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The Journal of Bone and Joint Surgery (American). 2006;88:909-922. doi:10.2106/JBJS.E.01398 © 2006 The Journal of Bone and Joint Surgery, Inc. What's New in Foot and Ankle Surgery
1 Penn Care Pennsylvania Orthopaedic Foot and Ankle Surgeons, 230 West
Washington Square, 5th Floor, Philadelphia, PA 19106
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 brief overview of research related to foot and ankle surgery that was published or presented between July 2004 and June 2005. The sources of these studies included The Journal of Bone and Joint Surgery (American Volume), Foot and Ankle International, and the proceedings of the Winter and Summer meetings of the American Orthopaedic Foot and Ankle Society (AOFAS) (held on February 26, 2005, in Washington, DC, and on July 15 through 17, 2005, in Boston, Massachusetts).
A patient with an isolated fibular fracture also may have concomitant medial ankle pain. In the study by Egol et al., 101 patients with an isolated fibular fracture and an intact mortise on standard ankle trauma radiographs were evaluated with stress radiographs1. Sixty-five percent of the patients had positive stress radiographs. The authors found that medial tenderness, swelling, and ecchymosis were not sensitive for predicting widening of the medial clear space. In the group of patients with a positive stress test but without signs of medial ankle injury, ten underwent operative treatment and twenty were treated nonoperatively. In the subgroup of patients who had a positive stress test and were treated nonoperatively, only two patients had evidence of persistent widening of the medial clear space at the time of the final follow-up, and only one was symptomatic. There are several options for the treatment of distal metaphyseal tibial fractures. The goals of treatment for this type of fracture are to provide stable fixation of the osseous injury and to minimize additional trauma to the soft tissue. In the study by Nork et al., thirty-six distal metaphyseal tibial fractures that were located within 5 cm of the ankle joint were treated with intramedullary nailing2. Ten fractures were associated with an articular extension that was treated initially with reduction and screw fixation prior to the insertion of the intramedullary nail. There was one deep infection and one iatrogenic fracture at the time of intramedullary nailing. On the basis of the Musculoskeletal Function Assessment (MFA), there were still significant limitations in several categories one year after surgery. However, the MFA scores continued to improve with time. Collinge reported on the results of surgical treatment of high-energy metaphyseal distal tibial fractures with use of subcutaneous medial plating and indirect reduction3. Twenty-seven patients were available for follow-up. There were nine type-A2 fractures, nine type-A3 fractures, six type-C1 fractures, and three type-C2 fractures, with twelve open fractures. The mean time to osseous union was twenty-five weeks for closed fractures and forty-seven weeks for open fractures. One infection developed at eleven months after the injury. Nonunion occurred in association with six of seven open fractures. Nine patients underwent eleven additional procedures to achieve union. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 84 at the time of the final follow-up. The typical posterior malleolar fragment seen in association with a trimalleolar ankle fracture is triangular in shape and usually involves only the posterior malleolus. A subtype of trimalleolar fracture with the posterior malleolar fragment involving the entire posterior tibial lip, including the posterior half of the medial malleolus, was described by Weber4. Ten patients with this subtype of trimalleolar fracture were managed surgically over a three-year period. Radiographically, a pathognomonic double-contour sign above the medial malleolus was present in all of the patients. In one patient, the posteromedial fracture was not recognized and posteromedial instability was present. This patient was managed with an osteotomy of the malunited fragment. The other nine patients were managed with a double posterior approach, with the fractures repaired from medial to lateral. The author reported excellent results in all of the patients, including the one patient who was managed with the reconstructive osteotomy. In the study by Rossi et al.5, the effectiveness of using a videotape to give patients information before signing the consent form for ankle fracture surgery was compared with the effectiveness of using conventional verbal information. Forty-eight patients were randomized into two study groups: one group watched a videotape containing information about the risks, benefits, and treatment alternatives, whereas the other group obtained this information verbally. All patients completed a multiple-choice questionnaire to determine comprehension and retention immediately after receiving this information, and thirty-seven patients were available to complete the questionnaire at an average of ten weeks later. Patients, especially those with less education, had a notable increase in comprehension when the information about the surgery was given using a videotape. The prevalence of lateral ligament injury after lateral ankle fracture is not well known. In the study by Bombaci et al.6, fifty-four patients who had had treatment of a Weber type-B or C fracture were evaluated with a Telos stress device after fracture-healing. An abnormal talar tilt angle was noted in twelve patients, and excessive anterior displacement was seen in five patients. Even though these seventeen patients had an abnormal stress test, only one had clinical symptoms. Open reduction and internal fixation of unstable Weber type-B fractures of the lateral malleolus is commonly performed with use of either interfragmentary screws with a lateral neutralizing plate or a posterolateral antiglide plate. Biomechanically, posterolateral antiglide plating is stronger than lateral plating. However, the distal end of the plate or screws may cause peroneal tendon problems. Weber and Krause evaluated seventy patients who were managed with an antiglide plate and found that 43% required plate removal because of peroneal tendon symptoms7. Twenty-three of these thirty patients had the most distal hole of the plate filled with a screw. Nine of the thirty patients had an abnormality involving the peroneus brevis (specifically, two patients had tenosynovitis, four had a superficial abrasion, one had a partial transverse tear, and two had a longitudinal split), and three patients had additional peroneus longus abrasions. A high correlation was found between a peroneal tendon lesion and a prominent or oblique screw in the most distal hole of the plate. In a separate cadaveric study, the authors found that in the ten specimens, the shape and size of the osteosynovial part of the peroneal groove were uniform. However, the length of the groove did not correlate with the length of the foot.
