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The Journal of Bone and Joint Surgery (American). 2005;87:909-917. doi:10.2106/JBJS.D.02955 © 2005 The Journal of Bone and Joint Surgery, Inc.
What's New in Foot and Ankle Surgery?
1 Department of Orthopaedic Surgery, University of New Mexico, Health Sciences
Center, MSC10 5600, 1 University of New Mexico, Albuquerque, NM 87131-0001.
Email address for R.A. Miller:
rmiller{at}salud.unm.edu
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
The following is a summary of research related to the subspecialty of foot and ankle surgery that was published or presented between July 2003 and June 2004. The sources of these studies were The Journal of Bone and Joint Surgery, Foot and Ankle International, and the proceedings of the Winter and Summer meetings of the American Orthopaedic Foot and Ankle Society (AOFAS) (held on March 13, 2004, in San Francisco, California, and on July 29 through 31, 2004, in Seattle, Washington).
Functional recovery of the ability to operate the foot controls of an automobile was addressed by Egol et al. with use of a driving simulator1. A group of patients who had undergone operative fixation of a right ankle fracture were compared with normal controls. The patients had been managed with a functional brace, non-weight-bearing, and early range of motion prior to testing, which was done six, nine, and twelve weeks postoperatively. Total braking time was significantly impaired at six weeks, but it had returned to near normal by nine weeks. Injury to the superficial peroneal nerve may result in persistent pain after ankle fracture. Redfern et al. examined 120 patients with malleolar fractures one to three years after the time of the injury2. A symptomatic superficial peroneal nerve injury was found in 21% of the patients who had been managed operatively and in 9% of those who had been managed with a cast. The mean AOFAS ankle-hindfoot score was decreased in the patients who had a symptomatic nerve injury. None of the patients in the operative treatment group who had been managed with a posterolateral approach to the fibula had a nerve injury. The authors concluded that surgeons should be aware that this nerve is at risk during the lateral approach to the fibula and that injury to this nerve can be identified as a cause of chronic ankle pain after ankle fracture. Moore et al.3 reported on 127 patients in whom a syndesmotic disruption was stabilized with use of fully threaded cortical screws that were placed through either three or four cortices. After an average of 150 days of follow-up, there was no difference between the groups with regard to loss of reduction, screw breakage, or the need for hardware removal. While there was a trend toward a higher rate of loss of reduction in the group in which the screws had been placed through three cortices, it appears that syndesmotic disruption can be stabilized equally well with either three or four-cortex fixation.
Open reduction and internal fixation of talar body fractures may improve alignment and articular congruity and may allow for early joint motion; however, a review of talar body fractures revealed a high rate of osteonecrosis, posttraumatic arthritis, and poor outcomes4. Open fractures and talar body fractures that were associated with a talar neck fracture tended to have the worst prognosis. The extended lateral incision is a popular approach for open reduction and internal fixation of calcaneal fractures. With this approach, an L-shaped incision is created over the lateral part of the hindfoot and full-thickness flaps are elevated over the lateral part of the calcaneus. Wound complications associated with the extended lateral approach remain a concern. An alternative incision for the treatment of calcaneal fractures is the modified Palmer lateral approach. This approach involves a straight incision beginning 1 cm distal to the tip of the lateral malleolus and extending toward the base of the fourth metatarsal. Gupta et al. reported satisfactory fracture alignment and a low rate of wound complications in association with the use of the modified Palmer lateral incision for the treatment of calcaneal fractures5. Heier et al., in a study of forty-three open calcaneal fractures, reported an overall infection rate of 37% after a protocol of early débridement, irrigation, and stabilization6. Open reduction and internal fixation or fusion was performed in selected cases after the wound was clean and soft-tissue swelling had diminished. The authors reviewed wound size, wound location, fracture pattern, and internal fixation in an attempt to correlate these factors with the outcome. They concluded that type-I and II open fractures that are associated with a medial wound can be treated with open reduction and internal fixation, whereas type-II open fractures that are associated with a nonmedial wound and type-IIIA open fractures should be treated with external fixation or limited percutaneous lag-screw fixation. External fixation was recommended for type-IIIB fractures because of the high complication rate in patients with such injuries, who may require multiple operations for the treatment of wound problems. Six of the thirteen patients in that study who had a type-IIIB open fracture eventually underwent amputation. Rammelt et al. reported on ten patients who had secondary surgical reconstruction following a talar fracture7. Five of these patients had a malunion, two had a nonunion, and three had partial avascular necrosis with either a malunion or a nonunion. Twenty-six months after the reconstruction, all patients but one were fully satisfied and the mean Maryland Foot Score had increased from 41 to 87. Swords et al. evaluated the prognostic value of computerized tomographic classification systems for calcaneal fractures in a study of thirty-five patients who had been followed for more than two years after the injury8. The computerized tomographic scans were classified according to the systems of Crosby and Fitzgibbons, Eastwood, and Sanders. All patients completed the Musculoskeletal Functional Assessment questionnaire to measure functional outcomes. The most predictive measure was the operating surgeon's overall impression of the severity of the fracture. The Sanders classification system was the most reliable of the three grading systems. The results of delayed open reduction and internal fixation of calcaneal fractures were evaluated by Shank et al.9. Twenty patients who had undergone open reduction and internal fixation at least twenty-five days after the injury were identified. Eighteen patients were available for study after an average duration of follow-up of twenty-six months, and none of them had undergone a subtalar arthrodesis.
