Black Bone Disease of the Foot: A Two-Year Follow-Up Case Study

“Black bone disease” is a term commonly used to describe a condition characterized by a blue/green/brown discoloration to the bone that often resembles infracted or necrotic bone. The chronic use of minocycline or tetracycline has been reported in previous data as a cause of this discoloration to the skin, bone, and teeth. However, the occurrence in bone is rare, with few studies reported regarding the discoloration. We previously presented a case of this condition encountered during cheilectomy of the first metatarsophalangeal joint in a patient who had had long-term usage of minocycline for adult acne. Two years after the initial case, the patient returned for correction of a hammertoe deformity on the second left proximal phalanx of the same foot. We present the findings and photographs from the second surgery. In addition, we have provided the relevant case data and figures from the first case for ease of comparison.     

Black Bone Disease of the Foot: A Case Study and Review of Literature Demonstrating a Correlation of Long-term Minocycline Therapy and Bone Hyperpigmentation

The chronic use of minocycline and tetracycline has been widely reported in published studies to cause discoloration of skin and teeth. There are very few case reports with regard to discoloration of bone. Those cases reported have been termed black bone disease or blue bone disease because the resulting change to the bone is a blue, green, or brown discoloration that resembles necrotic bone. Documentation of the occurrence in bone, however, is rare, with very few studies noted and only 1 other case that reported changes to the bones of the foot. The mechanism responsible for bone discoloration is not clearly understood. We present a case of this condition encountered during cheilectomy of the first metatarsophalangeal joint in a patient who had required long-term usage of minocycline for adult acne.     

Case Study: An intraoperative finding of black bone disease in a podiatric surgery patient

Black bone disease has been recognised as a potential consequence of long-term treatment with tetracycline antibiotics. Largely documented affecting structures in the head and skull, there are few reported cases of black bone disease in the foot and ankle. The case of a 55 years old patient, who as a teenager, had undergone treatment with minocycline hydrochloride for chronic acne, and was found to have bone discolouration consistent with minocycline induced black bone disease (MIBBD) during the course of hallux valgus corrective surgery some 40 years later, is presented. In spite of the intraoperative findings, the patient’s post-operative recovery and bone healing was uneventful. The literature on minocycline induced black bone disease is reviewed.     

Bone graft substitutes: osteobiologics

Future devolvement of osteobiologic materials will no doubt replace materials currently being used. As techniques to improve biointegration and manipulation of the healing environment proceed, future graft substitutes may exceed even autogenous bone in their reliability. The primary role of bone graft use in foot and ankle surgery has been to fill traumatic defects and benign tumors or to augment arthrodesis techniques. This article highlights the osteobiologics in use today, including calcium-based ceramics, hydroxyapatite, calcium phosphates and calcium composite materials, collagen composite materials, calcium sulfate, calcium cements, and allograft.     

Minocycline-induced black bone disease with synovial pigmentation in a patient undergoing revision anterior cruciate ligament surgery: A case report

IntroductionLong-term use of minocycline at high doses is associated with hyperpigmentation with multiple sites of involvement. While the cutaneous organs and the oral cavity are most commonly affected, bone discoloration is a rare entity.Case presentationA 19-year-old male patient with a history of acne vulgaris and intermittent treatment with high dose minocycline for three years presented with recurrent anterior cruciate ligament (ACL) tear. During arthroscopic surgery, however, hyperpigmentation of the femur and synovium was observed. Abnormal tissue was biopsied and confirmed through histopathological examination to contain melanin-related minocycline pigmentation. Revision surgery was re-scheduled with no intraoperative complications and excellent long-term clinical outcomes.Clinical discussionThere are several possible causes of hyperpigmentation, including hemosiderin deposition, infection, aseptic necrosis, demineralization, and metastatic disease. Black bone disease, caused by minocycline-induced hyperpigmentation, is rare. While the appearance is grossly abnormal in black bone disease, there has been no evidence suggesting that tissue integrity is compromised.ConclusionThis case confirms that hyperpigmentation does not affect bone integrity and that surgical procedures can be performed safely. Knowing the adverse effects of minocycline administration could reduce inappropriate postponement of surgical procedures, thereby saving time and resources.     

