Journal of Foot and Ankle Surgery (Asia Pacific)

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2023 | January-March | Volume 10 | Issue 1

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Siddhartha Sharma

New Horizons in Foot and Ankle Surgery Research: Are We Losing Sight of the Shore?

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:1] [Pages No:197 - 197]

   DOI: 10.5005/jp-journals-10040-1283  |  Open Access |  How to cite  | 



Karina Mirochnik, Nour Nassour, Joris RH Hendriks, Noopur Ranganathan, Andreea Lucaciu, Gregory R Waryasz

Is There a Correlation Between the Driving Distance to Healthcare Facilities and Postoperative Complications After Achilles Tendon Rupture Surgical Repair? A Geospatial Study

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:6] [Pages No:198 - 203]

Keywords: Geographic distribution, Geographic information system, Healthcare accessibility, Healthcare equity, Social determinants of health

   DOI: 10.5005/jp-journals-10040-1277  |  Open Access |  How to cite  | 


Background: Geospatial access to healthcare is defined as the ability of patients to obtain healthcare services based on their locations. Therefore, we aimed to investigate patients’ proximity to healthcare and its correlation with the complications of surgically treated Achilles tendon rupture (ATR) including venous thromboembolism (VTE), rerupture, and wound problems. Methods: We included 426 patients who lived in the United States (US) Tri-State Area with surgically treated for ATR. We used patient and hospital addresses and zip codes to calculate the distances to healthcare centers. The Shapiro–Wilk test was used to determine normal distribution. Mann–Whitney U test was used to compare the groups with and without complication. The point biserial correlation test was used to determine any correlations between driving distance and the incidence of complications (p < 0.05 was considered significant). Results: The average driving distance to the patient’s specific healthcare center was 62.16 ± 76.54 km. There was no significant difference between the distances for patients with and without overall complications (p = 0.65), with and without VTE (p = 0.70), with and without rerupture (p = 0.84), and with and without wound problems (p = 0.36). No correlation between complications and the distance to healthcare centers was found (p = 0.65). Conclusion: Geospatial information is important within the context of healthcare accessibility and can provide crucial guidance to healthcare planning for patients and healthcare policymakers. Although this study showed that driving distance to healthcare facilities did not lead to significantly higher complication rates amongst ATR patients, it does not resolve the need for further studies looking at a larger population and wider geographical segments.



The Incidence of and Demographic Disparities Among Fifth Metatarsal Fracture Nonunions

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:5] [Pages No:204 - 208]

Keywords: Fifth metatarsal, Metatarsal fracture, Nonunion

   DOI: 10.5005/jp-journals-10040-1275  |  Open Access |  How to cite  | 


Aim: This study aimed to assess the incidence and demographics of fifth metatarsal (5MT) fractures, as well as the association of these factors with nonunion rates. Materials and methods: A total of 1,000 adult patients with confirmed 5MT fractures were recruited retrospectively. Patients were screened for union vs nonunion, where nonunion was defined as failure to heal completely within 180 days of fracture diagnosis. Inclusion criteria were: (1) age of ≥ 18-year-old and (2) confirmation of 5MT fracture by experts based on examination and radiograph. Exclusion criteria were: (1) missing data on final healing status, (2) presence of another traumatic injury to the foot during the healing process of the primary 5MT fracture, (3) lack of radiologic proof of healing or nonhealing, and (4) missing demographic data or relevant clinical or operative notes. Data on demographics, fracture characteristics, and treatment methods (conservative vs operative) were also collected. One-way analysis of variance (ANOVA) and Chi-square analysis was used, and p < 0.05 was considered statistically significant. Results: The overall nonunion rate was 22.4%, with zone 2 demonstrating the highest nonunion rate (28.1%). Weight and body mass index (BMI) were correlated with a higher nonunion rate (p = 0.002 and p = 0.012, respectively). Type of treatment (operative vs conservative) and displacement were not correlated with nonunion; however, stratification by both types of treatment and displacement revealed a difference in nonunion between the three fracture zones. Clinical significance: 5MT fracture nonunion remains a prevalent problem. The association between nonunion and weight, BMI, and fracture characteristics can be used by clinicians in the decision-making process regarding treatment and management of 5MT fractures to reduce the incidence of nonunion, improve patient-reported outcomes, and reduce the healthcare burden.



