Search

Background: Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects., Methods: Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps., Results: Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups., Conclusions: Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021 Jong-Ho Kim et al.)

Background: The treatment for displaced Salter-Harris II (S-H II) distal tibia fractures remains controversial. The purpose of this study was to review S-H II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction and internal fixation (ORIF)., Methods: We reviewed the charts and radiographs of S-H II fractures of the distal tibia with displacement > 3 mm between 2012 and 2019 treated by ORIF. Patients were followed up for a minimum of 6 months. CT scans of injured side or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening of the involved leg was documented. Multivariable logistic regression was performed to identify risk factors for the occurrence of PPC., Results: A total of 65 patients with a mean age of 11.8 years were included in this study. The mean initial displacement was 8.0 mm. All patients but one were treated within 7 days after injury and the mean interval was 3.7 days. Supination-external rotation injuries occurred in 50 patients, pronation-eversion external rotation in 13, and supination-plantar flexion in two. The residual gap was less than 1 mm in all patients following ORIF and all fractures healed within 4-6 weeks. Superficial skin infection developed in one patient. Ten patients complained of the cosmetic scar. The rate of PPC was 29.2% and two patients with PPC developed a varus deformity of the ankle. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Age, gender, injured side, mechanism of injury, amount of initial displacement, interval from injury to surgery, or energy of injury did not significantly affect the rate of PPC., Conclusions: ORIF was an effective choice of treatment for S-H II distal tibia fractures with displacement > 3 mm to obtain a satisfactory reduction. PPC is a common complication following ORIF. The presence of concomitant fibula fracture was associated with PPC.

Purpose: To evaluate the surgical outcome in terms of radiographic measurements, functional outcomes, and complications following arthroscopic ankle arthrodesis (AAA) in patients 60 years of age or older, and to compare the results of patients with mildly deformed ankle with those of patients with severely deformed ankle., Methods: We retrospectively reviewed patients who underwent AAA with 3 cannulated screws between January 2008 and December 2017 and followed postoperatively for at least 24 months. All included patients were 60 years of age or older. Demographic data and radiographic and functional outcomes were compared between patients with coronal deformity of less than 15° (group I) and those with a deformity equal to or greater than 15 degrees (group II)., Results: A total of 41 patients with a mean age of 70.6 years were included (group I, n = 26; group II, n = 15) and mean follow-up was 51.4 months. Group II had significantly more severe preoperative coronal deformity of tibiotalar angle than group I (20.1 ± 2.9 vs 6.6 ± 4.1°, P < .01). Near-normal tibiotalar alignment was achieved postoperatively in both groups (group I, 3.4 ± 3.3 vs group II, 4.7 ± 3.1°, P = .227). Union was achieved in 39 (95.1%) patients with 2 cases in group I experiencing non-union. Union rate, mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and visual analog scale pain scores were not significantly different between the 2 groups at final follow-up., Conclusions: AAA is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. In addition, arthroscopic intra-articular malleolar osteotomy was a useful technique for correcting severe coronal deformity in our series., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Case: Congenital tibiofibular diastasis is a relatively rare form of limb deficiency, characterized by distal tibial tapering, absent ankle mortise, equinovarus foot deformity, and variable lower leg shortening. Treatment described has ranged from various forms of foot centralization with or without leg lengthening to amputation. We describe 2 cases treated in childhood by staged foot centralization by soft-tissue distraction, distal tibiotalar fusion, tibial lengthening, and subsequent limb length discrepancy equalization. At skeletal maturity, both patients ambulated independently without aid., Conclusions: Staged reconstruction with foot centralization and distal tibiotalar fusion is an option for carefully selected patients with tibiofibular diastasis who refuse foot ablation.

Most of the anatomic variations of the extensor hallucis longus (EHL) muscle are related to the tendon of insertion. We show a double origin of the EHL from the medial aspect of the fibula and the lateral aspect of the tibia. A 27-year-old male with a double closed fracture of tibia and fibula showed an involuntary extension of the big toe during foot plantar flexion after surgery. A tendon fibrosis by the fixation plates could be the cause of the foot functional alteration. Interestingly, the anatomic variation described could be related to the postsurgical foot dysfunction, since when the fibrotic tissue was removed the normal extension of big toe recovered. As illustrated in this case report, knowledge of anatomic variations is very useful, particularly in the context of foot surgery.

