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The patient acceptable symptom state (PASS) represents the threshold beyond which patients are satisfied with their outcome. This study aimed to define PASS thresholds for progressive collapsing foot deformity (PCFD) reconstruction using Patient-Reported Outcomes Measurement Information System (PROMIS) scores and anchor question responses. This retrospective study consisted of 109 patients who underwent flexible PCFD reconstruction, had preoperative and 2-year postoperative PROMIS scores, and 2-year postoperative anchor question responses. ROC curve analyses were performed to quantify PASS thresholds. PASS thresholds for the PROMIS Physical Function (PF) and Pain Interference (PI) domains were found to be lower and higher, respectively, than population norms. Furthermore, patients with higher preoperative PROMIS PF scores or lower preoperative PROMIS PI scores had a significantly higher likelihood of achieving the PASS thresholds. In addition to guiding future outcomes research, these results may help surgeons optimize treatment for PCFD and better manage patient expectations. III, retrospective cohort study [ABSTRACT FROM AUTHOR]

Talocalcaneal coalitions (TCC) is the second most frequent tarsal coalition reported. Our aim was to review talocalcaneal coalition classifications and to propose a new classification emphasizing a therapeutic approach. None of the classifications described for TCC mention the presence of flatfoot or valgus hindfoot, which are the key elements when defining the optimal treatment of this disease. We defined five clinical and radiological factors that would guide the choice of surgical treatment and based on these, we proposed a new classification system. [ABSTRACT FROM AUTHOR]

In progressive collapsing foot deformity (PCFD), the goal of surgery is to obtain a well-balanced plantigrade foot. It remains unclear if restoration of the alignment and subsequent improvement in radiological parameters is associated with improved patient-reported outcome measures (PROMs). The aim of the current systematic review was to investigate whether there is a correlation between radiographic assessment and PROMs in patients treated surgically for flexible PCFD. The study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A comprehensive literature search was performed in Pubmed, EMBASE, Cochrane Central Register of Controlled Trails (CENTRAL), and KINAHL. We included all the studies reporting both PROMs and radiological outcomes in patients treated surgically for PCFD. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. Six retrospective studies were included. Radiological parameters related to forefoot plantarflexion were associated with statistically significant differences in postoperative PROMs. A neutral hindfoot and midfoot position was positively correlated with postoperative PROMs but a statistically significant difference could not be established in all studies. The medial arch height was positively correlated with PROMs, but in one study this was the case only in revision surgeries. The literature so far suggests restoration of the alignment may be associated with improved PROMs. Future prospective studies that investigate possible radiological and clinical correlations in PCFD surgery are needed. III. [ABSTRACT FROM AUTHOR]

Peripheral nerve blocks may be essential elements in a multimodal pain management regime following foot and ankle surgery. We assessed the effects of ankle blocks compared with no intervention/sham block or a sciatic nerve block in patients undergoing surgery of the foot or ankle. We searched CENTRAL, Medline, and Embase for randomised clinical trials comparing ankle block with no intervention/sham block or a sciatic nerve block for patients undergoing surgery of the foot or ankle. Our primary outcomes were duration of analgesia and cumulative 24-hour opioid consumption. We followed the recommendations of the Cochrane Handbook, and performed meta-analysis, Trial Sequential Analysis (TSA), and assessed the risk of bias and certainty of the evidence using the GRADE approach. We included five trials (362 participants) comparing ankle block with no intervention/sham block and three trials (247 participants) comparing ankle block with a sciatic nerve block. Ankle block may increase the duration of analgesia when compared with no intervention/sham block (MD 431 min; 96.7% CI 208 to 654), but the evidence was very uncertain. Duration was decreased when compared with a sciatic nerve block (MD −410 min; 96.7% CI −462 to −358). The ankle block duration was probably important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain in both comparisons. Ankle block may increase the duration of analgesia when compared with no intervention/sham block, but the evidence was very uncertain, and decrease the duration of analgesia when compared with a sciatic nerve block. The ankle block duration was probably clinically important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain. [ABSTRACT FROM AUTHOR]

Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0–3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. IV. [ABSTRACT FROM AUTHOR]

Introduction: Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge. Methods: This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score. Results: Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002). Conclusion: This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies. [ABSTRACT FROM AUTHOR]