Hirotaka Nakagawa, Gregory R Waryasz, Alberto Panero, Walter I Sussman

Application of Amniotic Membrane Allograft in the Treatment of Foot and Ankle Pathologies: A Review of the Basic Science and Clinical Evidence

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:7] [Pages No:209 - 215]

Keywords: Amniotic graft, Amniotic membrane, Amniotic mesenchymal stem cells, Achilles tendonitis, Nerve wrap, Osteoarthritis, Plantar fasciitis

   DOI: 10.5005/jp-journals-10040-1274  |  Open Access |  How to cite  | 


Background: In recent years, an increasing number of studies have investigated the use of AM for various orthopedic indications. AM allografts’ anti-inflammatory and anti-scarring properties make them a promising agent used to augment the healing of pathological soft tissue. Purpose: The purpose of this study is to review the published studies on the use of amniotic membrane (AM)-derived allografts in human subjects for various indications in the foot and ankle. Results: Studies suggest that when it is used for the treatment of plantar fasciitis, the efficacy of AM-derived products is at least equivocal to corticosteroid injections in the short term and superior to placebo injection in the long term. Fewer studies have investigated the application of AM-derived products in Achilles tendinitis, ankle and foot osteoarthritis (OA), or peripheral nerve pathology. Conclusion: Additional high-quality supportive data is needed to support the efficacy and safety of AM-derived products in the foot and ankle. Furthermore, clinicians should be aware of the regulatory status of any AM-derived product before its use in clinical practice.



Andreea Lucaciu, Joris RH Hendriks, Riley Baker, Nour Nassour

Unmonitored Patient Demographic Data Changes can Lead to Bias in Reported Outcomes and Data Registry Development

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:2] [Pages No:216 - 217]

Keywords: Clinical data, Data registry, SDOH, Social determinants of health

   DOI: 10.5005/jp-journals-10040-1273  |  Open Access |  How to cite  | 



Alireza Ebrahimi

Customer Discovery is Necessary for the Development of Artificial Intelligence-based Solutions in Orthopedic Surgery

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:2] [Pages No:218 - 219]

Keywords: Artificial, Customer, Discovery, Intelligence

   DOI: 10.5005/jp-journals-10040-1266  |  Open Access |  How to cite  | 


The applications of artificial intelligence (AI) in both clinical practice and biomedical research have been expanding remarkably during the past few decades. Although billions of dollars have been spent on AI technologies, human is still dealing with the hype of AI and have relatively failed to realize the real uses of this technology and utilize it in the most cost-effective pathway. Customer discovery helps developers make hypotheses about potential customers, update and change their value propositions, find possible revenue streams, and make a draft of their business plan.



Padam Singh Bhandari, Vaishali Srivastava

Medial Plantar Artery Flap for Heel Reconstruction: A 22-year Follow-up

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:4] [Pages No:220 - 223]

Keywords: Foot ulcer, Heel defect, Heel pad, Medial planter artery, Posterior heel defect, Surgical technique

   DOI: 10.5005/jp-journals-10040-1257  |  Open Access |  How to cite  | 


Introduction: Heel reconstruction is a surgical challenge because of unique nature of its tissue. The instep flap based on the medial plantar artery neurovascular bundle provides a sensate flap with tissue similar to that of the heel. Materials and methods: The study includes 29 patients with soft tissue defects of the heel who presented between 1998 and 2021. Medial plantar artery flap was done to cover the defect. The patients were followed up for sensations and any ulceration in the flap for a maximum period of 22 years. Results: Twenty-nine patients with soft tissue defects of the heel underwent medial plantar artery flap and were included in the study. Eleven patients continued their follow-up for 22 years. All except one flap survived and did not develop any ulceration in long-term follow-up also. Protective sensations were present in the flap in patients who had normal sensations in the foot before surgery. Results were inferior in patients who had decreased sensations in the sole before surgery such as diabetics and postspinal injury patients. Conclusion: Medial plantar artery flap is a robust and reliable option for heel reconstruction even in long-term follow-up. Clinical significance: Medial plantar artery flap can be safely opted for heel reconstruction and satisfactory results can be expected even after 20 years.



Abhijit Bandyopadhyay, Sanjay Kumar

Different Measurement Methods of Heel Pad Thickness and their Clinical Implications: A Narrative Review

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:5] [Pages No:224 - 228]

Keywords: Complications, Diagnosis, Heel pad thickness, Magnetic resonance imaging, Ultrasonography

