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© 2002 The Journal of Bone and Joint Surgery, Inc.
What’s New in Foot and Ankle Surgery
This report reviews the information and ideas presented at recent meetings of the American Orthopaedic Foot and Ankle Society (AOFAS) as well as studies presented at the annual meeting of the American Academy of Orthopaedic Surgeons and at other subspecialty meetings. Pertinent points from articles in Foot and Ankle International and other journals are also highlighted in an effort to present an overview of the major advances and new concepts in foot and ankle surgery. Posterior Tibial Tendinitis Dysfunction of the posterior tibial tendon continues to be intensely investigated. In stage 1, posterior tibial tendinitis is characterized by inflammation. In stage 2, the posterior tibial tendon is elongated and the foot assumes the typical planovalgus posture. Because the insertion of the gastrocnemius tendon on the calcaneal tubercle in this posture is lateral to the axis of the subtalar joint, the hindfoot is everted. The hindfoot, in this stage, fails to invert with attempted single-leg toe-rises, but the hindfoot joints remain supple. Hindfoot and midfoot stiffness and arthritis progress in stage 3. Soft-tissue reconstruction is not possible at this stage, and triple arthrodesis is generally necessary. Most current discussion has focused on stage-2 reconstruction techniques, and these generally involve tendon transfers to the medial navicular to reestablish the function of the posterior tibial tendon. Because the ligamentous support of the medial longitudinal arch is attenuated and the muscle grafts cannot provide comparable stability, procedures on osseous structures are necessary to reduce the mechanical advantage of the deforming muscles. Flexor digitorum longus transfer with medial calcaneal osteotomy is currently a widely used technique. Guyton et al.1 reviewed a series of these reconstructions at a mean of thirty-two months after surgery. Although radiographic alignment was improved, only one-half of the patients noticed the improvement clinically. Pain relief was rated as good or excellent by 91% of the patients. Recovery was prolonged, requiring an average of ten months to reach maximal improvement. Fayazi similarly reported a 96% rate of good and excellent results. Alternative or concurrent possible tendon donors include the peroneus brevis and the flexor hallucis longus. The results of reconstructions with these tendons have been shown to be comparable with those of reconstructions with the flexor digitorum longus. Neither technique is associated with substantial donor morbidity. Realignment of the foot by the addition of an osteotomy or a limited arthrodesis in the reconstruction of a posterior tibial tendon with stage-2 tendinitis is intended to redirect the deforming forces, specifically the gastrocnemius or peroneal musculature, and to correct the deformity, forefoot abduction, and hindfoot valgus. Commonly reported techniques include subtalar arthrodesis, anterior calcaneal lengthening, calcaneocuboid distraction arthrodesis, calcaneal medial displacement osteotomy, and a double osteotomy consisting of anterior calcaneal lengthening and medial displacement osteotomy. The results of double calcaneal osteotomy were evaluated at an average of five years postoperatively2. The average AOFAS ankle-hindfoot score was 90 points postoperatively. Radiographic indices of hindfoot alignment improved to nearly normal values. Osteoarthritis of the calcaneocuboid joint developed in four feet (14%), and only one remained symptomatic. There are two methods for lengthening the lateral column of the foot and reducing the abduction of the forefoot. Proponents of calcaneocuboid distraction arthrodesis cite concern over increased joint pressure and the potential development of osteoarthritis in the calcaneocuboid joint after lengthening of the joint through the anterior portion of the calcaneus. Proponents of anterior calcaneal lengthening cite the preservation of the flexibility of the joint as a prime advantage of that procedure. Calcaneocuboid joint pressure was examined in a cadaveric specimen before ligament sectioning, after medial ligament sectioning to represent the acquired flatfoot model, and after anterior calcaneal lengthening3. When compared with the intact foot, the flatfoot model demonstrated an increase in calcaneocuboid joint pressure. Anterior calcaneal lengthening did not increase joint pressure compared with that seen in the flatfoot model. As a result, there is some question with regard to whether lateral column lengthening increases calcaneocuboid pressure in a foot with planovalgus deformity. A clinical study in which anterior calcaneal lengthening osteotomy was compared