Objective: To summarize the main methods and comprehensive effects of limited surgery combined with external fixation for the treatment of flail foot with sensory disorder of spina bifida sequela in adult., Method: The clinical data of 22 cases (30 feet) of the adult spina bifida sequela who suffered from flail foot with sensory disorder and treated by limited surgery combined with external fixation were retrospectively analysed between January 2005 and December 2015. There were 14 males and 8 females with an age of 8-38 years (mean, 21.5 years). All 30 feet were distal ankle sensory loss, including 2 cases (2 feet) on the left side, 2 cases (2 feet) on the right side, and 18 cases (26 feet) on both sides. There was 1 foot accompanied by ulcerative plantar ulcers, and 3 feet lost their toes due to foot osteomyelitis in the weight-bearing area. Combined with 3 cases of hip dislocation, 3 cases of scoliosis, 4 cases of knee deformity, and 3 cases of ptosis. There were 5 cases of normal control of urine and stool, 10 cases of partial control of urine and stool, 6 cases of overflow urinary incontinence, and 1 case of cystostomy. According to X-ray film, the lesion of spina bifida was evaluated, the laminar insufficiency was located at L 3 -L 5 in 8 cases, L 5 , S 1 in 9 cases, and L 3 -S 3 in 5 cases. In the patients, 12 feet were performed ankle joint arthrodesis, 10 feet subtalar arthrodesis, and 8 feet tibia-talus-calcaneus arthrodesis. Ilizarov external fixator was used in 18 feet, Hybrid fixator in 8 feet, Hybrid fixator and cannulate screws in 3 feet, and Ilizarov fixator and cannulate screws in 1 foot., Results: All 22 patients were followed up 10-80 months (mean, 48.5 months). All ankle deformities were corrected effectively after operation, the middle and hind feet were stable, the plantar foot was restored, the whole foot was loaded, and the ulcer healed without recurrence. There were 2 cannulate screws ruptured in the subtalar arthrodesis, bone healed after screws break; no complication such as surgical infection, neurovascular injury, and so on happened. At last follow-up, based on the evaluation criteria of QIN Sihe lower limb deformity correction, the results were excellent in 15 feet, good in 9 feet, and fair in 6 feet, with an excellent and good rate of 80.0%., Conclusion: The treatment of flail foot with sensory disorder of spina bifida sequela is more demanding. The limited surgeries combined with external fixation play an important role for recovering the stability of foot and ankle, better clinical results, and less complications.

Objective: To assess the efficiency of knee-ankle-foot orthoses for treating painful genu recurvatum, and to determine users' tolerance and satisfaction., Patients: Patients included in the study had a genu recurvatum during the stance phase, confirmed by a medical doctor on physical examination. A total of 27 patients with 31 knee-ankle-foot orthoses were included., Methods: The main outcome was scored on a verbal numerical rating scale (VNRS) before and at least 3 months after a knee-ankle-foot orthosis was fitted, and scored on a verbal numerical pain rating scale (VRS). Secondary outcomes were rated with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST)., Results: After fitting the knee-ankle-foot orthosis, the median VNRS pain score decreased from 85/100 to 25/100 (p ≤ 0.001) and the description of pain on the VRS decreased from "extreme" to "mild" (p ≤ 0.001). The QUEST total score was 4.0., Conclusion: Treating a painful genu recurvatum with a knee-ankle-foot orthosis reduced the pain efficiently whatever the patients' diagnosis, and high scores were obtained for patients' satisfaction.

Introduction: Foot deformities are frequent complications in Charcot-Marie-Tooth disease (CMT) patients, often requiring orthopedic surgery. However, there are no prospective, randomized studies on surgical management, and there is variation in the approaches among centers both within and between countries., Methods: In this study we assessed the frequency of foot deformities and surgery among patients recruited into the Inherited Neuropathies Consortium (INC). We also designed a survey addressed to orthopedic surgeons at INC centers to determine whether surgical approaches to orthopedic complications in CMT are variable., Results: Foot deformities were reported in 71% of CMT patients; 30% of the patients had surgery. Survey questions were answered by 16 surgeons working in different specialized centers. Most of the respondents were foot and ankle surgeons. There was marked variation in surgical management., Discussion: Our findings confirm that the approaches to orthopedic management of CMT are varied. We identify areas that require further research. Muscle Nerve 57: 255-259, 2018., (© 2017 The Authors Muscle & Nerve Published by Wiley Periodicals, Inc.)

