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© 2003 The Journal of Bone and Joint Surgery, Inc.
What's New in Foot and Ankle Surgery
Gregory P. Guyton, MD
The purpose of this review is to update the reader on current topics of interest in the foot and ankle community. It provides a brief overview of the material presented at the recent meetings of the American Orthopaedic Foot and Ankle Society (AOFAS) and the American Academy of Orthopaedic Surgeons (AAOS). Selected articles published in Foot and Ankle International and other journals since the last update are discussed as well. Some of the studies discussed last year have now passed the peer-review process and are emphasized again. Progress across the field continues to be stepwise and evolutionary; it is not surprising that the primary topics of interest have changed little over the last year.
The distal chevron osteotomy, the proximal metatarsal osteotomy, and the Lapidus procedure are appropriately regarded as mainstays in the treatment of adult hallux valgus. Much debate continues over the precise indications for each of the three procedures. Glasoe and colleagues introduced doubt into one critical decision-making step by examining the reliability of manual testing for first metatarsocuneiform instability 1 . They compared subjective clinical findings, as reported by a group of trained examiners, with measurements obtained with use of a previously validated mechanical apparatus in a series of fifteen subjects. The correlation between the instrumented measurements and the clinical assessment was poor (r = 0.21), calling into question the utility of the clinical assessment of first metatarsocuneiform instability when one is deciding whether or not to perform a proximal metatarsal osteotomy or a Lapidus procedure. To address another recurring question related to hallux valgus surgery, Thordarson and Krewer examined whether true osseous hypertrophy occurs at the medial eminence when a bunion develops 2 . They found no significant difference between a group of patients with hallux valgus and an age-matched control group without the disease with regard to the width of the medial eminence. Although their results do not rule out the possibility that soft-tissue hypertrophy contributes to the visible prominence of the bunion, they do confirm that an additional osseous reaction is not part of the pathology. In addition to the variations on proximal osteotomies, distal osteotomies, and fusions, a vast array of alternative bunion procedures have been described. The SCARF osteotomy of the first ray corrects a widened intermetatarsal angle through a long z-shaped cut in the shaft of the metatarsal. In theory, this osteotomy can achieve substantial correction while avoiding the complications of shortening that have been historically encountered in association with another long shaft osteotomy, the Mitchell procedure. Although the procedure is modeled after a common cutting pattern in woodworking and is well over seventy years old, it has enjoyed resurgent interest outside North America. Kristen et al. reported on a large retrospective series of eighty-nine patients in whom moderate to severe hallux valgus deformities were treated with the SCARF procedure 3 . The clinical results were encouraging: recurrent deformity occurred in 6% of the patients, and patient satisfaction was considered to be high after three years of follow-up. The literature awaits a direct comparison between the SCARF procedure and the proximal metatarsal osteotomy. At the opposite end of the spectrum, the once-common Keller procedure has more recently been held as a minimalist approach suitable only for the elderly, low-demand patient because it is considered to have a poor potential for correction and is associated with the possibility of creating a cock-up toe deformity. Donley et al. challenged this view in a report on their technique, which incorporates a lateral sesamoidectomy into the classic Keller resection arthroplasty 4 . The authors hypothesized that resection of the sesamoid relaxes the tight adductor mechanism and allows greater correction to be achieved. In their series of carefully selected patients, correction of the intermetatarsal angle was achieved and patient satisfaction was approximately 95%. Classic teaching has dictated that the first metatarsal should routinely be stabilized by fusion when multiple metatarsal head resections are performed as part of a forefoot reconstruction for inflammatory arthritis. This precept was taken beyond the anecdotal level by Thordarson et al., who reviewed the cases of eight patients (fifteen feet) in whom the first metatarsophalangeal joint was preserved at the time of the initial reconstruction 5 . Most of the joints were malaligned despite the absence of inflammatory erosions, and a variety of distal osteotomies were performed to realign the hallux. The vast majority of procedures went on to failure because of the development of new erosive changes at the metatarsophalangeal joint, severe hallux valgus deformity, or both. Metatarsal shortening osteotomies continue to draw attention as a utilitarian tactic with which to manage several pathological processes involving the lesser metatarsophalangeal joints. With this in mind, Petersen and colleagues examined the detailed anatomy of the blood supply to the lesser metatarsal heads 6 . Their arterial injection study indicated that much of the blood supply to the head enters through vessels closely applied to the bone at the sites of the collateral ligament attachments. Although osteonecrosis and collapse of the head fragment has not figured prominently as a reported complication of the procedure, they recommended that extensive capsular stripping along the medial and lateral sides of the metatarsal heads be limited as a precautionary measure.
