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The Journal of Bone and Joint Surgery (American). 2008;90:928-942. doi:10.2106/JBJS.G.01289 © 2008 The Journal of Bone and Joint Surgery, Inc. What's New in Foot and Ankle Surgery
1 Department of Orthopedics, University of Miami, P.O. Box 016960 (D-27), Miami, FL 33101
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2006 and July 2007. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot and Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on February 17, 2007, in San Diego, California; and the summer meeting of the American Orthopaedic Foot and Ankle Society (AOFAS), held on July 13, 14, and 15, 2007, in Toronto, Ontario, Canada.
Supination-external rotation is the most common mechanism of injury producing ankle fractures. Operative intervention after a lateral malleolar fracture is guided by the integrity of the medial ankle structures (the medial malleolus or the deltoid ligament). In a prospective study, Gill et al. compared manual and gravity stress radiographs for the detection of deltoid ligament injury after isolated supination-external rotation-type fibular fractures1. Twenty-five patients (including thirteen with supination-external rotation type-II fractures and twelve with supination-external rotation type-IV fractures) were enrolled in the study. In each patient, measurements of talar shift and medial clear space produced by both stress techniques were found to be equivalent for each variable. Significant differences were noted in medial clear space measurements between the supination-external rotation type-II and type-IV fracture groups, showing that both manual and gravity stress radiographs were able to effectively demonstrate deltoid ligament incompetence. Furthermore, for the supination-external rotation type-IV fractures, both stress radiograph techniques demonstrated a mean medial clear space of >5 mm and a mean talar shift of >2 mm. Pinzur et al. reported comparable results in a similar study of twenty-nine patients with isolated supination-external rotation-type fibular fractures2. In addition to assessing medial ligament integrity, the authors recorded the visual analog score for pain after each stress examination. A significant difference in pain was noted between manual and gravity stress examinations, confirming that patients perceive less pain with gravity stress testing. The study suggests that gravity stress examination may replace manual testing as a screening tool for the diagnosis of unstable supination-external rotation-type ankle fractures because of its high sensitivity and relative patient comfort. Moore et al. performed a prospective surgeon-randomized study that compared the clinical results associated with the use of three and four cortices of screw fixation for the treatment of syndesmotic ankle disruptions3. One hundred and twenty-seven patients with Orthopaedic Trauma Association (OTA) type 44-C fibular fractures with fluoroscopically confirmed tibiofibular instability received one 3.5-mm fully threaded cortical syndesmotic screw placed through a one-third tubular plate with either three or four cortices of purchase. With the relatively limited numbers available in the study, statistical analysis showed no significant difference between three and four cortices of fixation with regard to loss of reduction, screw breakage, or the need for hardware removal. A trend toward greater loss of reduction was noted in the group with three cortices of fixation, but all patients with loss of reduction were noncompliant with postoperative weight-bearing restrictions. Radiolucency around the syndesmotic screw was found in 53% and 59% of the patients in the three and four-cortex fixation subgroups, respectively. Retention of syndesmotic implants despite fixation failure did not appear to be clinically problematic, and the authors advised against the routine removal of syndesmotic screws. Siegel and Tornetta reported on their technique and outcomes with extraperiosteal plating of stage-III pronation-abduction ankle fractures4. This mechanism of injury is characterized by a comminuted lateral fibular cortex, which may compromise the fibular endosteal blood supply. Previous series have demonstrated the need to augment these defects with bone graft as well as high rates of nonunion in cases in which bone graft was not used. In contrast to the standard technique of open fracture reduction with some degree of periosteal splitting, the authors' technique leaves the surrounding soft-tissue sleeve intact. A precontoured nonlocking, one-third tubular plate was placed superficial to the periosteum and was used in a manner similar to that of a bridge-plate that spans the comminuted lateral fibular cortex. The plate also functioned as an indirect reduction tool, with the periosteum and soft-tissue envelope being used to assist in reduction of the fibular fracture fragments and for restoration of fibular length. Syndesmosis screws were placed through the plate, and medial malleolar fixation was performed as the fracture pattern dictated. Thirty-one patients with stage-III pronation-abduction ankle fractures were managed with this operative technique. All fibular fractures healed without displacement by ten weeks, and no bone-grafting was performed. The average AOFAS score was 82, with a mean ankle dorsiflexion of 13° and a mean plantar flexion of 31°. The authors recommended this technique for the treatment of comminuted pronation-abduction ankle fractures. Operative stabilization of the medial malleolus is commonly used for the treatment of displaced medial malleolar and unstable bimalleolar and trimalleolar fractures. Femino et al. performed a cadaver experiment to guide the placement of screws into the medial malleolus without disturbing the adjacent anatomy5. Using a triple guide, the authors placed three parallel Kirschner wires into the anterior colliculus (zone 1), the intercollicular groove (zone 2), and the posterior colliculus (zone 3). The wires were then overdrilled, and 4.0-mm partially threaded screws were inserted. The proximity of the screws and of the screw abutment to the nearby posterior tibial tendon and damage to the tendon were assessed after dissection. Zone 1 was deemed to be the safe zone because no screw in this area damaged or abutted tendon. Screws in zone 2 were located an