Fractures of the calcaneus often necessitate surgical intervention in order to restore articular congruency and correct deformity. Herscovici et al. reviewed the results of surgical treatment of thirty-seven calcaneal fractures in patients older than sixty-five years of age8. Ninety-seven percent of the fractures healed at an average of 110 days. Twelve patients had development of subtalar arthritis. There were twelve minor complications and four major complications. All of the complications were treated successfully. The authors concluded that surgical treatment of displaced calcaneal fractures in patients more than sixty-five years of age is an acceptable option. However, careful selection is especially important in this patient population. Malunion is a common difficulty resulting from the nonoperative treatment of displaced, intra-articular calcaneal fractures. Stephens and Sanders introduced a classification system for calcaneal malunion in 1996. Clare et al. devised a treatment protocol for calcaneal malunion with use of this classification system9. Seventy patients with malunion of the calcaneus after nonoperative treatment of a displaced, intra-articular calcaneal fracture were managed with use of this protocol. Forty-five feet were available for follow-up after a minimum duration of follow-up of two years (average, 5.3 years). Type-I malunions were treated with lateral wall exostectomy and peroneal tenolysis. Type-II malunions were treated with lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis. Type-III malunions were treated with lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and calcaneal osteotomy. Following surgery, all of the feet were plantigrade, with 93% in neutral or slight valgus hindfoot alignment. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had persistent pain in the lateral aspect of the ankle. The authors recommended acute operative treatment of displaced, intra-articular calcaneal fractures because restoration of the calcaneal height and talocalcaneal relationship can be difficult in the surgical treatment of calcaneal malunion. Osteonecrosis and posttraumatic arthritis are wellknown complications of talar neck and/or body fractures. Lindvall et al. reviewed the long-term results of internal fixation of talar neck and/or body fractures after an average duration of follow-up of seventy-four months10. The authors found an 88% overall union rate. Regardless of the delay in surgical fixation, all closed, displaced talar neck fractures healed without an increased prevalence of osteonecrosis. All patients had development of posttraumatic arthritis of the subtalar joint. Osteonecrosis occurred in association with thirteen of the twenty-six fractures and six of the seven open fractures. Even after anatomic reduction and stable fixation of a displaced talar neck and/or body fracture, posttraumatic arthritis, chronic pain, and osteonecrosis are not uncommon outcomes. Vallier et al. reported the results of operative treatment in a study of fifty-seven patients with talar body fractures11. Eleven fractures were open. Twenty-three patients also had a talar neck fracture. Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Of the twenty-six patients who were followed with a complete set of radiographs, ten had development of osteonecrosis of the talar body. In this group of twenty-six patients, more patients had posttraumatic arthritis of the ankle joint (seventeen patients) than of the subtalar joint (nine patients). Eighty-eight percent of patients had radiographic evidence of posttraumatic arthritis and/or osteonecrosis. The authors found that all patients with an open fracture and osteonecrosis had collapse of the talar dome. Also, all patients with an open fracture had evidence of end-stage posttraumatic arthritis. Osteonecrosis and/or posttraumatic arthritis are common even after open reduction with stable fixation of talar body fractures. Open fractures and concomitant talar neck fractures are more commonly associated with osteonecrosis or posttraumatic arthritis. Early and late complications after operative treatment of talar neck fractures were evaluated by Vallier et al.12. The authors also examined the effect of surgical delay on the development of osteonecrosis in this group of patients. The average duration of follow-up after surgery was thirty-six months. Osteonecrosis occurred in 31% of the thirty-nine patients who had complete radiographic data. There was no correlation between surgical delay and the development of osteonecrosis. However, comminuted talar neck fractures and open fractures were more frequently associated with posttraumatic arthritis and osteonecrosis. The pathomechanics, results of operative and nonoperative treatment, and prevalence of posttraumatic arthritis of the subtalar joint were reported by Valderrabano et al. in a study of patients who had a fracture of the lateral process of the talus, also known as a snowboarder's fracture13. The mechanism of injury was reported to be axial impact for 100% of the fractures, dorsiflexion for 95%, external rotation for 80%, and eversion for 45%. The mean AOFAS ankle-hindfoot score was 97 in the operative treatment group and 85 in the nonoperative treatment group. Early degenerative changes in the subtalar joint were noted in one patient in the operative treatment