Foot and Ankle Forklift Injuries; Diagnosis to Treatment Options, Return to Work and Functional Outcomes

As our tertiary-level trauma center is close to an industrial zone and associated international port, industrial injuries are seen more often than is expected in routine practice. The aim of this study was to present the demographic data, treatment options, and changes in work-life of patients with foot and ankle injuries due to a forklift accident, and to determine the factors affecting the clinical outcome. The study was conducted in our university hospital and included patients who presented with a foot and ankle injury resulting from a forklift accident. Data were collected including age, sex, dominant extremity, history of trauma, presence of fracture, management (surgical or conservative), complications, time of return to work, workforce loss, and the American Orthopaedic Foot and Ankle Society (AOFAS) and Short Form Health Survey (SF-36) scores at the final follow-up examination. Evaluation was made of 132 patients, comprising 113 (85.6%) males and 19 (14.4%) females with a mean age of 32 years (range 16-65 years). The most frequently recorded occupational group was shipyard workers (50%). The most common mechanism of injury was crushing under the forklift wheel (n = 63, 47.7%). The most frequently injured foot region was the forefoot (47%). A total of 90 (68.1%) patients continued to work in the same position on return to work. The lowest mean AOFAS score (73.4) and SF-36 (physical component) score (37.3) were determined in cases with mixed region injuries (p = .0001, p = .0001). The wearing of protective footwear had no effect on the rate of return to work (p = .195), workforce loss (p = .34) and AOFAS score (p = .166). This study is the largest series of patients with foot and ankle injuries related to forklift accidents. Forklift injuries can be treated conservatively or surgically according to the clinical condition of the patient. The main indicators of return to work and functional outcome are which foot region is injured and whether or not the injury causes a fracture.

Outcomes of Surgically Treated Purely Ligamentous Stage II Lisfranc Injuries

BACKGROUND

Low-energy stage II Lisfranc injuries are rare, and treatment can be operative or nonoperative based on a surgeon's assessment of midfoot stability. No previously published patient-reported outcome measures (PROMs) data for Lisfranc injuries isolates purely ligamentous stage II injuries. The purpose of this study was to analyze PROMs for patients who underwent operative management of stage II Lisfranc injuries.

METHODS

Thirty-nine patients (39 feet) with confirmed Nunley-Vertullo stage II Lisfranc injuries between May 2012 and February 2022 were identified through a retrospective chart review. PROMs that were analyzed were the visual analog scale (VAS) pain scale, Veterans RAND 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), and patient satisfaction.

RESULTS

Thirty-two open reduction internal fixations (ORIFs) and 7 fusions were performed. The mean latest follow-up was 44.6 (range, 12-92) months. There were 2 complications (5%, 2/39) that required a revision procedure. Twenty-six patients (67%, 26/39) underwent secondary surgery to remove retained hardware. The mean time to hardware removal was 3.97 (range, 2.70-7.47) months. The overall mean patient satisfaction score with overall medical care including clinical visits and interactions with medical staff personnel was 93.6/100. All PROMs (VAS, VR-12, FAAM) demonstrated statistically significant improvement (P < .05) from preoperative (injury) values to latest follow-up postinjury values.

CONCLUSION

Patients who were treated surgically with stage II purely ligamentous Lisfranc injuries via the methods used were found to mostly undergo hardware removal and have high levels of overall satisfaction with their process of medical care.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Impact of Podiatric Surgery Consultation for Foot and Ankle Wounds on Patient Outcomes in a Community Hospital

Previous studies have demonstrated that timely podiatric surgery consultation results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The primary aim of this study is to determine if consulting podiatric services was associated with lower 30-day readmission rates and impact on length of stay in patients with lower extremity wounds. The secondary aim was to investigate medical and socio-economic factors associated with better outcomes. This study was a cross-sectional descriptive study. A retrospective chart review utilizing the hospital's electronic medical record system identified patients with lower extremity wounds (based on ICD-10 codes) admitted between July 2018 and December 2020. The results showed a 3-fold decrease in 30-day readmission rates in patients with podiatric surgery consultation compared to patients without consultation with lower extremity wounds (4.2% vs 11.3%, p = .03). Multivariate regression models showed patients with gangrene (AOR = 7.61; p = .04) or osteomyelitis (AOR = 9.07; p = .013) had a higher likelihood of readmission than patients with venous ulcer (reference category) after controlling for podiatric consultation. Among the group of patients with podiatric consultation, earlier podiatric consultations resulted in decreased length of stay. This study identifies prior amputation history and lack of podiatric consultation increased 30-day readmission rates.