The last decade has seen the gradual dissemination of the use of extracorporeal shock wave therapy for the treatment of plantar fasciitis. The technology is derived from devices developed for urologic lithotripsy in the 1980s. Small-scale European studies have supported the use of extracorporeal shock wave therapy for a variety of enthesopathies in the past, but recently a much broader range of evidence in support of the technique for plantar fasciitis has appeared. Rompe et al. reported the long-term results of an observer-blinded randomized trial of two different protocols of shock wave therapy 7 . The group that received three low-energy 1000-impulse applications had a notable improvement in visual analog pain scores at six months. No intermediate-term pain relief was seen in a separate group that received three applications of only ten impulses. Subsequently, five of the thirty-eight patients who received the 1000-impulse regimen underwent surgery within the next five years, whereas twenty-three of the forty patients who received the ten-impulse regimen underwent surgical release. The results of an American-based double-blinded randomized trial of 150 patients treated with a different regimen were also presented this year. The Dornier Epos Ultra device was used to apply a single twenty-minute session of directed extracorporeal shock wave therapy to the plantar fascia. Anesthesia is not required for this lower-energy device according to the manufacturer's specifications. Three months after treatment, the active treatment group demonstrated a 56% success rate on the basis of visual analog pain scale scores compared with a 45% success rate in the sham treatment group. No long-term comparative data were generated as the subjects were unblinded at three months and extracorporeal shock wave therapy was offered to all patients in the sham treatment group who had not improved. Further information has also recently been published on the use of the OssaTron, a higher-energy device. Regional anesthesia is required according to the manufacturer's published protocol for this machine. Ogden et al., in an FDA-approved randomized double-blind study of the device, found that 56% more of the treated patients had a successful result at three months, according to all four evaluation criteria, compared with patients who had been treated with sham procedures 8 . Alvarez, in a longer-term study of twenty patients who received a single treatment of 1000 shockwaves, noted that, at one year, eighteen patients had had improvement and indicated that they would undergo the procedure again 9 . In total, the weight of evidence now suggests that extracorporeal shock wave therapy is a safe modality that at least has a detectable clinical effect in the population of patients with chronic plantar fasciitis. This view was validated in a meta-analysis of eight studies in which 840 patients were followed for at least one year 10 . In the coming years, the foot and ankle community can hope for more information about treatment protocols and the relative efficacy of high-energy and low-energy devices.
