Journal of Foot and Ankle Surgery (Asia Pacific)

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2018 | December | Volume 5 | Issue 2

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Jagdish Chander, Sanjay Gupta, Ashok Attri, Sudhansoo Khanna, Mayankjayant

Outcome in Patients of Diabetic Foot Infection with Multidrug Resistant Organisms

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:5] [Pages No:51 - 55]

Keywords: Diabetic foot infection, Methicillin-resistant S. aureus, Multidrug-resistant organisms

   DOI: 10.5005/jp-journals-10040-1089  |  Open Access |  How to cite  | 


Aim and objectives: To study the spectrum of microorganisms in patients of diabetic foot infection (DFI) and to evaluate the outcome in patients of DFI with multidrug resistant organisms (MDRO). Materials and methods: A total of 116 patients, visiting diabetic foot clinic of our institute with DFI were observed in a prospective manner. Diagnosis of infection was based on clinical findings using International Working Group on Diabetic Foot and Infection Diseases Society of America (IWGDF-IDSA). The microbiological profile of wound assessed at the time of admission and patients were followed up for wound healing rate, need for amputation and surgical interventions, hospital stay, and mortality for 6 months. Observation and results: The microbiological profile of our patients showed that Gram-negative microorganisms were commonly isolated (78.4%) from our patients. The culture trends revealed that most common isolates were E. coli (33.6%), Pseudomonas (19.8%), Proteus (18%), Klebsiella (16%), Acinetobacter and Citrobacter among the Gram-negative organisms. Among Gram-positive organisms, Staphylococcus aureus was the most common isolate which was present in 29 (25%) of the patients. MDRO were isolated from 13.8% of patients. Most common MDRO isolated were methicillin-resistant S. aureus (MRSA) and vancomycin-resistant Enterococci (VRE). The outcome was assessed in terms of mortality rate, the rate of major amputation, rate of minor amputation, the rate of multiple surgical interventions, duration of hospitalisation and requirement of intensive care unit (ICU) admission, re-admission rate, antibiotic requirement which were not significantly different in patients with MDRO than that with non-MDRO (p-value > 0.05). The mean healing rate in patients with MDRO was not significantly different than that from patients with non-MDRO (p-value > 0.05). Conclusion: Although the number of patients with MDRO is small as compared to non-MDRO, the study found that MDRO has no significance on the outcome of the patients with DFI.



Sonal T Lal, Chandanpreet K Kahlon, Deepak J Bhatti

Reusable Frame for Pedicle Protection in Heel and Ankle Defects

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:3] [Pages No:56 - 58]

Keywords: Heel defects, Metatarsophalangeal joints, Pedicle protection, Reusable frame splint

   DOI: 10.5005/jp-journals-10040-1090  |  Open Access |  How to cite  | 


Introduction: It has always been a challenging task for the reconstructive surgeons to resurface the lost skin and soft tissue over the heel. This is done by use of skin grafts, local flap or microvascular free flap (MFF). The postoperative care and splintage of these limbs is a difficult task, and often the success or failure of the flap will depend on proper postoperative splintage and positioning of the operated limb. A simple and reusable frame is being described for pedicle protection in flap surgery for posterior heel and ankle wounds. Aims and objective: To devise a reusable frame for pedicle protection in heel and ankle defects. Materials and methods: A reusable frame splint designed by holding up the foot against gravity at a narrower circumference of forefoot just proximal to the wider circumference of the foot at the metatar sophalangeal joint (MTP) level. This frame was used in the early postoperative period for positioning the lower limb in patients undergoing surgery for coverage of posterior heel defects. Result: A total of 14 patients underwent wound coverage of post heel defect over a period of 3 years. Out of these 14 patients, nine had reverse sural artery pedicle flap, three had split-thickness skin grafting and remaining two had MFF done. In all the cases, a specially designed frame was used for pedicle protection. One patient had developed erosion and blistering, which healed subsequently. Conclusion: This innovation in the splint helps in providing adequate elevation of limb and protection of pedicle of local or MFF used for coverage of heel and ankle defects.



