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© 2004 The Journal of Bone and Joint Surgery, Inc. What's New in Foot and Ankle Surgery
1 Department of Orthopaedic Surgery, Baylor College of Medicine, The Methodist
Hospital, 6560 Fannin, Suite 400, Houston, TX 77030
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
Since the introduction of the newer generation of total ankle prostheses for the treatment of ankle arthritis, surgeons have been evaluating their intermediate-term results and refining their technique. With the substantial learning curve, experienced surgeons are better able to define clinical pearls and pitfalls. Conti presented the intermediate-term results of 120 total ankle arthroplasties that had been performed with use of the Agility prosthesis (DePuy, Warsaw, Indiana)1. Although patients reported a high degree of satisfaction after an average duration of follow-up of four years, complications were well defined during this period. These complications included eight medial malleolar fractures and one lateral malleolar fracture. The prevalence of component malpositioning was 10%, the prevalence of postoperative varus positioning of the talar component was 7%, and the prevalence of syndesmotic nonunion was 3%. Another series demonstrated a substantial learning curve with a decreasing prevalence of well-defined complications after total ankle arthroplasty2. The senior author reported more complications in his first group of twenty-five patients (six minor wound complications, four nerve or tendon lacerations, and five intraoperative fractures) than in his second group of twenty-five patients (two minor wound complications and two fractures). The type of physician training does not have an impact on the results of total ankle arthroplasty3. Observing a total ankle arthroplasty performed by a surgeon-inventor, participating in a hands-on course in total ankle arthroplasty, or completing a one-year foot and ankle fellowship with exposure to total ankle arthroplasty all resulted in similar final outcomes after the initial total ankle arthroplasties performed by the reporting authors. Because of the complexity of this procedure, all of these authors recommended caution and careful planning when performing total ankle arthroplasty. Techniques for the improvement of total ankle arthroplasty are being investigated, particularly to reduce the rate of complications. Oxygen tensiometry may assist the surgeon in evaluating the risk of postoperative wound complications4. In one series, the use of a one-third semitubular fibular plate was shown to decrease the prevalence of syndesmotic nonunions5. Maintaining a good soft-tissue envelope is important not only for wound-healing but also for stability of the ankle after arthroplasty6. With the advancement of better techniques for total ankle arthroplasty, the rate of complications can be reduced, the quality of life can be improved, and the long-term survival of implants can be extended. With these advances, total ankle arthroplasty may prove to be cost-effective when compared with ankle fusion over time7.
A recent retrospective evaluation of twenty patients who had been treated nonoperatively and forty patients who had been treated operatively for Sanders type-II and III intra-articular calcaneal fractures showed no significant difference in functional outcome between the two treatment groups8. Patients in both treatment groups recorded the highest functional outcome scores in terms of walking on flat ground and less pain at night. Both groups also reported morning stiffness and running as the worst conditions. In contrast, another series supported acute operative fixation as a solution to the problem of a short, wide heel because it has the potential to avoid long-term stiffness and pain9. Techniques to repair intra-articular calcaneal fractures are evolving. The mainstay of treatment remains the lateral approach for open reduction and internal fixation with a plate and screws. One study demonstrated excellent results in association with a low-profile titanium calcaneal perimeter plate10. The authors reported that all forty-two intra-articular calcaneal fractures in the study healed without complications. Another technique involving the use of indirect reduction and small wire ring external fixation may be a viable alternative to open reduction and internal fixation11. The authors reported that all thirty-two calcaneal fractures that had been so treated healed uneventfully. Complications included superficial pin-track infections (which were easily treated with pin care and antibiotics) as well as one deep infection that developed in a patient with diabetes who had fracture blisters. Although technically difficult, this method avoids potential lateral wound complications, allows for immediate weight-bearing, and provides an alternative to primary subtalar fusion for extensively comminuted fractures.