The recent wave of interest in finding alternatives to ankle fusion has continued. Two recent gait-analysis studies outlined different facets of the problem and supported the view that adjacent joint pathology plays a critical role in the clinical problem of ankle arthritis. Daniels et al. reported significant differences in gait parameters when patients who had had an ankle fusion were compared with controls, despite a relatively high rate of patient satisfaction. They also noted a significant correlation between limited subtalar and midfoot motion and patient outcome as determined with use of the MODEMS (Musculoskeletal Outcomes Data Evaluation and Management System) and Ankle Osteoarthritis Scale instruments. Kitaoka and colleagues studied patients who had a clinical diagnosis of isolated ankle osteoarthritis prior to any surgical intervention. They demonstrated that limitations in a number of gait parameters (including sagittal, coronal, and transverse plane motion) were already present in these patients, suggesting that at least some of the late adjacent-joint hindfoot arthritis seen in long-term studies of ankle fusion may have begun prior to any intervention. Clare and colleagues delineated the extreme difficulties that can be encountered when adjacent-joint pathology is surgically addressed at the time of ankle arthrodesis. They presented a series of twenty-nine multiple-joint ankle and hindfoot fusions performed with use of compression screw techniques. Of the eighteen pantalar arthrodeses in the series, eight were followed by the development of a nonunion at the ankle joint. The results of the remaining procedures, which involved fusion of the ankle joint with one other joint, were no better, with five of eleven procedures followed by the development of a nonunion. The authors suggested that motion-sparing alternatives at the ankle may play a role in avoiding this dismal scenario. Joint distraction as a joint-sparing procedure for ankle arthritis has steadily drawn more attention. The procedure has been adapted to the ankle by van Roermund and his colleagues at Utrecht in The Netherlands. A fine-wire ring fixator is used to maintain as much as 5 mm of distraction of the involved ankle joint. Weight-bearing is allowed during the three-month period of treatment. The investigators expanded upon their previously published data 11 and presented a series of fifty patients with end-stage ankle arthritis with one year of follow-up. Improvement was not universal; thirteen of the fifty patients ultimately required arthrodesis. Nevertheless, approximately three-quarters of the patients demonstrated substantial clinical improvement and required no further surgical intervention. Brage et al. provided their first reports on a wholly different therapeutic direction. Those investigators presented a chart-review study of sixteen fresh tibiotalar "shell" allografts that were used for the treatment of severe ankle arthritis. In that technique, the ankle joint is biologically reconstructed with use of bulk osteoarticular allograft taken from both sides of a cadaveric ankle joint. The investigators believed that the use of total ankle replacement jigs to make matching cuts in the talus and tibia of both the recipient and the donor cadaver represented an important technical feature of the procedure. Two of the sixteen patients required conversion to fusion. This technique is experimental, and long-term follow-up data are not yet available. Total ankle arthroplasty continues to be performed with increasing frequency in this country. A two-piece mortise-replacing design, the Depuy Agility Ankle, is FDA-approved and is widely available. The FDA study for approval of a mobile-bearing three-piece resurfacing design, the Link STAR, is in the final stages of preparation. Both devices have shown early clinical promise that outstrips the performance of earlier designs 12,13 . Further clinical studies of both prostheses with use of modern follow-up outcome instruments are expected in the near future. Some concern has been raised about the potential for polyethylene component failure in association with current total ankle replacement designs. Nicholson and colleagues, in a component-loading model with use of an MTS machine, demonstrated that the peak contract stresses on the polyethylene surface of the Agility Ankle approached or exceeded the maximum recommended limits for the material in medical use. Their work suggests that as the longevity of ankle prostheses improves, close attention will need to be paid to the potential for polyethylene failure, a lesson already painfully learned by the orthopaedic community with regard to hip and knee arthroplasty.