with calcaneocuboid distraction arthrodesis demonstrated equivalent rates of complications and patient satisfaction4. Achilles Tendon The surgical management of insertional Achilles tendinitis was reviewed in two studies. Watson et al.5 compared the results of retrocalcaneal decompression in patients who had retrocalcaneal bursitis with those in patients who had insertional Achilles tendinitis with a calcific spur. The patients with a calcific spur required nearly twice as much time before maximal improvement of the symptoms was reached and had worse results than the patients with bursitis. The rate of satisfaction was 93% for the patients with retrocalcaneal bursitis and 74% for those with insertional Achilles tendinitis with a calcific spur. A more aggressive surgical approach was evaluated by Bhole. He reported on patients with severe insertional Achilles tendinitis who were treated with complete detachment and débridement of the Achilles tendon. The tendon was lengthened with use of a proximal V-Y advancement and was reattached with use of suture anchors. A group of patients with less severe abnormalities who were treated with use of a variety of other methods was used for comparison. The patients treated with débridement and reattachment improved more rapidly than the other patients did, and 78% had a good or excellent result. Options in the treatment of Achilles tendon rupture include nonoperative, open, and percutaneous techniques of repair. Moller et al., in a randomized multicenter trial, compared thirty-three patients managed with open repair and early functional rehabilitation with thirty-three managed with nonoperative treatment and eight weeks of cast immobilization6. The authors reported that the rerupture rate was 21% for the patients managed nonoperatively and 2% for those managed operatively. The functional results, however, were equivalent. In another study, patients managed with percutaneous repair and those managed with open repair were shown to have similar functional results7. The percutaneous method was favored because the patients managed with open repair had a high number of complications, including wound infections in 21% of the patients. Plantar Fascia Nonoperative treatment remains the primary therapy for plantar fasciitis. Porter evaluated the results of treatment of plantar fasciitis with aggressive stretching exercises for the Achilles tendon. Two closely monitored protocols consisting of sustained stretching resulted in measurable improvement of ankle dorsiflexion. The patients had a substantial improvement in the function of the lower limb and considerable resolution of plantar fascial pain. Ninety-seven percent of the patients were able to avoid surgical treatment. These results suggest that stretching exercises for the Achilles tendon can be an important component in the initial treatment of plantar fasciitis. Close monitoring and specific instructions are necessary to ensure compliance with these protocols. Extracorporeal shock wave application was approved for the treatment of plantar fasciitis by the Food and Drug Administration in October 2000. This technique involves the application of a transducer that delivers electrohydraulically generated sonic waves into the origin of the plantar fascia. The procedure requires the use of anesthesia. Many studies on the effectiveness of this technique for the treatment of plantar fasciitis that is resistant to nonoperative therapy have been published in the past year. In a randomized, controlled, double-blind study, 56% more of the patients managed with shock wave therapy had a successful result, according to the four clinical evaluation criteria, at three months compared with those who had a placebo procedure8. In another study, Rompe evaluated the results of this technique at five years. He found that patients managed with shock wave therapy had improved function and decreased pain compared with those treated with a sham procedure. The need for surgical treatment was reduced from 68% in the control group to 13% in the group managed with shock wave therapy. Lateral Ankle Sprain Functional treatment of acute injury of the lateral ankle ligament has long been the standard therapy. Surgical repair has been suggested for the treatment of a ligament rupture in athletes. Pijnenburg reported on a prospective trial in which the treatment of lateral ligament rupture was evaluated. The patients were randomized to anatomic surgical repair or functional treatment. At an average of 7.7 years of follow-up, the patients managed with surgical repair had fewer reports of instability and recurrent sprain than did those managed with functional treatment. The anterior drawer test was positive less frequently in the surgically managed patients as well. Additional study