Clinical features of bone and soft tissue tumors of the foot and ankle: Results from a retrospective single-center case-series

BackgroundThe malignant potential of the musculoskeletal tumors of the foot and ankle has often been underestimated because of their rarity. The current study reviewed the clinical features of the tumors of the foot and ankle, and evaluated the tumor size via imaging-based analysis to distinguish between benign and malignant lesions.MethodsA retrospective review was performed using the clinical records of all patients with histologically confirmed musculoskeletal tumors of the foot and ankle, treated between 1998 and 2020 at our institution. We examined the distribution of tumors, rate of unplanned excision for primary surgery, and subsequent outcomes. In addition, the tumor size was examined via magnetic resonance imaging, and the cut-off value was determined via receiver operating characteristic (ROC) curve.ResultsA total of 103 bone and soft tissue tumors of the foot and ankle were included, of which 78 were soft tissue tumors and 25 were bone tumors. Of the 14 cases of malignant bone and soft tissue tumors, 6 (42.9%) received unplanned excision in the primary surgery, followed by amputation in 3 cases. Tumor size of malignant soft tissue tumors was significantly larger than that of benign soft tissue tumors (47.6 mm vs. 31.0 mm, respectively, P < .001). However, the difference between benign and malignant bone tumors was not statistically significant with the numbers available. ROC curve determined that the optimum diagnostic cutoff value for soft tissue tumor size was 40 mm, with a high area under the ROC curve 0.816 (95% CI: 0.711–0.921, sensitivity 91.7%, specificity 70.5%)ConclusionsWe highlighted that bone and soft tissue tumors of the foot and ankle were often misdiagnosed and initially inadequately treated. We suggest that a cutoff value of 40 mm may be a useful index for prediction of malignancy in soft tissue tumors of the foot and ankle.Level of evidenceⅢ     

单中心170 例足踝部肿瘤及瘤样病变临床分析

 目的 探讨足踝部肿瘤和瘤样病变的流行病学特点、临床表现以及恶性肿瘤的预后。方法 通过对25年间170例足踝部肿瘤及瘤样病变的临床资料进行回顾性分析,并对恶性肿瘤进行随访,分析其年龄和性别分布、临床表现、肿瘤组织类型、解剖学部位分布、肿瘤大小与良恶性的关系以及恶性肿瘤的预后。结果 170例足踝部肿瘤及瘤样病变中,男91例,女79例。骨肿瘤51例,软组织肿瘤119例。良性126例,恶性44例。年龄7个月~76岁,中位年龄32岁,平均年龄33.1岁。良性肿瘤以10~19岁和20~29岁最多,平均年龄29.54岁;恶性肿瘤以40~49岁和50~59岁最多,平均年龄为43.73岁。临床出现皮损往往提示恶性肿瘤。足踝部肿瘤主要以软组织肿瘤和良性肿瘤为主。软组织良性肿瘤以腱鞘巨细胞瘤最为多见;骨的良性肿瘤以甲下外生骨疣和内生软骨瘤最为多见。软组织恶性肿瘤以黑色素瘤和滑膜肉瘤最为常见。骨的原发恶性肿瘤和转移瘤均非常罕见。前足是肿瘤好发的解剖学部位。软组织肿瘤的大小与良恶性没有相关性,骨肿瘤的肿瘤大小与良恶性显著相关。44例恶性肿瘤中16例采用保肢术,28例截肢(趾)。平均随访时间32.4月,6例无瘤存活,5年无瘤生存率16.13%。结论足踝部肿瘤和瘤样病变以软组织肿瘤和良性肿瘤最为常见,恶性肿瘤发病年龄较高,出现皮损提示恶性肿瘤可能,前足是肿瘤的好发部位,骨肿瘤大小与良恶性相关,恶性肿瘤的预后较差。     