The management of the adult acquired flatfoot deformity associated with posterior tibial tendon rupture or dysfunction continues to generate controversy. The disparities in clinical practice were highlighted by the results of a survey of academic foot and ankle surgeons as reported by Pinney et al. The transfer of the flexor digitorum longus to substitute for the function of the posterior tibial tendon remains the benchmark procedure, but a variety of procedures continue to be recommended to augment the technique. In the report by Pinney et al., these included lengthening of the gastrocsoleus complex (used by 75% of the respondents), medial displacement osteotomy of the calcaneus (used by 77% of the respondents), and distraction arthrodesis of the calcaneocuboid joint (used by 48% of the respondents). Fusion of the medial column was employed by 23% of respondents, while fusion of the subtalar or talonavicular joint was recommended by 12% of the respondents. Wacker et al. reported the intermediate-term results of flexor digitorum longus transfer combined with medial displacement osteotomy for the treatment of stage-II posterior tibial tendon pathology 14 . After a mean of fifty-one months, two of the forty-four procedures had failed and had subsequently been converted to calcaneocuboid fusion. Although functional outcomes were not individually reported, the overall ultimate subjective outcome was rated as good to excellent in all but one patient. Below and McCluskey presented the results of one of the less commonly used procedures for stage-II posterior tibial tendon pathology, the isolated talonavicular fusion. Their results were embedded in a larger series that also included patients in whom isolated talonavicular fusion was performed for the treatment of posttraumatic arthritis. They noted incomplete radiographic fusion in three of the eleven patients with posterior tibial tendon pathology who returned for follow-up. Only five of the eleven patients were either completely satisfied or satisfied with minor reservations, and a large number had degenerative changes in the subtalar joint at the time of follow-up. Even after excluding the dramatic limitations in hindfoot motion incurred by the procedure, the investigators believed that their experience with isolated talonavicular fusion had been poor enough to warrant its abandonment in the treatment of stage-II posterior tibial tendon dysfunction. Greisberg and Sangeorzan focused attention forward in the foot in their report on patients with adult acquired pes planus who were evaluated with simulated weight-bearing computed tomography scans. Those investigators demonstrated that medial column collapse occurred through the talonavicular joint in 20% of the feet, whereas it occurred through the naviculocuneiform joint in the majority of the remaining feet. The two patterns were almost mutually exclusive, with only one patient demonstrating a pattern of medial column collapse through both joints. Although the tarsometatarsal joints did not usually angulate, they did show a common tendency to subluxate dorsally. There was a substantial amount of degenerative disease on computed tomography scans that was not readily apparent on plain weight-bearing radiographs. Their findings lend credence to a growing body of thought that the universe of flatfoot pathology includes a great deal more subtle variation than can be accounted for in the commonly used staging system. It may very well be that the difficulties that the foot and ankle community has had in reaching consensus on the treatment of stage-II disease have more to do with the heterogeneous nature of this patient population than with the relative advantages of one procedure over another. Reconstruction of the midfoot following arthrodesis for primary or posttraumatic arthritis continues to be a mainstay of treatment. Pliemann et al. presented data that reemphasized the efficacy of the procedure in achieving pain relief but that also demonstrated, upon close examination, a higher rate of minor complications and radiographic nonunion than had previously been reported. They noted that ten of fifty-eight patients had at least one joint that failed to progress to union. In all cases but one, the nonunion occurred following attempted multiple-joint fusions rather than after an isolated single-joint procedure. Smoking was considered to be a contributory factor in six of the ten patients with nonunion. Importantly, the investigators also noted that radiographic evidence of nonunion of one joint of the midfoot does not doom a multiple-joint fusion to clinical failure. Only four of the ten patients underwent a revision fusion procedure. While fusion remains the accepted clinical standard for the treatment of disabling arthritis of the medial column, the far less common problem of pathology in the fourth and fifth tarsometatarsal joints remains an issue. Although the majority of patients with these problems can be treated nonoperatively, there are proponents of both fusion and resection arthroplasty when surgery is required. Berlet et al. recently reported on their experience with tendon interposition resection arthroplasty of the fourth and fifth tarsometatarsal joints 15 . Six of the eight patients who participated in follow-up indicated that they would undergo the procedure again. The authors noted that a positive preoperative diagnostic injection of the joint with local anesthetic appeared to correlate highly with the ultimate clinical result. Although the data are scant, that small series at least focused attention on the problem of lateral column pathology and highlighted the need for further work in this area.