Minimally invasive surgical (MIS) osteotomies are increasing as a surgical option for treating midfoot and forefoot conditions. This study aimed to evaluate the impact of each burr pass on the degree of correction, gap size, and alignment in MIS Akin and first metatarsal dorsiflexion osteotomies (DFO). MIS Akin and first metatarsal DFO were performed on ten cadaveric specimens. Fluoroscopic measurements included the metatarsal dorsiflexion angle (MDA), dorsal cortical length (MDCL), first phalangeal medial cortical length (PCML) and proximal to distal phalangeal articular angle (PDPAA). The average decrease in PCML with each burr pass was as follows: 1.53, 1.33, 1.27, 1.23 and 1.13 mm at the 1st to 5th pass, respectively. The MDCL sequentially decreased by 1.80, 1.59, 1.35, 0.75, and 0.60 mm. The MDA consistently decreased, and the PDPAA incrementally became more valgus oriented. On average, a first metatarsal dorsal wedge resection of 4.7 mm and first phalangeal medial wedge resection of 2.9 mm was achieved after 3 and 2 burr passes, respectively. This data may aid surgeons determine the optimal number of burr passes required to achieve the desired patient-specific surgical correction. [ABSTRACT FROM AUTHOR]

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery. A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included. Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies. Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations. Level IV: Scoping review of Level II-IV studies [ABSTRACT FROM AUTHOR]

Older patients with lower limb amputation, categorised as having "limited community mobility", are under-researched. Understanding their experience with a new prosthetic ankle-foot is important when designing clinical trials. The aim of this qualitative study was to explore the adjustments they made after amputation and the acceptability of a self-aligning ankle-foot (SA-AF) to older adults. Fourteen participants, who took part in the STEPFORWARD randomised controlled feasibility trial (ISRCTN15043643), were purposively recruited; nine were intervention participants and five were standard care participants. They were asked to reflect on their life prior to and consider the adjustments they made following their amputation. Participants in the intervention group were also asked about their views of the new SA-AF compared to their standard non-SA-AF. A thematic analysis was undertaken. Three broad themes were identified: The impact of the amputation; Role of clinical support; and Experiences of the SA-AF. The findings tell a narrative of the long-term impact that amputation has on these individuals' lives. Participants randomised to receive the SA-AF were very positive about it, reporting less pain, greater mobility and being able to do more. Participants who used the SA-AF found it an acceptable intervention. These findings suggest that a full-scale RCT is warranted. There is a high degree of acceptability among an older patient group with a transtibial amputation to use a self-aligning ankle foot. Patients reported experiencing better mobility and more prosthetic comfort with the self-aligning ankle-foot. Key outcomes important to participants include engagement in social and daily activities and balance confidence. [ABSTRACT FROM AUTHOR]

This systematic review and meta‐analysis evaluate the impact of ultrasound‐guided subsheath versus extrasheath sciatic nerve blocks on postoperative wound pain in tibial and foot surgeries, crucial for effective pain management and patient recovery. Adhering to PRISMA guidelines, this study used a PICO framework, focusing on patients undergoing tibial and foot surgeries and comparing the efficacy and safety of subsheath and extrasheath sciatic nerve blocks. The literature search spanned four databases without time restrictions, assessing various outcomes like success rate, onset time, duration of analgesia and complication rates. Quality assessment employed the Cochrane Collaboration's risk of bias tool, and statistical analyses included heterogeneity assessment, fixed‐effect and random‐effects models, sensitivity analysis and publication bias evaluation using funnel plots and Egger's linear regression test. From an initial pool of 1213 articles, six met the inclusion criteria. The subsheath group showed a significantly higher success rate of complete sensory blockade within 30 min compared with the extrasheath group (OR = 5.39; 95% CI: 2.82–10.28; p < 0.01). No significant differences were found in procedure duration or incidence of nerve‐related complications between the two techniques. The subsheath approach also demonstrated a quicker onset time of sensory blockade (MD = −8.57; 95% CI: −11.27 to −5.88; p < 0.01). Sensitivity analysis confirmed the stability of the results, and no significant publication bias was detected. Ultrasound‐guided subsheath sciatic nerve blocks are more effective than extrasheath blocks in achieving rapid and complete sensory blockade for tibial and foot surgeries, with a quicker onset time and comparable safety profile. Subsheath injections are thus recommended as a preferred method for anaesthesia and postoperative pain management in these surgical procedures, enhancing overall patient outcomes. [ABSTRACT FROM AUTHOR]