Injuries to the ankle and foot are common in the young athlete, especially with increasing participation and high levels of competitiveness in youth sports programs. Knowledge of the normal development of the foot and ankle is crucial to understand age-specific injury patterns because acute or chronic/repetitive stress to the developing skeleton results in injuries that differ from those seen in adults. Congenital abnormalities may also predispose children to increased risk of injury and pain. Radiologists must be aware of these distinctions to diagnose and classify injuries correctly for optimum treatment. We describe common and unique foot and ankle injuries in the young athlete. Throughout the article we focus not only on imaging findings but also on the mechanism of injury., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Os subtibiale is a rare accessory ossicle located at the tip of the medial malleolus. Although this small ossicle usually has no clinical significance, in some cases it may be a source of ankle pain. Symptomatic os subtibiale is an extremely rare diagnosis, and few cases have been reported to date. The case presented is of a 35-year-old female patient with symptomatic os subtibiale, with a discussion of the diagnosis, clinical findings, and treatment options.

Foot and ankle abnormalities are common in Singapore because of the compulsory conscription, the slipper-wearing culture, and the promotion of healthy living through exercise. The rapidly aging population, lack of elite sportsmen, and social and cultural norms pose unique challenges to foot and ankle surgery. Orthopedic surgery in Singapore has progressed because of the good infrastructure and modern practices executed by fellowship-trained surgeons. Evolving local practices are polarized by practice trends emulated from North America and Europe. The small community of foot and ankle surgeons currently practicing in Singapore allows for easier communication, corroborative educational events, and research initiatives., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Haemophilic arthropathy of the ankle is rare disorder caused by recurrent haemarthorses beginning in early adulthood., Aim: Our aim was to evaluate the fusion rate of various techniques of hindfoot fusion using internal fixation for the treatment of haemophilic arthropathy of the hindfoot., Methods: We have evaluated the fusion rate of various techniques of hindfoot (tibiotalar and subtalar joints) fusion for the treatment of haemophilic arthropathy of the hindfoot. Twenty-eight patients underwent a total of 41 procedures. Thirty-four ankle (tibiotalar) fusions were performed, seven were done arthroscopically, six using a minimal access approach and 21 with an open approach. There were two isolated subtalar fusions, three combined tibiotalar and subtalar fusions, one of which included a talonavicular fusion at the second operation. There was one peritalar ankle fusion (tibiotalar, subtalar and talonavicular). The mean age at operation was 40.3 years (SD, 12.3; range, 18.7-65.7 years). The mean time to last follow-up was 77 months (SD, 50.4; range, 7-190)., Results: The overall non-union rate was 9.7%. All non-unions occurred in tibiotalar fusions (there were no non-unions in cases of subtalar or talonavicular fusion). A single deep infection (2.4%) occurred in an arthroscopically fused ankle. The revision rate was 4.8% (2 cases) and was carried out for non-unions. Both revisions were successful., Conclusion: Hindfoot arthrodesis in patients with haemophilic ankle arthropathy provides a high fusion rate with few complications. Arthroscopic tibiotalar fusion did not result in shorter hospital stays. Revision surgery for the haemophilic hindfoot is successful, and fusion of the entire hindfoot can be achieved without complications., (© 2016 John Wiley & Sons Ltd.)

Background: Fitness to drive a car has been investigated increasingly over recent years. However, most research has focussed on perioperative driving performance, and few data are available on how orthoses influence the ability to perform an emergency stop. This study investigated the effect of 4 common ankle braces (Kallassy, CaligaLoc, Air-Stirrup, ASO) on reaction time, foot transfer time (together: brake response time) and brake force. The hypothesis was that wearing these braces on the right ankle impairs braking performance, specifically by increasing foot transfer time, but also by altering brake force., Methods: A car cabin was set up with measurement equipment to register reaction time, foot transfer time, brake response time and brake force under realistic spatial constraints. A crossover repeated measures design was used to test 30 healthy volunteers with and without each of the braces., Results: All 4 braces resulted in statistically significantly increased foot transfer time (p < 0.001), compared with measurements without a brace. Reaction time with a brace was significantly prolonged, with the exception of the Kallasy. Brake force was not statistically significantly impaired., Conclusion: This study demonstrates that ankle braces lead to impaired braking performance. Depending on the type of brace, a stopping distance increase of more than 1 m at 100 km/h can be expected.