Osteochondral lesions of the talus continue to present challenging problems for the foot and ankle specialist. While the modern standard treatment of arthroscopic débridement combined with drilling or microfracture can be effective in a large number of cases, many surgeons have begun to seek alternatives for larger or more problematic lesions. The osteochondral autograft transfer system, originally developed and applied to chondral defects within the knee, has been applied to the treatment of talar dome lesions. Gautier et al., in a study of eleven patients who were treated with this technique, reported good to excellent results according to the MODEMS instrument at a mean of two years 16 . Al-Shaikh and colleagues reported on a series of nineteen patients who were treated with the osteochondral autograft transfer system with use of the ipsilateral knee as a harvest site 17 . The sizes of the lesions in that series were quite large, and thirteen of the nineteen patients had had a previous failure of operative intervention. The subjective results were good, and seventeen of the nineteen patients indicated that they would undergo the procedure again. Two patients had mild knee pain at the time of follow-up. Also during the last year, Kolker and Wilson presented their experience with twenty-one patients who were treated in a similar fashion. At a mean of 20.5 months following the procedure, good to excellent results were noted for the ankle with use of the AAOS MODEMS outcomes instrument. Seven of the twenty-one patients had minor complaints related to the donor knee. The authors believed that the presence of a bipolar ankle lesion (a matching distal tibial plafond lesion associated with the talar dome lesion) portended a poor prognosis. Overall, the weight of the current evidence suggests that the osteochondral autograft transfer system procedure has reasonable efficacy, although no studies to date have directly compared the technique with simple arthroscopic débridement and microfracture. At least some concern remains over the potential for donor-site morbidity in the knee, although the studies to date have shown such complaints to be relatively minor. The literature also still suffers from the heterogeneity of the patient populations studied; some series have included mostly revision procedures performed after an earlier failed arthroscopic débridement, whereas others have included only primary procedures.
Recent studies have provided a greater understanding of the anatomic alignment issues that contribute to instability problems in the hindfoot. Berkewitz et al. presented data corroborating the earlier theory of Scranton et al. 18 that a fibula positioned posteriorly relative to the axis of the ankle in the mortise is associated with lateral ankle instability necessitating surgical repair. They reviewed computed tomography scans from sixty-eight patients who had undergone stabilization procedures and calculated the axial malleolar index (AMI), a measure of the relative position of the fibula, as described by Scranton et al. The AMI for patients who presented for surgical correction of lateral ankle instability was significantly higher than that for a control group of patients who had other indications for the imaging study. Van Bergeyk et al. recently presented data suggesting that overall hindfoot alignment may contribute to ankle instability as well 19 . They demonstrated a significant trend toward hindfoot varus when the simulated weight-bearing computed tomography scans of eleven patients with lateral ankle instability were compared with those of twelve unaffected control patients. Taken together, these studies suggest that subtle differences in osseous anatomy may play an important role in generating the clinical problem. Otis and colleagues addressed a discrepancy in the literature over whether the peroneus longus or the peroneus brevis is the more effective evertor. Their biomechanical study of six cadaveric feet indicated that identical loads that were sequentially applied to the peroneus brevis and peroneus longus in a custom jig resulted in consistently greater subtalar eversion from the peroneus brevis. The authors believed that these data might be valuable when determining which peroneal tendon should be partially or wholly harvested for use in reconstruction procedures performed for the treatment of instability. Tochigi and colleagues, in a biomechanical study of six cadaveric specimens, provided data to assist in the difficult clinical evaluation of subtalar joint instability. A custom jig was used to apply a 60-N displacing force to the calcaneus relative to the talus in a variety of axes both before and after sectioning of the interosseous talocalcaneal ligament. The maximum increase in motion of the subtalar joint following isolated sectioning of the ligament occurred along an axis running roughly from the anteromedial corner of the medial malleolus to a point just posterior to the fibula. The authors suggested that checking for laxity along this axis would maximize the chance of detecting this often subtle pathology clinically.