Functional Outcomes After High-Energy Lisfranc Injuries

BACKGROUND

Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury.

METHODS

A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome.

RESULTS

Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes.

CONCLUSION

Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury.

LEVEL OF EVIDENCE

Level IV, retrospective, prognostic.

Short-Term Outcomes of Jones-Specific Implant Versus Intramedullary Screw and Plate Fixation for Proximal Fifth Metatarsal Fractures

Although intramedullary screw fixation is commonly performed for proximal fifth metatarsal fractures, high rates of nonunion, refracture, and hardware prominence have been reported. The Jones Specific Implant (JSI) is a novel surgical implant which contours to the native curvature of the fifth metatarsal allowing for a more anatomic fixation. The purpose of this study was to compare short-term complication rates and outcomes of patients treated with the JSI to other fixation types such as plates and intramedullary screws. Electronic records were queried for adult patients with proximal fifth metatarsal fractures who underwent primary fixation from 2010 to 2021. All patients were treated by a foot and ankle fellowship-trained surgeon with intramedullary screws, plates, or JSI (Arthrex Inc., Naples, FL). Visual analog scale (VAS) and the American Orthopedic Foot and Ankle Score (AOFAS) were recorded and compared using univariate statistics. Eighty-five patients underwent fixation using intramedullary screw (n = 51, 60%), plate (n = 22, 25.9%), or JSI (n = 12, 14.1%) with a mean follow-up of 11.1 ± 14.6 months. The total cohort demonstrated a significant improvement in VAS pain (p < .0001) as well as AOFAS (p < .0001) scores. When comparing the cohort treated with JSI and the cohort treated with all other types of fixation, there were no significant differences in postoperative VAS or AOFAS scores. Only 3 complications, one with JSI (3.5%) required removal of the symptomatic hardware. The JSI is a novel treatment for proximal fifth metatarsal fractures, with similar early outcomes and complication rates when compared with intramedullary screw and plate fixation.

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries

BACKGROUND

Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes.

METHODS

Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up.

RESULTS

Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis.

CONCLUSION

APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures

BACKGROUND

Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA).

METHODS

A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included.

RESULTS

Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF.

CONCLUSION

The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

[Curative effects of the superficial peroneal artery perforator flap carrying multiple perforators in repairing hand and foot wounds]

Objective: To investigate the curative effects of the superficial peroneal artery perforator flap carrying two and more homologous perforators in repairing hand and foot wounds. Methods: A retrospective observational study was conducted. From January to September 2021, 23 patients with hand and foot wounds combined with bone or tendon exposure who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 16 males and 7 females, aged 23 to 68 years. After expansion of the wound, the wound area was 3.0 cm×2.0 cm to 11.0 cm×4.0 cm. All the wounds were repaired with the superficial peroneal artery perforator flap carrying two and more homologous perforators. The area of the resected flap was 4.0 cm×2.0 cm to 12.0 cm×5.0 cm. All the wounds in donor areas were sutured directly. During the operation, the resection of the flap, the number and caliber of carried perforators, the caliber of superficial peroneal artery, the length of vascular pedicle, and the number of accompanying veins of the superficial peroneal artery were recorded. The survival of the flap, the occurrence of complications, and the wound healing in the donor area were observed after operation. The recovery of the donor and recipient areas was followed up. At the last follow-up, the comprehensive evaluation scale was used to evaluate the curative effect of flap repair, and the sensory grading scale was used to evaluate the sensory function of the recipient area. Results: Totally 24 flaps were successfully resected in surgical operations, carrying 56 superficial peroneal artery perforators in total, with the caliber of perforators of 0.20-0.70 mm. The calibers of all perforators carried by 7 flaps were smaller than 0.40 mm. Nineteen flaps carried 2 perforators each, 3 flaps carried 3 perforators each, 1 flap carried 4 perforators, and 1 flap carried 5 perforators. During the operation, the superficial peroneal artery was resected with a caliber of 0.40-1.50 mm, the vascular pedicle was 2-6 cm in length, and each superficial peroneal artery had two accompanying veins. After operation, all the flaps survived smoothly, no vascular crisis or distal necrosis occurred, and the wounds healed well in the donor area. During the follow-up of 6 to 10 months after operation, the color, texture, and elasticity of the recipient area were good. Among them, 6 recipient areas were thinned and reshaped because of bloating. There was only linear scar and no obvious scar hyperplasia or pigmentation in the donor area, without significant change in sensory or motor function. At the last follow-up, the curative effect evaluation of flap repair was excellent in 22 flaps and good in 2 flaps, and the sensory function evaluation of the recipient area was grade S3 in 1 area and grade S2 in 23 areas. Conclusions: The superficial peroneal artery perforator flap with two and more homologous perforators has sufficient and reliable blood supply and is effective in repairing hand and foot wounds. It provides an ideal solution for the clinical problem in which the original operation scheme is abandoned due to the existence of only multiple slender perforators of caliber smaller than 0.40 mm, and only a single perforator in the operative field that cannot satisfy the needs of the flap blood supply and recipient area.