   DOI: 10.5005/jp-journals-10040-1246  |  Open Access |  How to cite  | 


Introduction: The heel pad has an important role in pain-free locomotion due to its shock-attenuation function. Various diagnostic techniques are available to measure heel pad thickness. However, each measurement method makes a different clinical impact on heel pad thickness. Aim of the study: The current study will be aimed to evaluate the clinical impact of different measurement methods on heel pad thickness. Methodology: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be used for conducting this systematic review and meta-analysis. Literature searches will be carried out on the following databases, such as Cochrane, Google Scholar, PubMed, EMBASE, and Medline databases with the appropriate key terms. Relevant articles will be chosen for full-text screening after the application of the eligibility criteria. Meta-analysis will be performed using Review Manager 5.3 software. Observations and analysis: The current systematic review and meta-analysis will include all the published studies regarding the impact of different measurement methods on heel pad thickness. Finally, the review will summarize and analyze the results of the included studies to find out the most frequently used measurement methods and their clinical impact. Discussion: Increased heel pad thickness, commonly known as the heel pad sign, is characterized by an increase in the soft tissue thickness of the heel pad on lateral ankle radiographs in a variety of circumstances (Rogers et al., 2022; Morales-Orcajo et al., 2018). Studies on heel pad thickness using nonweight-bearing radiographs have indicated atrophy of the heel pad in elderly, sedentary subjects, while a recent study has demonstrated that ultrasonic heel pad thickness was significantly greater in patients suffering from unilateral displaced intra-articular fractures of the calcaneum at 21–35 months after injury (Lin et al., 2022; Taş, 2018). Conclusion: Different methods like photography, radiography, ultrasonography, and magnetic resonance imaging (MRI) have been used for the measurement of thickness of heel pad. However, ultrasonography and radiographic methods have found the maximum use in clinical applications for individuals with or without health issues. Hence, although the most widely used method is ultrasound due to its safety and efficacy, this is dependent on the requirement and availability of the choice of these methods which may vary.



Staged Reconstruction of Post-traumatic Medial Malleolus Bone Defects Using Fibular Head Osteochondral Graft: A Report of Two Cases

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:5] [Pages No:229 - 233]

Keywords: Ankle defect, Ankle reconstruction, Bone graft, Complex ankle fracture, Fibular head osteochondral graft, Medial malleolus fracture, Medial malleolus reconstruction

   DOI: 10.5005/jp-journals-10040-1244  |  Open Access |  How to cite  | 


Aim: The aim of this study was to report a novel technique for reconstruction of post-traumatic medial malleolar bone defects, by the use of fibular head osteochondral grafting. Background: Severe open ankle injuries involving loss of bone and soft tissue are challenging entities to treat. There are very few reports in literature on reconstruction of post-traumatic medial malleolar bone loss, and they predominantly describe the use of a composite vascularized pedicle-based flap. Case description: We report two cases of post-traumatic medial malleolar fractures with bone and soft tissue loss, and ankle instability, managed by staged anatomic reconstruction using autologous ipsilateral fibular head osteochondral grafts without a composite vascular pedicle-based flap, following primary soft tissue reconstruction and ankle-spanning external fixation. At 2 years’ follow-up, both patients had good functional outcomes with a stable, painless ankle joint and were able to ambulate unaided. They had no donor site morbidity. Both patients had nearly normal plantar flexion, while one had restriction of dorsiflexion. Radiographs showed bony union and graft incorporation with no signs of graft resorption or secondary ankle arthritis. Conclusion: The use of fibular head osteochondral grafts for reconstruction of medial malleolar bone loss is a simpler alternative to microsurgical osseous reconstruction using vascular pedicle-based composite flaps in the management of complex ankle injuries with medial malleolar bone loss, and yields good mid-term results. Clinical significance: Fibular head osteochondral grafting of medial malleolar bone defects could be a useful tool in the armamentarium of the trauma surgeon, especially at smaller trauma care centers, where access to infrastructure or a surgeon skilled and experienced in performing vascularized grafts is limited.



Jeremy Bliss, Sandeep Albert, Manasseh Nithyananth

Lisfranc Fracture Dislocation: A Review

[Year:2023] [Month:January-March] [Volume:10] [Number:1] [Pages:8] [Pages No:234 - 241]

Keywords: Diagnosis, Fixation, Lisfranc fracture dislocation, Lisfranc injury, Literature review, Review, Treatment

   DOI: 10.5005/jp-journals-10040-1236  |  Open Access |  How to cite  | 


Introduction: Lisfranc joint is the articulation between midfoot and forefoot which is composed of the five tarsometatarsal joints, named after Jacques Lisfranc de Saint-Martin who was a field surgeon in Napoleon’s army. Epidemiology and background: Lisfranc injuries constitute approximately 0.2% of all fractures. Although rare, they can be missed by the treating orthopedic surgeon, since present literature knowledge reveals that 20% of these injuries are missed or diagnosed late. As the consequences of missing such injuries are debilitating for the patients who end up with serious disability. Diagnosis: To make accurate diagnosis, strong background knowledge of the anatomy of the Lisfranc joint is mandatory. Plain and stress radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) are augments to proper history taking and clinical examination and help in diagnosis especially in subtle unstable injuries. Treatment: Stable injuries are treated nonoperatively. Unstable injuries are treated surgically; here, anatomical reduction and stable fixation is the standard of care. If closed reduction is unsatisfactory, open reduction should be performed. There are many modalities of fixation available, however, final outcome depends on early diagnosis, achieving anatomic reduction and maintaining it, irrespective of the method of reduction or the mode of fixation. Complications: The common complications include osteoarthritis, persistent pain and gait abnormalities, implant-related problems, and skin problems.


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