Meng Zhu, Jerry Y Chen, Terry HL Teo, Kevin OT Koo, Inderjeet S Rikhraj

Predicting Treatment Success after Scarf Osteotomy for Hallux Valgus using The American Orthopedic Foot and Ankle Society and Short Form Health Survey Scores

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:5] [Pages No:59 - 63]

Keywords: Hallux valgus, Patient-reported outcome, Scarf osteotomy, The American Orthopedic Foot and Ankle Society- Health Management Information System, Threshold score, Treatment success

   DOI: 10.5005/jp-journals-10040-1091  |  Open Access |  How to cite  | 


Aim: Various hallux valgus corrective surgeries, including Scarf osteotomy, have demonstrated improvement in patients' forefoot function and quality of life. However, no threshold values of these measures have been reported to define the success of surgery from the patients' perspective. This study aims to define treatment success threshold values of The American Orthopedic Foot and Ankle Society (AOFAS)-Health Manage-ment Information System (HMIS) and Short Form (36) Health Survey (SF-36) Scores for patients underwent Scarf osteotomy (SO) for hallux valgus. Materials and methods: A retrospective analysis of patients who underwent scarf osteotomy between 2007 and 2013 was conducted. Patients were evaluated for AOFAS-HMIS, SF-36 score, satisfaction, and pain scoreatvarious time points. Treatment success was defined as a significant improvement in pain and satisfaction with surgery. Using receiver operating characteristic (ROC) analysis, threshold score for treatment success was defined as the cut-off value providing the largest sum of sensitivity and specificity. Results: A total of 360 and 345 patients completed assessments at 6-month and 2-year after surgery, with a success rate of 70.0% and 77.4%, respectively. The AOFAS-HMIS and physical component score (PCS) improved significantly atboth postoperative time points as compared to preoperatively. The ROC analyses revealed the excellent predictive value of AOFAS-HMIS for treatment success (AUC = 0.840 and 0.835). Conclusion: The American Orthopedic Foot and Ankle Society-Health Management Information System of 84 and above at 6-month, or 89 and above at 2-year after surgery can be used to define treatment success of OS for hallux valgus. Anincreasingly higher threshold is required to define treatment success with time.



Huang Y Lun, Lee K Hwee, Koo Kevin, Inderjeet R Singh

Review of Surgical Outcomes between Plate and Screw Fixations in Lapidus Procedure for Asians’ with Hallux Valgus

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:4] [Pages No:64 - 67]

Keywords: Hallux valgus, Lapidus arthrodesis first metatarsophalangeal joint, Screw fixation, X-plate fixation

   DOI: 10.5005/jp-journals-10040-1092  |  Open Access |  How to cite  | 


Background: This study aims to evaluate the clinical outcomes of the Lapidus procedure utilizing either plate osteosynthesis or screw fixation in a significantly sized patient group with a minimum of 2 years follow-up. Materials and methods: This is a retrospective analysis of prospectively collected data of 68 consecutive hallux valgus in 56 patients who underwent the Lapidus procedure with a plate (Synthes X plate 38 feet) or screw fixation (29 feet) by a single surgeon in a single institution from 2007 to 2011. Patients were followed up at 6 months and 2 years and evaluation included clinical assessment, weight-bearing radiographs, and patient-reported outcome measures, namely pain visual analog score (VAS), American Orthopedic Foot and Ankle Society (AOFAS) hallux score. Results: In the plate osteosynthesis group, the VAS score improved significantly from 5.09 to 0.94 (p < 0.001) 2 years postoperatively. Similarly, the AOFAS hallux score improved significantly from 53.5 to 83.7 (p < 0.001) 2 years postoperatively. In the screw fixation group, the VAS score improved significantly from 4.68 preoperatively to 1.74 (p = 0.03) 2 years postoperatively. Similarly, the AOFAS hallux score improved significantly from 53.5 preoperatively to 76.6 (p < 0.001) 2 years postoperatively. Comparing the two groups, there was no difference in the improvement of VAS and AOFAS hallux scores. Similarly, at 2 years, there was no difference between the groups regarding patient's satisfaction and expectations. Conclusion: The Lapidus procedure utilizing either plate osteosynthesis or screw fixation is a reliable and safe option for hallux valgus, with good clinical outcomes and low complication rates. Level of evidence: Level II