Background: In foot and ankle surgery, adequate surgical exposure often requires multiple incisions to be used near one another, thus creating a skin bridge. As the skin bridge becomes narrower, the wound edge vitality is potentially compromised and therefore the wound's ability to heal. The impact of local, host, and surgical factors on wound healing are well documented in the literature; however, little is known about the role of the skin bridge. The aim of this study is to determine if there is a recommendable safe skin bridge in elective foot and ankle surgery. Methods: A prospective study was performed on 56 patients with 60 feet who had elective foot surgery. The length of each incision and distance between the incisions were recorded. The wounds were assessed for complications at 2, 4, and 6 weeks after surgery. Patient demographics and host risk factors were documented. Results: The average incision length was 5.5 (range: 3-8.5) cm. The average skin bridge was 3.9 (range: 2-6.8) cm. Five (8.3%) of the 60 feet developed a wound complication. Four (80%) of these patients had a known comorbidity. Two patients had diabetes and 2 were smokers. The incidence of relevant comorbidities was 5.5% (n = 3) for patients without a wound complication (P < .001). Age did not differ significantly between patients with and without a wound complication. Patients with a wound complication had significantly longer incision lengths (P = .047). There was no significant independent association between skin bridge width and risk of wound complications (P > .05) with skin bridge widths of 2 cm or larger. Conclusion: In this relatively small cohort of 60 elective operative foot surgeries, we did not find increased wound complications in skin bridges 2 cm or larger, when meticulous surgical technique is practiced and host risk factors are optimized. [ABSTRACT FROM AUTHOR]

Background: Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established. Methods: Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function. Results: The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary. Conclusion: Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process. [ABSTRACT FROM AUTHOR]

Background: Malalignment has been suggested as a predisposing factor for the development of osteochondral lesions of the talus (OLTs). Purpose: To evaluate the clinical and radiographic outcomes of realignment surgery in patients with a large cystic OLT of the talar shoulder and concurrent malalignment of the foot and ankle. Study Design: Case series; Level of evidence, 4. Methods: The authors reviewed consecutive patients with large cystic OLTs (diameter, >10 mm) of the talar shoulder and concurrent malalignment of the foot and ankle who underwent realignment surgery between September 2013 and April 2021. The type of realignment procedure was determined based on patient symptoms and findings on plain radiographs and weightbearing computed tomography. Clinical improvement was assessed using pre- and postoperative Foot Function Index (FFI) scores and the visual analog scale (VAS) for pain. The OLT location was categorized according to Raikin zone, and the OLT area and volume were measured and compared pre- and postoperatively. The comparative analysis was performed using the Wilcoxon signed-rank test. Results: In total, 27 ankles in 27 patients (mean age, 34.4 ± 11.9 years) were included in the analysis. There were 25 patients with a medial lesion (zone 4 [n = 19], zone 7 [n = 5], and zone 1 [n = 1]), and 2 patients with a lateral lesion (zone 6). Despite OLT location, patients’ symptoms varied; 15 (55.6%) patients reported both medial- and lateral-sided pain, 10 (37%) reported lateral-sided pain, and 2 (7%) reported medial-sided pain. Supramalleolar osteotomy was performed in 18 patients, while foot and hindfoot correction without supramalleolar osteotomy was performed in 9 patients. Postoperatively, both the median FFI (from 44.4 [interquartile range (IQR), 35.7-52.2] to 9.1 [IQR, 5.2-13.9]) and median VAS pain score (from 6 [IQR, 5-6] to 1 [IQR, 1-2]) improved significantly (P < .0001 for both), and the median lesion size (from 25.8 mm² [IQR, 19.3-45.2 mm²] to 13.8 mm² [IQR, 6.8-26.5 mm²]) and median volume (from 2226.8 mm³ [IQR, 1311-3104 mm³] to 1326.5 mm³ [IQR, 714-2100 mm³]) decreased significantly (P < .0001 for both). During the mean follow-up of 4.1 ± 2.1 years, no subsequent surgery for OLT was necessary. Conclusion: The results suggest that realignment procedures can improve the symptoms and radiographic profile of OLTs in patients with large cystic OLTs of the talar shoulder and malalignment of the foot and ankle. [ABSTRACT FROM AUTHOR]

Abstract Background Complex regional pain syndrome type I is a pathological condition characterized by an exaggerated response of tissues to low or moderate pain stimuli. The exact pathogenesis and optimal medical treatment for complex regional pain syndrome type I are still not fully understood, although bisphosphonates have shown positive effects in reducing pain. Foot surgery can be complicated by the development of complex regional pain syndrome type I, leading to functional decline and difficulties in weight-bearing. Case presentation The authors present a clinical case involving complex regional pain syndrome type I that developed after surgical foot arthrodesis. The patient, a 42-year-old Caucasian male, did not respond to clodronate treatment but experienced successful outcomes upon the addition of teriparatide, which effectively stimulated the healing of arthrodesis. Conclusion Teriparatide cannot be considered the primary treatment for complex regional pain syndrome due to insufficient solid clinical data. However, when complex regional pain syndrome is associated with or caused by delayed union, teriparatide can be used to address the underlying cause of complex regional pain syndrome.

