Journal of Foot and Ankle Surgery (Asia Pacific)

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2024 | July-September | Volume 11 | Issue 3

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Mandeep S Dhillon

The Changing Nomenclature of Adult Flatfoot

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:2] [Pages No:103 - 104]

   DOI: 10.5005/jp-journals-10040-1354  |  Open Access |  How to cite  | 



Tirupathi Visalatchi Raja, Sandeep Kuniyil Mavali, Pramod Mohan, Raja Annamalai Ashwin

Bunionette Deformity with Plantar Ulcers: Scarf Osteotomy as a Solution

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:6] [Pages No:105 - 110]

Keywords: Bunionette deformity, Plantar ulcers, Scarf osteotomy, Tailor's bunion

   DOI: 10.5005/jp-journals-10040-1333  |  Open Access |  How to cite  | 


Aim of the study: Treatment of bunionette deformity with plantar ulcers is not well elaborated in the literature at present. Scarf osteotomy, as the most preferred mode of treatment in cases of bunionette deformity without ulcers, has been described. Our study is to analyze the efficacy of scarf osteotomy in treating bunionette deformity with different grades of plantar ulcers. Materials and methods: Twenty patients with bunionette deformities with plantar ulcers (male—9, female—11) were included in the study. We retrospectively analyzed the functional score foot function index (FFI), clinical-healing time of the ulcers, and radiographic parameters—fourth/fifth intermetatarsal and lateral deviation angles (LDAs). Complications (three patients) were also reviewed during the follow-up. The patients were operated on between 2021 and 2023, with the most extended follow-up of 24 months. Results: The average FFI score improved from 49.22 to 10.7, the 4–5 intermetatarsal angle (IMA) decreased from 11.2 ± 3.14 preoperatively to 4.97 ± 1.09, and the LDA decreased from 6.7 ± 3.42 preoperatively to 3.21 ± 0.42 at final follow-up, respectively. The average ulcer healing time recorded in this study was 44.5 days, and the average osteotomy healing duration was 90 days. The complications noted were infections, ulcer recurrence, and implant removal. Conclusion: The scarf osteotomy can be an acceptable treatment modality for bunionette deformity with plantar ulcers, offering good results at midterm follow-up.



Chandramohan Arunkamal, Ranjit K Patra, Ramesh Perumal, Velmurugesan P Sundaram, Dheenadhayalan Jayaramaraju, Shanmuganathan Rajasekaran

Does the Fracture Morphology, Timing of Intervention Determine the Outcome in Operated Talus Neck and Body Fractures? A Retrospective Analysis of 49 Patients

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:6] [Pages No:111 - 116]

Keywords: American Orthopaedic Foot and Ankle Society score, Avascular necrosis of talus, Hawkin's sign, Secondary arthritis, Talus body fracture, Talus neck fracture

   DOI: 10.5005/jp-journals-10040-1339  |  Open Access |  How to cite  | 


Background: Talus fractures comprise approximately 0.1–0.85% of all fractures. They usually present following a high-velocity trauma and with soft tissue damage. Our objectives are to study whether the fracture morphology, the timing of intervention, the injury status, and the presence of Hawkin's sign influence the outcomes in operated cases with talus fractures. To test our hypothesis that open talus fractures, talus body fractures with comminution, and the time delay in initiating treatment cause poor results. Materials and methods: It is a retrospective analysis of all operated talus fractures between 2015 and 2019. Of the total 62 patients, 49 patients met our inclusion criteria. Preoperative X-rays and preoperative computed tomography (CT) scans were analyzed. Based on the fracture morphology, cases were divided into groups A (talus neck) and B (talus body). Postoperative assessment for the fracture union, presence of Hawkin's sign, the incidence of avascular necrosis (AVN), rate of infections, and secondary arthritis were noted. The functional outcomes were calculated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. Results: Among 49 patients, 34 talus neck fractures and 15 talus body fractures were assessed. The risk of AVN in talus neck fracture increases with injury severity (p-value of 0.04). There was no statistical difference between the closed and open talus fractures regarding AVN, infection rate, and secondary arthritis. The mean AOFAS score was 84.9 in group I and 81.8 in group II. Hawkin's sign showed 61.1% reliability for detecting AVN. However, the specificity is limited. Conclusion: The talus neck and body fracture outcome did not vary significantly. The incidence of AVN positively correlated with the increasing severity of the talus neck fracture. According to Sneppen's fracture variants, the sagittal split-type talus body fracture had a marginally better outcome than the coronal split type and crushing-type body fracture with comminution. The rates of infection and AVN between closed and open talus fractures and the initial time delay for surgery did not influence our final results, and there was no statistical difference.