group and in two patients in the nonoperative treatment group. Posteromedial talar fractures are relatively rare. Swords et al. evaluated the results of surgical fixation of this type of fracture with use of a posteromedial approach in a study of ten patients with an average duration of follow-up of 4.5 years (range, one to ten years)14. Six of the ten patients had a subtalar dislocation at the time of presentation, with two of the dislocations being open. Two patients had development of paresthesias in the medial calcaneal nerve distribution postoperatively. No patient had undergone arthrodesis at the time of follow-up. The treatment principle for displaced talar neck fractures is open reduction and internal fixation of the fracture as soon after injury as possible to minimize the risk of osteonecrosis. Patel et al. conducted a survey of orthopaedic trauma experts to determine what they considered to be "the maximal acceptable time delay from injury to the operating room representing the minimal standard of care at a level 1 trauma center for a displaced talar neck."15 Each orthopaedic trauma expert in that study had been selected as a moderator at a national orthopaedic trauma meeting in the past five years. Eighty-two percent responded to the survey. Sixty percent responded that treatment after eight hours was acceptable, and 46% responded that treatment at or after twenty-four hours was acceptable. The development of posttraumatic arthritis of the subtalar joint is common in patients with intra-articular calcaneal fractures. Ball et al. analyzed chondrocyte viability in intra-articular calcaneal fractures and correlated it with the severity of injury, the time between the injury and surgery, patient age, and comorbidities16. Cartilage from twelve intraarticular calcaneal fractures was harvested and analyzed. The viability was the lowest in the superficial zone. The viability declined in association with higher-energy injuries, longer length of time between the injury and surgery, increasing patient age, and smoking. Displaced intra-articular calcaneus fractures are devastating injuries. Very few studies have evaluated patient satisfaction with gait after this type of injury. A prospective, randomized study was performed by O'Brien et al. to determine how patient demographics, fracture type, and treatment affected gait satisfaction17. In that study, 351 fractures were randomly assigned to open reduction and internal fixation or nonoperative treatment. At two to eight years of follow-up, the gait satisfaction scores were not significantly different between the two groups. In the open reduction and internal fixation group, personal gait satisfaction scores were better for patients who were younger than thirty years of age, for those in whom the injury was not work-related, for those with a moderate workload, and for those in whom the Bohler angle was restored to >0°. The effect of subtalar motion on patient satisfaction after a displaced intra-articular calcaneal fracture was evaluated by Kingwell et al.18. The patients in the study group were randomized to either open reduction and internal fixation or nonoperative treatment. The subtalar motion was measured at least twelve weeks after the fracture, and patient-oriented outcomes were measured at two years. Satisfaction with gait and Short Form-36 (SF-36) scores were increased in association with increasing subtalar motion. In patients with a moderate or heavy preinjury workload, patient satisfaction was closely related to subtalar motion regardless of the method of treatment. Functional outcome after the treatment of a displaced intra-articular calcaneal fracture was compared with normative data, data on other orthopaedic conditions, and data on other medical conditions in a study of 312 patients by Van Tetering and Buckley19. Overall, the outcomes for patients with these fractures were not as good when compared with the population norms or with data on patients with other orthopaedic conditions, organ transplants, or myocardial infarction. The findings of the study indicated that there is clinical and social relevance to this injury. The results of operative and nonoperative treatment of these fractures in women were reported by Barla et al.20. Forty-three fractures were randomly assigned to either operative or nonoperative treatment. High SF-36 scores were 3.18 times more common in the operative treatment group as compared with the nonoperative treatment group. The outcomes in the operative treatment group were better than those reported for men who had had operative treatment. In general, the fractures in women were caused by low-energy trauma and were not due to work-related causes. The effect of augmentation of standard internal fixation with use of calcium phosphate bone cement was evaluated by Thordarson and Bollinger in a study of fifteen displaced intraarticular calcaneal fractures21. The osseous defect below the posterior facet was impacted with a curette and was filled with SRS bone cement (Skeletal Repair System; Norian, Cupertino, California). The first six patients in this series were allowed to bear weight at six weeks after surgery, and the following nine patients were allowed to bear weight at three weeks after surgery. There was no soft-tissue reaction or loss of reduction in this study group.