[Clinical effects of lateral supramalleolar perforator island flaps with low rotation points in repairing foot skin and soft tissue defect wounds]

Objective: To investigate the clinical effects of lateral supramalleolar perforator island flaps with low rotation points in repairing foot skin and soft tissue defect wounds. Methods: The retrospective observational study was conducted. From October 2017 to August 2020, 14 patients (6 males and 8 females, aged 14-77 years) with foot skin and soft tissue defect wounds were admitted to Lanzhou University Second Hospital, including 4 cases of plantar skin tumor, 4 cases of chronic plantar ulcer, 4 cases of foot traffic injury, and 2 cases of residual wounds after deep foot burns. The wound size was 2.0 cm×2.0 cm to 7.0 cm×5.0 cm after tumor resection or debridement, which was repaired with island flap pedicled with the descending branch of the lateral supramalleolar perforator and the rotation point located at the lower front edge of the lateral ankle. The size of the flap ranged from 3.0 cm×2.0 cm to 8.0 cm×6.0 cm, and the length of vascular pedicle ranged from 8.0 to 14.0 cm. The flap was transferred by subcutaneous tunnel to repair the wound. The donor site wound of the flap was repaired with medium thickness skin graft from the lateral thigh. The survival of flaps, wound healing of the donor and recipient sites, and the occurrence of complications after operation were observed. The appearances of flaps and donor sites, and foot function were observed during follow-up. Results: The flaps of 14 patients survived successfully after operation, and the wounds in the donor and recipient sites healed well, without vascular crisis, venous congestion, or other complications. Follow-up for 2 to 24 months showed that the flaps had good appearance without bloating and were wear-resistant, the functions of wearing shoes and walking were not affected, and there was no obvious scar hyperplasia or hyperpigmentation at the donor site. Conclusions: With the descending branch of the lateral supramalleolar perforator as the pedicle and the rotation point located at the lower front edge of the lateral ankle, the island flap has a good effect in repairing the skin and soft tissue defect wound of the foot because of its reliable blood supply, simple design and operation, no need for vascular anastomosis, low rotation point, long vascular pedicle, and large radius of rotation.

[Effectiveness comparison of two surgical methods in treatment of intra-articular displaced calcaneal fractures in older children]

Objective

To compare the effectiveness of open reduction and internal fixation with plate and closed reduction and internal fixation with Kirschner wire (K-wire) in the treatment of intra-articular displaced calcaneal fractures in older children.

Methods

A clinical data of 35 older children (37 feet) with intra-articular displaced calcaneal fractures who were admitted between November 2014 and November 2020 and met the selection criteria were retrospectively analyzed. Among them, 19 cases (20 feet) underwent open reduction and internal fixation with plate (plate group), and 16 cases (17 feet) underwent closed reduction and internal fixation with K-wire (K-wire group). There was no significant difference in gender, age, cause of injury, side and type of fracture, and time from injury to admission, and preoperative calcaneal Gissane angle and Böhler angle ( P>0.05). The postoperative calcaneal Gissane angle, Böhler angle, complications, and fracture healing were compared between the two groups. The ankle function was evaluated based on the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system.