Madhu Periasamy, Vamseedharan Muthukumar, Kumanan Asokan, Shanmuganathan Raja Sabapathy

Outcomes of Flexor Hallucis Longus Percutaneous Tenotomy for Great Toe Tip Callosity and Ulcers in Patients with Diabetes Mellitus: Cohort Study

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:4] [Pages No:117 - 120]

Keywords: Callosity, Diabetic foot, Flexor hallucis longus, Great toe, Hallux, Percutaneous, Tenotomy, Ulcer

   DOI: 10.5005/jp-journals-10040-1341  |  Open Access |  How to cite  | 


Aims and background: Great toe ulcers are the most common index lesion in persons with diabetic foot syndrome in 43–55.5% of patients. The most typical foot deformity in persons with diabetic peripheral neuropathy is claw toe deformity. The present study is a retrospective analysis of percutaneous flexor hallucis longus (FHL) tenotomies done on patients with diabetes, hallux claw deformities with ulcers of the hallux tip and their outcomes. Methods: A retrospective study was done to identify patients who underwent percutaneous FHL tenotomy between May 2016 and January 2022. Results: A total of 38 diabetic patients had percutaneous tenotomy of FHL. A total of 18 patients had grade 0, 12 patients had grade I, and eight patients had grade II ulcers, according to Wagner's grading. The mean time to heal for callosities and ulcers was 37 and 45 days, respectively, post tenotomy. Four patients had a recurrence of toe tip ulcer in a mean of 14 months. One patient had developed a transfer ulcer at the interphalangeal (IP) joint region. None of the patients had difficulty in gait or doing routine day-to-day activities and wearing footwear due to the loss of FHL action. Conclusion: Percutaneous tenotomy of the FHL tendon resulted in the healing of great toe tip ulcers in 94.8% of patients at a mean follow-up of 24 months. Clinical significance: Neglected great toe tip ulcers lead to gangrene and amputation of the affected toe. Timely treatment of these ulcers can prevent needless amputations.



Wei L Cheong, Yet Y Yan, Kinjal V Mehta

Ultrasound Guidance vs Anatomical Landmark for Ankle Arthroscopic Portal Insertions: A Randomized Cadaveric Study

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:6] [Pages No:121 - 126]