Objective: To correct the underlying inframalleolar varus deformity and to restore physiologic biomechanics of the hindfoot., Indications: Neurologic, posttraumatic, congenital, and idiopathic cavovarus deformity. In patients with end-stage ankle osteoarthritis with varus heel malposition as additional single-stage procedure complementing total ankle replacement. Severe peroneal tendinopathy with concomitant cavovarus deformity., Contraindications: General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g., Charcot arthropathy), end-stage osteoarthritis of the subtalar joint, severely reduced bone quality, high age, insulin-dependent diabetes mellitus, smoking., Surgical Technique: The lateral calcaneus cortex is exposed using a lateral incision. The osteotomy is performed through an oscillating saw. The posterior osteotomy fragment is manually mobilized and shifted laterally. If needed, a laterally based wedge can be removed and/or the osteotomy fragment can be translated cranially. The osteotomy is stabilized with two cannulated screws, followed by wound closure., Postoperative Management: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated step by step., Results: Between January 2009 and June 2013, a Dwyer osteotomy was performed in 31 patients with a mean age of 45.7 ± 16.3 years (range 21.5-77.4 years). All patients had a substantial inframalleolar cavovarus deformity with preoperative moment arm of the calcaneus of -17.9 ± 3.3 mm (range -22.5 to -10.5 mm), which has been improved significantly to 1.6 ± 5.9 mm (range -16.9 to 9.9 mm). Significant pain relief from 6.3 ± 1.9 (range 4-10) to 1.1 ± 1.1 (range 0-4) using the visual analogue scale was observed. The American Orthopaedic Foot and Ankle Society score significantly improved from 33.1 ± 14.2 (range 10-60) to 78.0 ± 10.5 (range 55-95).

Advancements in total ankle arthroplasty (TAA) over the past several decades have led to improved patient outcomes and implant survivorship. Despite these innovations, many implant manufacturers still consider a preoperative coronal plane deformity greater than 10° a relative contraindication to TAA. Without proper intraoperative alignment, these implants may experience abnormal wear and hardware failure. Correcting these deformities, often through the use of soft tissue procedures and/or osteotomies, not only increases the difficulty of a case, but also the intraoperative time and radiation exposure. The authors report a case in which a 54-year-old man with a severe right ankle varus deformity of 29° underwent successful TAA using the INBONE II Prophecy total ankle system (Wright Medical Technology, Inc, Memphis, Tennessee) and additional soft tissue reconstruction. Intraoperatively, the patient's coronal deformity was corrected to 1.8°. At 8 months postoperatively, the patient ambulated without restriction and had substantial improvement in validated patient outcome scores, specifically the Academy of Orthopaedic Surgeons Foot and Ankle Module and the Short Form Health Survey-12 This unique report documents the first time that this particular implant, with an exclusive preoperative computed tomography-derived patient-specific guide, has been used effectively for a severe preoperative varus deformity greater than 20° without the need for an osteotomy. Future studies should be directed toward the prospective evaluation of different total ankle implant systems and their outcomes with severe coronal plane deformity, specifically computed tomography-derived patient-specific guided implants., (Copyright 2015, SLACK Incorporated.)

Clubfoot, talipes equino varus (TEV), is a common congenital foot anomaly. Some cases are resistant to conservative treatment. Many causes of resistance have been reported, among these, the presence of anomalous muscles; however, the effect of the presence of anomalous muscles on the outcome of conservative management is not well studied. These aberrant muscles are discovered during the extensive surgical release as an abnormal finding. The aim of this work is to study the demographic characteristics of patients with resistant TEV that necessitated extensive soft tissue release at Sudan Clubfoot Clinic and to document the prevalence of flexor digitorum accessorius longus (FDAL) muscle in a large series of clubfoot patients treated by extensive surgery: posteromedial release. Also, we introduce a new observation as an indication by which the surgeon can predict the presence of FDAL. On the basis of an observation that there is a special posture of the big toe in extension in relation to other flexed toes associated with the presence of FDAL, records of patients of clubfoot treated by extensive surgery between 2007 and 2012 at the Sudan Clubfoot Project were reviewed. Demographic characteristics were studied. Only patients with idiopathic TEV were included. Resistant clubfeet necessitated extensive release in 261 patients, 197 males and 64 females. Their ages ranged between 1 day and 15 years at presentation. FDAL muscle was found in 48 patients (54 feet) out of 261 patients (411 feet, 13.14%). In 46 of the 48 patients (95.8%), the presence of the FDAL could be predicted by a sign. FDAL is prevalent in 13% of resistant TEV cases requiring extensive soft tissue release, and the surgeon can expect resistant clubfoot and predict the presence of the FDAL in over 95% before he operates by observing the Samir-Adam sign.

From February to March 2014, six natural villages in Zhoucheng Town, Binchuan County of Yunan Province, were randomly selected by cluster sampling. Serum anti-fascioliasis IgG was detected by ELISA. The sero-positive individuals were further tested for Fasciola infection using sediment detection with nylon bag (260 meshes) and Kato-Katz method. Among 1207 sampled persons, the sero-positive rate was 3.0% (36/1207). The rate in males and females was 2.3% (12/530) and 3.6% (24/677) (u=1.46, P>0.05). The sero-positive rate in Zhoucheng Village and Baizhuang Village was 4.0% (24/616) and 2.0% (12/591), respectively (u=2.07, P<0.05). The positive rate of stool examination in serum-positive persons was 6.5% (2/31). One stool-egg-positive patients was the case in 2012 outbreak, and the eggs were stale. The other patient was newly infected, and further clinical diagnosis indicated that it was a case of chronic fascioliasis.