Bone grafting in surgery about the foot and ankle: indications and techniques

Bone grafting is a common procedure in foot and ankle surgery. Historically, autogenous bone graft has most often been harvested from the ipsilateral iliac crest. However, other sites offer similar volumes of cancellous bone and are associated with fewer complications. The ipsilateral proximal tibia, distal tibia, and calcaneus provide adequate amounts of bone graft material for most arthrodesis procedures about the foot and ankle. Emerging techniques have enabled the development of a seemingly unlimited supply of alternative bone graft materials with osteoconductive properties. The osteoprogenitor cells in bone marrow aspirates can be concentrated by use of selective retention systems. These aspirate-matrix composites may be combined with allograft preparations, resulting in a product that promotes osteoconduction, osteoinduction, and osteogenesis with limited morbidity.     

The indications and use of bone morphogenetic proteins in foot, ankle, and tibia surgery

Tissue engineering is an area of rapid growth. Tissue engineering in orthopedic surgery involves the use of growth factors, mesenchymal stem cells, and scaffolds, individually or in combination, toward the growth and restoration of various musculoskeletal tissues, such as ligaments, tendons, muscles, nerves, and bone. These advances are constantly evolving in foot and ankle surgery as well. Bone morphogenetic proteins (BMPs) have played an integral role in the advancement of tissue engineering strategies across multiple orthopedic subspecialities and have proved to play a role in the development of bone and musculoskeletal tissues. BMPs have recently been applied in several areas of foot and ankle surgery, including acute fracture augmentation, nonunions, and arthrodesis, with promising results. This article reviews the key aspects of clinical translation of strategies in tissue engineering as well as current applications and results of BMP use in tibia, foot, and ankle surgery. Future applications of BMP and novel materials in foot and ankle surgery are also reviewed.     

Foot and ankle infections after surgery

Infection after foot and ankle surgery or trauma can range from the common superficial cellulitis to the less common deep soft tissue or bone infections that can have disastrous consequences. The emergence of antibiotic-resistant organisms has made treatment of infection more difficult, even though promising new antibiotics are being developed. Prevention of infection, through proper patient selection and meticulous surgical technique, is essential to satisfactory outcomes.     

Comparison and Use of Allograft Bone Morphogenetic Protein Versus Other Materials in Ankle and Hindfoot Fusions

Bone grafting is a common procedure in foot and ankle surgery. Because autogenous graft use results in comorbidity to the patient, the search has been ongoing for the ideal substitute. A novel processing technique for allograft using bone marrow, which retains many of the growth factors, has shown promise in the spinal data and early reports of foot and ankle surgery. We performed a retrospective, comparative study of patients undergoing hindfoot and ankle arthrodesis, with a total of 68 patients included. Of the 68 patients, 29 (42.65%) received a bone morphogenetic protein allograft and 39 (57.35%) did not. The patient demographics and social and medical history were similar between the 2 groups and both groups had a similar time to union (p?=?.581). Of the 29 patients in the bone morphogenetic protein allograft group, 3 (10.3%) experienced nonunion and 4 (13.8%) developed a complication. Of the 39 patients undergoing other treatment, 7 (17.9%) experienced nonunion and 14 (35.9%) developed a complication. The difference for nonunion was not statistically significant (p?=?.5). However, the difference in the overall complication rate was statistically significant (p?=?.04). We found that this novel bone graft substitute is safe and can be used for foot and ankle arthrodesis.     

第一跖骨近端斜楔形截骨联合软组织手术治疗重度拇外翻

目的:探讨第一跖骨近端斜楔形截骨联合软组织手术治疗重度拇外翻的临床疗效。方法:2008年7月～2010年7月对21例重度拇外翻患者采用第一跖骨近端斜楔形截骨,同时对外侧关节囊松解、内侧关节囊紧缩、拇内收肌腱部分切断治疗。测量患足负重X线,采用美国足踝外科协会Maryl and的评分方法对患足进行手术前后评定。结果:本组患者21例,术后随访6～24个月,无截骨不愈合及延迟愈合现象。23足无疼痛,1足偶有轻微疼痛。术后Mar yl and评分:90～100分19足,80～89分4足,70～79分1足,优良率95%。结论:第一跖骨近端斜楔形截骨联合软组织手术治疗重度拇外翻效果可靠,可以推广。     

Bone graft harvest from the proximal tibia in foot and ankle arthrodesis surgery

BACKGROUND: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control. METHODS: A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction. RESULTS: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing CONCLUSIONS: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.     