Frank et al. analyzed the history and findings for a consecutive series of patients who were managed for posttraumatic arthritis of the ankle and found that 17.5% of the patients had chronic ankle instability22. In this group of patients, 10.8% had a history of recurrent ankle sprains and 6.7% had only a single sprain. The average time from the initial trauma to surgical treatment for end-stage osteoarthritis was 21.1 months for fractures, 37.1 months for recurrent sprains, and 22.5 months for a single sprain. These results suggest that posttraumatic arthritis can develop after a single sprain or recurrent sprains of the ankle. After syndesmosis injury, chronic ankle pain can occur if the diagnosis is missed and appropriate treatment is not rendered. Lee et al. determined the sensitivity, specificity, and accuracy of magnetic resonance imaging in the evaluation of chronic syndesmosis injury to be 88.9%, 94.8%, and 93.4%, respectively23. Patients with syndesmosis widening of >2 mm on arthroscopy, without medial ankle instability and lateral displacement of the talus, were divided into two groups. Group 1 underwent arthroscopic débridement and fixation of the syndesmosis with a screw. Group 2 underwent arthroscopic débridement only. There was no significant difference between the two groups in terms of the AOFAS ankle-hindfoot score at the time of follow-up. Ankle instability may depend on the osseous joint configuration and not just the competence of the collateral ligaments. Frigg et al. compared the radius of the talus, the height of the talus, and the tibial coverage of the talus in forty-one patients who had had a minimum of three recurrent sprains with those in 100 patients who did not have a history of an ankle sprain24. The tibial coverage of the talus was smaller and the talar radius was larger in the patients with instability than in the patients in the control group. There was no difference between the two groups with regard to the height of the talus. Persistent anterolateral ankle or hindfoot pain can develop after an ankle injury. Extensor digitorum longus impingement at the anterolateral osseous ridge of the talar head was described by Borus et al.25. It was diagnosed on the basis of physical examination and dynamic ultrasound. Eight patients underwent tenolysis of the extensor digitorum longus tendon and exostectomy of the osseous prominence of the anterolateral talar head after the failure of nonoperative treatment. Three patients had an excellent result, four had a good result, and one had a fair result. Impingement of the extensor digitorum longus tendon over the anterolateral aspect of the talar head should be considered in the differential diagnosis of chronic anterolateral ankle and hindfoot pain. Dynamic ultrasound is a useful study with which to confirm this diagnosis. Soft-tissue impingement is a part of the differential diagnosis of chronic ankle pain after injury. Most of the time, the diagnosis is made on the basis of the history and clinical examination as most imaging studies are not helpful. Lee et al. evaluated thirty-eight patients who had chronic ankle pain after trauma to the ankle26. All of the patients underwent contrast-enhanced, fat-suppressed, three-dimensional, fast-gradient-recalled acquisition in the steady state with radiofrequency-spoiling (CE 3D-FSPGR) magnetic resonance imaging preoperatively and after arthroscopic treatment. The CE 3D-FSPGR magnetic resonance imaging showed a sensitivity of 91.9%, a specificity of 84.4%, and an accuracy of 87.5%. After arthroscopic débridement of the soft-tissue impingement, all patients had an excellent or good result.