Nonoperative treatment is the standard of care for most acute lateral ankle sprains. Recurrent instability with laxity can be treated with the Brostrom procedure of ligament repair. The Gould modification of the Brostrom procedure allows the surgeon to augment the repair by suturing the inferior extensor retinaculum to the fibula10. Mechanical testing of fresh cadaveric feet showed a mean 58% increase in torque to failure in feet that had been treated with the Gould modification as compared with those that had been treated without augmentation6. Coughlin et al. reported on twenty-nine ankles that underwent ligamentous reconstruction with use of a free gracilis tendon graft harvested from the ipsilateral knee11. All patients had an excellent or good result, without any adverse effect on ankle or subtalar range of motion. Talar tilt was reduced from a mean of 13° to 3°, and anterior drawer was reduced from a mean of 10 mm to 5 mm. The mean AOFAS score improved from 57 to 98. The authors promoted this procedure as a method for stabilizing the lateral part of the ankle without compromising the function of the peroneal tendons. Hintermann et al.12 evaluated fifty-two ankles that were treated surgically because of medial instability. All had medial gutter pain, fourteen (27%) had posterior tibial tendon pain, and thirteen (25%) had pain along the anterior border of the lateral malleolus. Lateral ankle instability was also noted in forty ankles (77%). Posterior tendon abnormality (but not rupture) was noted in twelve (23%). The deltoid ligament was reconstructed in all ankles, the spring ligament was repaired in thirteen (25%), and the lateral ligaments were repaired in forty (77%). A calcaneal lengthening osteotomy was carried out in fourteen legs (27%). At an average of 4.4 years of follow-up, the result was judged to be good or excellent for forty-seven ankles (90%) and the average AOFAS hindfoot score had improved from 42.9 to 91.6.
The effects of diabetes on the foot are well documented. Ulceration, infection, amputation, and neuroarthropathy are common complications. Smith et al. followed 400 patients with diabetes mellitus for two years13. During this time-period, eleven patients required lower limb amputation. While only one amputation was related to footwear, six amputations were the result of minor environmental trauma resulting in a break of the skin. Diabetic patients who are at risk for foot ulceration and infection include those who lack protective sensation. Saltzman et al. found that screening for protective sensation could be done with a 4.5-g monofilament beneath each first metatarsal head14. If the patient cannot detect this monofilament, then protective sensation is probably lost. This relatively simple and time-efficient test has a high sensitivity and can alert physicians to at-risk patients. Options for the treatment of plantar foot ulceration in a patient with diabetes include walking cast-boots and total contact casting. The study by Crenshaw et al. demonstrated that varying the position of the ankle in a walking cast-boot changes the pressure distribution on the forefoot and hindfoot15. Decreased forefoot pressure was seen in association with ankle plantar flexion, and decreased hindfoot pressure was seen in association with ankle dorsiflexion. The study by Hartsell et al. demonstrated similar reduction of plantar pressure in association with the use of a plaster-based total contact cast when compared with a fiberglass-based total contact cast16. Both of those studies were performed in healthy subjects. The rate of recurrence of forefoot ulcers after total contact casting is high17. In a study of thirty-one patients with limited ankle dorsiflexion, Achilles tendon lengthening was shown to decrease this recurrence rate by 52% at two years18. Granberry19 reported on thirty-five patients at an average of twenty-three months after amputation of the first toe or ray. Only 10% (one) of ten ischemic limbs healed primarily. Following great-toe amputation, common complications included deformity of the second toe. Two of fourteen patients with an amputation at or proximal to the metatarsophalangeal joint had development of ulcerations under the second metatarsal. Katz et al.20, in a randomized, prospective study, reported on the treatment of neuropathic ulcers with either a total contact cast or a removable cast walker that was rendered irremovable by wrapping with a single strip of fiberglass cast material. No demonstrable differences in healing time or complications were observed. The so-called instant total contact cast was found to be equally as effective as the total contact cast while also being quicker, easier to apply, and more cost-effective. Baumhauer et al.21 studied the etiology of Charcot arthropathy by examining tissue samples from twenty feet. Excessive numbers of osteoclasts were found to be lining the resorptive bone lacunae. All of the specimens exhibited immunoreactivity to IL-1 (interleukin-1), IL-6 (interleukin-6), and TNF-alpha (tumor necrosis factor-alpha), with moderate or diffuse reactivity. These findings bring into question the traumatic etiology of Charcot arthropathy and support bone resorption as the primary event.