Injuries to the Lisfranc joint complex often have serious long-term consequences. Patients with an isolated Lisfranc joint injury who undergo operative intervention after more than three months and those who have filed a Workers' Compensation claim can expect a poor prognosis. In the report by Calder and Saxby12, thirteen of forty-six patients had a poor outcome. Of the thirteen patients with a poor outcome, eleven had had a three-month delay in treatment and eleven had filed a compensation claim. The standard for fixation remains open reduction and internal fixation with transarticular screws. Cortical screw placement in the first three rays is essential in order to achieve medial column rigidity13. Biomechanically, the results of dorsal plating have been similar to those associated with the use of transarticular screws, with less disruption of the articular surfaces of the midfoot14. The results of primary complete arthrodesis (arthrodesis of all tarsometatarsal joints) have been inferior to those of open reduction and internal fixation with screws or partial arthrodesis (with the fourth and fifth tarsometatarsal joints being left unfused)15.
Numerous physical examination maneuvers can be used to evaluate a syndesmotic injury. Beumer et al., in a cadaveric study involving the use of displacement transducers, showed that one cannot clinically appreciate the degree of displacement occurring at an injured syndesmosis when using the Cotton test, the external rotation test, the squeeze test, or the fibula translation test16. Pain, not displacement, should be the outcome measure for the tests. When the syndesmosis is evaluated radiographically, the tibiofibular clear space is the most reliable parameter on plain radiographs. A cadaveric study showed that while other radiographic parameters changed, the size of the clear space was not significantly affected by rotation of the lower extremity17. One of us (M.S.M.) reported that, when surgical fixation of an ankle fracture is performed, the syndesmosis can be evaluated with use of a variation of the Cotton test18. With this intraoperative technique, a Key elevator is inserted into the syndesmotic region and a twisting force is applied to it. Under direct vision or with image intensification, any widening of the tibiofibular clear space demonstrates incompetence of the ligament complex. The usual method of fixation for a syndesmotic disruption involves the placement of a metallic screw across three or four cortices while the ankle is held in dorsiflexion. Recent research has explored alternatives. Sinisaari et al. reported no significant differences between one group in which a bioabsorbable screw had been placed across four cortices and another group in which a metallic screw had been placed across three cortices19. One cadaveric study supported the use of a syndesmotic staple as an alternative to transsyndesmotic screw fixation20. Another cadaveric study showed no significant differences in the range of motion of the ankle when a syndesmotic screw was placed with the ankle held in dorsiflexion or plantar flexion21.
When addressing the problem of Achilles tendon rupture, the physician must consider the various treatment options and apply them to the appropriate patients. Surgical repair remains the treatment of choice for younger, active adults. Nonsurgical treatment is a proven option for patients who decline surgery or who are poor candidates for surgery. In their recent study on Achilles tendon injury in rabbits, in which one group was treated nonsurgically with an orthosis and two groups were treated surgically, Thermann et al. found no histological, immunohistological, or ultrasonographic differences in tendon-healing at twelve weeks22. In their series of thirty-nine patients (forty ruptures) who were managed with an immediate full-weight-bearing short-leg equinus cast, Josey et al. reported a 6.25% rate of rerupture and found no significant differences in terms of calf circumference, range of motion of the ankle, or measured plantar flexion strength when the involved limb was compared with the noninjured limb after an average duration of follow-up of fifty-five months23. The rate of patient satisfaction was 95%, and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was >80 points in 97.4% of the patients. Other studies have evaluated various surgical techniques. A biomechanical study on fresh-frozen sheep Achilles tendons showed no significant difference in initial pullout strength between a Bunnel-type suture and a Krackow locking loop but demonstrated that a Kessler suture could be pulled out of the tendon with less force24. A cadaveric study defined parameters for selecting the location at which to harvest the flexor hallucis longus tendon for an Achilles tendon repair25. Harvesting the flexor hallucis longus at the ankle provided adequate length for fixation through a drill-hole in the calcaneus and should be used when muscle strength is primarily needed. Harvesting the flexor hallucis longus at the medial aspect of the midfoot provides more length, but not enough for multiple weaves across the tendon defect. A prospective series of twenty-five patients in whom an Achilles tendon repair was done with a minimally invasive suture system showed excellent results, no rerupture, and no sural nerve injuries after a minimum duration of follow-up of one year26. The authors of that study used a small horizontal incision rather than the originally described longitudinal incision. Patients also underwent an accelerated rehabilitation program with a brace for six weeks postoperatively. Another study demonstrated excellent results in association with a pull-out wire technique, although that approach required a second operative procedure to remove the wire27.