Ly and Coetzee performed a prospective, randomized clinical trial in which primary arthrodesis was compared with open reduction and internal fixation for the treatment of ligamentous Lisfranc injuries27. Twenty patients underwent open reduction and internal fixation, and twenty-one patients underwent primary arthrodesis. After a mean duration of follow-up of thirty-five months, the AOFAS midfoot score was 62 for the open reduction and internal fixation group and 83 for the arthrodesis group. Only 55% of the patients in the open reduction and internal fixation group returned to their preinjury level of activity, compared with 76% of those in the arthrodesis group. Five patients in the open reduction and internal fixation group required subsequent fusion because of persistent pain or the development of severe osteoarthritis. The current standard treatment of displaced ligamentous injuries of the tarsometatarsal joints is open reduction and internal fixation with use of transarticular screws. An alternative method of fixation with use of dorsal plates was investigated by Alberta et al.28. Ten matched pairs of fresh-froze cadaveric lower extremities were studied. After sectioning of the Lisfranc and tarsometatarsal joint ligaments, the first and second tarsometatarsal joints of the right foot were fixed with transarticular 3.5-mm cortical screws and the left foot was fixed with dorsal 2.7-mm one-quarter tubular plates with screws. There was no significant difference between the plates and the screws in terms of their ability to realign the first and second tarsometatarsal joints and to maintain alignment during loading with use of a servohydraulic materials testing machine. The potential advantage of dorsal plating was the avoidance of additional articular surface damage, at the cost of a possibly larger area of surgical dissection.
One of the surgical treatment options for large osteochondral lesions of the talus is mosaic autogenous osteochondral transplantation. In the study by Pedowitz et al., eleven patients who had undergone this procedure were evaluated at an average of forty-seven months postoperatively29. The osteochondral graft had been obtained from the ipsilateral knee in all of the patients. None of the patients had had previous knee surgery or had had any knee symptoms prior to surgery. The Lysholm knee scale was used to assess donor site morbidity. There were five excellent, two good, and four poor results. Patients who had a good or a poor result complained of instability with daily activities, pain after walking  1 mile (1.6 km), a slight
limp, and difficulty with squatting.
A total contact cast is highly effective for the treatment of plantar ulcerations in patients with diabetic neuropathy. Initially, a period of non-weight-bearing is generally recommended. Saltzman et al. evaluated the effect of initial weight-bearing in a total contact cast on healing of diabetic forefoot or midfoot ulcers in a study of forty patients30. They found that most patients walked immediately in the cast despite being instructed to maintain strict non-weight-bearing. Modest amounts of early weight-bearing had a negligible effect on the rate of healing of these ulcers. Achilles tendon lengthening is commonly performed for diabetic patients with forefoot ulcers. However, forefoot pressure has been shown to return to the preoperative level within eight months after Achilles tendon lengthening. Orendurff et al. studied the relationship between equinus deformity and forefoot pressure during gait in a study of twenty-seven diabetic patients31. Peak forefoot pressure only accounted for 15% of the variance. Other factors, such as tissue thickness and foot morphology, may have a more substantial effect on peak forefoot pressure during walking. The authors concluded that patient selection for Achilles tendon lengthening should be done with more objective measures. Total contact casts and high-calf pneumatic walking boots have been found to reduce forefoot plantar pressure in order to promote healing of diabetic ulcers. Many new designs of off-the-shelf walking boots have been introduced to the market. DiLiberto et al. compared the effects of three different types of walking boots and a shoe on plantar forefoot pressure32. The high calf, rockersole design provided the greatest peak pressure reduction (34%). The low calf boots and lower rockersoles were not as effective for lowering the peak forefoot pressure. The treatment of Charcot arthropathy is difficult and controversial. Pinzur reported that eighty-seven (59.2%) of 147 feet with midfoot Charcot arthropathy achieved the desired end point (a plantigrade foot with use of standard, commercially available, therapeutic depth-inlay shoes and custom-fabricated accommodative foot orthoses) without surgical intervention33. The other sixty feet (40.8%) required surgery. Forty-two patients required corrective osteotomy, and eighteen required débridement or exostectomy. In patients with Charcot arthropathy and a diabetic foot ulcer, it is often difficult to differentiate between osseous changes associated with Charcot arthropathy and osteomyelitis on the basis of magnetic resonance imaging. Also, any metallic implants from previous surgery will distort the magnetic resonance images. Hopfner et al. evaluated two types of positron emission tomography in the preoperative evaluation of diabetic patients with Charcot foot deformities34. Sixteen patients with type-II diabetes and Charcot arthropathy underwent ring positron emission tomography, hybrid positron emission tomography, and magnetic resonance imaging scans preoperatively. Of the thirty-nine Charcot lesions that were confirmed at the time of surgery, thirty-seven were detected with use of ring positron emission tomography, thirty were detected with use of hybrid positron emission tomography, and thirty-one were detected with use of magnetic resonance imaging. Positron emission tomography has the advantage of distinguishing between osteomyelitis and Charcot lesions. Willrich et al. evaluated health-related quality of life, cognitive function, and depression in diabetic patients with foot ulcers, Charcot arthropathy, or lower extremity amputation35. Two focus groups of twenty patients each (including one group of patients with foot ulcers or Charcot arthropathy and another group of patients with lower extremity amputation) were compared with a control group of patients who had evidence of peripheral neuropathy without foot problems. The SF-36 scores were lower and similar in both focus groups compared with controls. Bone and soft-tissue defects of the heel are frequent sequelae after the treatment of chronic diabetic heel ulcers or foot trauma. Johnson et al. reported the results of treatment for twenty-two patients who had been managed with a new custom total contact hindfoot containment orthosis36. The design purposes of the orthosis were to contain the soft tissue of the heel, to reduce shear forces, to redistribute weight-bearing load, and to accommodate any osseous or soft tissue deformity of the heel. Ten patients had development of a superficial ulceration after wearing the orthosis. None required revision surgery. The overall result was good for seventeen patients, fair for four patients, and poor for one patient. A total of sixty-two refabrications of the orthosis were performed in a two-year period.