The plantar aponeurosis is essential to foot biomechanics. It transmits Achilles tendon forces from the hindfoot to the forefoot during the stance phase of gait22. Most patients with plantar fasciitis complain of pain and tenderness in the area of the medial tubercle of the calcaneus. Pain is usually worse with the first steps when arising, and it worsens with increased weightbearing activity. Riddle and Schappert reported that approximately one million patient visits per year are made to medical doctors because of plantar fasciitis23. Visits to podiatrists were not included in this estimate. It was estimated that 62% of visits are made to primary care physicians and 31% are made to orthopaedic surgeons. In an examination of the factors associated with disability related to plantar fasciitis, Riddle et al. found that increased body-mass index was the only variable that was significantly associated with increased disability24. The activities most affected were running-related activities and the patients' usual work and hobbies. Non-weight-bearing activities and household activities of daily living were least affected. Numerous nonoperative modalities are used in the treatment of plantar fasciitis. Among them is stretching. DiGiovanni et al., in a study of patients with chronic heel pain, found that tissue-specific plantar fascia stretching was associated with improved results when compared with weight-bearing Achilles tendon stretching25. High-energy extracorporeal shock wave treatment with use of an Ossa Tron device (HealthTronics, Marietta, Georgia) has been given the term Orthotripsy. This form of treatment is an option for patients with plantar fasciitis who continue to have pain after multiple nonoperative modalities (such as nonsteroidal anti-inflammatory medications, night splints, stretching exercises, orthotics, walking casts, shoe modifications, and injections) have been employed. Alvarez et al., in a study involving the use of Orthotripsy for the treatment of recalcitrant plantar fasciitis, reported a satisfactory result in 83% of patients at one year after one or two treatments26. The duration of symptoms had minimal impact on the result of Orthotripsy. A 76% rate of satisfactory results was reported for patients in whom symptoms had been present for more than two years. Placebo treatment was associated with a 55% rate of satisfactory results. Lee et al. reported similar results regardless of whether or not a heel spur was present on radiographs27. The rate of satisfactory results was 82% for patients with plantar fasciitis and a heel spur and 79% for patients with plantar fasciitis and no heel spur. The heel spur did not disappear after treatment. Levy et al.28 retrospectively reviewed the charts and radiographs for 157 consecutive patients (216 heels) who had presented with nontraumatic plantar heel pain. For 212 heels, the radiographs that had been made at the time of the initial office visit did not contribute to the patient's care. The radiographs of the remaining four heels demonstrated an abnormal finding that required further work-up. The authors recommended that plain radiographs be reserved for patients who do not improve as expected or who present with unusual symptoms or physical findings.