The number of approaches to the complex problems of diabetic ulceration and neuroarthropathy has continued to expand. A growing interest in the use of external fixation in the management of Charcot arthropathy is reflected by the publication of the report, by Farber and colleagues, on eleven patients with both neuropathic ulceration and Charcot changes 20 . A protocol of débridement, multiplanar osteotomy, and external fixation in addition to directed antibiotic therapy was used to achieve limb salvage. No patient progressed to amputation, and all but one returned to walking in therapeutic shoewear. Cooper et al. described a separate series of seventy-seven patients with both neuropathic ulceration and Charcot arthropathy. All patients were treated with a combination of ulcer débridement, multiplanar osteotomy to correct the deformities, and fine-wire fixator application to neutralize the construct. The fixators remained in place for a mean of ninety-one days. After a mean duration of follow-up of twenty months, no patient had had recurrence of ulceration. Clinicians interested in using external fixation for the treatment of neuroarthropathy should note the report by Pommer et al. 21 , who performed a randomized trial in which hydroxyapatite-coated Shanz half-pins were compared with standard titanium Shanz pins in another situation requiring prolonged external fixation, distraction osteogenesis. The group treated with hydroxyapatite-coated pins had a dramatically reduced prevalence of complications and infection. The data are likely to be equally applicable in the setting of Charcot arthropathy. External fixation is not universally advocated for reconstruction in all cases of Charcot arthropathy, and a variety of internal fixation techniques have been proposed. Sammarco et al. reported on their experience with salvage midfoot arthrodesis for Charcot arthropathy with use of long, large-diameter screws traversing from the hindfoot all the way into the medullary canal of one or more metatarsals. As expected, they noted excellent compression of the arthrodesis site during surgery. Osseous union was achieved in ten of their twelve patients, and there were no recurrent plantar ulcerations. The clinical importance of the equinus contracture that often accompanies long-standing diabetes was reemphasized by Johnson and colleagues. Those investigators performed a prospective, randomized trial in which percutaneous Achilles tendon lengthening followed by total contact casting was compared with total contact casting alone for the treatment of neuropathic forefoot ulcers. The addition of the Achilles tendon lengthening resulted in a fourfold reduction in the rate of ulcer recurrence. Although forefoot peak plantar pressures were temporarily reduced in the Achilles tendon lengthening group immediately following the procedure, they returned to baseline values within six months after treatment. This work validates the findings of earlier studies suggesting the importance of the tight gastrocsoleus complex in maintaining excessively high plantar pressures in the forefoot 22,23 . In a similar vein, Caselli et al. presented data evaluating the absolute values of peak forefoot and rearfoot pressures with use of an F-scan device as well as the ratio of the two values (the "F/R pressure ratio") in a thirty-month prospective cohort study of patients with diabetes and peripheral neuropathy 24 . The ratio of forefoot to rearfoot pressures was found to be a more sensitive predictor of foot ulceration during that period than the absolute pressure values were. These data again emphasize the likely importance of soft-tissue contracture in establishing the abnormal mechanical environment that potentiates foot ulceration. The forefoot-to-rearfoot ratio may be closely associated with the presence of shear forces in the forefoot that contribute to skin breakdown. Although iatrogenic complications associated with the use of the total contact cast are often feared, the actual prevalence of such complications was not reported until this year. Guyton reviewed 398 consecutive total contact casts and found a minor complication rate of approximately 5.5% per cast or 30% per course of casting. The presence of Charcot arthropathy was strongly associated with an increased risk of new cast-related skin problems, whereas biologic factors such as age, duration of diabetes, and type of diabetes were not. Although complications were relatively frequent, only one area of breakdown led to a single toe amputation. Guyton believed that adherence to a strict regimen of weekly cast changes, at least in the early course of contact casting, allowed these lesions to be addressed before they progressed. Interest has revived in early prosthetic fitting of below-the-knee amputees. Newly developed off-the-shelf temporary sockets involving the use of air bladder technology were evaluated in two recent studies. Schon et al., in a report on nineteen patients who were treated with one such immediate postoperative prosthesis, noted a diminished length of time to fitting with the first custom prosthesis and fewer wound complications when the study group was compared with a group of historical controls who had been treated at the same institution 25 . Pinzur and Angelico reported their experience with a prefabricated immediate postoperative prosthesis system in a series of eighteen high-risk patients with diabetes and/or nonsalvageable gangrene. In general, rehabilitation was thought to be accelerated. One patient required revision to an above-the-knee level because of ischemic wound failure, two patients died in the early postoperative period, and two patients had substantial wound breakdown due to shear forces. The authors believed that their data supported the use of a prefabricated immediate postoperative prosthesis even in this high-risk population. Navid et al. reported on the use of an osseous bridge, constructed from the fibula at the time of below-the-knee amputation, to enhance the end-bearing capacity of the stump. The procedure is a modification of the bridging osteomyoplasty originally devised by Ertl 26 . Twelve of twenty-one patients who underwent the procedure were available for follow-up. Although the operative time was somewhat increased compared with that of a standard below-the-knee amputation, no difference in the prevalence of surgical complications was noted. The study group demonstrated improved visual analog pain and function scale scores compared with a historical control group undergoing standard below-the-knee amputation at the same institution.
