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Zioupos S, Westacott D. Flat-top talus after clubfoot treatment: a literature review. J Pediatr Orthop B 2024; 33:44-47. [PMID: 36728872 DOI: 10.1097/bpb.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite this, it receives little attention in textbooks, so our knowledge and understanding can be limited to anecdote and hearsay. In particular, its association with different treatments, especially the Ponseti method, is not well understood. This review provides some clarity on the possible pathoanatomical, radiological and iatrogenic causes of FTT. It summarises its prevalence following different treatments. It is seen after surgery, 'pre-Ponseti' casting and the Ponseti method, and seems least common following Ponseti. Potential surgical management strategies are also discussed.
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Faldini C, Artioli E, Panciera A, Bonelli S, Arceri A, Mazzotti A. Surgical management of clubfoot overcorrection: a case series. Arch Orthop Trauma Surg 2023; 143:6503-6511. [PMID: 37318629 DOI: 10.1007/s00402-023-04946-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Overcorrection is a possible complication of clubfoot treatment, whose prevalence varies from 5 to 67%. Overcorrected clubfoot usually presented as a complex flatfoot with different degrees of hindfoot valgus, flat top talus, dorsal bunion, and dorsal navicular subluxation. The management of clubfoot overcorrection is challenging, and both conservative and surgical treatments are available. This study aims to present our experience in the surgical management of overcorrected clubfoot and to provide an overview of actual treatment options for each specific sub-deformity. MATERIALS AND METHODS A retrospective cohort study of patients surgically treated for an overcorrected clubfoot from 2000 to 2015 at our Institution was conducted. Surgical procedures were tailored to the type and symptomatology of the deformity. A medializing calcaneal osteotomy or subtalar arthrodesis was performed for hindfoot valgus. Subtalar and/or midtarsal arthrodesis were considered in cases of dorsal navicular subluxation. The first metatarsus elevatus was addressed through a proximal plantarflexing osteotomy, sometimes associated with a tibialis anterior tendon transfer. Clinical scores and radiographic parameters were obtained pre-operatively and at the last follow-up. RESULTS Fifteen consecutive patients were enrolled. The series included 4 females and 11 males, with a mean age at surgery of 33,1 (18-56) years, and a mean follow-up of 4,46 (2-10) years. Seven medializing calcaneal osteotomies, 5 subtalar arthrodesis, 11 first metatarsal plantarflexing osteotomies, and 7 anterior tibialis tendon transfers were performed. A statistically significant improvement in both clinical and radiographic scores was observed. CONCLUSIONS Management of overcorrected clubfoot involves many surgical techniques because of the high interpersonal variability of the deformities. The surgical approach showed positive results, as long as the indication is based on clinical symptoms and functional impairment rather than morphological alterations and radiographic findings.
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Affiliation(s)
- Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123, Bologna, Italy
| | - Elena Artioli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Alessandro Panciera
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123, Bologna, Italy
| | - Simone Bonelli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Alberto Arceri
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Antonio Mazzotti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123, Bologna, Italy.
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Fijany AJ, Olsson SE, Givechian BK, Zago I, Bishay AE, Troia T, Page TS, Barnett A, Downey MW, Pekarev M. A Novel Orthoplastic Reconstruction of Relapsed Clubfoot With Total Ankle Arthroplasty. Cureus 2023; 15:e44796. [PMID: 37809200 PMCID: PMC10558358 DOI: 10.7759/cureus.44796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient's poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient's ankle issues and appears to be a viable option for clubfoot patients.
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Affiliation(s)
- Arman J Fijany
- Plastic Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Sofia E Olsson
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | | | - Ilana Zago
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Anthony E Bishay
- Neurosurgery, Vanderbilt University School of Medicine, Nashville, USA
| | - Thomas Troia
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Trevor S Page
- Plastic Surgery, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | | | - Michael W Downey
- Trauma and Reconstructive Surgery, Precision Orthopedics and Sports Medicine, Fort Worth, USA
| | - Maxim Pekarev
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
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Limb salvage versus below knee amputation for severe adult lower limb deformity - A retrospective, comparative series. Foot Ankle Surg 2022; 28:622-627. [PMID: 34274238 DOI: 10.1016/j.fas.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/12/2021] [Accepted: 07/01/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study compares outcomes of patients with severe, multiplanar, fixed, pantalar deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). METHODS Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17-72 years) and median follow-up duration was 49.9 months (24.0-253.7 months). Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgery and whether they would have the same surgery again. RESULTS There was no statistically significant difference in functional outcomes, satisfaction, or complications between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p = 0.414). There was no difference in the proportion of patients who would opt for the same procedure again (p = 0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p = 0.692). CONCLUSION This study concludes that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative pantalar deformities. This data may be useful in counselling patients when considering salvage versus amputation in such cases. LEVEL OF EVIDENCE Level 3(Original) Clinical Research Article.