Posterior tibial tendon dysfunction is a cause of acquired adult flatfoot deformity. Stage-II posterior tibial tendon dysfunction is characterized by a nonarthritic flatfoot deformity with hindfoot valgus that is mobile and passively correctable. Several operative procedures have been employed to correct the deformity and to restore function to the foot. A survey of academic foot and ankle surgeons revealed a wide variety of approaches used for the treatment of a typical case of stage-II posterior tibial tendon dysfunction29. The most common approach (used by 38% of the respondents) was to perform a medializing calcaneal osteotomy combined with posterior tibial tendon augmentation with use of the flexor hallucis longus or the flexor digitorum longus tendon. The second most common surgical approach (used by 22% of the respondents) was to perform a medializing calcaneal osteotomy combined with lateral column lengthening and posterior tibial tendon augmentation. Nine percent of surgeons employed a subtalar arthrodesis. In a study in which medializing calcaneal osteotomy alone was compared with medializing calcaneal osteotomy combined with lateral column calcaneal lengthening osteotomy, Choung et al. found a high rate of satisfaction in both groups30. Each group included twenty patients who were followed for a minimum of two years. In the group treated with the medializing osteotomy alone, 90% of the patients were satisfied or very satisfied and the average AOFAS score was 90.4. In the group treated with a medializing osteotomy combined with lateral column lengthening, 94% of the patients were satisfied or very satisfied and the average AOFAS score was 83.7. Pain and stiffness on the lateral side of the foot were more common in patients managed with the combined procedure. The addition of posterior tibial tendon augmentation instead of tendon débridement for the treatment of stage-II deformity was recommended by Valderrabano et al.31. This group showed the potential for some recovery of the posterior tibial muscle after surgical treatment with side-to-side augmentation with the flexor digitorum longus tendon. Brodsky reported on twelve patients with stage-II posterior tibial tendon dysfunction who were managed with flexor digitorum longus tendon transfer to the navicular, medial displacement calcaneal osteotomy, and spring ligament reconstruction32. Gait analysis, performed preoperatively and at one year postoperatively, revealed improvements in step length, cadence, velocity, and maximum sagittal ankle joint power at push-off.
Although many procedures have been described and are utilized for the treatment of hallux valgus, refinements continue to be made in order to improve outcomes and minimize complications. Feighan et al. reported that improved postoperative sesamoid position could be obtained in association with the use of a modified distal soft-tissue release through the metatarsophalangeal joint33. In patients managed with chevron osteotomy alone, the prevalence of sesamoid subluxation of grade-2 or greater was decreased from 81% preoperatively to 51% postoperatively. In patients managed with distal soft-tissue release combined with chevron osteotomy, the rate of sesamoid subluxation improved from 76% preoperatively to 9% postoperatively. Postoperative AOFAS scores were better in the group of patients with improved sesamoid position. Many surgeons consider hypermobility of the first ray to be an indication for first tarsometatarsal arthrodesis when addressing hallux valgus deformity. In the study by Faber et al., clinical hypermobility of the first ray did not affect the outcome for patients who had been randomized to treatment with either a distal metatarsal osteotomy (Hohmann procedure) or a first tarsometatarsal joint arthrodesis (Lapidus procedure)34. Both groups had an average 20° improvement of the metatarsophalangeal joint angle and an average 8° improvement of the intermetatarsal angle. There were no significant differences between the two treatment groups or between patients with and without hypermobility with regard to improvement in the mean AOFAS score, the reduction of pain, or the rate of satisfaction. An osteotomy that has not gained widespread popularity in the United States is the Scarf or z-type metatarsal osteotomy. Choung et al.35 described a series of thirty-four feet that had been treated with such an osteotomy and fixation with two 2.7-mm screws, followed by immediate weight-bearing in a postoperative shoe. Overall, 70.6% of the patients were satisfied with the result and 23.5% were satisfied with reservations. Recurrence of deformity occurred in two feet. The complication of transfer metatarsalgia after hallux valgus surgery can be minimized by avoiding shortening and dorsiflexion of the first metatarsal. Jung et al., in a cadaveric study, determined plantar forefoot pressure before and after metatarsal osteotomies36. The authors reported a significant decrease in pressure beneath the first metatarsal and increased pressure beneath the second metatarsal after a 5-mm dorsal closing-wedge first metatarsal osteotomy and after 5-mm and 10-mm shortening osteotomies. The Keller procedure (proximal phalangeal resection arthroplasty) has limited indications and generally is not recommended for younger active patients. Recurrent hallux valgus, cock-up deformity, and transfer metatarsalgia are known complications of this procedure. Machacek et al., in a study from Austria, reviewed the results of salvage procedures (arthrodesis, a repeat Keller procedure, or soft-tissue release) that had been performed after the failure of a Keller resection arthroplasty37. Excellent or good results were obtained in twenty-three of the twenty-nine feet that had an arthrodesis but in only six of the twenty-one feet that had a repeat Keller procedure or soft-tissue release. Radl et al. determined the rate of venous thrombosis after hallux valgus surgery in a study of 100 patients38. These patients had no risk factors for thrombosis, and they underwent phlebography at a mean of twenty-nine days postoperatively. Distal deep venous thrombosis occurred in four patients. No patient had a clinically recognized pulmonary embolism. There was a significant association between the rate of thrombosis and an age of more than sixty years. The authors concluded that the need for (and method of) prophylaxis against deep venous thrombosis should be determined individually for each patient according to his or her own risk factors.
