Volume 2, Dec 2022

Dear AFFAS members:
I am honored here to announce
that the 9th mee�ng of Asian Federa�on of Foot & Ankle Surgeons will beheld in Kaohsiung, Taiwan on November 24th-25th, 2023.

Peng-Ju Huang
President, 9th AFFAS mee�ng

We all realize that during thepast three years, the COVID-19 pandemic has greatly inﬂuenced our wayof living and career prac�ce. Fortunately the worst seems behind us, andwe are conﬁdent that there is a big chance for us to hold a face-to-face
AFFAS mee�ng this �me.

Kaohsiung is situated in the southern part of Taiwan with an interna�onal airport serving south-east Asia. If you take a ﬂight to Taipei, youcan arrive in Kaohsiung by high speed rail in 1.5 hours. The weather inKaohsiung during late November is very pleasant, which makes it thebest �me for travel.
I am sure we will do our best to make this AFFAS mee�ng anexcep�onal event in both academic and social aspects. Please come toTaiwan to experience our local hospitality, meet old friends, and makenew ones. The 9th AFFAS mee�ng is the event you won’t want to miss!
Submissions for the event are already open, with the deadline set
at April 30, 2023. Details for registra�on and payment will be availablesoon.
Best regards,Peng-Ju Huang
President, 9th AFFAS mee�ng

AFFAS 9thTriennial Mee�ng in Kaohsiung, Taiwan
Open for Submission Now!

Submission Deadline: April 30, 2023
No�ﬁca�on of Acceptance: June 1, 2023
Early Bird Registra�on Deadline: Aug 31, 2023

IFFAS 8th Scien�ﬁc Mee�ng
May 30-June 1, 2024
Coex, Gangnam, Seoul, Korea

Hosted by the Asian Federa�on of Foot and Ankle Surgeons

Save the Date!

Traveling to Kaohsiung and the event venue
From Taiwan Taoyuan
Interna�onal Airport (TPE)
Transfer to the Taiwan High Speed Rail (THSR)
Taoyuan Sta�on via taxi or the Taoyuan Interna�onal Airport Mass Rapid Transit (MRT) system.
Travel �me is approximately 20-25 minutes via
either method, although there may be a considerable wai�ng �me for a taxi.
Take the THSR to Zuoying Sta�on. Trains departapproximately every 30 minutes from 6:30 am to10:30 pm daily. Travel �me is about 1 hour and 40minutes.
From THSR Zuoying Sta�on, take either theKaohsiung MRT Red Line or a taxi to reachdowntown Kaohsiung. The event venue isabout a 15-minute walk from the R8 Sta�on ofthe Red Line.

Direct ﬂight to KaohsiungInterna�onal Airport (KHH)
Take either the Kaohsiung MRT Red Line or a taxi toreach downtown Kaohsiung. The event venue isabout a 15-minute walk from the R8 Sta�on of theRed Line.

Fibula autogra� in salvage surgery of a massive podagra:
A case report on surgical technique.
Ramalingam K; T. Akmal.F; M.Shahril.J; Azammuddin A
Orthopedic Department, Hospital Pengajar Universiti Putra
Malaysia
Acknowledgment: R Mohd Ali; A Ahmad
Pathology Department, Hospital Pengajar Universiti Putra
Malaysia

Abstract
Massive podagra with destruction of the
1st metatarsal is a challenge to the surgeon
in view of both soft tissue and skeletal
reconstructions. These patients often present with soft tissue ulcerations as well asinfection, and may end up with amputation.
However, in the absence of infection and a
motivated patient who has no other co-morbids, surgical excision of the podagra, andreconstruction of the 1st metatarsal/metatarsal phalangeal joint is a viable option.
We present a case and discuss surgical techniques in managing a case of a massive
podagra with a diseased 1st metatarsal. We
utilised a stage surgery where the pathology was excised and managing the deadspace with an antibiotic cement spacer. A
2nd stage reconstruction was done with anautologous fibula graft. Patient has had an
uncomplicated wound healing and follow
up at 6months has shown graft union.

INTRODUCTION
Gout is an inflammatory arthropathy due toan impaired purine metabolism resulting inprolonged, uncontrolled hyperuricemia.
This results in deposition of monosodium
urate monohydrate crystals within joints.
Crystal depositions in joint leads to pain,

restriction of movement, deformity as wellas complication such as infection and ulceration(1). The most common joint to beaffected is the first metatarsophalangeal
joint (MTPJ) of foot and this is termed as
podagra(2). Chronic gout may progress
into accumulation of large amount crystal
within joint causing formation of palpable
tophi and if left untreated, it may lead tojoint and bone destruction(3). Ulcerated
tophaceous gouty lesion are susceptible for
infection, and this usually ends up with asurgical debridement, or in worse cases amputations. The challenges include debridement, bony stability, wound closure, as wellas prevention of infection. We present thisreport the surgical method of managing
gouty tophi with limb salvation.

