight (94, 4%) patients, 31(96.9%) non-DM group vs 53(94.6%) DM group (p=0.534)) had no limitations in daily activities by the affected toe after 14 days. There were no treatment-related complications like bleeding or infection. Conclusion: Spiculectomy and orthonyxia resulted in a high patient satisfaction. Five of 88 patients needed referral for a partial nail resection. This treatment seems to be very suiTable for persons with a high risk for foot ulcerations.