Background: This study is aimed to assess differences in the pattern of practice and choice of management of end-stage ankle arthritis among established Asia-Pacific foot and ankle surgeons. Materials and methods: A survey was presented to fellowship trained foot and ankle surgeons registered with their respective national orthopedic professional societies practicing in the Asia-Pacific region. The e-mail-based survey contained eight questions and participation in the survey was entirely voluntary. A Microsoft Excel spreadsheet was used to collate the data and was subsequently analyzed using Windows-based statistical software. Multiple choice questions and visual analog scales were primarily used to gather demographic data and surgeons’ choice of managing end-stage ankle arthritis. Surgeons were also presented with open-ended questions to gather information about operation times and surgical treatment choices for a variety of clinical scenarios. Results: The response rate to the survey was 100%. The practice pattern demographics of surgeons included in the study were primarily foot and ankle-focused. There was a varied response with regards to the number of total ankle replacements (TARs) carried out in the previous 1 year at the time of the survey, with 14 (67%) had not carried out any, two (10%) had carried out one ankle replacement, two (10%) had two ankle replacements, two (10%) had three ankle replacements, and one (5%) surgeon had carried out over five ankle replacements in the previous year. About six (75%) of the surgeons who answered surgical duration reported an average time of 120 minutes to perform the operation. Around four (80%) of the surgeons who answered associated procedures had also performed a soft tissue plication and osteotomy, and one (20%) had performed a soft tissue plication only. The number of surgeons who performed zero, one, two, three, and over five ankle fusions was the same as ankle replacements. In the question asking about the levels of satisfaction when performing a TAR, most (62.5%) had a satisfaction level of 7/10. Regarding open ankle fusion, the majority (61%) of surgeons had a satisfaction level of 8/10 or more. Most surgeons (81%) had a satisfaction level of 7/10 or above when performing an arthroscopic ankle fusion. Conclusion: The prevalence of patients with end-stage ankle arthritis requiring surgery presenting to foot and ankle specialists in the region is low. Among specialists in the region, open ankle fusion remains the procedure of choice for the surgical management of end-stage ankle arthritis with the highest degree of surgeon comfort and satisfaction. Though infrequently performed, open ankle fusion, TAR, and arthroscopic ankle fusion are performed with a high degree of operator satisfaction in the minority of surgeons who do perform these procedures. Evidence in the modern literature for ankle fusions vs TAR is reflected by current practice trends in the Asia-Pacific region.

Background: Extensive anterolateral defects involving the lower leg, ankle, and proximal foot usually need the use of free flaps for optimal coverage. Usually, anterior tibial vessels are used as recipient vessels for such defects, but in situations where these vessels are not usable either because of a large zone of trauma or pre-existing scarring that may preclude the use of anterior tibial vessels without the use of a vein graft, peroneal vessels can be considered as the recipient vessel. Materials and methods: This retrospective series of six cases define the indications and the outcomes of peroneal vessels as a recipient. Results: In two of six cases, a preliminary exploration of the anterior tibial vessels revealed a non-usable situation. In the other four cases with similar clinical conditions, deliberate exploration of peroneal vessels after excising a segment of the fibula ensured the availability of a healthy recipient for a successful outcome. Discussion: In four cases, there was no morbidity on account of the fibular excision. Two developed ankle instability, but the nature of the injury was partially an attributable cause. Conclusion: The peroneal vessels need to be considered in preference to the posterior tibial as a recipient in extensive anterolateral lower third leg and foot defects crossing the ankle when the anterior tibial is in the zone of trauma or surrounded by scarring.

Aim and background: Iatrogenic injury to the superficial peroneal nerve (SPN) can occur during surgery on the foot or ankle. The purpose of the study was to evaluate the prevalence of the SPN clinically when using the ankle plantar flexion fourth toe flexion sign in our local population. Materials and methods: Between August and November 2020, all new patients between 21 and 70 years of age who attended our foot and ankle specialist clinic were invited to participate in the study. Participation was voluntary, and individuals with a history of surgery to the foot were excluded from the study. Volunteers were provided with a patient information leaflet and asked to complete an anonymous questionnaire with details of their age, sex, weight, height, race, shoe size, and weekly sports participation. Their feet were then examined by a consultant foot and ankle surgeon to record the presence of the SPN. The SPN can be identified by flexing the fourth toe with the ankle in plantar flexion and inversion (Fig. 1). This was recorded as either visible, not visible but palpable, or absent. Results: A total of 154 volunteers were recruited for the study (male = 93, female = 61). The SPN was visible in 35% (n = 54) of patients. In those patients where the nerve was not visible, another 14 patients had the nerve identified by means of palpation. In total, the nerve was identifiable 44% of the time on clinical examination. Body mass index (BMI) (p = 0.01) and sports participation (p = 0.011) were significant determinants of whether the nerve was clinically identifiable. Age, sex, shoe size, and race did not differ between the groups where the SPN was identifiable clinically. Conclusion and clinical significance: The ankle plantar flexion fourth toe flexion sign is a useful clinical sign to identify the SPN when planning incisions over the foot or ankle during surgery to reduce the chance of iatrogenic injury. This sign can aid in identifying the nerve in 44% of our local population. A lower BMI and the population who participated in sports were factors associated with identifying the nerve.