Background: Diagnosis of foot deformities is frequently supported by objective measures of bony alignment made on AP and lateral weight-bearing radiographs. The EOS biplanar imaging system has the capability of simultaneously capturing orthogonal AP and lateral images of the foot during weight-bearing with reduced radiation exposure. The purpose of this study was to evaluate the validity and reproducibility of common foot and ankle radiographic measurements made on images acquired with the EOS biplanar imaging system., Methods: Fifty consecutive patients indicated for foot and ankle realignment surgeries were enrolled. Radiographic studies included conventional AP and lateral ankle weight-bearing radiographs and long-leg AP and lateral weight-bearing images acquired using the EOS system with both a staggered feet and a nonstaggered feet position. Sixteen radiographic parameters of foot, ankle, and lower limb alignment were measured by 2 blinded observers, with 1 observer repeating all measurements 6 weeks later. Inter- and intraobserver reliability was assessed using intraclass correlation coefficients. Between-group comparison was assessed using Pearson correlation coefficients, ANOVA, and paired t-tests., Results: There was no statistically significant difference in any commonly used foot and ankle radiographic parameters measured on conventional radiographs or EOS images acquired with staggered and nonstaggered feet (ANOVA P = .792 to .997 and paired t tests P = .067 to .977). However, the staggered foot position resulted in significantly different limb length measurements in the rear leg (P = .000 to .049). Intra- and interrater reliabilities of limb alignment measurements from EOS system images were excellent in both foot positions (ICC = .938 to 1.000)., Conclusion: Images acquired using EOS biplanar imaging system allowed for valid and reliable measurement of commonly used foot and ankle radiographic parameters; however, the staggered foot position required for simultaneous imaging of both feet in the lateral view affected limb length measurements in the rear leg., Level of Evidence: Level II, prospective comparative study., (© The Author(s) 2014.)

The flexor digitorum accessorius longus (FDAL), a variant leg muscle, can cause tarsal tunnel syndrome. This study was performed to classify the variants of the FDAL by dissection and to correlate the dissection results with clinical cases of tarsal tunnel syndrome caused by this muscle. Eighty lower limbs of embalmed Korean cadavers were dissected. MR images of two clinical cases of tarsal tunnel syndrome caused by the FDAL were correlated with the dissection results. The FDAL was observed in nine out of 80 specimens (11.3%) and it was classified into three types depending on its site of origin and its relationship to the posterior tibial neurovascular bundle (PTNV) in the leg. In Type I (6.3%), the FDAL originated in the leg and ran superficially along the PTNV, either not crossing (Type Ia, 3.8%) or crossing (Type Ib, 2.5%) the neurovascular bundle. In Type II (6.3%), it originated in the tarsal tunnel. Most FDALs followed a similar course in the tarsal tunnel and the plantar pedis. On correlating the MR images of the clinical cases with this classification, the FDAL corresponded to Types Ia and II. All three types of FDAL can compress the tibial nerve in the tarsal tunnel or the distal leg. Clarification of the topographical relationship between this muscle and the PTNV would help to improve the results of surgery for tarsal tunnel syndrome caused by the FDAL., (© 2014 Wiley Periodicals, Inc.)

Foot and ankle injuries are very common, particularly among young active athletic individuals. MR imaging has become one of the modalities of choice in the assessment of foot and ankle injuries. Accurate interpretation of MR images and diagnosis of pathology requires familiarity with normal anatomical variants and common diagnostic pitfalls. This article describes the common anatomical variants and technical pitfalls in MR imaging of the foot and ankle., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The anterolateral thigh flap has been used for coverage of defects in the foot and ankle for years. Conventional extended anterolateral thigh flaps do not undergo thinning procedures, which limit their application. Here, a clinical series of 24 patients is reported in which extended anterolateral thigh flaps were used for posttraumatic foot and ankle reconstruction. Of the 24 flaps, 14 were simple extended anterolateral thigh fasciocutaneous flaps and 10 were thinned extended anterolateral thigh flaps. One artery and two veins, including a superficial vein and an accompanying vein, were anastomosed to vascularize each flap. Follow-up of the 24 patients ranged from 10 months to 4 years postoperatively. All 24 flaps survived successfully, except one case that had partial flap necrosis distally due to excessive thinning. The cutaneous flap territory ranged from 250 cm(2) to 400 cm(2) (mean, 297 cm(2)). Only one patient received a debulking procedure. No ulceration occurred in any of the flaps due to contact with the shoe. The extended anterolateral thigh flap is a good alternative for extensive soft tissue defects of the foot and ankle. This study also supports the high reliability and excellent vascular supply of moderate thinned extended ALT flaps.