There are several advantages associated with the use of bioabsorbable implants in orthopaedic surgery28. They do not require removal, and there is less stress-shielding because the implants are composed of material that is less rigid than that of metallic implants. Also, they are radiolucent and do not generate x-ray scatter on magnetic resonance imaging or computed tomographic scanning. Thus, there has been an increasing popularity of bioabsorbable implants. As mentioned previously, excellent results have been reported in association with the use of bioabsorbable screws for the fixation of syndesmotic injuries19, and other authors have supported this concept29. Recent reports have supported this type of fixation for the treatment of Lisfranc injuries30. One report on 100 elective forefoot operations showed good results in association with the use of bioabsorbable implants31. The authors noted that a failure of fixation occurred in two of sixteen patients who had had a chevron osteotomy and that a deep infection occurred in one of four patients who had had a Scarf osteotomy of the fifth metatarsal. As good results continue to be reported for this fixation method, its use and the support for its use are expected to increase.
Bone graft remains an important supplement to foot and ankle surgery, particularly when used to span osseous defects, to treat complex fractures, and to perform effective arthrodeses. While the gold standard remains autogenous cancellous bone graft, the location for obtaining that graft has been the subject of recent debate. The iliac crest has always been the site of an ample supply of bone, and one recent retrospective report showed minimal morbidity and demonstrated the optimal nature of the bone graft material that was obtained32. However, the morbidity that has been noted in other reports has led to the identification of different sources of autogenous bone. One study demonstrated low added morbidity and adequate graft material when autogenous cancellous bone was taken from the proximal part of the ipsilateral tibia33. The authors of another study supported harvesting local bone graft from the distal part of the ipsilateral tibia or from the ipsilateral calcaneus and reported no major complications such as fractures, neuromas, or chronic pain affecting function34. A recent cadaveric study investigated the possibility of developing rotational bone grafts by identifying the previously unnamed blood supply to the distal part of the tibia, the distal part of the fibula, the cuboid, and cuneiforms35. Finally, a recent study of four different bone-graft substitutes demonstrated that a successful result was achieved after twenty-four of twenty-eight procedures36.