Results

Incision necrosis occurred in 1 foot in the plate group after operation, which healed after symptomatic treatment; the other incisions in the two groups healed by first intention. All children were followed up 12-39 months (mean, 19 months). X-ray films showed that the fractures in both groups healed; the healing time was (2.65±0.71) months in the plate group and (2.24±1.38) months in the K-wire group respectively, with no significant difference ( t=1.161, P=0.253). At last follow-up, the calcaneal Gissane angle and Böhler angle returned to normal; and the difference between pre- and post-operation in the two group was significant (P<0.05), but there was no significant difference between the two groups in the difference between before and after operation ( P>0.05). In the plate group, the plate was removed at 11-22 months after operation (mean, 16.8 months). At last follow-up, the AOFAS ankle-hindfoot score in the plate group was 91.2±5.1, which was significantly higher than that in the K-wire group (86.9±6.1) ( t=2.316, P=0.027). The ankle function was rated as excellent in 15 feet, good in 4 feet, and fair in 1 foot in the plate group, and excellent in 14 feet and good in 3 feet in the K-wire group, and the difference between the two groups was not significant ( Z=1.712, P=0.092).

Conclusion

For intra-articular displaced calcaneal fracture in older children, the open reduction and internal fixation with plate and closed reduction and internal fixation with K-wire can achieve good effectiveness, but the former has better recovery of ankle function.

What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

BACKGROUND

Fractures of the proximal fifth metatarsal are common, and often they are classified using a three-part scale first proposed by Lawrence and Botte. A clear consensus on prognosis and treatment for these fractures is lacking, particularly for fractures in the middle classification, Zone 2; the reliability of the classification scheme itself may be partly at fault for this. The intra- and interrater reliability of the classification itself has never been established, and it remains unclear whether the three-part classification of fifth metatarsal fractures can be applied consistently enough to guide treatment.

QUESTIONS/PURPOSES

When used by experienced orthopaedic surgeons, (1) What is the overall interrater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (2) What is the overall intrarater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (3) What are these same metrics for the individual transitions within the classification (Zone 1-2 and Zone 2-3)?

METHODS

Thirty sets of initial presentation radiographs representing an equal number of fractures originally diagnosed by treating clinicians as Zone 1, Zone 2, and Zone 3 were evaluated and classified by three orthopaedic surgeons specializing in foot and ankle surgery and eight foot and ankle fellows to determine interrater reliability. Two weeks later, the same set of radiographs were reevaluated in random order to determine intrarater reliability. Kappa values for interrater and intrarater reliability were calculated. Additionally, the individual transitions between zones were separately analyzed by calculating kappa values for a hypothetical two-part classification based on each transition.

RESULTS

The three-part Lawrence and Botte classification of fifth metatarsal fractures demonstrated an overall interrater agreement of κ = 0.66 (observed agreement 77% versus chance agreement 33%). Intrarater reliability for the 11 surgeons ranged from κ = 0.60 to κ = 0.90. A two-part scheme divided by the transition between Zone 1 and Zone 2 demonstrated an interrater agreement of κ = 0.83, and a two-part scheme divided by the transition between Zone 2 and Zone 3 demonstrated a much lower interrater reliability of κ = 0.66.

CONCLUSION

The three-part Lawrence and Botte classification system demonstrated a concerningly low level of interrater reliability with an observed agreement of 77% compared with a chance agreement of 33%. The primary source of concern is the assessment of the interface between Zone 2 and Zone 3, which proved much less reliable than that between Zone 1 and Zone 2. This suggests that previous studies of isolated Zone 1 fractures likely contain a homogeneous fracture cohort, whereas studies of Zone 2 or Zone 3 fractures are likely to include a mixture of fracture types. In practice, the consensus treatment of fifth metatarsal fractures differs based on whether they represent a more proximal, avulsive injury or a more distal injury from indirect trauma. Our data suggest that the Lawrence and Botte classification should be abandoned. Further work should focus on developing a new classification scheme that demonstrates improved interobserver reliability and more directly corresponds to this treatment paradigm.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Treatment of Severe Destructive Foot and Ankle Injury in a Young Child with a Skin Regeneration Technique

Null.