Background: The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence (LOE) available to support the operative technique of distraction ankle arthroplasty for the current generally accepted indications and make a grade of recommendation for each., Methods: A comprehensive review of the literature was performed (November 2010 to January 2011) using the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of distraction ankle arthroplasty. All articles were reviewed and assigned a classification (I-V) of Level of Evidence. An analysis of the literature reviewed was used to assign a Grade of Recommendation for each current generally accepted indication for distraction ankle arthroplasty., Results: There is insufficient evidence based literature (Grade I) to support or refute the procedure for either: post-traumatic ankle arthritis, arthritis associated with ligamentous instability, primary degenerative joint disease, chondrolysis, deformity associated with arthritis, osteochondral defects and congenital ankle abnormalities., Conclusion: Inadequate evidence based literature exists to support or refute all currently accepted indications for distraction ankle arthroplasty and further high quality, scientific studies are needed upgrade to these recommendations.

Considerable recent orthopedic literature is dedicated to either the surgical management of OLTs and correction of varus ankle alignment, but little is published on the combination of these 2 problems. We anticipate that future clinical and biomechanical research will address their simultaneous treatment; until then, we will continue to extrapolate from their independent management.

Objective: To study surgical strategies for ankle and foot deformities secondary to spina bifida and treatment methods for different types of deformities., Methods: From January 1990 and July 2009, 107 patients with ankle and foot deformities secondary to spina bifida were retrospectively analyzed. There were 44 males and 63 females, with an average age of 17.7 years (rangd from 1.3 to 52 years). Among the patients, 58 patients had double ankle deformities, 49 patients had unilateral deformities (22 cases on the left side, 27 cases on the right). Ninety-nine patients with equinus deformities were treated by achilles tendon lengthening and tendon transfering; 25 patients with talipes were treated by release of anterior tendon of ankle and tendon transfer; 17 patients with valgus and varus deformities were treated by tendon transfer and calcaneal osteotomy; 15 patients with flail deformities were managed treated by bone fusion between calcaneus and talus and shortening of achilles tendon; 9 patients with claw toe deformities were treated by bone fusion of interphalangeal joint or Ilizarovs distraction. AOFAS (American Orthopaedic Foot & Ankle Society) comprehensive scoring system was used to evaluate subjective pain and objective functional., Results: Seventy-nine (127 feet) of 107 patients were followed up, and the duration ranged from 48 to 180 months (averaged, 64 months). According to AOFAS scoring system, the results were rated as excellent in 89 feet, good in 26 feet, moderate in 9 feet and poor in 3 feet., Conclusion: Treatment strategies for ankle-foot deformities mainly included four principles, deformity correction, muscular balance, joint stability and reservation of foot elasticity. Different combined procedure was applied for different foot deformities and received good therapeutic effects.

A detailed clinical examination is an essential component in the assessment of the cavus foot. A complex interaction of pathologic conditions can only be assessed completely with physical examination. Imaging such as computed tomography or magnetic resonance imaging (MRI) may confound the physician, such as in anterior talofibular ligament tears on MRI while the ankle is stable or arthritic joints that are asymptomatic but abnormal on imaging. At the end of the day, the physical examination supersedes all other investigations. After investigations have been performed, the patient needs to be reviewed and the results interpreted in light of the clinical findings. At this point the examiner will be able to determine what is significant and decide on an appropriate treatment plan.

If left uncorrected, valgus ankle deformity in multiple hereditary exostoses can cause significant disability in skeletally immature children and in adults. Various management methods have been described, including hemiepiphyseal stapling, transphyseal screw placement, fibular-Achilles tenodesis, distal tibial osteotomy, and ablative epiphyseodesis. In this article, we report the cases of 3 skeletally immature children who had undergone hemiepiphyseal stapling of the medial distal tibial epiphysis for correction of valgus ankle deformity in multiple hereditary exostoses. Correction of the tibiotalar axis, in relation to chronological and bone age, was evaluated. Hemiepiphyseal stapling of the medial distal tibial epiphysis provides ipsilateral corrective potential while allowing staple removal for reversal of growth retardation. This procedure is useful in the management of ankle valgus in multiple hereditary exostoses.