is necessary before this treatment can be recommended. The modified Evans procedure for treatment of chronic instability of the lateral ligament involves tenodesis of part of the distal portion of the peroneus brevis tendon to the distal aspect of the fibula to stabilize the lateral aspect of the ankle and subtalar joint. An evaluation of the modified Evans procedure9 after an average of ten years of follow-up revealed a substantial prevalence of residual hindfoot stiffness and laxity. The rate of patient satisfaction, however, remained high. This procedure remains an important adjunct to anatomic repair in patients with insufficient ligamentous tissues. Diabetes Mellitus Complications related to the foot in patients with diabetes mellitus are a serious cause of morbidity and amputation in the United States. However, a substantial portion of patients with diabetes mellitus do not appreciate their risk for these complications. Poor foot care and improper shoewear are common habits that can have disastrous consequences. Other health problems, such as impaired eyesight and poor mobility of the back and hip, interfere with self-care of the foot. Low-cost screening, education, and instruction programs have been shown to improve compliance and should be a routine and continuing part of the medical care of these patients, but these programs are often underutilized by at-risk populations. Ulceration is a common complication of the neuropathy caused by diabetes. Treatment is based on the removal of necrotic and infected tissue, including bone, cartilage, tendon, and fascia. Various techniques, such as use of a total-contact cast to protect the wound from weight-bearing and from shoe-related pressure, encourage healing. The proper environment is promoted by dressings that keep the wound moist and absorb wound exudates, which contain proteases that retard healing. Becaplermin gel is a topical medication that contains recombinant human platelet-derived growth factor-BB. It has been shown to accelerate healing and improve the rate of success in properly managed diabetic ulcers. In a recent study, Abidi reported that viable fascia and tendon may be retained during treatment with becaplermin. Successful healing occurred even when these structures were exposed. The use of becaplermin gel remains a cost-effective adjunct in treating properly selected patients with resistant neuropathic ulcers. Controversy continues with regard to the appropriate treatment of fractures in the foot in patients with diabetic neuropathy. There is no question that such patients have more complications than do nondiabetic patients. Maiers-Yelden found that diabetic patients who sustained an ankle fracture were more likely to have infection, nonunion, or malunion and to require bracing than were age-matched controls. The need for amputation was also more frequent. When neuropathic changes occur and fixation fails after an ankle fracture, transarticular stabilization with use of retrograde intramedullary nailing is an effective means of promoting union10. Use of the ankle fusion nail, however, is associated with stress fracture of the tibia at the proximal nail tip. The author advocated insertion of a retrograde femoral nail into the proximal tibial metaphysis to circumvent this problem. Total Ankle Arthroplasty Progress toward an enduring and reliable prosthetic ankle arthroplasty was made during the past year. Refinements in the technique and design of all total ankle replacements continue, but no long-term results are yet available on the current designs. In a study comparing the preoperative and postoperative gait of patients managed with the Scandinavian total ankle replacement, Dyrby reported that ankle motion and moments improved and approached normal control values. Andersson demonstrated that 70% of patients managed with the Scandinavian total ankle replacement were satisfied with the result at a median follow-up of forty-eight months. Twelve patients (23%) needed a revision, which the authors attributed to "technical problems." Six of these patients had an arthrodesis, and six had an exchange arthroplasty. Proper placement of the ankle prostheses is a complicated and demanding technique. Myerson, in a study of patients managed with use of the Agility ankle replacement (DePuy, Warsaw, Indiana) noted a substantial learning curve when the results in the first twenty-five patients were compared with those in twenty-five subsequent patients. Perioperative problems, such as malleolar fractures and tendon lacerations, were reduced considerably in the subsequent patients. Wound complications were also noted to decrease in the patients treated later. The surgeons’ ability to optimally place the components improved. Immediate-term and long-term clinical data are necessary