Background: Complex regional pain syndrome type I is a pathological condition characterized by an exaggerated response of tissues to low or moderate pain stimuli. The exact pathogenesis and optimal medical treatment for complex regional pain syndrome type I are still not fully understood, although bisphosphonates have shown positive effects in reducing pain. Foot surgery can be complicated by the development of complex regional pain syndrome type I, leading to functional decline and difficulties in weight-bearing. Case presentation: The authors present a clinical case involving complex regional pain syndrome type I that developed after surgical foot arthrodesis. The patient, a 42-year-old Caucasian male, did not respond to clodronate treatment but experienced successful outcomes upon the addition of teriparatide, which effectively stimulated the healing of arthrodesis. Conclusion: Teriparatide cannot be considered the primary treatment for complex regional pain syndrome due to insufficient solid clinical data. However, when complex regional pain syndrome is associated with or caused by delayed union, teriparatide can be used to address the underlying cause of complex regional pain syndrome. [ABSTRACT FROM AUTHOR]

Prescription opioids, particularly for treating musculoskeletal pain, are a significant contributor to the opioid epidemic in North America. There is also evidence to suggest that chronic use of opioids is associated with poor outcomes after orthopedic surgery. However, whether this association is relevant in foot and ankle surgery is still unclear. Accordingly, a systematic review of the literature was undertaken to assess the impact of preoperative opioid use in patients undergoing foot and ankle surgery concerning postoperative pain, complications, and postoperative opioid dependence. Four databases, including EMBASE, MEDLINE, PubMed, and CINAHL, were searched to March 2022 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use after foot and ankle surgery. A total of 22,092 patients were included in the final synthesis of 8 studies. Most of which were level 3 evidence (5 studies). Around 18% of the patients used opioids preoperatively. Preoperative opioid use was associated with more quantities and prolonged use of opioids postoperatively. Two studies showed an increased risk of complications postoperatively in patients who used opioids preoperatively compared to the nonopioid group. Preoperative opioid use in patients undergoing foot and ankle surgeries is associated with increased and prolonged use of opioids postoperatively and may therefore predict the potential for misuse. [ABSTRACT FROM AUTHOR]

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Purpose: We analyzed the published literature on return-to-driving (RTD) recommendations following lower extremity orthopedic surgery, including knee and hip arthroplasty and ankle and foot surgery. Methods: We conducted a PubMed MEDLINE database search for the relevant literature spanning from 1988 to 2022. Data were extracted from the selected articles independently by six investigators, and the mean, standard deviation, and range of RTD recommendations for each surgical region and procedure were calculated. Results: The 34 studies included in our review evaluated brake response time, reaction time, movement time, braking force, and other parameters. Average RTD recommendations in weeks were: hip surgeries, 4.1 (± 2.7); foot surgeries, 6.67 (± 0.94); Achilles surgeries, 6.67 (± 0.25); ankle surgeries, 4 (± 2); knee surgeries, 5.42 (± 0.77); and multiple lower extremity surgeries, 3.85 (± 0.15). Conclusion: Our findings can assist physicians in providing informed recommendations to patients, promoting safe driving practices, and optimizing postoperative recovery. Level of evidence: Therapeutic, Level III: Retrospective comparative study. [ABSTRACT FROM AUTHOR]