Plantar fasciitis remains the most common cause of heel pain. The condition is thought to be an inflammation of the plantar fascia, and yet its cause remains unknown. Some have suggested that plantar fasciitis is related to arch malalignment, although a recent study did not support this supposition37. Other research efforts have explored the development of plantar fasciitis. One study suggested that heel pad thickness may be related to the development of plantar heel pain in active patients, regardless of body mass index, although a cause-and-effect relationship was not certain38. Nonsurgical treatment of plantar fasciitis remains the standard. Stretching, heel cushions, shoe stiffening, and night splints are all part of the regimen to relieve pain. Anti-inflammatory medications can be helpful. Immobilization in a weight-bearing cast for four to six weeks often allows severe, recalcitrant cases to subside. Corticosteroid injections are painful and should be done with caution because of the possibilities of heel pad atrophy and plantar fascial rupture. For the patient who does not respond to conservative measures, shock wave therapy (orthotripsy) has become a noninvasive option for the treatment of plantar fasciitis. Currently, only two forms of orthotripsy are available in the United States: electrohydraulic (high-energy) orthotripsy and electromagnetic (low-energy) orthotripsy. Each form theoretically uses the energy of the shock wave to disrupt scar tissue, thereby allowing new blood-vessel formation and healing39,40. Wang et al. investigated the effects of electrohydraulic (high-energy) shock wave therapy, performed with use of the OssaTron device, in a study of seventy-nine patients (eighty-five heels) with plantar fasciitis41. After one year of follow-up, 75.3% of the patients were complaint-free and another 18.8% were significantly better. No complications were reported. Alvarez reported on twenty patients (twenty heels) who were treated with the OssaTron device42. After one year of follow-up, no complications were noted and eighteen of twenty patients reported improvement or were pain-free. In a meta-analysis of the literature supporting the use of shock wave therapy, Ogden et al. reported a success rate of >80% in most studies that involved the use of high-energy shock wave therapy40. Thus, this treatment has shown promising results. Surgical options for the treatment of plantar fasciitis that is resistant to conservative treatment include endoscopic and open fasciotomy. Endoscopic release allows for smaller incisions and less dissection. Its proponents have stated that the plantar fascia is directly visualized so that only the thickened portion is released43. In one series, all seventeen patients reported marked improvement and satisfaction with endoscopic release after sixteen months of follow-up, although three patients required corticosteroid injections for complete relief of the pain44. Recent reports on open complete plantar fasciotomy in conjunction with tarsal tunnel release for chronic plantar fasciitis with neuritic symptoms45 and on open partial plantar fasciotomy with release of the nerve to the abductor digiti minimi46 showed 90% and 77% rates of good and excellent results, respectively, after more than two years of follow-up.
The devastating effects of diabetes on the foot and ankle are well known. The treatment of ulcers in diabetic patients includes local wound care and relief of pressure on the affected area. Pressure can be relieved with use of orthotic devices or total contact casting. Total contact casts reduce plantar pressures by redistributing the weight-bearing load through the calf47. Pressure relief can be augmented in a total contact cast with an appropriate terminal cast device. In one study, forefoot pressures were significantly decreased in patients who wore a total contact cast along with either a conventional cast shoe (EBI, Parsippany, New Jersey) or a rigid rocker cast shoe (NPS, St. Louis, Missouri)48. Midfoot pressures were decreased maximally with the addition of any of the terminal cast devices studied (cast shoe, rigid rocker shoe, rubber rocker heel [Cast Walker; DM Systems, Evanston, Illinois], and traditional flat rubber heel [Zimmer, Warsaw, Indiana]). Hindfoot pressures were lowest in association with the rubber rocker heel or the flat rubber heel. Another study supported the use of a diabetic walking boot as an alternative to total contact casting49. When pressure relief fails, there are other options with which to promote healing or to salvage limb length. Vacuum Assisted Closure (Kinetic Concepts, San Antonio, Texas), a negative-pressure technique, has been emerging as an excellent means of reducing the size of nonhealing foot ulcers. One study demonstrated that treatment with Vacuum Assisted Closure resulted in a significant reduction in wound size, allowing for full healing, secondary healing with granulation tissue, or secondary healing following the application of a split-thickness skin graft50. Salvage of foot length depends on adequate preparation and management of wounds. One study series showed that a high salvage rate can be achieved in association with the use of modern wound-healing and reconstructive techniques, such as revascularization (when indicated), adequate débridement, hyperbaric oxygen, soft-tissue flaps, and skin grafts51. Another study showed that although patients with diabetes require more procedures for closure than patients without diabetes do, muscle flaps and free flaps can heal with the same success and at the same rate in patients with and without diabetes52. Treatment alternatives for Charcot arthropathy include total contact casting and primary fusion. One study supported the use of non-weight-bearing total contact casting early in the course of Charcot arthropathy to avoid late deformity53, while another suggested that early primary fusion is the answer54. Other surgeons reserve fusion for use as a salvage procedure55, but the goal of both treatment options is clear—a patient who is capable of walking in extra-width, extra-depth shoes with an accommodative orthosis.