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Li S, Myerson MS. Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity. Foot Ankle Clin 2022; 27:491-512. [PMID: 35680301 DOI: 10.1016/j.fcl.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.
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Affiliation(s)
- Shuyuan Li
- Department of Orthopaedic Surgery, University of Colorado School of Medicine; Steps2Walk.
| | - Mark S Myerson
- Department of Orthopaedic Surgery, University of Colorado School of Medicine; Steps2Walk
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The Novel Application of Three-Dimensional Printing Assisted Patient-Specific Instrument Osteotomy Guide in the Precise Osteotomy of Adult Talipes Equinovarus. BIOMED RESEARCH INTERNATIONAL 2021; 2021:1004849. [PMID: 34901265 PMCID: PMC8660203 DOI: 10.1155/2021/1004849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/26/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
Objective This current research is aimed at assessing clinical efficacy and prognosis of three-dimensional (3D) printing assisted patient-specific instrument (PSI) osteotomy guide in precise osteotomy of adult talipes equinovarus (ATE). Methods We included a total of 27 patients of ATE malformation (including 12 males and 15 females) from June 2014 to June 2018 in the current research. The patients were divided into the routine group (n = 12) and 3D printing group (n = 15) based on different operative methods. The parameters, including the operative time, intraoperative blood loss, complications, time to obtain bony fusion, functional outcomes based on American Orthopedic Foot and Ankle Society (AOFAS), and International Congenital Clubfoot Study group (ICFSG) scoring systems between the two groups were observed and recorded regularly. Results The 3D printing group exhibits superiorities in shorter operative time, less intraoperative blood loss, higher rate of excellent, and good outcomes presented by ICFSG score at last follow-up (P < 0.001, P < 0.001, P = 0.019) than the routine group. However, there was no significant difference exhibited in the AOFAS score at the last follow-up and total rate of complications between the two groups (P = 0.136, P = 0.291). Conclusion Operation assisted by 3D printing PSI osteotomy guide for correcting the ATE malformation is novel and feasible, which might be an effective method to polish up the precise osteotomy of ATE malformation and enhance the clinical efficacy.
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Hamel J. The Overcorrected Clubfoot in Children. Foot Ankle Clin 2021; 26:747-764. [PMID: 34752237 DOI: 10.1016/j.fcl.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Clubfoot overcorrection can develop gradually over years and is characterized in school age by hindfoot valgus position due to excessive rigid peritalar eversion, sometimes accompanied by supramalleolar valgus malalignment. Surgical treatment is recommended in severe cases and consists of bony realignment at the peritalar complex by osteotomy or fusion, correction of the supramalleolar valgus deformity in younger children by hemiepiphyseodesis, or osteotomy in adolescents. In addition, dorsal bunion requires stabilization of the medial tarsometatarsal ray and transfer of the tendons of Mm. tibialis anterior and flexor hallucis longus.
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Affiliation(s)
- Johannes Hamel
- Schön Klinik München Harlaching, Harlachinger Straße 51, München D - 81547, Germany.
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Böhm H, Döderlein L, Fujak A, Dussa CU. Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities? Foot Ankle Surg 2020; 26:801-809. [PMID: 31694790 DOI: 10.1016/j.fas.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 06/04/2019] [Accepted: 10/21/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function. METHODS Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures. RESULTS The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation. CONCLUSIONS The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.
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Affiliation(s)
- Harald Böhm
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau gGmbH, Bernauer str. 18, 83229 Aschau i. Chiemgau, Germany.
| | | | - Albert Fujak
- Friedrich-Alexander-University of Erlangen-Nürnberg, Department of Orthopaedic Surgery Rathsberger str. 57, 91054 Erlangen, Germany
| | - Chakravarty U Dussa
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau gGmbH, Bernauer str. 18, 83229 Aschau i. Chiemgau, Germany; Friedrich-Alexander-University of Erlangen-Nürnberg, Department of Orthopaedic Surgery Rathsberger str. 57, 91054 Erlangen, Germany
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Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e1900126. [PMID: 33970571 PMCID: PMC7434041 DOI: 10.5435/jaaosglobal-d-19-00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.