The present systematic review and meta‐analysis aimed to determine the prevalence of surgical site infection (SSI) and related factors in patients after foot and ankle surgery. A comprehensive, systematic search was conducted in different international electronic databases, such as Scopus, PubMed, Web of Science and Persian electronic databases such as Iranmedex and Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as 'Prevalence', 'Surgical wound infection', 'Surgical site infection' and 'Orthopaedics' from the earliest to 1 June 2023. The appraisal tool for cross‐sectional studies (AXIS tool) evaluates the quality of the included studies. A total of 10 447 patients undergoing foot and ankle surgery participated in nine studies. The pooled prevalence of SSI in patients who underwent foot and ankle surgery was reported in nine studies was 4.2% (95% CI: 2.4%–7.2%; I2 = 96.793%; p < 0.001). The odds ratio of SSI prevalence in men was higher than that of women and was significant (OR: 1.335; 95% CI: 1.106–1.612; Z = 3.009; p = 0.003). The pooled prevalence of SSI in patients with hindfoot fracture sites reported in five studies was 4.9% (95% CI: 2.6%–8.9%; I2 = 90.768%; p < 0.001). The pooled prevalence of SSI in patients with diabetes mellitus (DM) reported in six studies was 9.1% (95% CI: 5.6%–14.6%; I2 = 73.957%; p = 0.002). The pooled prevalence of SSI in patients with hypertension (HTN) reported in five studies was 5.5% (95% CI: 2.5%–11.6%; I2 = 91.346%; p < 0.001). The pooled prevalence of SSI in patients with tobacco use reported in eight studies was 6.6% (95% CI: 4.1%–10.4%; I2 = 85.379%; p < 0.001). In general, the existing differences in the prevalence of SSI after foot and ankle surgery in different studies can be based on different risk factors such as comorbidities and gender. Therefore, it is suggested to design appropriate interventions to reduce SSI in these patients. [ABSTRACT FROM AUTHOR]

Background: Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details. Results: Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA. Conclusion: This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results. [ABSTRACT FROM AUTHOR]

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group. Conclusion: We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions. [ABSTRACT FROM AUTHOR]

Background: Previous studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries. Methods: A retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications. Results: A total of 366 patients were included in this study--240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1). Conclusion: Our results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery. [ABSTRACT FROM AUTHOR]

Forefoot osteotomies to improve the alignment are difficult procedures and can lead to a variety of complications. Preoperative planning in three dimensions might assist in the successful management of forefoot deformities. The purpose of this study was to develop a global coordinate system in the foot for the planning of forefoot corrections. Two strategies (CS1 and CS2) were developed for defining a global coordinate system that meets the criteria of being well-defined, robust, highly repeatable, clinically relevant, compatible with foot CT scans, independent of the ankle joint angle, and does not include bones in the forefoot. The absolute angle of rotation was used to quantify repeatability. The anatomical planes of the coordinate systems were visually inspected by an orthopedic surgeon to evaluate the clinical relevancy. The repeatability of CS1 ranged from 0.48° to 5.86°. The definition of CS2 was fully automated and, therefore, had a perfect repeatability (0°). Clinically relevant anatomical planes were observed with CS2. In conclusion, this study presents an automated method for defining a global coordinate system in the foot according to predefined requirements for the planning of forefoot corrections. [ABSTRACT FROM AUTHOR]

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33–61.2%), 2 (7−12.9%) and 3 (14–25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of research investigating the harms associated with orthopaedic knee scooter (OKS) use and patient safety perceptions. This prospective study aimed to define the prevalence of OKS-related injuries, describe the patient perceptions of OKS safety, and identify potential risk factors. Methods: This study was conducted at a single foot and ankle fellowship-trained surgeon's community-based clinic from 6/2020 to 4/2021 and enrolled 134 patients. Our primary outcome was an OKS-related event (injury or fall) and informed an a priori power analysis. Point estimate of association magnitude was calculated as an odds ratio (OR) for statistically and clinically significant associations. Results: There were 118 (88%) patients eligible for analysis; fourteen enrolled patients did not use OKS, and two withdrew. The prevalence of patient falls was 37% (44/118), and the prevalence of patient injury was 15% (18/118). Four percent of patients would not recommend OKS and 8% would not use an OKS again. Sedentary lifestyle increased risk (OR = 4.67, 1.52–14.35 95 CI) for OKS-related injury. Conclusions: Despite a high prevalence of patient falls (37%), there is a low prevalence of injury (15%) and a favorable perception of OKS safety. Sedentary lifestyles may be a risk factor for OKS-related injury and should be considered in the development of a risk model. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to evaluate the effect of variations in bony and soft tissue foot widths on clinical and functional outcomes after hallux valgus correction with the Lapidus procedure. Methods: Forty-three feet in 35 patients with a mean follow-up of 18.5 months undergoing the LP were reviewed. Clinical and functional data were assessed with the VAS for pain, AOFAS Scale, LEFS and SF-12 health survey, which is divided into physical and mental health composite scales (PCS-12 and MCS-12). Radiographic analysis of forefoot width was based on bony and soft tissue limits. Intermetatarsal-angle and HV-angle were also assessed. Results: Bony width changed significantly from 95.5 mm to 84.2 mm (11.8%) and soft tissue width from 107.12 mm to 100.84 mm (5.86%) (p < 0.001). IMA and HVA improved significantly. Significant clinical and functional improvements were observed, except in MCS-12. In simple linear regression, correlation was found between variations of bony width with Δ-AOFAS and Δ-PCS-12, meaning that as the forefoot narrows, their values increase (p = 0.02 and p = 0.005, respectively). It was also related to Δ-IMA, meaning that the forefoot narrows as these parameters improve (p < 0.001 and p < 0.001). Soft tissue width was related to Δ-PCS-12 and Δ-AIM. In multiple linear regression, the strongest correlation was between bony width variation and Δ-IMA (p = 0.029, r2 = 0.22). Conclusion: Forefoot narrowing was correlated with improved clinical and functional outcomes, as measured by AOFAS and PCS-12. In addition, correction of the radiographic parameters, mainly IMA, reflected on a significant decrease in the forefoot width. [ABSTRACT FROM AUTHOR]