Both operative and nonoperative treatment of Achilles tendon ruptures can be successful. Wound problems continue to be the major potential complication associated with operative treatment. Bruggeman and Turner, in a review of 165 consecutive open Achilles tendon repairs, reported seventeen wound complications (prevalence, 10.3%)39. Ten were treated nonoperatively, and two required soft-tissue coverage. A relatively increased risk of wound problems was noted in association with tobacco use, steroid use, and female gender. A trend toward an increased risk was seen in patients with diabetes. A wound complication occurred in eight (42.1%) of nineteen patients with two or more of the above risk factors, compared with nine (6.2%) of 146 patients without risk factors. Percutaneous repair has been advocated by some authors as a method for securing the tendon and allowing early mobilization while minimizing potential wound complications. Gorschewsky et al., in a review of sixty-six patients who had been managed with percutaneous repair of an acute Achilles tendon rupture, reported no wound complications, although one patient sustained a rerupture as a result of trauma three weeks after the procedure40. Haji et al. reported similar results and complication rates in a study comparing open and percutaneous Achilles tendon repairs that had been performed over a fourteen-year period41. Josey et al., in a study on the nonoperative treatment of Achilles tendon ruptures, reported a 95% rate of satisfactory results42. The patients in the study were managed with an equinus cast with a heel buildup and were allowed immediate weight-bearing as tolerated. After two months, the patients wore a shoe with a heel rise. At the time of follow-up, there was no significant difference in plantar flexion strength between the injured and uninjured limbs. The rate of rerupture of the Achilles tendon was 6.3% (three of forty-eight). The authors estimated the total cost of this form of treatment to be $1000. Wallace et al., in a study on the effectiveness of a nonoperative treatment protocol that was developed in Northern Ireland, reported an excellent or good result in 120 (86%) of 140 patients43. The patients were managed with an equinus cast within twenty-four hours after the diagnosis of an Achilles tendon rupture. They remained non-weight-bearing for four weeks, after which they were managed with a rigid polypropylene double-shell patellar-tendon-bearing orthosis molded in 15° to 20° of plantar flexion. The orthosis could be worn during weight-bearing and was removed for range-of-motion exercises. The overall complication rate was 8%, but close supervision by an experienced physician was thought to be important.
In the past year, several studies addressed the treatment of Achilles tendinosis. This entity is characterized by pain, tenderness, and thickening of the Achilles tendon. The tendinosis may be insertional, a condition that is commonly associated with ossification within the tendon, or it may occur proximal to the insertion. Achilles tendinosis should be differentiated from Haglund deformity, which is a bone prominence emanating from the superior portion of the posterior calcaneal tuberosity. Haglund deformity causes pain in the region of the retrocalcaneal bursa that can be increased in association with shoewear and activity. Nonoperative treatment of Achilles tendinosis includes modification of activity, use of heel lifts, stretching, and use of anti-inflammatory medication. Corticosteroid injection is controversial because of concerns about Achilles tendon rupture following injection. Hugate et al., in a study of rabbits, reported that intratendinous injections of corticosteroid significantly weakened the Achilles tendon44. Additionally, injections into the retrocalcaneal bursa resulted in a significant decrease in Achilles tendon strength. The injections were given weekly for three weeks, and the tendon was harvested four weeks after the last injection. Gill et al. reviewed the results of corticosteroid injections in patients with Achilles tendinopathy45. In that study, fluoroscopically guided injections were placed in a peritendinous position and not within the tendon substance. Most commonly, 10 to 20 mg of triamcinolone and 0.25% bupiv-acaine was utilized. Forty-three patients were available for evaluation after a minimum duration of follow-up of two years. Forty percent of the patients reported improvement, 53% thought that their condition was unchanged, and 7% thought that their condition was worse than it had been before the injection. No ruptures of the Achilles tendon or other major complications occurred. In a double-blind study from Australia, topical glyceryl trinitrate patches that were applied for six months were found to be more effective than a placebo for the treatment of chronic noninsertional Achilles tendinopathy46. Patients who received the medicated patch had significantly reduced pain with activity at six months. Seventy-eight percent of the thirty-six tendons in the medicated group were asymptomatic with activities of daily living, compared with 49% of the forty-one tendons in the placebo group. Leitze et al. reported that endoscopic decompression was an effective alternative to open decompression for the treatment of Haglund deformity and retrocalcaneal bursitis47. With the patient prone, a hooded burr was used, under fluoroscopic guidance, to resect the osseous prominence of the calcaneus through a medial portal. The average AOFAS ankle-hindfoot score improved from 61.8 points preoperatively to 87.5 points postoperatively. The scores after the endoscopic procedure were numerically, but not statistically, better than those after the open procedure. The endoscopic procedure was associated with fewer complications than the open procedure was. McBryde et al. reported on thirty patients (thirty-two heels) who were managed with endoscopic osseous and soft-tissue decompression for the treatment of retrocalcaneal bursitis48. Twenty-five patients had an excellent result, and three had a good result. Two patients had a complication; specifically, one patient had an Achilles tendon rupture, and one patient had residual pain that necessitated a second operative procedure.