Use of structural allograft to compensate for bone loss in arthrodesis of the foot and ankle

Allografts have several important advantages over other forms of bone graft augmentation. In addition to preventing the morbidity of autogenous bone graft harvesting, the quantity of allograft bone is essentially unlimited and is therefore valuable for use in treating very large defects that exceed the yield of the iliac crest. Allografts are particularly helpful in obese patients or patients with systemic disease because the they has the potential to reduce blood loss and anesthesia time. Regional anesthesia with either an ankle or a spinal block may be safer for the rheumatoid patient with cervical instability. In addition, the use of an allograft makes it possible to do many foot and ankle fusions as outpatient procedures, whereas it is commonly necessary to hospitalize patients who have bone graft harvested from the iliac crest. Like the findings of other authors, our experience suggests that structural allograft is an attractive alternative in reconstructive surgery and in arthrodesis of the foot and ankle and is a valuable part of the surgeon's armamentarium.     

Knochen- und Weichteiltumoren des Fußes und Sprunggelenkes

BACKGROUND: This study reports the epidemiology of bone and soft-tissue tumors of the foot and ankle, presents therapy strategies, and evaluates mid-term clinicofunctional outcome after surgery for malignant tumors.METHODS: Two hundred four patients with tumors of the foot and ankle were analyzed (163 benign and 41 malignant). Epidemiology and surgical therapy are reported.RESULTS: The most frequent tumors were exostosis, bone cyst, and osteoid osteoma for benign tumors and metastases and chondrosarcoma and Ewing's sarcoma for malignant tumors. In more than 90% of the benign tumors, local resection could be carried out, whereas in malignant tumors, ablative procedures and arthrodeses were almost as common as limb- and joint-sparing techniques. However, follow-up revealed good functional results and a 5-year survival rate of 84% for patients with primary malignant tumors.CONCLUSION: Tumors of the foot and ankle require a thorough therapeutic strategy. Mid-term functional results and survival rate after surgical treatment are good, although a high percentage of ablative procedures or fusions could not be avoided in our patients.     

Patient Satisfaction After Ambulatory Phlebectomy of Varicose Veins in the Foot

BACKGROUND: Ambulatory phlebectomy is an accepted therapy for varicose veins of the ankle and foot region. Although most phlebologists regard this therapy highly, little is known about patient satisfaction. OBJECTIVE: To investigate patient satisfaction and complaints as reported by the patient after ambulatory phlebectomy for varicose veins in the ankle and foot region. METHODS: A questionnaire was taken from patients who received ambulatory phlebectomy for varicose veins of the ankle and foot region between 1996 and 2000. RESULTS: According to the results of the questionnaire, 50% of the patient population was not completely satisfied, mostly because of persisting pain, reported discoloration, and perceived recurrence. CONCLUSION: The most important factors that influence patient satisfaction are discoloration, persistent pain, and the perception of varices after surgery. To avoid misunderstandings and/or disappointments, attention should be given to patient information before and after surgery.     