CASE REPORTA 52-year-old gentleman presents to ourorthopaedic clinic with a 5-year history of
progressively increasing gouty tophis overboth his feet. The main reason for his visit
was difficulty in accommodating shoes aswell as non-infective ulcerations on theright foot. The largest ulcerated tophi werelocated over dorsal right 1st MTPJ measuring 6x8cm. The swelling is hyperpigmented with thinning of the surround skin.
While it did not cause any tenderness on
palpation, the swelling resulted in a rigid
first metatarsophalangeal joint. His uricacid levels were expectantly high withother laboratory investigation unremarkable, with no evidence of infection. PlainFig. 2. 1st stage surgery.

radiographs show bony erosion over baseof proximal phalanx of right great toe andhead of first MTPJ (Fig. 1). Surgical intervention was offered to the patient, and a toe
salvage procedure was agreed upon. Due tothe swelling and bony involvement, a twostage surgery strategy was utilised. The
first stage involved debulking of the tophi,
bone resection as well as placement of antibiotic cement. An intramedullary k-wire
was used as a temporary stabilizer (Fig. 2).
This was done to maintain the length ofthe medial column as well as to prepare forthe 2nd stage. Gross histology revealedirregular chalky white material measuring
90mm in diameter while microscopy
showed multiple aggregates of pale eosinophilic amorphous material surrounded byhistiocytes and multinucleated giant cells(Fig. 3). Two months later, the 2nd stage
was carried out, replacing the antibiotic
cement spacer with autologous fibula grafting (Fig. 4). The graft was secured with alocking compression T-plate. His stay inthe hospital was unremarkable and hiswounds healed well. He was followed up at
7 months of index surgery and his wounds
have healed well, and the graft united (Fig.
5).
Fig. 1. Preoperative gross appearance and X-rays.

Fig. 3. Histology of excised lesion.

Fig. 4. 2nd surgery, six weeks after 1st surgery.

Fig. 5. Seven months after 2nd surgery.

DISCUSSION
The podagra presents itself as a result ofgout in 43-76% of cases. Stewart et all in
their meta-analysis report a 79% incidenceof 1st MTB erosion on radiographs, alongwith spur formation (40%), joint space narrowing (39%) as well as sclerosis in 73% ofcases(4). This highlights the severity anddebilitating effects of the disease. If the 1st
MTB is minimally involved, as reported byTanner et al, a soft tissue excision is usuallyadequate enough to provide an improvement in the quality of life of thepatients(5). In cases of podagra with bony
involvement, the decision for surgery isdifficult. Stapleton et al utilised a staged
procedure similar to our case, utilizing anantibiotic cement spacer with an external
fixator to manage the dead space(6). They
followed this up by an iliac crest graft andplating. Their patient had complete softtissue and osseous healing. In cases where
there is structural compromise, fibula
grafting is a suitable option. Vascularizedbone grafts acquired properties whichallow the intact endosteal blood supply toinitiate, stimulate, and facilitate bony healing but is more technically demanding. The
rewards are a very high bony union rates
and allow to improve regional circulation,
particularly when surrounding tissues havebeen prone for infection(7). Surgical intervention of a gouty tophus is indicated forfunctional restoration as well as cosmetic
restoration amongst others (8). The goalfor patient to undergo surgery is mainly torestore function and permits wearing shoes,

control drainage or infection, reduce pain,
decompression of nerves and cosmetic restoration
In our patient, his chronic gout had given ahuge impact in his quality of life evidenced
by having limitation in mobility and being
unable to wear footwear. He has no othermedical illness (emphasis on non-diabetic
and no peripheral vascular disease) besides
gout and preferred limb salvaging surgery
over amputation. Patient was also able tofollow post operative orders and dressing
regimes. A detailed risk and benefits discussion was held with the patient pre operatively, with emphasis of wound issues,
non-union, as well as possible ischemia organgrene leading to amputation later. With
only limited risk factor and patient footcondition was not infected, arthrodesis andbone graft operation were suitable for him.
During the first surgery, we noted total
destruction of the distal 1st metatarsal aswell as the 1st MTPJ. After resection of thetophi and eroded bone cement spacer wasinserted as a temporary void filler to maintain the length of the big toe as well asantibiotic prophylaxis to eradicate any possible local infection. Intramedullary K-wire
was inserted instead of external fixation inview of limitation of pin insertion over thedistal phalanx. The definitive surgery
using the fibula bone graft to replace thebone defect over the metatarsal and proximal phalanx with advantage of restoring
toe length, geometrical shape and mechanical strength.
Arthrodesis with T-plate permits adequate