Keywords: Ankle arthroscopy, Nerve injury, Ultrasound

   DOI: 10.5005/jp-journals-10040-1343  |  Open Access |  How to cite  | 


Background: To determine the safety and efficacy of using ultrasound in topographic marking of the neurovascular structures and tendons in the foot and ankle and identification of a safe zone for arthroscopic portal creation, compared to using anatomical landmarks. Materials and methods: Twelve cadaveric samples were randomly divided into two groups of six. The first group underwent ultrasound assessment by a board-certified radiologist, who identified zones of safety for ultrasound-guided insertion of anteromedial, anterolateral, and posteromedial arthroscopic portals. Ankle arthroscopy was then performed. The other group underwent similar ankle arthroscopy assessment utilizing conventional anatomical landmarks. Straws were used to delineate arthroscopy portal tracts. The cadaveric samples were then dissected. The following distances were measured between the portals and important anatomical structures—the anterolateral portal and superficial peroneal nerve (SPN) as well as extensor digitorum longus (EDL); anteromedial portal and the great saphenous vein (GSV) as well as tibialis anterior (TA); and the posteromedial portal and the flexor hallucis longus (FHL). Results: No neurovascular structures or tendons were injured in all 12 cadaveric samples. Compared with the nonultrasonography group, the group that underwent ultrasonography assessment had statistically significant larger distance of the SPN, EDL, and TA from the anterolateral and anteromedial arthroscopic portals (p-values = 0.045, 0.046, and 0.025, respectively). No difference was found between the distance of the GSV from the anteromedial arthroscopic portal as well as the distance of the FHL from the posteromedial arthroscopic portal. Conclusion: Ultrasound assessment and topographic identification of the safe zone for ankle arthroscopic portal creation are a safe and effective processes that may reduce the risk of iatrogenic injury to neurovascular structures and tendons in anterior and posterior ankle arthroscopy. Level of evidence: IV; cadaveric study.



Hernán E Coria, Héctor J Masaragian, Nicolas Ameriso, Luciano Mizdraji, Fernando D Perin, Leonel Rega

Diabetic Foot: Influence of Atmospheric Pressure and Temperature on its Epidemiology

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:5] [Pages No:127 - 131]

Keywords: Atmospheric incidence, Diabetic foot, Epidemiology

   DOI: 10.5005/jp-journals-10040-1348  |  Open Access |  How to cite  | 


Introduction: Diabetic foot is a frequent pathology for foot and ankle surgeons. About 20% of diabetic patients will suffer from an ulcer at some time in their lives. Epidemiology is crucial for prevention, and seasonal incidence variations should be taken into account to prevent new cases. The objective of this research is to evaluate whether seasonal variations in pressure and temperature have an influence on the incidence of diabetic foot. Materials and methods: A retrospective study was performed from 2014 to 2016 inclusive. Data was obtained from a hospital in the Autonomous City of Buenos Aires. All surgeries and consultations for diabetic feet were recorded. Daily and monthly variation data on temperature and atmospheric pressure was obtained for this period. The statistical study was carried out for all data comparisons in order to evaluate the differences and their significance. Results: Average temperature increase of 3.5°C and average atmospheric pressure decrease of 3.2 hPa were associated with an increase in the incidence of diabetic foot. Increase of 315% in the number of surgeries and 42.7% in consultations were observed. Conclusion: There is a significant association between atmospheric pressure, temperature, and number of cases of diabetic foot. Temperature increases of 3.5°C associated with pressure drops of 3.2 hPa generated an increase in the number of cases. This relationship is more frequent in warm months. Prospective and multicenter studies should be carried out. The validity of our hypothesis would allow us to foresee increases in incidence and design preventive actions. Level of evidence: IV.



Donatas Chlebinskas, Dhrumin Sangoi, Venu Kavarthapu

Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:6] [Pages No:132 - 137]