Verteilungsmuster von Fuß- und Sprunggelenkstumoren

BackgroundUnclear bone lesions and soft tissue masses of the foot and ankle are not uncommon, but pseudotumorous lesions must be strictly differentiated from real neoplasia. Delayed and incorrect diagnoses are more common here than in other localizations of the musculoskeletal system, sometimes with serious consequences for affected patients.Awareness of true musculo-skeletal tumours is low due to the rarity of these diseases and neoplasia is often not considered.In the scarce literature on this topic there is no uniform definition of the term foot tumor, which makes it difficult to compare and correctly classify the different entities. The aim of this study is to show incidence and distribution patterns of foot and ankle tumors of a university tumor institute in order to improve the understanding of this rare and heterogeneous disease pattern, and to present a simple definition of the term foot tumor.MethodsIn a retrospective, monocentric study, data of patients treated between June 1997 and December 2015 for foot and ankle tumors at a musculoskeletal university tumor center were analyzed with respect to epidemiological data, entity and localization. This included all cases with foot and ankle tumors defined according to the WHO. Exclusion criteria were incomplete data on patient or entity and all pseudotumorous lesions.ResultsOut of a total of 7487 musculo-skeletal tumors, 413 cases (5.52%) of foot and ankle tumors were indentified in 409 patients (215 male and 198 female patients). The average age of the affected patients was 36 ± 18 years (min.3 years, max.92 years). There were 266 bone tumors (64%), among them 231 (87%) benign and 35 (13%) malignant tumors. Of 147 soft tissue tumors (36%) 104 (71%) were benign and 43 (29%) malignant. The most frequent benign osseous tumor lesions included juvenile / simple bone cysts, enchondromas and osteochondromas. By far the most frequent malignant bone tumor was chondrosarcoma. Common benign soft tissue tumors included tenosynovial giant cell tumor (including pigmented villo-nodular synovitis), superficial fibromatosis and schwannoma, while the most frequent malignant entities were synovial arcoma and myxofibrosarcoma. In terms of anatomical localization, the hindfoot was most frequently affected.ConclusionsKnowledge of incidence and the corresponding distribution patterns of foot and ankle tumors can help to correctly assess unclear bumps and lumps and to initiate the right steps in further diagnosis and treatment. Ignorance can lead to delayed diagnosis and inadequate treatment with serious consequences for the affected patient.     

Bone tumors of the foot: epidemiology and diagnosis

The authors reviewed 260 cases of bone tumors localized in the foot and treated at the Tumor Center of the Rizzoli Orthopaedic Institute: 191 were benign and 58 malignant and 11 metastasis. There was predilection for the hindfoot (57%), followed by the forefoot (33%) (prevalently the metatarsals). Localizations in the midfoot were rare (10%). Osteoid osteoma was observed in 26% of all of the tumors of the foot and in 35% of the benign forms. Among malignant neoplasms Ewing's sarcoma (27.5%) was the most frequent. Conservative surgery, which was always carried out in benign tumors, was also performed in some of the malignant ones, having an early diagnosis and a correct preoperative study. The indications and the limits of the different imaging techniques available are reported (bone scan, arteriography, CAT, MRI), and the role of biopsy in the definitive diagnosis of these neoplasms in discussed.     

Minimally Invasive Soft Tissue Release of Foot and Ankle Contracture Secondary to Stroke

Lower extremity contracture associated with stroke commonly results in a nonreducible, spastic equinovarus deformity of the foot and ankle. Rigid contracture deformity leads to gait instability, pain, bracing difficulties, and ulcerations. The classic surgical approach for stroke-related contracture of the foot and ankle has been combinations of tendon lengthening, tendon transfer, osteotomy, and joint fusion procedures. Recovery after traditional foot and ankle reconstructive surgery requires a period of non-weightbearing that is not typically practical for these patients. Little focus has been given in published studies on minimally invasive soft tissue release of contracture. We present the case of a 61-year-old female with an equinovarus foot contracture deformity secondary to stroke. The patient underwent Achilles tendon lengthening, posterior tibial tendon Z lengthening, and digital flexor tenotomy of each toe with immediate weightbearing in a walking boot, followed by transition to an ankle-foot orthosis. The surgical principles and technique tips are presented to demonstrate our minimally invasive approach to release of foot and ankle contracture secondary to stroke. The main goal of this approach is to improve foot and ankle alignment for ease of bracing, which, in turn, will improve gait, reduce the risk of falls, decrease pain, and avoid the development of pressure sores.     

The Role of Polymethylmethacrylate Antibiotic–loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections. The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention. A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009. There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years). A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3). All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion. A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (90.4%) and 7 positive for bacterial growth (9.6%). Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively. When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.