As Malaysia modernized with time, the specialty of foot and ankle surgery became more relevant and has gained tremendous interest among trainees and practicing orthopedic surgeons. This commentary gives a brief view of the status of foot and ankle surgery in Malaysia.

Aim and objective: To compare the clinicoradiological outcome between in situ and distraction bone block arthrodesis in patients with malunited calcaneal fracture. Materials and methods: Patients presenting with painful subtalar joint arthritis between January 2015 and March 2018 were included after thorough clinical and radiological evaluation. In situ group I had 22 patients and distraction group II had 14. All patients were evaluated at final follow-up for functional outcome with American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and radiological parameters including talocalcaneal height (TCH), calcaneal pitch (CP), lateral talocalcaneal angle (LTCA), and talar declination angle (TDA). Results: Mean follow-up was 19.26 months for in situ and 12.91 months for distraction group. AOFAS ankle-hindfoot score improved postoperative in both groups, but the difference between the groups was not significant (p value = 0.371). Statistically significant improvement was observed in radiological parameters of talocalcaneal height (p value = 0.006), calcaneal pitch (p value = 0.025), lateral talocalcaneal angle (p value = 0.078), and talar declination angle(p value = 0.02) in the distraction group. Conclusion: Distraction arthrodesis restores hindfoot radiological parameters better compared to the in situ group; however, there is no significant difference in functional outcome between the groups.

Aim and objective: This study compared the maximum load to failure of Krackow and Uchiyama suture techniques in an acute tendon repair in an ex vivo porcine model. Background: Achilles tendon rupture is a common injury in athletes and active individuals. In 2007, Uchiyama et al. published a case series of a modified operation for Achilles tendon ruptures. This technique is reported to allow strong and stable repair with subsequent early weight bearing and range of motion exercises. However, no biomechanical studies have been performed to compare this novel suturing technique to a standard like Krackow. Materials and methods: Twenty freshly harvested porcine digital flexor tendons were transected transversely at the mid-substance. Ten were repaired with double-strand Krackow suture technique using non-absorbable polyester braided suture Ethibond®2. The other 10 tendons were further divided into bundles approximately 5 mm wide—2 proximal and 2 distal. The Uchiyama repair was completed by gathering each bundle by Bunell-like sutures using Ethibond®2-0. Biomechanical testing was conducted on the samples using a mechanical universal testing machine (Shimadzu® AGS-X Series). Longitudinal traction at an advancement rate of 0.85 mm/second was performed and maximum load to failure and mode of failure were statistically compared. Results: The average maximum load to failure was not significantly different between the Krackow repair (119.18 N ± 37.4) and Uchiyama (112.98 ± 32.06) (p = 0.34). All modes of failure were due to suture breakage. Conclusion: There is no significant difference between the maximum load to failure of Uchiyama and Krackow suture technique. Significance: Uchiyama suture technique may be an alternative to open repair of acute tendon of Achilles rupture. This warrants further studies to investigate other properties like failure to cyclic loading, tendon gapping, etc. In vivo studies may be geared toward effect of greater surface contact and smaller caliber sutures in tendon healing.

Aim and objective: Achilles tendon rupture can be adequately treated by surgical repair. This study aimed to represent the incidence, presentation, outcome of treatment of Ethibond granuloma, which is a rare complication following surgical repair. Materials and methods: This study was a review of 672 patients who had open surgical repair of the Achilles tendon rupture using Ethibond sutures. Eleven (1.6%) patients developed suture granuloma postoperatively and were included in the study. Epidemiological, clinical, radiological, and histopathological data were reviewed. The outcome of treatment was evaluated. Results: This study included ten males and one female, with a mean age of 31.4 ± 13.7 years. Two patients had diabetes mellitus, and three patients were smoking. All patients presented with swelling and discharge around the surgical site compromising their daily living activities. The mean time interval between the surgical procedure and the diagnosis of granuloma formation was 6 ± 3.2 months. Patients were treated by surgical debridement and granuloma excision. The healing and fixation strength of the primary repair were not affected. The wound healed entirely at a mean of 2.6 ± 0.5 weeks. With a mean follow-up period of 14.6 ± 2.2 months, all patients had a fully functional tendon and were able to resume normal daily living activities. Conclusion: Ethibond sutures may rarely cause granuloma formation months after the primary repair of Achilles tendon rupture. The granuloma does not affect the strength of the primary repair and can be treated adequately with debridement and excision with a complete wound resolution. Clinical significance: Defining the incidence and outcome of treatment of Ethibond suture granuloma as a devastating complication following acute Achilles tendon repair. Level of evidence: Level IV, retrospective.