Over the last two decades, there has been a growing emphasis on the publication quality in Foot & Ankle research. A level-of-evidence rating system for clinical scientific papers has been proposed by the Centre for Evidence-based medicine in Oxford, United Kingdom. As opposed to other subspecialities, foot & ankle surgery deals with a wide variety of clinical problems and surgical solutions, which in turn leads to a generally low number of patients available for study groups. However, level III and IV studies still have a valuable place in orthopaedic research, given the challenges in running high-level studies.The measurement of outcomes in medicine from the patients' perspective (PROMS:(patient reported outcome measures) has grown almost exponentially in all surgical specialties including foot & ankle surgery. There are many PROMs available to foot & ankle surgeons, but there is little consensus on which assessment is most appropriate for a given procedure or diagnosis. Their use in research and clinical practice offers many advantages in clinical practice and research, however, besides the advantages there are also some downsides. [ABSTRACT FROM AUTHOR]

Surgical correction of hammertoe deformities with arthrodesis of the proximal interphalangeal joint (PIP) is one of the most frequent forefoot procedures. Recently, new intramedullary fixation devices for PIP arthrodesis have been introduced. The aim of this study was to compare a newly developed absorbable intramedullary implant made of magnesium (mm.PIP), an already available intramedullary implant made of titanium (PipTree), and the classical Kirschner-wire (K-wire). The three intramedullary devices (mm.PIP, PipTree, and K-wire) for PIP arthrodesis were compared. A classical arthrodesis of the PIP joint was performed on fifty-four composite synthetic bone pairs. After arthrodesis, torsional load, weight-bearing and cyclic load tests were performed, and stability of the synthetic bone pairs was analyzed. The mm.PIP was the most torsion resistant (mm.PIP vs. PipTree and K-wire, p < 0.001). The PipTree showed the best overall stability during cyclic weight-bearing simulation (PipTree vs. mm.PIP and K-wire, p < 0.001). K-wire demonstrated the highest breaking loads during bending tests (K-wire vs. mm-PIP and PipTree, p < 0.001). Biomechanical properties of two new intramedullar implants, the bioresorbable mm.PIP made of magnesium and the PipTree made of titanium, were found to be comparable to the biomechanical properties of a K-wire which is commonly used for this procedure. Future work should be directed towards a clinical assessment of the bioabsorbable fixation devices for hammertoe procedures. [ABSTRACT FROM AUTHOR]