before this procedure should be in general use. Arthritis and Arthrodesis of the Hindfoot Arthrodesis of the ankle remains the gold standard for the treatment of symptomatic end-stage arthritis of the ankle. However, the long-term results of this procedure are controversial and often disappointing. Coester et al. reported that, at a mean of twenty-two years after ankle arthrodesis, all joints of the hindfoot and midfoot of the involved ankle had an increased prevalence of radiographic findings of arthritis compared with that on the contralateral side11. These findings translated clinically into substantial problems, resulting in limitation of activity, pain, and disability. Osteoarthritis of the knee, however, was not found more frequently. An extended hindfoot arthrodesis has been shown to be successful in salvaging severe hindfoot deformities. Myerson et al. reviewed the cases of thirty patients with a severe deformity of the hindfoot that was not amenable to treatment with a brace who were managed with a tibiocalcaneal arthrodesis with use of an adolescent blade-plate and supplemental bone graft12. Twenty-six patients had diabetic arthropathy, thirteen had ulcers, and eight had documented osteomyelitis. Complications were common, but fusion was achieved in twenty-eight patients (93%). All patients needed to wear a brace, and the leg-length discrepancy averaged 2.5 cm. In a separate multicenter study, patients, most of whom did not have neuropathy, were managed with tibiotalocalcaneal arthrodesis and were followed for an average duration of twenty-six months13. Thirty percent had postoperative complications. Most of the patients continued to have some pain and required a brace for walking. The rate of subjective satisfaction was 87%. These procedures appear to be effective for the salvage of severe hindfoot problems in properly selected and counseled patients. A high rate of complications should be anticipated. Primary tarsometatarsal osteoarthritis is an etiology of midfoot pain that is often overlooked. Davitt reviewed the radiographs of patients with this condition who underwent a midfoot arthrodesis. The length of the second metatarsal was increased relative to the first metatarsal compared with that in controls, which suggests that this problem may be related to excessive mechanical load on the second metatarsal during gait. Trauma The appropriate treatment of intra-articular calcaneal fractures is controversial. Many studies have failed to find an advantage associated with operative treatment. The studies are sometimes poorly controlled and do not take into account the wide variability of the severity of the calcaneal injury and the quality of operative reduction and soft-tissue management. Buckley, in a large multicenter, prospective, randomized trial, recently addressed this issue. Four hundred and twenty-four patients with an intra-articular calcaneal fracture were followed for between two and eight years. The patients were randomized to operative or nonoperative treatment. The results were stratified with use of multiple demographic factors. Overall, no difference was noted between the operative and nonoperative groups with respect to clinical outcome scores. Arthrodesis was required more frequently in the patients managed nonoperatively than in those managed operatively. Clinical results were improved in patients who had anatomic or nearly anatomic reductions. The author concluded that operative treatment was beneficial for female or for younger male patients who were not receiving Workers’ Compensation, had an occupation involving light labor, and had had a single intra-articular fracture line. The best approach for the treatment of pediatric calcaneal fractures is also unknown. An evaluation of the results of treatment of these injuries after a mean of twenty-two years revealed that patients who are less than fourteen years of age at the time of injury had a good result regardless of the method of treatment or the involvement of the subtalar joint. Treatment of children who are more than fourteen years of age should be more aggressive, since the prognosis for these fractures tends to be poor if intra-articular displacement is allowed to heal without reduction. Ankle fractures in geriatric patients are associated with an increased risk of complications compared with those in the general population. While anatomic restoration by surgical reduction and fixation is considered the standard of care for most unstable fractures, it is unclear whether this method of treatment in certain elderly patients is optimal. Togninalli reported that patients who were more than eighty years of age had a rate of complications of 50% and a mortality rate of 5%. However, in another study, Pagliaro et al. reported satisfactory