Background: Calcaneocuboid syndrome is a common yet underdiagnosed condition. It has been noted as a FADI scores complication of plantar flexion and inversion ankle injuries which are one of the most common athletic injuries. It is common in ballet dancers and athletes. Presentation of this condition is lateral foot pain which is exaggerated on inversion. Aim and objectives: To determine the outcomes of a single platelet-rich plasma (PRP) injection combined with rehabilitation for calcaneocuboid syndrome. Materials and methods: Six patients (3 non-sportsperson, 2 footballers, 1 basketball player) who presented with complaints of chronic lateral ankle pain were evaluated clinically and radiologically and identified to have calcaneocuboid syndrome. Ultrasound-guided PRP injection was done. Preinjection and one and three months postinjection visual analog scale (VAS) and foot and ankle disability index (FADI) scores were noted. They also underwent a rehabilitation program. Results: One patient was lost to follow-up after 1 month. Five patients showed significant improvement in VAS and FADI at 3 months. Discussion: The use of PRP has shown proven benefits in the literature. Our study combined PRP along with a rehabilitation program for the subjects. Conclusion: Single PRP injection along with a rehabilitation program has shown to be effective in the management of calcaneocuboid syndrome.

Syndesmotic injuries are common after ankle fractures. Despite the growing number of manuscripts on the fluoroscopic images performing the topic, there is still debate surrounding key aspects of syndesmotic injuries. This review aims to present current concepts about the diagnosis and treatment of these injuries.

Plantar fasciitis (PF) is characterized by plantar medial heel pain, usually present in the morning at the first few steps. Obese individuals, who stand for prolonged periods and who walk on hard surfaces, typically suffer from PF, the most common cause of plantar heel pain in adults. The diagnosis can be achieved through patient clinical history and clinical findings. Stretching exercises, activity modification, and use of several analgesics resolve symptoms in over 80% of patients, while biomechanical factors can be corrected by insoles or various kinds of orthotics or night splints. In the outnumbered group of patients who develop intractable PF, other available strategies are extracorporeal shock wave therapy and corticosteroid injections. Surgical management of PF consists of plantar fascia release, but efficacy is still debated. In recent years, biological treatments have been getting popularity in many orthopedic conditions.

Introduction: Loss of skin over the dorsum of foot is a common clinical entity. Infection, trauma, and vascular disease represent the most common etiological factors. Salvage of foot in these cases has a bearing upon the quality of life of the patient. The reconstruction process is often complex and varied as per exigencies. Reverse sural artery flap is an easy and reliable option for reconstruction of dorsum of foot defect. Protocol and operative steps: Reverse sural artery draws its vascularity from the communication of the peroneal artery and the median sural artery. The flow of the flap is from the distal to the proximal and represents an elegant option for dorsum of foot. We have described the peninsular variant of the reverse sural artery. Conclusion: The coverage of the defects of the dorsum of foot in trauma can be performed either immediately if the wound conditions are favorable or we may have to delay the procedure of definitive cover by a few days till the wound conditions improve by use of vacuum-assisted closure (VAC) application. Split thickness graft, reverse sural artery flap, and free flaps provide safe and viable options for dorsum of foot defects. Reverse sural artery is reliable option in the armamentarium of the reconstructive surgeon.

Ankle joint is an inherently stable joint well supported with ligament and bones configuration. Ankle dislocation without fracture is a rare entity needs to be managed urgently in the form of immobilization in below knee cast for appropriate time period. Rehabilitation protocol is to be followed in order achieve targeted range of motion. Complication associated with ankle dislocation needs to be kept in mind while managing these kinds of condition.

Background: Open ankle dislocation without associated fractures is one of the rare orthopedic injuries. Early reduction and stabilization is required to prevent neurovascular damage and further complications. Case description: We present a case of 22-year-old male, who sustained injury to his right ankle after fall from height. On examination and X-ray evaluation, he had posterior open left ankle dislocation without any malleolar fractures. We managed with debridement, reduction of dislocation, and ankle stabilization by using ankle spanning external fixator. After the removal of the fixator, the patient is having painless ankle range of motions and bearing weight with no difficulty. Conclusion: Although open ankle dislocations without fracture are rare injuries but early intervention is essential to prevent the complications, to salvage the foot and to get better functional outcome. Clinical significance: Open ankle dislocation without fracture is rare entity; early reduction of dislocation with ankle stabilization and proper wound management helps in getting better functional outcome.