Short-segment transpedicular instrumentation of thoracolumbar burst fractures is associated with a high rate of failure that cannot be decreased by additional transpedicular intracorporeal grafting.

We treated 24 patients (18 women, six men; average age, 46.4 years; (range, 28 to 66 years) with fusion of the hallux metatarsophalangeal (MTP) joint using bone graft for the restoration of the length of the first ray. This procedure was performed after bone loss subsequent to previous surgeries for the correction of hallux valgus and hallux rigidus with: silastic arthroplasty (11), bunionectomy and distal metatarsal osteotomy (six), Keller resection arthroplasty (five), and total joint replacement (two). The indication for performing the arthrodesis with bone graft was a short first metatarsal, and associated metatarsalgia of the lesser metatarsals in addition to a painful MTP joint with or without deformity. This bone loss was associated with avascular necrosis of the first metatarsal (nine patients) and with osteomyelitis (seven patients). Of the 24 patients, 14 underwent additional concurrent surgery for correction of hammer toes (10), excision of a Morton's neuroma (two), and lesser metatarsal osteotomy (two). All patients were examined clinically and radiographically at a mean interval of 62.7 months after surgery (range, 26 to 108 months). The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux and MTP 100-point outcome scale. Arthrodesis occurred in 19/24 patients (79.1%) at a mean of 13.3 weeks (range, 11 to 16 weeks), and the first ray was lengthened by a mean of 13 mm (range, 0 to 29 mm). Of the five nonunions, two were asymptomatic, and three were subsequently revised successfully, with arthrodesis occurring at a mean of 10.7 weeks. Complications included one deep infection requiring intravenous antibiotics for treatment of osteomyelitis and two minor superficial wound infections. The mean AOFAS score improved from 39 points (range, 22 to 60 points) to 79 points (range, 64 to 90 points). All patients were satisfied with the final outcome of treatment and stated that they would undergo the surgical procedure again. We concluded that arthrodesis of the hallux MTP joint with bone graft to restore bone loss and length of the first ray may be a worthwhile procedure despite the technical difficulty and the high rate of nonunion.

Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus that can cause major morbidity including limb amputation. Since it was first described in 1883, and attributed to diabetes mellitus in 1936, the diagnosis of CN has been very challenging even for the experienced practitioners. Imaging plays a central role in the early and accurate diagnosis of CN, and in distinction of CN from osteomyelitis. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, and positron emission tomography are the imaging techniques currently in use for the evaluation of CN but modalities other than magnetic resonance imaging appeared to be complementary. This study focuses on imaging findings of acute and chronic neuropathic osteoarthropathy in diabetes and discrimination of infected vs. non-infected neuropathic osteoarthropathy.

Although a variety of diagnostic imaging modalities are available for the evaluation of diabetes-related foot complications, the distinction between neuroarthropathy and osteomyelitis is still challenging. The early and accurate diagnosis of diabetic foot complications can help reduce the incidence of infection-related morbidities, the need for and duration of hospitalization, and the incidence of major limb amputation. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, ultrasonography, and positron emission tomography are the main procedures currently in use for the evaluation of diabetes-related foot complications. However, each of these modalities does not provide enough information alone and a multimodal approach should be used for an accurate diagnosis. The present study is a review of the current concepts in imaging of diabetes-related foot complications and an analysis of the advantages and disadvantages of each method.