In a retrospective review of 160 patients who had had a hindfoot arthrodesis, the relative risk of nonunion was 2.7 times higher for patients who smoked than for patients who did not smoke56. The authors divided their patients into three groups—those who had smoked before and after surgery, those who had quit smoking before surgery, and those who had never smoked. Patients who had quit smoking before surgery had a slightly higher rate of nonunion than nonsmokers did, but this difference was not significant. Questions regarding the ability to participate in sports after surgery are commonly posed to orthopaedic surgeons. One recent study examined participation in elite sporting activities after lower extremity fusion57. Data were obtained with use of a questionnaire that was sent to members of the AOFAS. Most surgeons who replied supported a selective participation policy, depending on the joint fused. Suggested guidelines for participation in sports after arthrodesis were given. As a whole, surgeons believed that patients with a fusion of a smaller joint (such as the interphalangeal joint of the great toe) could return to their sport and with the proper medical care could return to an elite level of performance. Patients with a larger joint fusion or a more complex fusion (such as a triple arthrodesis or an ankle arthrodesis) should avoid high-impact sports. Recent reports have examined the use of intramedullary devices to achieve tibiocalcaneal fusion. Rodriguez and Watson, in a retrospective review of fifty-eight patients, reported an 85% rate of osseous union after a minimum duration of follow-up of three years58. The authors supported the use of an intramedullary device for salvage procedures as an alternative to primary amputation. Farber and DeOrio, in a report on a small series of six patients who underwent fusion with use of a second-generation intramedullary device with compression across the fusion site, reported that all patients had a successful fusion and were able to walk59. A biomechanical study on intramedullary nail length confirmed that with a short fusion nail, a focal area of strain (possibly leading to a stress fracture) occurs adjacent to the proximal interlocking screw60. Increased strain also was noted in the posterior part of the tibia during knee flexion. Ankle arthrodesis is a challenging surgical procedure, and nonunion is a known complication. Two studies on the use of revision ankle arthrodesis for the treatment of nonunion showed promising results with use of different techniques. In the first series, ten patients had a revision ankle arthrodesis with use of a unilateral external fixator combined with bone-grafting and an implantable bone stimulator61. Fusion occurred in all ten patients at an average of 12.8 weeks after the revision surgery. In the second series, eighteen patients had a revision ankle arthrodesis because of nonunion, malunion, or infection62. Crossed compression screws were used for sixteen patients and, in this subset, a 93.8% union rate was achieved. The time required to achieve fusion after revision arthrodesis was longer than that after primary arthrodesis (4.6 compared with 2.7 months).
A gait-analysis study of patients with posterior tibial tendon dysfunction confirmed abnormal kinematics and function during walking63. That study examined hindfoot and ankle motion in three planes: the coronal plane (inversion-eversion), the transverse plane (external-internal rotation), and the sagittal plane. Although motion was not different in the sagittal plane, patients with posterior tibial tendon dysfunction had significantly less dorsiflexion than did normal controls. The authors concluded that patients with posterior tibial tendon dysfunction had abnormal kinematics in all three planes. Current research is focusing on the surgical treatment options for adult acquired flatfoot. Medial displacement calcaneal osteotomy is an effective technique for improving the alignment and biomechanics of the hindfoot. One cadaveric study showed the effects of this procedure on Achilles tendon strain and plantar foot pressures64. The authors concluded that while there was no significant increase in strain on the Achilles tendon following medial displacement calcaneal osteotomy, pressure did increase on the lateral aspect of the plantar part of the forefoot. The increase in lateral forefoot pressure suggests that osteotomy alone may not be sufficient to correct all of the pathological changes associated with posterior tibial tendon insufficiency. Another cadaveric study showed that medial displacement calcaneal osteotomy is an effective option for correcting alignment in patients with flatfoot65. However, total correction was not achieved, even when a flexor digitorum longus transfer was added. Medial column procedures are also being investigated. A retrospective study of sixteen patients who underwent medial column fusion (either naviculocuneiform or tarsometatarsal fusion) showed excellent correction of the lateral tarsometatarsal angle, talonavicular coverage, and calcaneal pitch as seen on radiographs66. Two of the sixteen patients had a nonunion. A second study was performed to investigate the use of a plantar flexion opening-wedge medial cuneiform osteotomy for the correction of forefoot varus associated with flatfoot deformity67. The authors concluded, on the basis of clinical and radiographic follow-up, that forefoot varus is adequately corrected and first-ray mobility can be preserved with this technique. Eleven patients with an average duration of follow-up of 15.5 months described mild or no pain with walking. No nonunions or malunions were noted on the follow-up radiographs.