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Dussa CU, Böhm H, Döderlein L, Forst R, Fujak A. Does an overcorrected clubfoot caused by surgery or by the Ponseti method behave differently? Gait Posture 2020; 77:308-314. [PMID: 32135471 DOI: 10.1016/j.gaitpost.2020.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/08/2020] [Accepted: 02/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Overcorrection is a recognized problem following surgical treatment of congenital clubfoot. Recently this complication has also been mentioned following Ponseti treatment. RESEARCH QUESTION Do overcorrected clubfeet (OCCF) caused by surgery behave differently from those caused by Ponseti treatment in terms of segmental motion of the feet and show differences in the severity of deformity on X-rays? METHODS Children between 7 and 12 years with OCCF were included in this study. Depending on the aetiology causing them, the feet were divided into 2 groups (Ponseti and peritalar release surgery). 25 typically developing children served as controls. All subjects were subjected to clinical and radiological examination and 3-Dimensional gait analysis using the Oxford Foot Model. RESULTS Thirty-two children with OCCF, of these 18 feet in the surgical and 14 feet in the Ponseti group, were included in the study. No radiological differences were seen in the flatfoot parameters between OCCF groups except in the calcaneal inclination angle that was more pathological in the Ponseti group. The clinical ankle plantar flexion was significantly reduced in the surgical group. During walking the range motion of the hindfoot in the frontal plane was significantly reduced in surgically treated feet compared to the Ponseti group. The other parameters did not show any significant difference between groups. SIGNIFICANCE The overcorrected clubfeet following surgery and Ponseti showed similar appearance and showed no significant differences in 11/12 radiological parameters. The segmental motion of the feet showed no significant differences between groups except the in the range of motion of the subtalar eversion. A considerable subtalar joint motion was present even in the surgical group. These findings might help plan the treatment of these feet.
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Affiliation(s)
- Chakravarthy U Dussa
- Department of Paediatric Orthopaedics, Orthopaedische Kinderklinik, Bernauerstrasse 18, D-83229 Aschau i. Chiemgau, Bavaria, Germany.
| | - Harald Böhm
- Gait Laboratory, Orthopaedische Kinderklinik, Bernauerstrasse 18, D-83229 Aschau i. Chiemgau, Bavaria, Germany
| | - Leonhard Döderlein
- Peadiatric Orthopaedic Surgeon, Bismarckstrasse 60, 69198 Schriesheim, Germany
| | - Raimund Forst
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Rathsberger Str. 57, D-91054 Erlangen, Bavaria, Germany
| | - Albert Fujak
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Rathsberger Str. 57, D-91054 Erlangen, Bavaria, Germany
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Eberhardt O, Wachowsky M, Wirth T, Fernandez Fernandez F. Limitation of flatfoot surgery in overcorrected clubfeet after extensive surgery. Arch Orthop Trauma Surg 2018; 138:1037-1043. [PMID: 29633074 DOI: 10.1007/s00402-018-2932-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Flatfoot is a severe complication of extensive clubfoot surgery. In this retrospective study, we evaluated our results following flatfoot surgery in overcorrected clubfeet. The aim was to analyze the success of different surgical techniques, including tarsal osteotomies and arthrodesis, in correcting different types of flatfeet. MATERIAL AND METHOD Between January 1, 2011 and December 31, 2015 we treated 25 severe cases of flatfeet after extensive clubfoot surgery. We classified the hindfoot deformities into rotational valgus, hinge valgus or translatory valgus based on AP standing X-rays. Tarsal osteotomies (Mitchell, Evans, Cotton) and arthrodesis were adapted based on age and severity. Age, gender, pain, hindfoot valgus and function were documented. Function and X-rays were compared pre- and postoperatively. RESULTS There were 17 male and 4 female patients. Age at operation ranged from 11 to 26 years with an average age of 14.3 years. The mean follow-up was 27.6 months (7-60 months). Primary surgical treatment was a tarsal osteotomy in 19 cases and in six cases it was arthrodesis. Hindfoot valgus (Ø 18.6°-3.2°), calcaneal pitch (Ø 6.2°-14.6°), Costa Bartani angle (Ø155°-142°) and Meary angle (Ø 2.0°-8.8°) improved pre- to postoperatively. Range of motion did not improve after surgical correction. 81% were satisfied with the postoperative results. All flatfeet with translatory valgus, initially treated with a tarsal osteotomy, needed further arthrodesis due to primary undercorrection. CONCLUSION Tarsal osteotomies are successful methods for correcting flatfeet following extensive clubfoot surgery with rotational valgus and mild hinge valgus. Tarsal osteotomies are unable to successfully correct flatfeet that have a translatory valgus. In such cases, we recommend double or triple arthrodesis. The functional outcome is limited by the preop range of motion and the appearance of talus deformities.
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Affiliation(s)
- Oliver Eberhardt
- Olgahospital Stuttgart, Kriegsbergstrasse 62, 70174, Stuttgart, Germany.
| | - Michael Wachowsky
- Olgahospital Stuttgart, Kriegsbergstrasse 62, 70174, Stuttgart, Germany
| | - Thomas Wirth
- Olgahospital Stuttgart, Kriegsbergstrasse 62, 70174, Stuttgart, Germany
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Shtofmakher G, Kilfoil RL, Rozenstrauch A, Vitale T. Talipes equinovarus (clubfoot): neglected for 47 years and subsequent treatment. BMJ Case Rep 2014; 2014:bcr-2014-205395. [PMID: 24859734 DOI: 10.1136/bcr-2014-205395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | | | | | - Thomas Vitale
- Department of Surgery, New York College of Podiatric Medicine, New York, New York, USA
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