[All-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of Sanders Ⅱ and Ⅲ]

Objective: To investigate the surgical technology and clinical efficacy of using the all-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of Sanders Ⅱ and Ⅲ. Methods: The clinical data of 33 patients (33 feet) with intra-articular displaced calcaneal fractures treated by modified all-inside arthroscopic from March 2017 to March 2019 at Department of Orthopedics,Xuzhou Central Hospital were retrospectively analyzed.There were 19 male patients,and 14 female patients,aged (32.6±11.3) years(range:20 to 55 years). According to the Sanders classification,there were 12 cases of type Ⅱ and 21 cases of type Ⅲ. The duration from injury to surgery was (101.2±32.1) hours(range:6 to 140 hours).The preoperative visual analogue scale (VAS) was 6.4±2.9 (range: 4 to 8); The preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the SF-36 score was 63.3±11.8 (range:50 to 75) and 94.8±9.1 (range:70 to 105) respectively.All the patients were managed with the all-side subtalar arthroscopy through three portals combined with rafting screws technique.The incision healing,reduction of fracture,and fracture healing were recorded.The VAS,AOFAS ankle-hindfoot scale,and SF-36 score were used to assess the pain and functional outcomes.Repeated-measurement was used to compare the scores before and after surgery. Results: The time of operation was (69.7±10.4) minutes (range:40 to 110 minutes). All patients did not undergo bone grafting.The incision healed in one stage without complications of skin sensory and peroneal tendon injury.All patients were followed up for 24 months.At the last follow-up,all the patients were satisfied with the hindfoot alignment,function,and hindfoot appearance.Postoperative calcaneal imaging indicators (calcaneal length,calcaneal width,calcaneal height,Bohler angle and Gissane angle) were significantly improved compared with those before surgery (P<0.01).There was no statistically significant difference in the imaging indexes of calcaneus at 1 day,1 year and 2 years after surgery,indicating no loss of fracture reduction (all P>0.05).The VAS,AOFAS ankle-hindfoot scale,and SF-36 score were 1.5±0.4 (range: 0 to 2),94.0±6.5 (range:90 to 100),and 119.1±7.2 (range:105 to 130),respectively,which were better than those before surgery (all P>0.05).According to the AOFAS scoring system,27 cases were excellent,4 cases were good, 2 cases were fair,and the excellent and good rate was 94.0%. Conclusion: All-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of Sanders Ⅱ and Ⅲ provides precise reduction,reliable fixation,satisfactory function and limited complications,which is an alternative method.

[CLINICAL AND STATISTICAL ANALYSIS OF POSTERIOR FOOT INJURIES]

A clinical and statistical study of the frequency, structure and circumstances of posterior foot injury was carried out in 1047 patients admitted to the clinic in the period from 2007 to 2020. Age and gender groups have been identified, in which most often injuries leading to hospitalization occurred as a result of a fall with low kinetic energy at home or on the street, due to negligence, illegal actions and road accidents. The majority of patients were hospitalized urgently after injury, among which fractures of the calcaneus prevailed (84.82%). Two clinical groups were analyzed for the chosen treatment tactics. In the first group (comparison), depending on the severity of the injuries, conservative treatment was performed in 189 patients, operative (open reposition and internal fixation) - in 156. In the second group (studies), a closed reposition by Westhues / Essex-Lopresti and transosseous osteosynthesis according to the tactics developed by us were performed in 316 cases. Rammed arthrodesis was performed in both groups in 22 patients. The analysis of the functional results of conservative treatment according to AOFAS (88.7±5.2) and FFI (6.8±3.4) showed the advantages of closed methods and their effectiveness by 1.2 times compared with conservative treatment and internal osteosynthesis, respectively, 73.1±11.2 and 23.9±10.8 points.