Prasoon Kumar, Puneeth K Gowda, Monica Chabbra

Foot Biomechanics and Relation to the Gait Cycle

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:5] [Pages No:68 - 72]

Keywords: Ankle joint, Pelvis, Subtalar joint, Transverse tarsal joint, Windlass effect

   DOI: 10.5005/jp-journals-10040-1093  |  Open Access |  How to cite  | 


The foot and ankle are fundamental to all upright locomotion performed by the human, accommodating itself to the external environment and providing a harmonious relationship between body and the external environment by propagation. The evaluation of the mechanical behavior of different structural foot elements can be used to understand the foot behavior during different phases of the gait cycle. Understanding the foot biomechanics during gait helps in the design of the orthotics and prosthetics. These data are essential for identifying abnormal patterns and characterizing impairments, disabilities, and handicaps. In this article, we will explain the basic biomechanics of the foot during the normal gait cycle.



Ajaydeep Sud, Vandana Rana, Munish Sood, Uddandam Rajesh

Primary Giant Synovial Osteochondroma of Ankle

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:4] [Pages No:73 - 76]

Keywords: Ankle, Giant synovial osteochondroma, Primary

   DOI: 10.5005/jp-journals-10040-1094  |  Open Access |  How to cite  | 


Background: Giant synovial osteochondroma (SOC) is a clinical variant of synovial chondromatosis wherein the size of the osteochondral nodule exceeds 2 cm. This is a rare clinical entity and finds its description in a few case reports or case series only. Case description: A 28-year male patient presented with swelling of the ankle region for 5 months duration. Plain radiograph of the ankle showed well circumscribed, increased soft tissue density lesion in the posterior aspect of tibiotalar joint and talus. Magnetic resonance imaging (MRI) of the ankle showed a smoothly marginated lesion close to the tibiotalar joint which was heterogeneously hypointense on T1-weighted images and hyperintense on T2-weighted images. Hypointense foci within the lesion in both images were suggestive of ossification. Intraoperatively, the swelling was noted to arise from the tibiotalar joint capsule with no evidence of bony erosion. The mass was excised in toto, and wound closure was done in layers. Microscopic examination of the mass showed predominant chondroid element with irregularly distributed chondrocytes in lacunae and evidence of enchondral ossification along with cancellous bone mass suggesting a synovial osteochondroma. On postoperative follow-up at 2 months and 9 months, movements around ankle joint were full range and pain-free with no reappearance of swelling. Imaging including plain radiograph and MRI revealed no evidence of recurrence at 9 months. Conclusion: Giant SOC can present itself with the variety of symptoms. Imaging is helpful in ascertaining the diagnosis. The treatment of the condition remains surgical only. Post surgery, recurrence remains a possibility. Clinical significance: Giant SOC should form one of the clinical possibilities in swellings arising from synovial joints as early diagnosis of the condition can prevent arthritic changes to progress further.



Archit Agarwal, Rajesh Lalchandani

Osteochondritis of Intermediate Cuneiform with Delayed Appearance Ossification Centre of Navicular Bone–A Rarity

[Year:2018] [Month:December] [Volume:5] [Number:2] [Pages:3] [Pages No:77 - 79]

Keywords: Cuneiform, Navicular, Osteochondritis, Ossification centre

   DOI: 10.5005/jp-journals-10040-1095  |  Open Access |  How to cite  | 


Osteochondritis of intermediate cuneiform is an unusual entity in itself but it is even rarer to find it with delayed appearance of navicular ossification centre. We report a case who presented with unilateral deformity of foot. Diagnosis was established with help of ski gram and magnetic resonance imaging (MRI) of foot. Patient was managed conservatively. Thus osteochondritis can have varied presentation and affects mostly male children. On extensive review of literature we could not come across any report of such case from Indian subcontinent.


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