A recent study demonstrated that patient expectations regarding bunionectomy play a definite role in outcomes and satisfaction68. Questionnaires were sent to 120 patients, and the replies were recorded. The findings showed that expectations and age may influence the choice of operation in patients with hallux valgus. Patients less than forty years of age placed more importance on shoe wear and improving function, whereas patients more than sixty years of age were more concerned about pain in the other toes than they were about pain over the bunion. Patients between forty and sixty years of age were more concerned with the appearance of the great toe. Men desired improvement in walking ability and the ability to return to work. Women desired to wear different shoes and to return to work. Thus, understanding a patient's preoperative expectations is important for improving the clinical outcome of bunion surgery. Another recent study examined the outcomes and results of hallux valgus surgery69. This multicenter study investigated 328 patients, and their experiences both before and after surgery, as recorded on the foot and ankle module of the American Academy of Orthopaedic Surgeons (AAOS) outcome questionnaire. The patients' physicians also completed a questionnaire preoperatively and postoperatively. Four of the ten SF-36 scales (physical function, role-physical, bodily pain, and role-emotional) changed by >5 points. Significant improvement was also noted with regard to physical health and pain (as defined in the AAOS outcome questionnaire), satisfaction with symptoms, the global foot and ankle score, and shoe comfort. A prospective cohort study demonstrated that the Lapidus procedure is a good alternative for the treatment of moderate to severe metatarsus primus varus and hallux valgus70. In that series, 126 feet in 110 patients were followed for an average of 3.7 years. Significant improvements were noted in terms of the AOFAS Hallux Metatarsal Interphalangeal Scale score (from 47.5 to 87.8) and the Visual Analog Pain Scale (from 6.2 to 1.3). The rate of patient satisfaction was 81%, and rate of tarsometatarsal nonunion was 4%.
During 2002, the editorial staff of The Journal reviewed a large number of research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over forty medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eleven level-I articles were identified that were relevant to foot and ankle surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
The American Academy of Orthopaedic Surgery (AAOS) and the American Orthopaedic Foot and Ankle Society (AOFAS) promote education and the presentation of research projects at their annual meetings. The Twentieth Annual Summer Meeting of the AOFAS will be held in Seattle, Washington, on July 29 through 31, 2004. Upcoming courses include the Advanced Foot and Ankle Course, to be held on April 22 through 24, 2004, in Baltimore, Maryland, as well as the Complete Foot Care Course, to be held on May 14 through 16, 2004, in New Orleans, Louisiana. Also upcoming this year is the Innovations in Foot and Ankle Surgery course, to be held on October 15 through 17, 2004, in Chicago, Illinois, and the First Annual American Orthopaedic Foot and Ankle Society Resident and Fellow Conference, to be held on July 28, 2004, in Seattle, Washington. For more information, contact the AOFAS at 1-800-235-4855 (or online at www.aofas.org) or the AAOS Customer Service at 1-800-626-6726 (or online at www.aaos.org).