results after operative treatment in patients who were more than sixty-five years of age14. Complications, including two that resulted in a below-the-knee amputation, occurred but were associated with comorbidities, such as diabetes, peripheral vascular disease, and fracture severity. In making a treatment decision with regard to an ankle fracture in a geriatric patient, the surgeon should consider the general health and activity demands of the patient, the quality of the bone, and the stability of the fracture pattern. Injury to the syndesmosis is a common component of an unstable ankle fracture. Classically, it has been assumed that the extent of damage to the interosseous membrane, a component of the syndesmosis, is related to the level of the fibular fracture. However, in a study of extremities with unstable ankle fractures that were evaluated with magnetic resonance imaging, Nielsen demonstrated that this is not always true. Ten percent of the fractures had identifiable membrane injury proximal to the fibular fracture. Fractures in which the injury to the interosseous membrane did not extend to the fracture were also identified. An intraoperative test of the syndesmosis, such as the Cotton test, should be performed in operatively treated ankle fractures when trans-syndesmotic fixation is not deemed necessary. Arthroscopic evaluation of ankle fractures has revealed that there may be intra-articular injuries to the talar dome in unstable ankle fractures. It has been suggested that routine arthroscopy may improve the clinical outcome of ankle fractures. A series of prospectively randomized patients with an operatively stabilized ankle fracture was reviewed, and chondral injury was found in eight of the nine patients who underwent ankle arthroscopy15. The clinical outcome was not improved by arthroscopic treatment of these injuries in this small series. Osteochondral Defects of the Talus A considerable number of reports on the treatment of osteochondral lesions of the talus have recently been published in the literature. The use of the traditional approach of arthroscopic débridement and microfracture has been challenged by newer techniques. Several approaches that have been proposed include mosaicplasty16, osteoarticular transplantation17, and autologous chondrocyte transplantation18. These techniques often require a procedure to harvest donor cartilaginous or osteocartilaginous tissue from the knee. Arthrotomy and malleolar osteotomy are usually necessary to place the grafts accurately into the recipient defect. Many authors have reported encouraging results at short-term follow-up. A good or excellent result was noted in 94% of patients at an average of four years after mosaicplasty16. Second-look arthroscopy demonstrated normal cartilage stiffness and congruent surfaces without evidence of degeneration. Biopsy revealed type-II articular cartilage. Lin, however, noted poor results with mosaicplasty techniques, with nearly universal recurrence of the lesion radiographically and no improvement in clinical scores postoperatively. Forefoot Deformities Initial treatment options for a painful hallux valgus deformity should include education of the patient with regard to appropriate shoe selection. When a patient has realistic expectations, surgical treatment is effective. In a randomized, prospective trial19, patients who had a distal chevron osteotomy and were followed for one year had improved function compared with that in control patients who were managed with observation or orthotic treatment. In another study20, the rate of patient satisfaction continued to be high after five years of follow-up. In contrast to previous data, patients who were more than fifty years old were also noted to have excellent results. Although motion at the metatarsophalangeal joint had been decreased at the two-year follow-up evaluation, it was equal to the preoperative value at the time of the five-year follow-up. The chevron osteotomy is a simple and effective method of treating mild-to-moderate hallux valgus and has a high rate of patient satisfaction. Patients with moderate-to-severe hallux valgus who were managed with crescentic proximal metatarsal osteotomy combined with distal soft-tissue reconstruction demonstrated excellent results at a mean of twelve years of follow-up21. More than 90% of the patients were satisfied with the results, and there was no evidence of decreased satisfaction over time. In this technique, attention to detail is crucial to avoid a dorsiflexion malunion at the site of the metatarsal osteotomy. The addition of a shortening osteotomy of the second and/or third metatarsal to this procedure is effective in treating hallux valgus with painful callosities beneath the lesser metatarsals22. Instability of the first tarsometatarsal