Application of the distally based sural neurocutaneous flaps in the management of foot and ankle defects in patients with diabetic foot

BACKGROUND

We report our experience on the use of a distally based sural flap for soft tissue reconstruction of foot and ankle defects in patients with diabetic foot.

METHODS

The actual study is a retrospective, open, non-controlled, and clinical study of 25 patients treated with diabetic foot on whom reconstruction with distally based sural neurocutaneous flaps was performed from May 2019 to December 2021.

RESULTS

The mean age was 64.9 years, and there were 15 male and 10 female patients. The mean follow-up was 9.8 months, which ranged from 6 to 12 months. The size of the flaps ranged from 6 × 5 to 15 × 9 cm². Twenty-two of the 25 flaps survived intact with sufficient blood supply. Two cases had a small superficial necrosis, which was resolved after a change of daily dressing and was heeled eventually. In one case, partial necrosis was observed that was managed with minor revision and the use of split-thickness skin graft.

CONCLUSIONS

The distally based sural flap is considered to be useful for reconstruction of foot and ankle defects in patients with diabetic foot.

Versatility of the Peroneal Perforator Propeller Sural Flap for Various Types of Injuries in the Ankle and Foot Regions

OBJECTIVES

The goals of soft tissue reconstruction in the distal lower extremities are to provide a functional limb and to help patients return to a normal life with the capability of wearing shoes or boots. A peroneal perforator propeller sural flap is a combination of a sural flap and a peroneal propeller perforator flap. This article presents the versatility of this flap in the foot and ankle regions.

PATIENTS AND METHODS

Eleven peroneal perforator propeller sural flaps were harvested to reconstruct the ankle and foot regions. There were 9 male and 2 female patients, with ages ranging from 9 to 64 years. The flaps were used for 7 different defect types including avulsion, gunshot, crush injury, diabetic foot, defect secondary to orthopedic surgery, tumor resection, and electrical burn. The flaps included 3 different insetting types and 2 different utilizations of the sural nerve.

RESULTS

Eight direct propeller flaps, 2 interpolation propeller flaps, and 1 passing-through-style propeller flap were harvested as flap insetting types. In 1 patient, sural nerve coaptation was used, and in 2 patients, an additional posterior tibial artery perforator flap was used. One patient underwent surgery at the time of the injury. Only 2 patients had complications related to the type of injury. There was no need for debulking surgery for patients to wear their own shoes or boots.

CONCLUSIONS

The peroneal perforator propeller sural flap can be harvested as a sensory flap with sural nerve coaptation, a passing-through- style, an interpolation style, an extended style, or as a component of double perforator flaps. This type of flap provides various options in the challenging field of reconstructive surgery.

Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review

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Fractures of the proximal fifth metatarsal (PFMT) are one of the most common foot injuries, accounting for 61% to 78% of all foot fractures, but full consensus on their classification, diagnosis, and treatment has not yet been reached.

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The most commonly accepted classification is that of Lawrence and Botte, who divided the location of PFMT fractures into 3 zones with respect to their healing potential.

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Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended.

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Internal fixation may be considered for displaced fractures that extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for nondisplaced fractures in athletes or high-demand patients, with the aims of reducing the healing time and expediting return to sport or work.

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Stress fractures of the proximal diaphysis (zone 3) are preferably treated operatively, particularly in the presence of signs of delayed union. With nonoperative treatment, supportive measures such as ultrasonography or external/extracorporeal shockwave therapy have been demonstrated to have limited potential for the enhancement of fracture-healing.

Impact of the Subtle Lisfranc Injury on Foot Structure and Function

BACKGROUND

The subtle Lisfranc injury is the disruption of the osteoligamentary complex between the first cuneiform and the second metatarsal, resulting in minor widening of this space that is often difficult to detect with plain radiographs. In this study, we assessed the results after treatment of the different stages of subtle Lisfranc injuries, focusing on their impact on foot arch anatomy and functionality at short- to midterm follow-up.

METHODS

A retrospective study including patients treated in our center for a subtle Lisfranc injury between 2012 and 2019 was conducted. Demographic, epidemiologic, radiographic, and clinical data were obtained and assessed, focusing on foot arch structure and foot function, which was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and the Foot Function Index (FFI).