Background: Negative pressure wound therapy (NPWT) is an integral technique in treating severe wounds and preparing the wound bed for skin grafting in orthopedic surgery. The AquaVac system from the Philippines uses an aquarium pump in reverse and is available in the local setting. The benefits of NPWT may outweigh its minor complications, and several local skin problems have been observed especially with prolonged use. One of the remarkable complications found is a pressure injury to the integument caused by the suction tube. However, there have been limited studies as to the incidence of this specific local periwound skin complication. Methods: A retrospective case series was performed by going over the resident logbooks of the Department of Orthopedics and Traumatology in *Hospital Anonymized* from 1^st January 2013 to 31^st December 2022. Slides of cases that underwent NPWT were picked out and graded by three independent observers for the presence of pressure injury and other periwound skin complications on the wound bed and surrounding skin. The number of cases presenting with the complications was then tallied. Inter-rater reliability (Krippendorff) α-coefficient was computed using Statistical Package for the Social Sciences (SPSS) version 25. Results: Among 788 consecutive cases with retrievable documentation, 355 cases (45.10%) were found to have NPWT pressure-related injuries. The lower extremity comprised 656 (83.24%) of the series, while 118 (14.97) were from the upper extremity and 13 (1.65%) were applied on the sacrum. Among the 355 cases found to have a pressure-related injury, 290, (81.7%) were at-risk, for stage I ulceration and 65, (18.3%) had dermal injury equivalent to stage II ulceration. There were no patients with pressure injuries from NPWT application reaching the level of muscle or bone. Inter-rater reliability for pressure injury rating was in perfect agreement. Reliability for pressure injury grading showed an α-coefficient of 0.89. Conclusion: Stage II lesions were the deepest ulcers observed in our series. Awareness of this poorly reported finding can lead to a more defined protocol for the utilization of NPWT. We propose lining the suction tube with foam dressing to help alleviate this complication.

Total talar prosthesis is a state-of-the-art implant in the field of foot and ankle surgery. It has been in constant development for over four decades. Nowadays, its design, manufacturing techniques, and raw materials tend to result in a prosthesis that mimics the natural anatomical function and allows for personalized profiles, which leads to superior outcomes compared to the previous generations. Although several improvements in prosthesis manufacturing have been proposed, ongoing enhancements are still necessary to improve the overall outcome following prosthesis replacement. Here, we delineate and discuss the latest concepts, treatment outcomes, and other details concerning total talar prosthesis and related three-dimensional (3D) manufacturing technologies based on the author's experiences and current literature.

Aim: This case series reviewed challenging cases of Charcot neuropathy (CN) of the ankle joint and the efficacy of limb salvage procedures. Background: Charcot neuroarthropathy (CN) is a chronic debilitating pathology involving bone and joints, especially when affecting weight-bearing joints. Unfortunately, due to its relatively mild initial symptoms, many patients come to the hospital when CN is already in an advanced stage. When deciding between amputation and limb salvage, some aspects must be considered—general condition, local ankle condition, and availability of surgical equipment. Case description: We report three CN cases that presented late because of a lack of patient awareness or physician underdiagnosis. Despite ankle joint obliterations, all cases were successfully treated by limb salvage comprising debridement, reduction, and fixation using an intramedullary nail to achieve tibiocalcaneal arthrodesis. Patients’ weight-bearing ability was restored, and short-term quality of life was improved, despite varied fusion rates. Conclusion: Limb salvage by tibiocalcaneal arthrodesis using an intramedullary nail is a feasible option for CN, even in advanced stages with massive periarticular obliteration. Clinical significance: To avoid worsening conditions resulting from the underdiagnosis of CN, health promotion should be emphasized not only for the primary care clinician but also for the community as a whole. Although normal function is still difficult to achieve, treating advanced-stage CN by limb salvage will improve patients’ quality of life and daily activities.

Background: Low-grade central osteosarcoma (LGCOS) is an extremely rare variant of osteosarcoma, and its occurrence in the distal tibia is uncommon. While limb salvage surgery for a primary malignant bone tumor around a knee joint is now accepted worldwide as a standard procedure, challenges to improve the outcome for surgical treatment of lesions of the distal tibia still remain. Case description: A 26-year-old woman presented with swelling and persistent pain in her left lower leg for 6 months. Incisional biopsy demonstrated LGCOS in the distal tibia. Wide resection and reconstruction using intraoperative extracorporeal autogenous irradiated bone graft (IORBT) were performed. A cross-leg skin flap procedure was added to treat the wound complication of IORBT. There has been no evidence of disease in the last 15 years after surgery. Conclusion: The key to successful functional and oncological outcomes for the long-term in the rare case of LGCOS in the distal tibia is careful investigation before diagnosis, curative tumor resection, reconstruction using the IORBT procedure, and postoperative care, including the delay of weight-bearing and attaching of a patellar tendon-bearing (PTB) brace. Clinical significance: IORBT for the patient with LGCOS in the distal tibia is low-cost, safe, and effective.