joint has been increasingly recognized as an etiology of some cases of hallux valgus and recurrence of a bunion deformity after bunion surgery. King found that preoperative radiographic measures of tarsometatarsal mobility were higher in patients scheduled to undergo a Lapidus procedure. Treatment of hallux valgus that is secondary to a hypermobile first tarsometatarsal joint with a modified Lapidus procedure—that is, corrective arthrodesis of the tarsometatarsal joint in combination with a first metatarsophalangeal joint reconstruction—has been found to be reliable, although complications are not infrequent23. Coetzee found the procedure to be effective in treating symptomatic recurrence of hallux valgus. Congenital overlapping of the fifth toe is occasionally seen. Fortunately, many people with this problem are able to modify their shoewear to accommodate the deformity. When this approach is unsuccessful, patients who are managed surgically are often unsatisfied with the results. The classic treatment, the Ruiz-Mora procedure, which involves a proximal phalangectomy through a plantar approach, often results in an unsatisfactorily shortened, floppy toe. Prolonged swelling of the digit can follow release with use of a circumferential racquet incision. A dorsal z-plasty incision with periarticular soft-tissue release may be an effective alternative procedure. In a small series of patients managed with this technique, the cosmetic appearance was noted to be excellent and the deformity or instability of the toe did not recur24. Tarsal Tunnel Syndrome Surgical treatment of tarsal tunnel syndrome has not demonstrated the positive results seen with carpal tunnel release. Gondring retrospectively reviewed a series of patients with tarsal tunnel syndrome who had been treated surgically. While improvement in nerve conduction and clinical pain relief was marked, subjective assessment by the patients was less encouraging. The author attributed these findings to symptomatology of other comorbid foot and ankle diagnoses. Patient selection should be carefully considered when contemplating surgical treatment of tarsal tunnel syndrome. Other Issues in Foot and Ankle Surgery
Deep Venous Thrombosis
Surgical Preparation
Clinical Outcome Measures In an attempt to contrast postoperative with preoperative AOFAS score values, the authors of some studies have derived preoperative values from patient recall of preoperative symptoms. To test whether postoperative recall is valid, one study compared the preoperatively obtained AOFAS ankle-hindfoot score with that recalled by the patient following surgery25. The retrospectively acquired data underestimated the actual preoperative score by an average of 5 points. For 32% of the patients, it differed by 20 points. This finding strongly suggests that postoperative recall of preoperative symptoms is not scientifically valid. In a second study, a mathematical model was used to determine whether the AOFAS scales accurately reflected an idealized, theoretical distribution of data26. The resultant distribution demonstrated "bizarre, skewed behavior that bore little resemblance" to the original data. The author concluded that the small number of responses available on the scale potentially resulted in drastic differences in the score. It was calculated that increasing the number of rating intervals would substantially increase the precision of this instrument. Upcoming Meetings The following educational opportunities related to the treatment of foot and ankle problems should be noted: Fifth Biennial Foot and Ankle Symposium. 2002 April 20-21; Toronto, Ontario, Canada. Contact: Continuing Education, Faculty of Medicine, University of Toronto, 500 University Avenue, Suite 650, Toronto, ON M5G 1V7, Canada. E-mail address: ce.med@utoronto.ca. Fourth Congress of the European Foot and Ankle Society. 2002 April 4; Seville, Spain. Contact: Saucp Congresos, Virgen del Valle 26, 41011 Sevilla, Spain. E-mail address: Sayco@svq.servicom.es. Advanced Foot and Ankle Course: Reconstruction and Salvage of Complications. 2002 May 23-25; San Francisco, California. Contact: Kathleen Shepard. E-mail address: kathleen@aofas.org. American Orthopaedic Foot and Ankle Society Eighteenth Annual Summer Meeting. 2002 July 12-14; Traverse City, Michigan. Contact: Diane Fields. E-mail address: diane@aofas.org. First Triennial Meeting, International Federation of Foot and Ankle Societies. 2002 Sep 12-14; San Francisco, California. Contact: Diane Fields. E-mail address: diane@aofas.org. Surgery of the Foot and Ankle: A Symposium Honoring Roger A. Mann, MD. 2002 Oct 19; Stanford University, Palo Alto, California. Contact: Loretta Chou, MD. E-mail address: ml.lbc@forsythe.stanford.edu.
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