Achilles Tendon Rupture Kauranen K, Kangas J, Leppilahti J. Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical study about early functional treatment vs. early immobilization of Achilles tendon in tension. Foot Ankle Int. 2002;23:600-5. The authors evaluated thirty patients in whom an acute, complete, closed Achilles tendon rupture was repaired with Kessler sutures with an aponeurosis flap. The patients were randomized to treatment with immobilization in a plaster cast or an active brace. Measurements were made at twelve and twenty-four weeks postoperatively. There were no significant differences between the involved extremity and the contralateral, uninvolved lower extremity, regardless of immobilization technique, with regard to reaction time, speed of movement, tapping speed, anterior-posterior coordination, or lateral coordination at twenty-four weeks. Lateral coordination in the plaster-cast group was better than that in the active-brace group at twelve weeks, but this difference was not present at twenty-four weeks.
Ankle Injuries The authors reviewed seventeen studies involving a total of 1950 mostly young, active, adult males. Outcome measures were variously defined, and data for pooling for individual outcomes were only available for a maximum of eleven studies. The authors concluded that there were no significant differences between conservative and surgical treatment with regard to three primary outcome measures (nonreturn to preinjury level of sports, undefined pain or pain with activity, and subjective or functional instability) after modification of the analyses with use of the random effects model. There also was no significant difference with regard to ankle sprain recurrence, the other primary outcome measure. Van Der Windt DA, Van Der Heijden GJ, Van Den Berg SG, Ter Riet G, De Winter AF, Bouter LM. Ultrasound therapy for acute ankle sprains. Cochrane Database Syst Rev. 2002;1:CD001250. None of the four placebo-controlled trials that were reviewed by the authors demonstrated a significant difference between true and sham ultrasound therapy for any outcome measure after seven to fourteen days of follow-up. The authors concluded that the extent and quality of the available evidence regarding the effects of ultrasound therapy for acute ankle sprains is limited. Kerkhoffs GM, Struijs PA, Marti RK, Assendelft WJ, Blankevoort L, van Dijk CN. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;3:CD002938. The authors reviewed nine trials involving 892 participants with regard to the results of different functional treatment methods for acute lateral ankle ligament injuries. Use of a semirigid ankle support resulted in a shorter time to return to work compared with use of an elastic bandage. Participants who wore a lace-up ankle support had less persistent swelling at short-term follow-up when compared with participants who wore a semi-rigid ankle support, elastic bandage support, or tape support. Tape treatment resulted in significantly more complications, usually skin irritation, when compared with treatment with an elastic bandage. Pijnenburg AC, Glas AS, De Roos MA, Bogaard K, Lijmer JG, Bossuyt PM, Butzelaar RM, Keeman JN. Radiography in acute ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision rules. Ann Emerg Med. 2002;39:599-604. The authors evaluated 647 patients with a painful ankle after trauma. They diagnosed seventy-four ankle fractures (forty-one of which were clinically important) with the Ottawa Ankle Rules and with two local Dutch ankle rules in an effort to validate each set of diagnostic criteria. The Ottawa Ankle Rules had a sensitivity of 98% for the identification of clinically important fractures, whereas the local rules had sensitivities of 88% and 59%. Use of the Ottawa Ankle Rules also resulted in fewer radiographs being ordered compared with the other two sets of rules. The authors concluded that the Ottawa Ankle Rules are the most suitable for implementation in The Netherlands.