Nonunion following foot and ankle arthrodesis can cause chronic pain and disability, poor patient satisfaction, and increased healthcare costs. Nonunion rates are reported in 10%–12% of primary foot and/or ankle arthrodesis procedures, with significantly greater rates among patients with high-risk factors such as smoking, diabetes, obesity, or Charcot neuroarthropathy. Recombinant human platelet-derived growth factor BB-homodimer with beta-tricalcium phosphate (rhPDGF-BB/β-TCP) is a bone graft substitute that has demonstrated efficacy in foot and ankle fusion rates that are comparable to autograft. Charts and radiographs were retrospectively reviewed on consecutive adult patients undergoing talonavicular, calcaneal-cuboid, subtalar, and/or ankle arthrodesis utilizing rhPDGF-BB/β-TCP bone graft substitute. The primary outcome measures were rate of and mean time to fusion, mean time to return to function, and incidence of adverse events. This study reviewed133 patients who underwent 209 hindfoot and/or ankle joint arthrodesis procedures with a mean follow-up 20.34 ± 11.05 months. The overall fusion rate was 92.82% (194/209 joints) with a mean time to fusion of 13.14 ± 2.52 weeks and return to function of 16.56 ± 3.26 weeks. Overall, there were 7 (5.26%) patients who experienced an adverse event (AE) with 15 (7.18%) joints experiencing a nonunion. Fusion rates with rhPDGF-BB/β-TCP bone grafting material compared favorably to autograft controls when used in hindfoot and/or ankle arthrodesis. No AEwas related to rhPDGF-BB/β-TCP. This study suggests that using rhPDGF-BB/β-TCP is effective in hindfoot and/or ankle arthrodesis, even among patients with comorbidities who are at a higher risk of developing a nonunion. 3. [ABSTRACT FROM AUTHOR]

Background: Since the Physician Payments Sunshine Act in 2010, a substantial body of work has explored the supplemental income received by physicians to understand trends in industry payments and investigate sources of bias. To date, no study has examined how various fellowship characteristics impact industry earning levels at foot and ankle orthopaedic surgery fellowships. The purpose of this study is to examine the various fellowship and faculty-specific variables in correlation with industry earnings in foot and ankle orthopaedic surgery fellowships. Methods: This study is a retrospective analysis of foot and ankle orthopaedic surgery fellowships and respective faculty along with various fellowship characteristics in correlation to industry lifetime earning levels as of March 2023. Industry total lifetime earnings represent income directly paid to physicians, is not part of the physician's salary, and does not include any research grants or funding. Lifetime earnings represent all years recorded on the Open Payments Database website (2015-2021). Results: There are 165 faculty physicians and 48 programs with complete data out of all foot and ankle orthopaedic surgery fellowship programs in the United States. The mean fellowship H-Index per fellowship was 48.94 ± 38.92, and the mean fellowship lifetime earning was $1 551 791.66 ± $4 136 091.64. There was no significant association between fellowship lifetime earnings and Newsweek ranking of fellowship-affiliated hospitals (P =.906), Doximity ranking of fellowship-affiliated residencies (P =.703), and region of the United States (P =.126). There was a statistically significant increase in total lifetime earnings in programs with 4 fellows as compared to 1 fellow (P =.035). Conclusion: There was no statistically significant correlation between a variety of foot and ankle fellowship-specific factors and lifetime industry earnings, aside from increased earnings in programs having 4 fellows. Prestige factors, such as Doximity and Ranked Hospital Newsweek List rank, as well as region of the United States is not associated with industry earnings. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Visual Abstract This is a visual representation of the abstract. [ABSTRACT FROM AUTHOR]

Background: Artificial intelligence (AI) platforms, such as ChatGPT, have become increasingly popular outlets for the consumption and distribution of health care–related advice. Because of a lack of regulation and oversight, the reliability of health care–related responses has become a topic of controversy in the medical community. To date, no study has explored the quality of AI-derived information as it relates to common foot and ankle pathologies. This study aims to assess the quality and educational benefit of ChatGPT responses to common foot and ankle–related questions. Methods: ChatGPT was asked a series of 5 questions, including "What is the optimal treatment for ankle arthritis?" "How should I decide on ankle arthroplasty versus ankle arthrodesis?" "Do I need surgery for Jones fracture?" "How can I prevent Charcot arthropathy?" and "Do I need to see a doctor for my ankle sprain?" Five responses (1 per each question) were included after applying the exclusion criteria. The content was graded using DISCERN (a well-validated informational analysis tool) and AIRM (a self-designed tool for exercise evaluation). Results: Health care professionals graded the ChatGPT-generated responses as bottom tier 4.5% of the time, middle tier 27.3% of the time, and top tier 68.2% of the time. Conclusion: Although ChatGPT and other related AI platforms have become a popular means for medical information distribution, the educational value of the AI-generated responses related to foot and ankle pathologies was variable. With 4.5% of responses receiving a bottom-tier rating, 27.3% of responses receiving a middle-tier rating, and 68.2% of responses receiving a top-tier rating, health care professionals should be aware of the high viewership of variable-quality content easily accessible on ChatGPT. Level of Evidence: Level III, cross sectional study. [ABSTRACT FROM AUTHOR]