number of screws over the distal phalanx
and subsequently securing the fibula bonegraft, utilizing a bridge plate principle.
Patient was followed up on at 7 months ofindex surgery and his wounds have healed
well, and the graft united.

CONCLUSION
The presence of non-infected giant tophi
had impaired overall quality of life andfunction. Amputation, while the easier surgical option, may not always the best option
to patient. With a motivated patient andsurgeon, limb salvage surgery should beconsidered instead. A 2-staged surgery
offers a good outcome in these instances.

REFERENCES
1. Xu J, Zhu Z, Zhang W. Clinical characteristics of infectious ulceration over tophi inpatients with gout. J Int Med Res.
2018;46(6):2258-64.
2. Roddy E. Revisiting the pathogenesis ofpodagra: why does gout target the foot? JFoot Ankle Res. 2011;4(1):13.
3. Ragab G, Elshahaly M, Bardin T. Gout:
An old disease in new perspective - Areview. J Adv Res. 2017;8(5):495-511.
4. Stewart S, Dalbeth N, Vandal AC, Rome
K. The first metatarsophalangeal joint ingout: a systematic review and meta-analysis.
BMC Musculoskelet Disord. 2016;17:69.
5. Tanner N, Diaper R, King M, Metcalfe
SA. Case study: a case of debilitating goutin the 1st metatarsophalangeal joint. Foot(Edinb). 2015;25(1):45-50.
6. Stapleton JJ, Rodriguez RH, Jeffries LC,Zgonis T. Salvage of the first ray with concomitant septic and gouty arthritis by useof a bone block joint distraction arthrodesisand external fixation. Clin Podiatr MedSurg. 2008;25(4):755-62, xi.
7. Chen CM, Disa JJ, Lee HY, Mehrara BJ,
Hu QY, Nathan S, et al. Reconstruction ofextremity long bone defects after sarcoma
resection with vascularized fibula flaps: a10-year review. Plast Reconstr Surg.
2007;119(3):915-24; discussion 25-6.
8. Straub RL, Smith JW, Carpenter KG et al.
The surgery of gout in the upper extremity.
JBJS 1961; 4A: 731–751.

Highlighted Papers

This study was based on the Korean Foot and Ankle Society (KFAS) member survey andaimed to report the current trends in the epidemiology, diagnosis, and management of acuteAchilles tendon rupture (AATR) over the past few decades. A web-based questionnaire containing 34 questions was sent to all KFAS members in October 2021. The questions weremainly related to the clinical experience and preferred management of patients with AATR.
Answers with a prevalence ≥50% of the respondents were considered a tendency. Seventy-one (12.9%) of the 550 members responded to the survey. The male sex ratio in AATR
was answered mean 78%, and the most common age groups were 30~40 years (n=49;69.0%), and 40~50 years (n=37; 52.1%), in that order. The most common seasons for theoccurrence of AATR were spring (37 cases; 52.1%) and autumn (27 cases; 38.0%). Also,
sports-related rupture had an average occurrence of 76.2%. The most important clinicalfactor to determine the type of treatment was the history of previous injuries, and 75.9% ofrespondents started conservative treatment in the 2010s. The most preferred protocol ofconservative treatment was an orthosis capable of ankle range of motion after casting(68.5%), and 53.7% ‘satisfied’ and 1.9% ‘very satisfied’ with conservative treatment. The
most preferred surgical method was open repair (80.3%), and the Krackow method (60.6%),
and 49.3% of treated patients responded ‘satisfied’ and 45.1% ‘very satisfied’ with this treatment. This study gives updated information concerning the current trend of epidemiology,
diagnosis, and treatment of AATR in Korea. Both consensus and variation in the approachto AATR were identified using this survey study. This study may raise the awareness of various possible approaches toward AATR and should be used to further establish a standard
protocol for the management of this injury.