Plantar Fasciitis A prospective, randomized, blinded study of ninety-four patients (122 affected heels) was performed in an effort to determine the optimal duration and frequency of Achilles tendon stretching exercises to reduce the pain associated with painful heel syndrome. The patients were randomized into two groups. One group performed sustained stretches (three minutes, three times daily). The second group performed intermittent stretches (five sets, twenty seconds each, two times daily). The outcome measures were increased Achilles tendon flexibility and decreased pain. Both types of stretching increased flexibility and decreased pain. There was no significant difference in outcome between the two groups. Both types of stretching were effective nonsurgical treatments for painful heel syndrome. Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R. Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. Foot Ankle Int. 2002;23:309-13. In this study, extracorporeal shock-wave therapy was compared with a conservative regimen (consisting of nonsteroidal anti-inflammatory medications, use of a heel cup, use of an orthosis, local steroid injections, and electrotherapy) for the treatment of chronically painful proximal plantar fasciitis. Forty-seven patients (forty-nine feet) who had had a failure of at least six months of conservative treatment were randomized into two groups. The first group (twenty-five heels) underwent immediate extracorporeal shock-wave therapy with three sessions performed at weekly intervals, and the other group (twenty-four heels) continued to be treated conservatively for another twelve weeks. No significant differences in pain or walking time were seen after twelve weeks of conservative treatment in the second group. The patients in the second group then were managed with the extracorporeal shock-wave therapy protocol. Both groups had improved visual analog scale scores and increased comfortable walking time after extracorporeal shock-wave therapy. Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am. 2002;84:335-41. The authors compared two methods of administering low-energy shock-wave therapy. Group I (forty-nine patients) underwent three applications of 1000 impulses of low-energy shock waves, and Group II (forty-eight patients) underwent three applications of ten impulses of low-energy shock waves. At six months, the visual analog scale scores for Group I were significantly better than those for Group II. In addition, twenty-five of the forty-nine patients in Group I were able to walk without pain at six months, compared with zero of the forty-eight patients in Group II. By five years, many of the patients in Group II had had surgery, thus improving the overall outcomes in Group II and decreasing the differences between the groups. The authors concluded that treatment with three applications of 1000 impulses of low-energy shock waves appears to be effective therapy for plantar fasciitis and may help patients avoid surgery for heel pain.
Diabetes This author evaluated five randomized, controlled trials on methods of débridement of diabetic foot ulcers. Three trials involved the use of a hydrogel débridement technique, and the pooled data suggested that hydrogels are significantly more effective than gauze or standard care for the treatment of diabetic foot ulcers. The other trials that were evaluated were small and did not have significant results. Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C, Maciejewski ML, Yu O, Heagerty PJ, LeMaster J. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287:2552-8. The authors evaluated 400 diabetes patients with history of foot ulcers randomized into three groups. One group (121 patients) received three pairs of therapeutic shoes and three pairs of custom cork inserts with a neoprene closed-cell cover. The second group (119 patients) received three pairs of therapeutic shoes and three pairs of prefabricated, tapered polyurethane inserts with a brushed nylon cover. The control group (160 patients) wore their usual footwear. The main outcome measure was foot reulceration. The two-year cumulative rates of reulceration were low in all three groups (15%, 14%, and 17%, respectively). Therapeutic shoes and custom cork or preformed polyurethane inserts conferred no significant reduction in the rate of ulcer recurrence compared with the rate in the control group. van Schie CH, Whalley A, Armstrong DG, Vileikyte L, Boulton AJ. The effect of silicone injections in the diabetic foot on peak plantar pressure and plantar tissue thickness: a 2-year follow-up. Arch Phys Med Rehabil. 2002;83:919-23. Twenty-eight patients with diabetic neuropathy were randomized into an active treatment group (fourteen patients), in which six injections of 0.2 mL of liquid silicone were given under the metatarsal head sites with callus, and a placebo group (fourteen patients), in which equal volumes of saline solution were injected. Plantar tissue thickness and plantar pressures were measured at three, six, twelve, and twenty-four months. Plantar tissue thickness remained increased in the silicone group at twelve and twenty-four months. Plantar pressure was reduced in the silicone group at twelve months but not at twenty-four months. However, when considered along with the measured increase in plantar pressure in the placebo group at twenty-four months, the baseline plantar pressure in the silicone group at twenty-four months showed that the silicone may still retain some pressure-reducing properties.
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Total Ankle Arthroplasty
Calcaneal Fractures