The efficacy of electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis was evaluated by Ogden et al.37. Two hundred and ninety-three patients were randomized, and seventy-one patients were nonrandomized. In the active treatment group, each patient received one treatment. After three months, 47% of the patients in the active treatment group had a completely successful result, compared with 30% of those in the placebo group. In the nonrandomized group, 71% had a successful result after three months. In the randomized group, sixty-five of the sixty-seven actively treated patients continued to have a successful result after one year. Overall, 76.8% of the patients who had had one or more treatments had a good or excellent result.
Raikin et al. reported on nineteen chronic or missed Achilles tendon ruptures with a gap of >4 cm that were repaired with use of V-Y lengthening and an end-to-end repair augmented with a flexor hallucis longus tendon transfer38. The gap at the rupture site measured between 4 and 7 cm (average, 5.6 cm). The flexor hallucis longus tendon was harvested through the posterior incision without a separate medial incision on the foot. It was attached to the calcaneus through a bone tunnel with use of an interference screw. The patients were evaluated with use of the AOFAS ankle-hindfoot score and Cybex testing. Overall, 84% of the patients had a good to excellent result and 16% had a fair result. One patient had development of postoperative wound dehiscence, which healed without additional surgery. In one patient, the flexor hallucis longus tendon pulled out of the calcaneal tunnel. The morbidity associated with a flexor hallucis longus tendon transfer for the treatment of chronic Achilles tendinosus, chronic rupture, or insertional rupture of the tendon was evaluated by Willer et al. in a study of thirty-six patients39. The AOFAS hallux metatarsophalangeal-interphalangeal and SF-36 scores were excellent for all of these patients. Pedobarographic measurements showed a significant decrease in pressure beneath the distal phalanx of the great toe without a significant increase in pressure beneath the first or second metatarsal head. All patients had weakness on Cybex testing of hallux-metatarsophalangeal and interphalangeal flexion. However, no patient limited the activities of daily living. Many suture techniques have been described for the repair of Achilles tendon rupture. Vander Griend introduced a horizontal suture technique that interlaces the proximal and distal stump with use of 3-0 or 4-0 absorbable sutures40. Ten patients underwent surgical repair with use of this technique. All patients returned to full activity, and all five of the patients who were tested regained strength that was equal to or greater than that on the uninjured side.
Triple arthrodesis is the gold standard for correcting severe fixed hindfoot valgus. However, wound complication may occur secondary to stretching of the lateral skin. Vora et al. presented their experience with the use of a single extensile medial incision for triple arthrodesis in seventeen patients with a severe rigid hindfoot valgus deformity who were at risk for wound complication41. Eleven patients had rheumatoid arthritis, two had scarring of the lateral skin over the sinus tarsi due to a crush injury, one had an underlying diagnosis of neurofibromatosis, and three had rigid valgus deformity resulting from chronic posterior tibial tendon dysfunction. The mean duration of follow-up was 3.5 years (range, one to eight years). There were no wound complications. Arthrodesis was achieved in fifteen patients. Two patients with rheumatoid arthritis had a nonunion in the calcaneocuboid joint on plain radiographs but were asymptomatic. Patients with malalignment after a triple arthrodesis often have persistent pain and an abnormal gait. Multiple osteotomies are frequently required to correct the malalignment. Toolan described a biplanar lateral opening and medial closing-wedge osteotomy of the midfoot for the treatment of persistent abduction and rocker-bottom deformity of the midfoot and valgus deformity of the hindfoot after triple arthrodesis42. Five patients were studied after an average duration of follow-up of eighteen months. All clinical measurements were significantly improved at the time of follow-up. Two patients had superficial wound problems that resolved without additional intervention. Historically, triple arthrodesis was developed to correct hindfoot deformities as a result of neurologic disorders. Currently, it is more commonly performed for the treatment of posttraumatic arthritis, rheumatoid arthritis, and posterior tibial tendon dysfunction. Smith et al. studied twenty-six patients who were managed with triple arthrodesis for the treatment of chronic hindfoot problems43. After a minimum duration of follow-up of ten years, 93% of the patients were satisfied with the result of the procedure. However, only 41% of the patients reported the ability to perform moderate activity with mild or no pain in the foot and ankle and 74% of the patients reported difficulty or an inability to negotiate uneven surfaces. In addition, severe arthrosis was noted in the ankle joint of seven patients, in the naviculocuneiform joint of seven patients, and in the tarsometatarsal joint of six patients.