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value:.005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound. [ABSTRACT FROM AUTHOR]

This article describes the outpatient nursing experience of a female athlete who underwent foot and ankle ligament reconstruction surgery. During the seven follow-up visits from May 21 to July 16, 2020, Gordon's Function Health Patterns and Brief Symptom Rating Scale (BSRS-5) were used to assess and collect data through actual care, observations, interviews, and medical record reviews. It identified the main health problems as: uncertainty and anxiety, risk for falls and risk for infections. During the care process, the author established a good therapeutic interpersonal relationship and communication skill; guided the case to explain the reasons for anxiety and provided care measures to reduce uncertainty and anxiety; taught rehabilitation principles and the use of assistive devices to prevent falls; and used nursing skills to reduce potential wound infections. This sharing of care experience will serve as a reference for similar cases in future outpatient care. (Tzu Chi Nursing Journal, 2023; 22:4, 115-124) [ABSTRACT FROM AUTHOR]

The diabetic foot ulcer (DFU) and Charcot Neuroarthropathy (CN) are serious complications of diabetes mellitus in which wound closure is complex to achieve. Treating recurrent DFU in patients with a combination of infection, ischemia, and deformities is extremely challenging and this group of patients has a very poor outcome. This case series describes the outcomes of patients with a recurrent DFU and CN, with a mean SINBAD score of 4 and of which 40% had a TCS of D3, using a multidisciplinary protocol that includes reconstructive foot and ankle surgery. In 24/35 (69%) of patients, wound closure was achieved after a mean of 75 days postoperatively. The mean ulcer‐free period was 358 days. The mean number of interventions was 6.7 (range 3–9). Post treatment 27/35 (77%) of patients was mobile, without additional amputation or ulcer recurrence. This study shows that wound closure and a long ulcer‐free period can be achieved in patients with a DFU and CN and its multifactorial underlying diseases when treated in a multidisciplinary team, including reconstructive foot and ankle surgery. [ABSTRACT FROM AUTHOR]

Background: The calcaneal dorsal closing wedge osteotomy, otherwise known as the Zadek or Keck and Kelly osteotomy, is used to treat insertional Achilles tendinopathy. The purpose of this study is to investigate the clinical outcomes affiliated with the Zadek technique for insertional Achilles tendinopathy (IAT) as reported in the literature. Methods: An English literature search on PubMed was performed yielding 8 level IV retrospective case series. Results: The weighted mean of preoperative and postoperative Victorian Institute of Sports Assessment—Achilles Questionnaire (VISA-A) scores was 52.7 and 87.8, respectively. The weighted mean of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores was 56.3 and 92.9, respectively. Majority of the reported complications were minor events, including symptomatic hardware (2.8%; n = 7/247), sural nerve paresthesia (2%; n = 5/247), and superficial infection (3.2%; n = 8/247). There was 1 reported event of hardware failure resulting in re-operation. Deep vein thrombosis occurred at a rate of 0.8% (n = 2/247), complex regional pain syndrome at 0.4% (n = 1/247) and nonunion at a rate of 1.2% (n = 3/247). Conclusion: The Zadek osteotomy is a viable option for insertional Achilles tendinopathy based on significantly improved outcome measures and minor complication rates. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were.05 and.8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P =.041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery. [ABSTRACT FROM AUTHOR]

Background: The prosthetic management of Syme's amputation is a challenge when it comes to the attachment of SACH foot. SACH foot is made up of small narrow wooden keel which is covered by soft flexible sponge rubber therefore it is difficult to attach SACH foot directly to the Syme's socket. Moreover, there is no rigid structure of the SACH foot available for bonding with the laminated socket considering the Syme's amputee. Aim: This new design of prosthetic foot provide easy attachment to the Syme's socket, thus helping in the prosthetic management of Syme's amputation. Methodology: We have developed this Syme's prosthetic foot with polyurethane rigid foam block, balata cloth, high-density Ethaflex, wooden block, and microcellular rubber. The design and dimensions of the prosthetic foot were decided such that it helps in easy attachment to the Syme's prosthesis. Results: The attachment of this new Syme's foot to the laminated socket has made the fabrication procedure of the Syme's prosthesis more easy. The amputee also should improvement in cadence and more natural gait with this design. Conclusion: The Syme's foot design provides natural gait in addition to the reduction of energy expenditure. This foot can also be used for transtibial prosthesis in addition to Syme's prosthesis. [ABSTRACT FROM AUTHOR]