Roberts et al. reviewed the causes of end-stage ankle arthritis in a study of 435 patients49. All patients had had a failure of nonoperative treatment. A review of the records revealed that 58% of the ankles had posttraumatic arthritis due to a fracture, 13% had inflammatory arthritis, 18% had chronic instability and recurrent sprains, and 11% had osteoarthritis. The osteoarthritis was often due to malalignment secondary to clubfoot, Charcot-Marie-Tooth disease, tibial malunion, and other entities. Surgical options for the treatment of end-stage arthritis include arthrodesis and total ankle arthroplasty. Both procedures have been reported to result in a high rate of patient satisfaction and similar ankle function scores50. A limitation of arthrodesis has been the subsequent development of degenerative changes in adjacent joints, such as the subtalar and talonavicular joints51. Proponents of total ankle arthroplasty postulate that maintenance of ankle motion will protect these joints from the development of arthritis. With total ankle arthroplasty, however, the need for activity limitation and the potential for implant failure remain a concern. Because of the bone resection that is required for total ankle arthroplasty, conversion to ankle fusion after a failed arthroplasty is more complicated than primary ankle fusion is. Saltzman and colleagues reviewed the seven to sixteen-year results of 132 total ankle arthroplasties that had been performed by Dr. Alvine, the inventor of the Agility total ankle prosthesis (DePuy, Warsaw, Indiana)52. More than 90% of the patients reported decreased pain and were satisfied with the outcome. Progressive hindfoot arthritis occurred in <25% of the ankles. Fourteen of the 132 ankles required removal or replacement of one or both of the metal components or arthrodesis. Thirty-eight secondary operations were required; these procedures included syndesmosis screw removal (seventeen ankles), triple arthrodesis (three), subtalar arthrodesis (three), and calcaneal osteotomy (two). The results of the study were encouraging, but the consistent talar subsidence raised questions as to the longer-term results. Miller et al. reported that clinically successful total ankle arthroplasty led to an increase in step length and walking speed as demonstrated with use of gait analysis performed preoperatively and one year after surgery53. The Agility total ankle arthroplasty has been associated with improved outcomes when there is successful fusion of the syndesmosis53. This helps to buttress the tibial component, which is larger than the surface of the plafond alone. Sanders et al. reported a syndesmosis nonunion rate of 8% prior to the development of a new method to facilitate the arthrodesis54. With this new technique, which was successful in all sixteen patients in whom it was used, an oblique fibular osteotomy is created proximal to the syndesmosis screws to decrease the motion that occurs with loading an intact fibula. Total ankle arthroplasty has a steep learning curve55. Potential contraindications that have been discussed include recent joint infection, insufficient bone stock, severe malalignment, diabetes, peripheral vascular disease, peripheral neuropathy, and poor wound-healing potential56,57. Young patients and patients with a high level of activity should also be considered for fusion rather than arthroplasty; in the report by Spirt et al., younger age was shown to have an adverse effect on both the reoperation rate and the failure rate after total ankle arthroplasty58. Faux and Smith reviewed the results of ankle arthrodesis after a minimum duration of follow-up of ten years (average, fifteen years) and reported that 91% of the patients were definitely satisfied with the fusion and that 75% had a neutral opinion or were somewhat or very satisfied with the current symptoms59. Radiographic evidence of moderate to severe arthritis was present in 64% of the subtalar joints and 18% of the talonavicular joints. Three patients required additional hindfoot arthrodeses.
Cosmetic foot surgery has been the topic of several newspaper and magazine articles throughout the past year. This type of surgery is performed solely to change the appearance of the foot. The American Orthopaedic Foot and Ankle Society performed a public survey on this topic, the results of which were released at the American Academy of Orthopaedic Surgeons meeting in San Francisco. The AOFAS has issued a position statement against this type of surgery60. Foot surgery to realign deformities such as bunions and hammertoes is associated with a high rate of satisfactory results when performed because of pain, dysfunction, and reduced quality of life. However, there is the potential for surgical complications, resulting in pain, dysfunction, and the possibility of recurrent deformity. Therefore, it is the position of the AOFAS that, in the absence of pain, surgery should not be performed simply to improve the appearance of the foot.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 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, ten 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.