The flexor digitorum longus tendon is commonly used for reconstruction in patients with posterior tibial tendon dysfunction. The anatomic relationship between the flexor hallucis longus and the flexor digitorum longus was investigated by LaRue and Anctil in a study of twenty-four cadaveric specimens44. Three types of anatomic variations were noted: (1) type 1, a tendinous slip from flexor hallucis longus to the flexor digitorum longus only (ten specimens), (2) type 2, a slip from the flexor hallucis longus to the flexor digitorum longus and a slip from the flexor digitorum longus to the flexor hallucis longus (ten specimens), and (3) type 3, no attachment between the flexor hallucis longus and the flexor digitorum longus (four specimens). Four cadavera had a different anatomic configuration between the right foot and the left foot. The authors recommended tenodesis of the two tendons when a type-3 configuration exists. Many of the surgical procedures that are used to correct a flatfoot deformity are useful for correcting the valgus hindfoot. However, they may not adequately correct the fixed forefoot varus. Hirose and Johnson evaluated the effectiveness of a plantar flexion opening-wedge osteotomy in the medial cuneiform to correct forefoot varus associated with a variety of etiologies, including congenital flatfoot (six feet), tarsal coalition (five feet), overcorrected clubfoot (two feet), skew foot (one foot), posterior tibial tendon dysfunction (one foot), and rheumatoid arthritis (one foot)45. All of the radiographic parameters improved at the time of follow-up. All patients had mild or no pain with walking. There were no cases of nonunion or malunion.
Peroneal tendon tears occur usually through direct injury (usually laceration), indirect injury (at the myotendinous junction or at the insertion), or through attrition (overuse, entrapment, or chronic subluxation). In addition to the three anatomic zones (A, B, and C) previously described for the peroneus longus tendon, Sammarco added Zone D, the insertion of the tendon46. This system can also be used to evaluate the peroneus brevis tendon. Problems in Zone A usually are related to chronic subluxation at the superior peroneal retinaculum, a low-lying muscle belly of the peroneus brevis or the presence of an accessory peroneal muscle, or chronic ankle instability. Entrapment at the peroneal tubercle, due to either a large peroneal tubercle or an accessory peroneus brevis muscle, is considered to be a Zone-B lesion. Zone-C problems are related to injuries of the peroneus longus tendon as it courses under the osseous groove of the cuboid. Avulsion of the peroneus longus tendon at the insertion site is considered to be a Zone-D lesion. Sammarco recommended surgical treatment for all complete tendon ruptures and for attritional ruptures that fail to heal after nonoperative treatment. The differential diagnosis of chronic peroneal tendon pain includes tendonitis, tear, subluxation, and dislocation. Wilson and Schon reviewed the results of retrofibular groove deepening with use of a periosteal bone flap in a study of sixteen patients with chronic peroneal pain47. During surgery, seven patients had a shallow retrofibular groove, five had tendonitis, four had tendon tears, three had dislocated tendons, and three had subluxable tendons. After fifteen months of follow-up, all patients reported improvement in terms of function, stability on uneven terrain, and pain. An algorithm for the surgical treatment of chronic complete, partial, or longitudinal tears of both peroneal tendons was described by Redfern and Myerson48. Intraoperatively, if both tendons were grossly intact and the tears were repairable, then tendon repair was performed. If one tendon was irreparable, then tenodesis was performed. If both tendons were not salvageable, then a tendon graft (hamstring allograft) or a tendon transfer (flexor digitorum longus to peroneus brevis) was performed. Any concurrent deformity of the hindfoot or the ankle was corrected at the same time. Twenty-nine feet were treated with use of this algorithm. After a mean duration of follow-up of 4.6 years, the mean AOFAS ankle-hindfoot score was 82 and twenty-six feet had normal or moderate peroneal muscle strength.