We value your input!
Whether be it academic submissions, feedback on previous issues or thoughts
and reﬂec�ons about your prac�ce in general, you are welcome to share with theAFFAS community. Please forward your input totuohwu@gmail.com

Look forward to hearing from you

Highlighted Papers

This study sought to compare needle fenestration with a corticosteroid injection for thetreatment of chronic plantar fasciitis. We hypothesized that needle fenestration would be aseffective as a corticosteroid injection while avoiding the potential adverse effects of the corticosteroid. Forty female patients with unilateral chronic plantar fasciitis who did not
respond to a minimum of 6 months of various conservative treatments were prospectively
randomized to receive either a corticosteroid injection or needle fenestration. Visual analogue scale and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfootscore were used for all patients before treatment and at 3-, 6-, and 12-month following treatment. The corticosteroid injection group had a before-treatment average AOFAS
Ankle-Hindfoot score of 56.4, which increased to 87.3 at 3 months and 78.2 at 6 months
after treatment but decreased to 62.4 at 12 months. The needle fenestration group had abefore treatment average AOFAS ankle-hindfoot score of 49.5, which increased to 77.8 at 3months and 92.1 at 6 months after treatment and remained at a high score of 89.4 at 12months. There were no complications in either group. In the treatment of chronic plantar
fasciitis, needle fenestration is as effective at 3- and 6-month post-treatment as a corticosteroid injection. Also, unlike a corticosteroid, its effect remains until 12 months post-treatment.

We value your input!
Whether be it academic submissions, feedback on previous issues or thoughts
and reﬂec�ons about your prac�ce in general, you are welcome to share with theAFFAS community. Please forward your input totuohwu@gmail.com

Look forward to hearing from you

The Foot & Ankle Community
AFFAS – Asian Federation of Foot andAnkle Surgeons

IFFAS – International Federation of Foot& Ankle Societies

Council

CouncilPresident Xiangyang Xu (China)

President Jin Woo Lee (South Korea)

Vice President Peng-Ju Huang

President-Elect Mark E. Easley (USA)Council Member IFFAS Jin Woo Lee (South Korea)

Immediate Past President Cristian A. Ortiz (Chile)

Council Member IFFAS Yasuhito Tanaka (Japan)

Secretary Kristian Buedts (Belgium)

Past President Bavornrit Chuckpaiwong (Thailand)

Treasurer David Lunz (Australia)

Siu Kwai Ming (Hong Kong)

The Asian Federation of Foot and Ankle
Surgeons Representatives

Nikesh Shah (India)

Jin Woo Lee (South Korea)

Ihsan Oesman (Indonesia)

Peng-Ju Huang (Taiwan)

Hisateru Niki (Japan)

Yasuhito Tanaka (Japan)

Ki Won Yang (Korea)

Xiangyang Xu (China)

Yeok-Pin Chua (Malaysia)
Carlo Angelo V. Borbon (Philippines)

The European Foot and Ankle Society
Representatives

Alexey Mazalov (Russia)

Kristian Buedts (Belgium)

Ken Jin Tan (Singapore)

Beat Hintermann (Switzerland)

Pei-Yu Chen (Taiwan)

Don McBride (England)

Marut Arunakul (Thailand)

Yves Tourné (France)

Xiangyang Xu (China)

Akira Taniguchi (Chairman, Japan)

The Latin American Federation
Representatives

Hui Zhang (China)

Cristian A. Ortiz (Chile)

Kwai Ming Siu (Hong Kong)

Santiago Guerrero (Colombia)

Atsushi Teramoto (Japan)

Gabriel E. Khazen (Venezuela)

Byung Ki Cho (Korea)

Juan Yañez Arauz (Argentina)

Juan Agustin D. Coruna IV (Philippines)
Ooi lai Hock (Singapore)

The North American Federation of Foot &Ankle Societies Representatives

Chien-Shun Wang (Taiwan)

Mark E. Easley (USA)

Chamnanni Rungprai (Thailand)

J. Chris Coetzee (USA)

Scientific Committee

Newsletter Committee

Karl-Andre Lalonde (Canada)

Xingchen Li (China)

Lew C. Schon (USA)Ka Hei LEUNG (Hong Kong)
Satoshi Yamaguchi (Japan)

The Southern Federation of Foot and Ankle
Societies Representatives

Su-Young Bae (Korea)

David Lunz (Australia)

Leow Voon Chin (Malaysia)

Rhett B. Mason (New Zealand)Thomas T. Gonzales (Philippines)

Graham McCollum (South Africa)

Tang Zhi Hao (Singapore)David Shepherd (Australia)

Tuoh Wu (Taiwan)
Theerawoot Tharmviboonsri (Thailand)