Continuing medical education is offered by both The American Academy of Orthopaedic Surgeons (www.aaos.org) and the American Orthopaedic Foot and Ankle Society (www.aofas.org). The AAOS course entitled Foot and Ankle Trauma Management will be offered simultaneously in Charlotte, North Carolina, and Garden Grove, California, on June 11, 2005. Diagnostic and Treatment Strategies for the Foot and Ankle will be offered in Phoenix, Arizona, on November 11 through 13, 2005. Opportunities offered through the AOFAS include Sports Medicine of the Foot and Ankle, to be held on April 27 through May 1, 2005, in Scottsdale, Arizona, and the Twenty-first Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, to be held on July 15 through 17, 2005, in Boston, Massachusetts.
Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br.2003 ;85:324 -9. The authors performed ankle arthroscopy on fifty-two patients with ankle injuries to observe the status of the syndesmotic ligaments. The authors then compared the arthroscopic findings with the findings on preoperative anteroposterior and mortise radiographs and magnetic resonance imaging scans to determine their sensitivity, specificity, and accuracy in providing direct evidence of syndesmotic ligament injury. The arthroscopic findings that were considered to be diagnostic of syndesmotic ligament injury were (1) tibiofibular instability of >2 mm to stress, (2) an abnormal course or discontinuity of the anterior or posteroinferior tibiofibular ligament, and (3) a decrease in the tension of either of these two ligaments. Neither indirect evidence of syndesmotic injury on plain radiographs nor stress radiographs were considered. Syndesmotic ligament injury was not distinguished from syndesmotic instability after fracture fixation. All modalities (anteroposterior radiographs, mortise radiographs, and magnetic resonance images) were 100% specific for the diagnosis of a tear; however, magnetic resonance imaging was more sensitive and accurate than plain radiography. This study confirmed the ability of magnetic resonance imaging to visualize ligamentous injury with excellent specificity, without the potential complications of an invasive procedure. Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, van Dijk CN. Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial. J Bone Joint Surg Br.2003 ;85:525 -30. Consecutive patients with rupture of at least one lateral ankle ligament were randomly assigned to receive either operative treatment (by an orthopae-dist) or functional treatment (by a general surgeon). These patients were evaluated in a nonblinded fashion at twelve weeks and six years. Compared with functional treatment, operative treatment was associated with a slightly but significantly (p < 0.05) better result in terms of residual pain, recurrent sprains, and stability. Operative treatment was associated with much higher costs. Although not performed in this series, selective delayed operative stabilization was considered to be another reasonable option for the treatment of recurrent sprains. The results of this study are consistent with the finding of residual pain in a substantial number of patients with ankle sprains who are treated nonsurgically. A more aggressive, surgical regimen for healthy patients with severe sprains might be appropriate, although more studies need to be done. Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ.2003 ;327:75 . In this randomized, double-blind trial based in Germany, 135 participants who received extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis were compared with 137 patients in a placebo control group in whom the lithotriptor signal was cleverly blocked from reaching the foot. At twelve weeks, the success rate was 35% in the shock wave therapy group and 30% in the placebo group. Similar results were present in both groups at one year, and the authors concluded that extracorporeal shock wave therapy is ineffective for the treatment of plantar fasciitis. The findings of this study are somewhat different from those of the study by Hammer et al. that was reviewed in this Update last year, which showed some improvement in visual analog pain scale scores and comfortable walking time in patients who were managed with extracorporeal shock wave therapy for the treatment of plantar fasciitis. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;3:CD000416 . The authors conducted a meta-analysis of nineteen published reports involving 1626 patients and concluded that the trial quality was generally poor. They also concluded that there is limited evidence regarding the effectiveness of local corticosteroid therapy but that the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomized, controlled trials. More studies are clearly needed to evaluate treatments of this common orthopaedic complaint. Limiting the use of treatments that are associated with potentially significant complications appears to be appropriate at this time. Tsang MW, Wong WK, Hung CS,
Lai KM,Tang W, Cheung EY, Kam G, Leung L, Chan CW, Chu CM, Lam EK. Human
epidermal growth factor enhances healing of diabetic foot ulcers.