Morton originally hypothesized that hypertrophy of the second metatarsal shaft is a sign of increased mobility of the first metatarsal. Hypermobility of the first metatarsocuneiform joint has been associated with hallux valgus, hallux rigidus, and interdigital neuroma. Grebing and Coughlin examined four groups of forty-three subjects each, including one asymptomatic control group and three groups of patients with symptomatic hallux valgus, hallux rigidus, or interdigital neuroma49. Mobility of the first ray, arch height, and ankle dorsiflexion were evaluated by means of physical examination. Hypertrophy and the length of the second metatarsal, the hallux valgus angle, and the first-second intermetatarsal ankle were evaluated on plain weight-bearing radiographs. The investigators found no correlation between hypertrophy of the second metatarsal and increased mobility of the first metatarsal, relative shortness of the first metatarsal, pes planus, or decreased ankle dorsiflexion. It is difficult to accurately assess the mobility of the first ray as described by Morton. There is large variability in association with both manual examination and the use of an external measuring device. Grebing and Coughlin assessed motion of the first ray in various positions of the ankle with use of a modified Klaue device in normal individuals, patients with untreated moderate and severe hallux valgus deformity, patients who had undergone first metatarsophalangeal arthrodesis for the treatment of hallux valgus, and patients who had undergone plantar fasciotomy50. A total of 119 feet were evaluated. In all four groups, the motion of the first ray was significantly decreased when the ankle was placed into dorsiflexion. Except for the plantar fasciotomy group, all other groups showed significantly increased motion of the first ray when the ankle was placed into plantar flexion. With the ankle in neutral, the average motion of the first ray was 4.9 mm for the control group, 7.0 mm for the hallux valgus group, 4.4 mm for the first metatarsophalangeal fusion group, and 7.7 mm for the plantar fasciotomy group. Patients with hallux valgus deformity tend to have increased first ray mobility. The change in mobility after surgical correction of the hallux valgus deformity has not been studied extensively. Coughlin et al. evaluated the effect of distal soft-tissue release and proximal crescentic osteotomy on first ray mobility in a study of twelve fresh-frozen below-the-knee cadaveric specimens with hallux valgus deformity51. The mean hallux valgus angle and intermetatarsal angle were corrected from 28.6° to 11.0° and from 12.9° to 6.8°, respectively. The mean amount of first ray sagittal motion as measured with use of the Klaue device decreased from 11.0 mm to 5.2 mm after hallux valgus correction. This change was significant. The authors suggested that extrinsic anatomic features, and not just the first metatarsocuneiform joint, may play a role in first ray mobility. Thordarson et al. studied functional and health-related quality-of-life data on patients who had undergone surgical treatment of hallux valgus52. The authors found that general health scores were relatively stable in adults with bunions over a range of ages. The older groups had better scores than the general population did. Bodily pain scores, average global foot and ankle scores, and shoe comfort scores were lower in patients with hallux valgus deformity than in the general population. There was no correlation between any of the preoperative scores and the severity of the hallux valgus and the intermetatarsal angle. In another outcome study, Thordarson et al. studied the results of three different types of hallux valgus correction53. One hundred and ninety-six patients were involved: 106 patients were managed with distal first metatarsal chevron osteotomy, seventy-two patients were managed with proximal first metatarsal osteotomy with distal soft-tissue release, and eighteen patients were managed with a modified Lapidus procedure. The AOFAS metatarsophalangeal-interphalangeal scores, four of ten SF-36 scores, and four of five AAOS lower extremity scores improved after hallux valgus correction. Furthermore, the degree of deformity, the amount of correction, and the type of surgery did not influence outcome. Throughout the literature, many different types of osteotomies have been described for the correction of hallux valgus deformity. Magnan et al. evaluated the results of a percutaneous distal metatarsal osteotomy for the correction of mild-to-moderatehallux valgus deformity54. The authors stated that the advantages of the percutaneous technique were a shorter operating time and a reduction in complications related to surgical exposure. The patients were satisfied with 107 (91%) of the 118 procedures according to the AOFAS hallux-metatarsophalangeal-interphalangeal scale. The recurrence rate was 2.5%, and eight first metatarsophalangeal |
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Introduction
Ankle and Metaphyseal Tibial...