Keywords: Diabetic foot ulcers, Minimally invasive, Off-loading surgery

   DOI: 10.5005/jp-journals-10040-1330  |  Open Access |  How to cite  | 


Aim and background: It is estimated that between 19 and 34% of people with diabetes will have a diabetic foot ulcer (DFU) at some point in their lives. The forefoot is the most common anatomical region in the foot for the development of an ulcer. DFU leads to a 5-year mortality rate of >50%, which is similar to or even worse than many types of common cancers. Recognized off-loading with total contact casting (TCC) leads to successful ulcer healing but high reulceration rates. Concerns remain high on the wound complication rates following open surgical off-loading procedures due to the associated distal vascular impairment. Less invasive surgical approaches and techniques may reduce these risks when addressing such pathologies. We aimed to review the less invasive and percutaneous surgical off-loading options for chronic diabetic forefoot ulcers. Methods: We have performed a PubMed database search to review the literature on the development, pathophysiology, percutaneous surgical off-loading options, and the key surgical concepts of chronic diabetic plantar foot ulcers. We have reviewed only techniques that are backed by higher than level 5 evidence based on their success rates and complication rates. Results: For the most common lesser toes apical ulcers, percutaneous flexor digitorum longus (FDL) tenotomy has shown 98% ulcer healing rates and 6.4% recurrence rates; however, a 9.9% incidence of transfer ulcers for isolated tenotomies was reported. Hallux plantar ulcers are the second most prevalent plantar foot ulcers, and flexor hallucis longus (FHL) tenotomy has an 82% success rate without recurrence in over a 20-week follow-up. Medial forefoot ulcers are the third most common, and percutaneous Achilles tendon lengthening (ATL), followed by TCC, has demonstrated 100% healing rates and 38% recurrence in 2 years. Peroneus tendon lengthening and dorsal closing wedge osteotomy have been described as treatment methods. The lateral forefoot is the fourth most common site for ulcers, and the initial treatment is ATL. Similarly, dorsal distal to plantar proximal percutaneous distal metatarsal osteotomies have been reported for lesser metatarsal head-based ulcers with up to 100% ulcer resolution and no recurrence at mean 25-month follow-up. Conclusion: Deformity correction using minimally invasive techniques provides a surgical off-loading treatment option for chronic plantar diabetic forefoot ulcers and carries lower recurrence rates than nonsurgical options. Most of the studies reporting the results of these techniques are case reports and small series, and higher evidence-level studies would be needed to confidently recommend some of these techniques for developing guidelines. Clinical significance: Percutaneous and less invasive techniques range from established to emerging methods and are becoming important surgical tools in the armamentarium of a foot and ankle surgeon. These are safe to be used in the prophylaxis and treatment of DFUs and deformities with the benefit of reduced risk of infections and wound complications in these vulnerable patients.



Manish Ladhania, Nilesh Kothari, Nishanth V Pushkaran, Varun Chouhan

Management of Isolated Bilateral Sustentaculum Tali of Calcaneum Fracture with Long-term Follow-up: A Case Report

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:4] [Pages No:138 - 141]

Keywords: Case report, Hindfoot, Open reduction and internal fixation, Sustentaculum tali

   DOI: 10.5005/jp-journals-10040-1347  |  Open Access |  How to cite  | 


Isolated fractures of sustentaculum tali of calcaneum are rare and often missed at an initial visit; they have implication on future hindfoot function as it is a vital load-bearing structure. Thorough clinical examination and proper imaging is necessary not to miss this kind of fracture. The severity of injury, soft tissue compromise, amount of displacement, and stability of fixation are the key factors affecting the outcome. This article describes a case study of bilateral isolated fractures of sustentaculum tali with 3.5 years of follow-up. Conclusion: Isolated fractures of the sustentaculum tali tend to be ignored and misdiagnosed as acute ankle sprain. Anatomical open reduction and internal fixation through a medial approach reduce the long-term complications.



Ganesh S Dharmshaktu, Ishwar S Dharmshaktu, Tanuja Pangtey

Pigmented Villonodular Tenosynovitis Involving the Fourth Toe: Report of an Uncommon Case

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:5] [Pages No:142 - 146]

Keywords: Benign lesion, Biopsy, Case report, Foot, Lump, Mass, Pigmented villonodular tenosynovitis, Tenosynovitis, Toe

   DOI: 10.5005/jp-journals-10040-1350  |  Open Access |  How to cite  | 


Background: Pigmented villonodular synovitis (PVNS) is an uncommon entity that mostly involves larger joints like the knee and hip. The condition presents with synovial thickening and proliferation into the growth of the variable sizes, and the exact etiology is still not clear. Pigmented villonodular tenosynovitis (PVNTS), a variant, is the condition arising from the tendinous tissues. Its presentation as a lump over a singular toe is a rare occurrence. Case description: We hereby report a case of a mass over the left fourth toe of a young lady, with minimal clinical complaints except for difficulty in wearing footwear. Magnetic resonance imaging (MRI) was followed by excision biopsy, leading to the final diagnosis of PVNTS. Uneventful healing of the wound and no complication or recurrence were noted in the follow-up of 13 months. Conclusion: Mass lesions may occasionally present at unusual sites and require histopathological evaluation for an appropriate diagnosis. Clinical significance: Pigmented villonodular tenosynovitis should be kept as an uncommon differential diagnosis in cases of the lump affecting the foot and ankle region.