Diabetic foot is a serious complication of diabetes mellitus and the risk of lower extremity amputation is very high in this population when compared with people without diabetes. We have previously reported the lower-extremity amputation rate and significant factors in determining the risks for patients who had been admitted to Hacettepe University Hospital, a tertiary reference center for Turkey, between the years 1992 and 1996. In January 2000, a diabetic foot care team including an infectious diseases specialist, orthopaedic surgeons, endocrinologists, a plastic and reconstructive surgeon, a radiologist, and a diabetic foot nurse was assembled. To determine whether a change has occurred in the rate and the risk factors of lower extremity amputations after the establishment of this team, medical records of 66 patients (39 men, 27 women) with diabetic foot who had been admitted to Hacettepe University Hospital between 2000 and 2002 have now been retrospectively analysed. The grade distribution of diabetic foot according to Wagner classification was quite similar in the two studies (grade 1: 0 % vs. 4.5 %, grade 2: 15.6 % vs. 19.7 %, grade 3: 48 % vs. 33.3 %, grade 4: 24.4 % vs. 30.3 %, grade 5: 11.5 % vs. 12.1 % in the former and current study, respectively). The overall amputation rate in the current study was 39.4 % (36.7 % in the former study). Ray amputation (35 %) and below-knee amputations (30 %) were the two most commonly applied procedures. The rates of Syme, above knee, other amputations (i.e., Boyd, talonavicular amputations and partial calcanectomy) were 8 %, 8 % and 19 %, respectively. These data suggest that amputation is still a frequently encountered outcome for our patients with diabetic foot, but the amputation profile has changed. The implementation of a diabetic foot care team has relatively decreased the rate of major amputations in an attempt for limb salvage to improve the quality of life of the patients. Presence of osteomyelitis, peripheral vascular disease and gangrene still remain as significant predictors of amputation in our population.

Study Group for Diabetic Foot Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist societies and the Ministry of Health to issue a national consensus report on the diagnosis, treatment and prevention of diabetic foot (DF) wounds and diabetic foot infections (DFIs) in Turkey. In the periodical meetings of the assigned representatives from all the parties, various questions as to pathogenesis, microbiology, assessment and grading, treatment, prevention and control of diabetic foot were identified. Upon reviewing related literature and international guidelines, these questions were provided

The distal attachments of the extensor hallucis longus (EHL) tendons in 47 amputated legs and in eight cadavers were examined. The EHL had two tendons in 34 of the amputated legs and bilaterally in five cadavers. The lateral tendon was inserted to the middle of the dorsal aspect of the base of the distal phalanx of the hallux and the medial tendon to the medial side of the insertion of the lateral tendon. The length and thickness of these two tendons were measured and compared in order to obtain data for using these tendons in tendon repair and hallux varus corrections by autogenous tendon transfer surgery. Additionally, on the right foot of one of the cadavers, it was observed that the extensor hallucis brevis tendon united with the lateral tendon of the EHL. We recommend that foot-ankle surgeons be aware of the various accessory EHL tendons and their potential use in problematic cases.

TECHNIQUEThis is a new surgical technique to address osteochondral lesions of the medial talar dome. Preoperative planning of the surgery should include sagittal MRI or reconstructed CT for localization, grading of the lesion, and osteotomy planning.Under tourniquet control, a curved incision is made over the medial malleolus in standard fashion. An inverted U osteotomy is planned according to MRI or CT images. The width of the osteotomy depends on the size of the lesion. Deciding on the height of the osteotomy requires C-arm control to make certain enough bone is taken to allow access to the osteochondral lesion. Medial malleolus is predrilled before the osteotomy. The osteotomy is performed with a micro-sagittal saw (Synthes width: 6 mm). The osteotomized fragment, which is attached to deltoid ligament retracted inferiorly with a towel clamp or a small skin hook. Tibiotalar distraction is achieved with the aid an of external fixator or noninvasive ankle distraction technique. The AO femoral distractor (Synthes, Paoli, PA) is placed in the calcaneus and the tibia. The latter was described by Yates and Grana.' Intra-articular procedures such as debridement of the chondral lesion and microfracture technique would be performed after distraction. Plantarflexion of the ankle gives access to posterior aspect of the talus. The anterior aspect of talus can be seen with dorsiflexion of the ankle. If retrograde drilling is planned, one K-wire is drilled from center of the lesion to sinus tarsi. Drilling can be done with cannulated drill