RESULTS

A total of 42 patients with a mean age of 49 ± 17.5 years were included, with an average of 4.3 years' follow-up (range, 1-8). Stage I injuries according to Nunley classification represented 19% and were treated conservatively. Stage II (66.7%) and stage III (14.3%) injuries were treated operatively, via osteosynthesis with screws (74%), K-wires (19%), or plates (7%). Flattening of foot arch after treatment was observed in 42.9% of patients, with significant increases in Costa-Bertani (12 ± 7 degrees), Hibbs (7 ± 6 degrees), and Meary (3 ± 1 degrees) angles. Other complications included complex regional pain syndrome (28.6%) and painful hardware (23.8%). Secondary joint arthrodesis was needed in 16.6% of patients. Chronic pain was present in 71.4% of patients with a mean visual analog scale (VAS) pain score at final follow-up of 4 of 10 points. Results in AOFAS midfoot score and FFI were 87.4 ± 8.3 and 15 ± 6.4, respectively.

CONCLUSION

The subtle Lisfranc injury shows dissociation between the initial relatively mild radiographic changes and important future complications. Chronic pain and foot arch flattening were not uncommon. Overall foot function in the short- or midterm was found to be modestly diminished in this somewhat heterogenous cohort.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes

BACKGROUND

Sports-related fractures of the fifth metatarsal are common in professional athletes. Data regarding outcomes of surgical management including refracture, complications, and return-to-play statistics are available for other professional American sports with a notable exception of soccer.

PURPOSE

To quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) athletes, to compare outcomes as well as refracture and complication rates with other professional sports, to analyze factors that may contribute to treatment failure, and to report on return-to-play characteristics for affected players.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We searched all injuries in the prospectively collected HealtheAthlete database for MLS for operative fifth metatarsal fractures for seasons 2013 to 2017. Additional information regarding each fracture including demographics, treatment, postoperative course, and return-to-play statistics were compiled from HealtheAthlete and supplemented by teams' chief medical officers, coaches, trainers, and online sources.

RESULTS

There were 21 fractures in 18 players during the study period. Mean time to radiographic healing was 8.5 weeks (n = 17). Mean time to return to play was 11.1 weeks (n = 19). Of 21 fractures, 20 (95%) players returned to sport. Of 18 players, 4 (22.2%) experienced refracture. Of 18 players, 5 (27.8%) and 2 (11.1%) reported previous stress injuries on the contralateral and ipsilateral limb, respectively. Player performance characteristics showed small declines in the first year of return that improved by the second year.

CONCLUSION

MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts.

Functional Evaluation of Ankle Joint After 1-Stage Secondary Debulking Procedure After Flap Reconstruction

OBJECTIVE

Free or local flaps that are used to reconstruct the lower limb often result in poor functional outcome because of bulkiness of the flap and scar contracture over ankle joint region. The aim of this study was to evaluate the functional results of ankle joint after 1-stage secondary debulking procedure for lower limb trauma.

MATERIAL AND METHODS

From January of 2002 to October of 2018, debulking procedures were performed for 66 patients after flap reconstructions of the lower limb. Thirty-eight patients (group 1) of foot injury without ankle joint involvement and 20 patients (group 2) with ankle joint involvement were included. Range of motion (ROM) of ankle joint before and after debulking procedure was measured after 6 months of follow-up.

RESULTS

After debulking procedure, all the patients were able to dress in their preinjury shoes without any difficulty and with ease of ambulation. For all patients, with or without ankle involvement, the postdebulking ROM versus predebulking ROM improved significantly (P < 0.01). The ROM improvements for patients with ankle involvement were significantly better then patients without ankle involvement (P = 0.032).

CONCLUSIONS

One-stage debulking procedure can provide long-term constant, reliable, thin skin coverage for the lower limb after flap reconstruction with improved ankle ROM. This allows better functional results, especially for lower limb trauma patients with initial ankle involvement.

Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET)

BACKGROUND

Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation.

METHODS

This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work.

RESULTS

The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval [CI] = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns.