Performing an arthrodesis is a common technique to treat multiple different foot deformities. Primary osteoarthritis and post-traumatic conditions are the most frequent indications. Various complications and reasons for failure can occur like non-union, nerve damage, wound healing disorders or adjacent joint degeneration. The highest fusion rates can be achieved by compression of the joint space using modern osteosynthesis material. Postoperative care needs to be adapted to intraoperative stability, quantity and location of the fused joints and the compliance of the patient. Nerve damage and wound healing problems can be avoided by subtle soft tissue preparation and intraoperative hemostasis. Degeneration of the adjacent joints is inherent to method but can be minimized by selective arthrodesis of only the affected joints.

Most of the evidence to date on the Ilizarov method in the management of complex foot and ankle deformities in children is based on expert opinion and retrospective case series. Often the technique is used as a salvage option where conventional techniques are inappropriate or have failed. The decision to use the Ilizarov external fixator to an alternative technique depends on several issues: complexity of the pathology, patient compliance, surgeon skills, and the capacity of the institution to manage patients with multidisciplinary requirements. Nevertheless, the Ilizarov method has proved to be a valuable tool for the satisfactory management of many previously unresolved clinical problems. With greater experience and further developments, the exact place of this powerful treatment modality will become clearer and even more successful., (Copyright 2010 Elsevier Inc. All rights reserved.)

Unlabelled: Flexor digitorum accessorius longus is an anatomical variant that has previously been shown to be associated with a variety of pathological conditions localized to the posteromedial aspect of the ankle and hindfoot. In particular, this anomalous muscle has been reported to be the cause of tarsal tunnel syndrome. Despite recognition of this muscular anomaly as a cause of foot and ankle pathology, the origin, course, and insertion of flexor digitorum accessorius longus has not been thoroughly illustrated in the anatomical literature. In an effort to accurately detail the anatomy of the flexor digitorum accessorius longus, we undertook a cadaveric dissection and prepared a photographic study of this anomalous skeletal muscle., Level of Clinical Evidence: 5.

Tibialis posterior dysfunction is a complex progressive condition caused primarily by injury to the tibialis posterior tendon, leading to acquired pes planus. The tibialis posterior is the most frequent ankle tendon to be injured, and the disorder commonly occurs in late middle-aged females. Degenerative, inflammatory, functional and post-traumatic aetiologies have all been proposed. Failure of the tibialis posterior tendon causes excessive load stress on the spring ligament and sinus tarsi ligaments. A wide spectrum of bony and soft-tissue abnormalities may be seen on plain radiographs, ultrasound and MRI, including malalignment, anatomical variants, and enthesopathic and tendinopathic changes. Knowledge of the anatomical and biomechanical considerations in tibialis posterior dysfunction allows the radiologist to diagnose injury to key structures and provide prognostic information that may assist with management options to prevent further flat foot deformity.

Spondylocarpotarsal synostosis syndrome (SCT) is an autosomal recessive disease that is characterized by short stature, and fusions of the vertebrae and carpal and tarsal bones. SCT results from homozygosity or compound heterozygosity for nonsense mutations in FLNB. FLNB encodes filamin B, a multifunctional cytoplasmic protein that plays a critical role in skeletal development. Protein extracts derived from cells of SCT patients with nonsense mutations in FLNB did not contain filamin B, demonstrating that SCT results from absence of filamin B. To understand the role of filamin B in skeletal development, an Flnb-/- mouse model was generated. The Flnb-/- mice were phenotypically similar to individuals with SCT as they exhibited short stature and similar skeletal abnormalities. Newborn Flnb-/- mice had fusions between the neural arches of the vertebrae in the cervical and thoracic spine. At postnatal day 60, the vertebral fusions were more widespread and involved the vertebral bodies as well as the neural arches. In addition, fusions were seen in sternum and carpal bones. Analysis of the Flnb-/- mice phenotype showed that an absence of filamin B causes progressive vertebral fusions, which is contrary to the previous hypothesis that SCT results from failure of normal spinal segmentation. These findings suggest that spinal segmentation can occur normally in the absence of filamin B, but the protein is required for maintenance of intervertebral, carpal and sternal joints, and the joint fusion process commences antenatally.

A 35-year-old woman presented with bilateral leg pain on walking that had been present since childhood. Clinical examination showed bilateral absence of the tibialis anterior tendons and the left extensor hallucis longus tendon. Magnetic resonance imaging revealed that signal intensities in the location of the tibialis anterior muscles bilaterally and the left extensor hallucis longus muscle were uniformly high on T1-weighted images, consistent with fat tissue and aplastic muscles: findings not previously reported.