Diabetes Care.2003
;26:1856
-61. The authors conducted a randomized, controlled, double-blind study of sixty-one diabetic patients with foot ulcers that were treated with an Actovegin cream and routine foot care alone or in combination with human epidermal growth factor at a concentration of either 0.02% or 0.04%. The higher dose of human epidermal growth factor was associated with the best results; specifically, it was associated with a significantly higher healing rate (95% compared with 57% and 42%) and with a reduced need for amputation compared with the other treatments. The mechanism of action and cost were not discussed. Further evaluations will be necessary, but this well-controlled study deserves attention regarding a potential treatment for foot ulcers that heal poorly in patients with diabetes. Plank J, Haas W, Rakovac I,
Gorzer E, Sommer R, Siebenhofer A, Pieber TR. Evaluation of the impact of
chiropodist care in the secondary prevention of foot ulcerations in diabetic
subjects. Diabetes Care.2003
;26:1691
-5. Ninety diabetic patients from Austria with healed foot ulcers were randomized to routine follow-up or routine follow-up combined with monthly care by a chiropodist. At one year, 56% of patients who had been managed with routine follow-up had another ulcer compared with only 30% of those who had been managed by a chiropodist. This difference was significant. This finding is consistent with the accepted concept that neuropathic patients benefit from routine foot care by a medical professional. Marston WA, Hanft J, Norwood
P, Pollak R; Dermagraft Diabetic Foot Ulcer Study Group. The efficacy and
safety of Dermagraft in improving the healing of chronic diabetic foot ulcers:
results of a prospective randomized trial. Diabetes
Care. 2003;26:1701
-5. In this prospective, randomized study of 314 diabetic patients, Dermagraft combined with conventional therapy was compared with conventional therapy alone for the treatment of chronic foot ulcers. Thirty percent of the ulcers that were treated with Dermagraft healed by twelve weeks, compared with 18% of the ulcers that were treated with conventional therapy alone (p < 0.05). This study offers a note of optimism regarding the use of bioengineered dermal substitutes for the treatment of diabetic foot ulcers. Kalani M, Apelqvist J,
Blomback M, Brismar K, Eliasson B, Eriksson JW, Fagrell B, Hamsten A, Torffvit
O, Jorneskog G. Effect of dalteparin on healing of chronic foot ulcers in
diabetic patients with peripheral arterial occlusive disease: a prospective,
randomized, double-blind, placebo-controlled study. Diabetes
Care. 2003;26:2575
-80. Eighty-seven patients with diabetic foot ulcers and peripheral arterial occlusive disease were randomized to routine care combined with daily subcutaneous injections of dalteparin or saline solution. Dalteparin is a low-molecular-weight heparin with anticoagulating effects. In the dalteparin group, 66% of patients had improvement and 5% underwent amputation. In the placebo group, 54% of the patients had improvement and 19% underwent amputation. Patients were considered to have an "improved" outcome if the ulcer healed or if it decreased in size by at least 50%; these criteria contrasted with those in the other studies reviewed here, in which only ulcer healing was considered to be indicative of successful treatment. The authors concluded that treatment with dalteparin is associated with improved outcomes. This study invites further consideration of anticoagulation treatment of many or all patients with neuropathic ulcers and a compromised vascular system. Gimbel JS, Richards P,
Portenoy RK. Controlled-release oxycodone for pain in diabetic neuropathy:
a randomized controlled trial. Neurology.2003
;60:927
-34. Controlled-release oxycodone was compared with placebo for the control of pain in this six-week, multicenter, randomized, double-blind study of 159 patients with diabetic neuropathy. The average daily pain intensity, rated on a scale from 0 (no pain) to 10 (worst pain imaginable), was 5.3 in the placebo group compared with 4.1 in the oxycodone group. However, 96% of the patients in the oxycodone group reported adverse side effects, compared with 68% of those in the placebo group. The use of narcotics (such as oxycodone) for the control of the pain of diabetic peripheral neuropathy appears to have substantial drawbacks and limited success. Kangas J, Pajala A, Siira P, Hamalainen M, Leppilahti J. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma. 2003;54:1171 -81.[Medline] Fifty patients with operative repair of Achilles tendon ruptures were randomized to early motion or casting with the ankle in a neutral position. The overall outcome at one year was similar in the two groups. The early-motion group had somewhat better (but not significantly better) calf strength at one year. The similarity of the results for the early-motion and casting groups raises important questions about the benefits of early motion after the surgical repair of an Achilles tendon rupture.
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