CONCLUSIONS

Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgical Management of a Pediatric Cuboid Nutcracker Fracture: A Case Report

CASE

Cuboid impaction fractures (nutcracker fractures) result from high-energy trauma and are exceedingly rare in children. We present a case of an 8-year-old boy who sustained a comminuted cuboid nutcracker fracture after a fall from height. The patient underwent open reduction and internal fixation with a locking plate. At 1 year postoperatively, lateral column length and articular congruency were maintained, and the patient return to full function and activity.

CONCLUSION

Cuboid nutcracker fractures in children are rare and can be successfully treated with open reduction and internal fixation with locking plates, with excellent radiographic and functional outcomes.

Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries: Two case reports

RATIONALE

Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion.

PATIENT CONCERNS

Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin.

DIAGNOSIS

Clinical inspection revealed significant degloving of the glabrous skin in both patients.

INTERVENTIONS

After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed.

OUTCOMES

In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation.

LESSONS

ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

Bone Defects After Surgery for Displaced Intraarticular Calcaneal Fractures Spontaneously Improve Without Bone Grafting

BACKGROUND

Most intraarticular displaced calcaneal fractures are accompanied by bone defects after surgical treatment, but the concern about negative effects of bone defects has not been resolved yet owing to the few studies on this issue. Therefore, studies on volumetric changes in bone defects over time and the correlation between postoperative outcomes and residual bone defects will be helpful to address the controversy on the necessity of bone grafting in bone defects of calcaneal fractures.

QUESTIONS/PURPOSES

(1) Do bone defects change in size in the first year after surgical treatment of displaced intraarticular calcaneal fractures? (2) Does the size of residual bone defects correlate with postoperative radiographic or clinical outcomes?

METHODS

Between 2015 and 2019, 99 patients with displaced intraarticular calcaneal fractures visited the investigators' institution, of whom 95 received surgical treatment. Of the patients treated with surgery, 25% (24 of 95) did not undergo open reduction and internal fixation via an extensile lateral approach, and 19% (18 of 95) had multiple fractures, bilateral fractures, open fractures, or a history of previous surgery on the calcaneus; all of these patients were excluded. During the study period, CT was routinely performed for calcaneal fractures immediately after and 12 months after the surgery, but 6% (6 of 95) of the patients had insufficient CT data due to loss to follow-up before 12 months or other reasons, leaving 47 patients for evaluation in this retrospective study. Fractures were fixed with plate and screws, and bone grafting was not performed in all patients. To answer our first question, which was on the changes in bone defects over time, volumetric measurements of the bone defect were performed using CT via the ITK-SNAP software. The percentage of volumetric change was calculated as a fraction of the volumetric change over 12 months from the initial volume. The percentage of the residual bone defect was calculated as a fraction of the volume of the residual bone defect relative to the volume of the entire calcaneus. To answer our second question, which was on the correlation between residual bone defects and postoperative outcomes, we assessed the Böhler angle, Gissane angle, calcaneal height, Olerud-Molander Ankle Score (OMAS), and VAS score for pain and compared these parameters with the size of the residual bone defect using the Pearson correlation coefficient. The OMAS and VAS scores for pain were evaluated and recorded during patient visits, and we obtained the scores through a chart review. All volumetric measurements and radiographic evaluations were performed by two orthopaedic surgeons, and the intraobserver and interobserver reliability were assessed using the intraclass correlation coefficient.

RESULTS

The mean volume of the bone defect measured using CT was 4 ± 3 cm3 immediately after surgery and 1 ± 1 cm3 12 months after surgery. During the first 12 months after surgery, the mean volume of the bone defect was reduced by 77% (95% confidence interval 73% to 80%). The mean residual bone defect in the entire calcaneus was 2% (95% CI 1% to 2%), and none of the postoperative outcomes were correlated with the residual bone defect.

CONCLUSION

As bone defects substantially resolve without treatment, surgeons do not need to use bone graft for the surgical treatment of displaced intraarticular calcaneal fractures. Future studies that include patients who underwent bone grafting for the treatment of calcaneal fractures are needed to confirm our findings and to further investigate whether bone grafting has additional benefits for the recovery of bone defects.

LEVEL OF EVIDENCE

Level III, therapeutic study.