The solitary osteochondroma, a common pediatric bone tumor, is a cartilage-capped exostosis. Hereditary multiple exostosis is an autosomal dominant disorder manifested by the presence of multiple osteochondromas. Linkage analysis has implicated mutations in the EXT gene family, resulting in an error in the regulation of normal chondrocyte proliferation and maturation that leads to abnormal bone growth. Although exostoses are benign lesions, they are often associated with characteristic progressive skeletal deformities and may cause clinical symptoms. The most common deformities include short stature, limb-length discrepancies, valgus deformities of the knee and ankle, asymmetry of the pectoral and pelvic girdles, bowing of the radius with ulnar deviation of the wrist, and subluxation of the radiocapitellar joint. For certain deformities, surgery can prevent progression and provide correction. Patients with hereditary multiple exostosis have a slight risk of sarcomatous transformation of the cartilaginous portion of the exostosis.

Cranio-osteoarthropathy is a rare condition. Classically, signs are identifiable in infancy with clubbing of fingers, and delayed closure of the clinically enlarged cranial sutures, followed by periosteal new bone formation on X-rays of the long bones. Ultimately, joint swelling and stiffness follow, typically involving the large joints. We report two unrelated patients with features of cranio-osteoarthropathy, both of whom also had a history of congenital heart disease. Moreover, the cases reported here, manifesting significant differences in radiological features, emphasize the variability of radiological findings which can attend this condition.

Supramalleolar osteotomy is an effective surgical strategy to treat malunion, arthrosis, and congenital deformities about the ankle. Strict adherence to the principles of deformity correction provides reliable limb realignment and redistribution of joint forces without the introduction of secondary deformities. Clinical outcomes support the role of osteotomy as an effective joint preservation procedure with few complications.

We present the clinical and radiographic findings in a mother and son with a dominantly inherited mesomelic skeletal dysplasia almost identical to that described in a large Thai family by Kantaputra et al., in which ankle, carpal and tarsal synostoses were noted. The proband in the family is a 48-year-old woman with mesomelic limb shortening, most pronounced in the upper limbs. Her parents were of normal stature and build. Her 15-year-old son has similar mesomelic limb shortening, and in addition talipes equinovarus. Radiological examination showed severe shortening of the radius and ulna with bowing of the radius and dislocation of the radial head. Multiple carpal and tarsal synostoses were present and in addition, the talus and calcaneum were fused. In the original Thai family, linkage to chromosome 2q24-q32, which contains the HOXD cluster has been reported, and it is postulated that the phenotype may result from a disturbance of regulation of the HOXD cluster. Although linkage analysis was not possible in our family, molecular analysis was undertaken and HOXD11 was sequenced, however, no mutations were detected. This is only the second reported family affected with Kantaputra mesomelic dysplasia (MIM 156232), a distinct mesomelic skeletal dysplasia., (Copyright 2004 Wiley-Liss, Inc.)

A newborn girl with hemorrhagic purpura, suspected neonatal sepsis, and pale and dry skin was lethargic with remarkable hepatosplenomegaly, convergent strabismus, severe anemia, and elevated alkaline phosphatase activity. Radiographs showed a generalized increase in bone density, small medullary cavities, sclerosis of the skull and vertebrae, transverse wavy stripes of sclerotic bone in the metaphyses, and bone-in-bone appearance in phalanges of hands and feet. On this basis, she was diagnosed with malignant infantile osteopetrosis. On the first day of life, the infant was given a blood transfusion and vitamin K (1 mg intravenously [iv]). Corticosteroid therapy was started with prednisone (2 mg/kg per day). She showed marked improvement of symptoms. On the 26th day and 42nd day of life, she received additional blood transfusions. On the 49th day, the patient was discharged and corticosteroid therapy was continued at a regimen of 5 mg/day. Subsequent blood sample analyses revealed normal values for age. At 1 year of life, a bone marrow sample showed normal white and red cell lineages. X-ray confirmed attenuation of the bone sclerosis; therefore, bone marrow transplantation (BMT) was not implemented. At the age of 1.5 years, prednisone therapy was discontinued gradually and withdrawn before the age of 2 years. Subsequent follow-up showed normalization of all radiological and hematologic parameters. At present, the patient is 3 years old and appears healthy with apparently complete regression of the disease.

MR imaging plays a valuable role in the evaluation of foot and ankle in infants and children. In young children with nonossified bones, MR imaging offers the advantage of effectively demonstrating the cartilaginous anlage in addition to soft tissue and bone marrow. The MR imaging examination is tailored to the clinical question, the child's age, foot size, and ability to cooperate. This article reviews the MR imaging of a number of familiar and uncommon disorders of the pediatric foot and ankle.