Latif Z Jilani, Mohammad Istiyak, Yasir S Siddiqui

Stieda Process as a Source of Posterior Ankle Pain: A Case Report with Its Structural and Clinical Implication

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:5] [Pages No:147 - 151]

Keywords: Ankle pain, Case report, Os trigonum, Posterior ankle impingement, Stieda process

   DOI: 10.5005/jp-journals-10040-1351  |  Open Access |  How to cite  | 


Posterior ankle pain commonly presents in young active populations. Several anatomical changes can cause posterior ankle pain like bony prominences, anomalous muscles, and ligament hypertrophies. An uncommon and unidentified cause of posterior ankle pain is the Stieda process (SP), an extended posterolateral talar process. In this case study, we discussed a 25-year-old young active female who is overweight having posterior ankle pain for the last 1 year. She was neither a dancer nor an athlete. The pain had no association with excessive plantar flexion. X-ray was advised which showed SP. The diagnosis was confirmed by magnetic resonance imaging (MRI). Conservative modality of treatment was tried first but the patient did not find much relief. So, an open surgical excision was done. At 6 months’ follow-up, the patient again had pain in the opposite ankle. An X-ray revealed the SP. Surgical excision with similar postoperative rehabilitation was followed. At 1-year follow-up, the patient had no pain with full range of motion (ROM) of bilateral ankles. We also discussed various differentials of posterior ankle pain.



Vivek M Sodhai, Arjun K Unnam, Sandeep A Patwardhan, Parag K Sancheti

Sole Surprises—An Atypical Encounter with Pilar Cyst in the Foot: A Case Report

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:4] [Pages No:152 - 155]

Keywords: Case report, Cystic lesion foot, Excision biopsy, Hemangiovenous malformation, Pilar cyst, Trichilemmal cyst

   DOI: 10.5005/jp-journals-10040-1349  |  Open Access |  How to cite  | 


Aim and background: Pilar cysts in the foot are uncommon occurrences and pose diagnostic challenges, as they are difficult to distinguish from other cystic lesions through both clinical examination and radiological imaging. Consequently, surgical excision is often deemed necessary for definitive diagnosis and treatment. Case description: A 12-year-old female presented with persistent right foot pain subsequent to a glass prick injury. Ultrasonography (USG) of the foot suggested an infective collection, while magnetic resonance imaging (MRI) revealed a well-lobulated lesion along the plantar aspect of the 3rd and 4th toes, initially indicative of a posttraumatic collection or hemangiovenous malformation. Excision biopsy was performed, and histopathological examination revealed a classical pilar cyst with the cyst wall lined by keratinizing squamous epithelium. Conclusion: Pilar cysts in the foot are exceptionally rare and can mimic foreign body granulomas or arteriovenous (AV) malformations. Surgical excision emerges as the preferred treatment for symptomatic cases, emphasizing the significance of accurate diagnosis and intervention. Clinical significance: Persistent foot pain subsequent to a glass prick injury warrants thorough investigation, including consideration of foreign body granuloma or pilar cyst. This case underscores the need for surgical intervention in such cases to rule out uncommon but significant pathologies and provide appropriate treatment.



Ganesh S Dharmshaktu, Ronak N Kotian

The Indian Foot and Ankle Society's Advanced Training Program Report 2024

[Year:2024] [Month:July-September] [Volume:11] [Number:3] [Pages:3] [Pages No:156 - 158]

   DOI: 10.5005/jp-journals-10040-1352  |  Open Access |  How to cite  | 


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