The marked degradation in outcome that is seen when operative complications are encountered during the treatment of calcaneal fractures has prompted some groups to return to manipulative reduction and minimally invasive fixation in select cases. Sangeorzan and colleagues reported on a series of patients who were treated with this protocol for tongue-type fractures. Twenty-one of the thirty-six patients were reviewed for follow-up. There were no infections or implant failures, and the average duration of hospitalization was 2.2 days. Overall outcomes, measured with use of the Foot Function Index, were at least in line with those seen after uncomplicated open reduction and internal fixation with use of an extensile approach and traditional plate fixation. The authors believed that their results indicated that minimally invasive reduction and fixation was sufficiently promising to warrant a future prospective investigation. To investigate whether age alone should play a role in planning the treatment of calcaneal fractures, Herscovici et al. presented the results for twenty-five patients over the age of sixty-five years who had been treated with open reduction and internal fixation at a major center. Twelve patients (48%) had substantial complications. Despite the high complication rate, the authors noted that none of the patients without substantial medical comorbidities had problems. The authors argued that calcaneal fracture surgery in the elderly should not be denied on the basis of age alone and that the patient's overall medical status should be the prime determining factor. The relatively uncommon injury of subtalar dislocation was the focus of a presentation by Bibbo et al. Of the twenty-three patients reviewed, twelve had a medial dislocation, seven had a lateral dislocation, and four had a dislocation that could not be classified on the basis of a chart review. The outcomes following subtalar dislocation were not as innocuous as has been reported previously. Surprisingly, three patients had development osteonecrosis of the talus, a previously unreported finding in this context. Seven patients required operative procedures for pain control; these procedures included four subtalar fusions and one ankle fusion. Most of the remaining patients demonstrated radiographic evidence of subtalar or adjacent joint arthrosis. The data demonstrate that although high-energy subtalar dislocations are clearly associated with poor outcomes, even low-energy "basketball foot" is not something to be dismissed. Debate continues over the proper method of fixation of the ankle syndesmosis, and there has been continued interest in bioabsorbable fixation. Hovis et al. reported a series of twenty-three patients in whom a syndesmotic disruption was fixed with 4.5-mm polylevolactic acid (PLLA) screws 27 . No failures of fixation were noted, and no complications of extensive osteolysis were encountered. No subsequent surgical procedures were required. The reported complication rate was lower than that encountered with other absorbable screw polymer formulations.
The American Orthopaedic Foot and Ankle Society (AOFAS) presents new research papers as well as educational symposia at its meetings. The annual summer meeting will be held on June 27, 28, and 29, 2003, on Hilton Head Island, South Carolina. The annual winter meeting will be held on Specialty Day, at the annual meeting of the AAOS, on March 10 through 14, 2004, in San Francisco, California. The AOFAS will sponsor a course on Sports Medicine of the Foot and Ankle, to be held on March 26 through 30, 2003, in Snowmass, Colorado. Further information is available from the American Orthopaedic Foot and Ankle Society, at www.aofas.org or 1-800-235-4855. The AAOS will sponsor a course on Advanced Techniques in Foot and Ankle Surgery, to be held on March 14, 15, and 16, 2003, in Rosemont, Illinois, and a course on Controversies and Practical Solutions in the Foot and Ankle, to be held on October 10, 11, and 12, 2003, in San Francisco, California. More information is available from the AAOS at www.aaos.org or 1-800-626-6726.
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