Background: Giant cell tumor (GCT) of the feet is rare and occurs in less than 1% of all GCTs of the extremities. Some may have a secondary formation of an aneurysmal bone cyst (ABC). Diagnostics may include radiographs and magnetic resonance imaging (MRI) and treatment varies depending on its classification. Preferably, limb salvage is the treatment of choice. Presentation of Case: We present a 21-year-old male with a large mass in the right heel with pain and difficulty ambulating. The mass involves clinically the whole of calcaneus and is hard, non-tender, non-erythematous, and non-movable. Radiographs show a well-defined osteolytic lesion with a sclerotic rim and neocorticalization. MRI shows fluid-fluid levels. A core needle biopsy was done revealing GCT with secondary ABC. Neoadjuvant therapy using denosumab was given. The patient underwent a marginal excision via total calcanectomy, with reconstruction and subtalar joint arthrodesis using proximal femur allograft secured with 4mm cancellous screws and Achilles tendon V-Y lengthening and reattachment to the allograft via single row suture anchor fixation. At 5 months follow-up, the patient had an excellent clinical appearance with a fused subtalar joint and stable calcaneocuboid joint. Discussion: Intralesional curettage is still the mainstay of treatment when feasible. However, large aggressive lesions may need marginal or wide excision and reconstruction, and in rare cases maybe amputation. We decided to do salvage surgery for the patient and restore as much function as we can. We used the proximal femur allograft as its size and shape are almost the same as with the contralateral calcaneus. Conclusion: Limb salvage surgery, via total calcanectomy and reconstruction using a proximal femur bone allograft, is one good option in treating GTC involving the whole calcaneus. Its main advantage is that the proximal femoral allograft could be fashioned and contoured to be similar in shape and dimensions to the native calcaneus.

Background: Cartiva^® synthetic cartilage implant (SCI) was introduced in our department in 2016 as an alternative treatment for advanced degenerative disease of the hallux metatarsophalangeal joint (MTPJ) requiring fusion, but we would rather prefer to maintain joint movement. Method: A prospective audit was commenced to monitor clinical results limiting selection criteria to young patients with advanced disease with no hallux deformity and no inflammatory arthritis. Outcome measures include patient-reported outcomes using the Manchester-Oxford Foot Questionnaire (MOXFQ) and total range of movement. Result: Between 2016 and 2019, we performed Cartiva^® SCI in 19 toes in 16 patients. The 13 toes were grade IV, and six were grade III. Outcome data were collected at 3, 6, 12, and 24 months. We have complete follow-up data for 19 of 19 cases at 3 and 6 months, 14 of 19 at 1 year, and seven of 19 at 24 months. Results show significant improvement in MOXFQ scores compared to preoperative (pre-op) scores, with peak improvement at 6 months, followed by a slight decline but stayed significantly better compared to pre-op scores. This was observed in all components of the MOXFQ except for social interaction, which showed continuous improvement for up to 2 years. The total range of movement showed steady improvement from a mean pre-op baseline of 31–55° at 3 months (p ≤ 0.001), 63° at 6 months (p ≤ 0.00), 59° at 12 months (p ≤ 0.003), and 80° at 24 months (p ≤ 0.043). Two patients required further procedures for continuing pain and stiffness. One was converted to fusion after 2 years. One patient had a manipulation and steroid injection. One patient developed a “squeegee” sensation when walking and moving the toe, which spontaneously resolved after 6 months. Conclusion: Our results indicate good short-term results in 17 of 19 patients with Cartiva^® SCI based on patient-reported outcomes and the total range of joint movement. Level of evidence: IV–case series.

Background: Matrix Rhythm Therapy (MaRhyThe^©) is a recent advancement in the field of physiotherapy. It is a treatment instrument which helps in enactment and equalization of the typical physiological vibrations of the skeletal muscles and the sensory system. Objective: To describe the effect of MaRhyThe^© as an adjunct in patients in heterogeneous ulcers of the leg. Design: Case series. Setting: Orthopedic and physiotherapy center in Solapur. Patients: Five cases with heterogeneous leg ulcers from a single center were recruited and were treated with MaRhyThe^©, a handheld resonator by trained therapists. The cases have all received appropriate therapies, however, they failed to heal before the referral. The ulcers were measured before the start of therapy and MaRhyThe^© was applied around the wound edges and the whole of the affected limb. Most cases received 60 minutes of therapy once weekly or twice weekly depending on the size of the ulcer until the absence of the wound. All cases were followed up regularly to confirm wound closure posttreatment period. Results: The median age was 50 (38–65) years. The nonhealing median period was 13 (8–16) weeks. The underlying cause of the ulcer was trauma and pressure sores. The median time to healing was 4 (2–8) weeks. In all cases, proliferation was observed following on from the first treatment session and improved with every therapy week until wound closure. Conclusion: Matrix Rhythm Therapy is a noninvasive, safe therapy and effective in treating heterogeneous ulcers of a leg in these retrospective cases.