average of 2 mm from tendon, and four of ten screws abutted the posterior tibial tendon. All screws placed in zone 3 contacted the posterior tibial tendon, and half of the specimens displayed tendon damage. There are currently no accepted methods for the evaluation of fibular torsional deformities after fixation of ankle fractures associated with syndesmotic disruption. Several studies have shown that postoperative plain radiographs lack the sensitivity to accurately detect subtle fibular subluxations or torsional malreductions. To compare torsional symmetry, Vasarhelyi et al. evaluated postoperative computed tomography scans of both ankles of sixty-one patients after fixation of ankle fractures that were associated with syndesmotic disruption6. The investigators found two valid and reproducible methods for evaluating fibular torsional deformity and correlated asymmetry of >10° with AOFAS scores. Applying these two methods, the authors reported fibular torsional asymmetry of >10° in thirty-five patients and asymmetry of >15° in eight patients. Functional outcome, as determined with the AOFAS score, was related to the degree of fibular torsion as measured with both computed tomography analyzing methods. The poorest clinical function was reported for patients with asymmetry of >15°. Tejwani et al. compared the epidemiologic characteristics and functional outcomes after the surgical treatment of the two types of supination-external rotation type-IV injuries: (1) distal fibular fractures with deltoid ligament rupture and (2) bimalleolar fractures7. Two hundred and thirteen patients were followed for at least one year postoperatively and were evaluated clinically and radiographically. Function was assessed with the Short Musculoskeletal Function Assessment (SMFA) score and the AOFAS score. Among the significant findings, bimalleolar fractures occurred most commonly in women, in patients older than sixty years, and in patients with the greatest number of comorbidities. Functionally, the bimalleolar fractures fared statistically worse at one year, but no significant difference in pain status was found between fracture subgroups. The authors concluded that the supination-external rotation type-IV variant with medial malleolar fracture is a more serious injury than its ligamentous counterpart and that it occurs more frequently in women and older patients.
Calcaneal stress injuries have been poorly characterized since the advent of magnetic resonance imaging as a primary diagnostic tool. Using this imaging modality, Sormaala et al. reported on the incidence, demographics, and anatomic distribution of calcaneal stress injuries in a large population of military recruits8. Their results revealed an incidence of 2.6 calcaneal stress injuries per 10,000 person-years and no differences in the demographic variables of recruits with and without calcaneal stress injuries. All areas of the calcaneus were affected, but injury occurred most frequently in the posterior one-third and superior one-half. Only 15% of the injuries that were confirmed with magnetic resonance imaging were originally found or suspected on plain radiographs. The high sensitivity of magnetic resonance imaging allowed detection not only of lower-grade calcaneal injuries that manifested as bone marrow edema but also of stress injuries of adjacent bones, most commonly the talus, navicular, and cuboid. The authors recommended acquiring a magnetic resonance imaging scan when a calcaneal stress injury is suspected despite a benign radiographic appearance. Anatomic reduction and fixation of Sanders type-II displaced intra-articular calcaneal fractures can improve outcomes by restoring function and lowering the risk of posttraumatic subtalar arthritis. In the study by Rammelt et al., the results of percutaneous reduction and screw fixation were compared with those of open reduction and internal fixation with a lateral plate through an extensile lateral approach9. Percutaneous reduction was performed under fluoroscopic and subtalar arthroscopic visualization, and fixation was achieved with use of 2.5-mm small-fragment screws. Both surgical approaches produced good-to-excellent subjective results, function, and restoration of the Bohler angle. The percutaneous reduction-screw fixation group had no wound complications, an earlier return to rehabilitation, and a significantly better hindfoot range of motion than did the plate fixation group. In the latter group, one patient had development of wound-edge necrosis that healed without complication. Many patients have development of considerable subtalar arthritis despite anatomic reduction and fixation of intra-articular calcaneal fractures. Ball et al. sought to demonstrate that the initial impact of the injury causes articular cartilage chondrocyte necrosis, which affects future subtalar arthritis10. Irreducible osteochondral fragments of calcaneal fractures were obtained intraoperatively for the assessment of chondrocyte viability and were compared with control cartilage obtained from donors who died from unrelated causes. Samples taken from patients with fractures demonstrated an average chondrocyte viability of 73% ± 13%, which was significantly lower than the value of 95% ± 1.5% found in controls. Strong trends that did not reach the level of significance were identified between lower chondrocyte viability and both the time from the injury to surgery and increasing patient age. The authors believed that their results provide a reason for subtalar arthritis despite an anatomic reduction after intra-articular calcaneal fractures. Smith et al., in a study of nineteen patients, reported the results of reimplantation of the extruded talus following pantalar dislocation or an associated talar fracture-dislocation11. The treatment of these injuries included immediate wound irrigation, administration of appropriate intravenous antibiotics, and reduction before the patient was transported to the operating room. When the extruded talus had no soft-tissue connections, it was placed in a bacitracin solution for transport to the operating room and then was washed successively in two or three baths of bacitracin solution prior to reimplantation. Stabilization was achieved with internal fixation, external fixation, or a combination of the two. Contrary to previous reports on the results of talar reimplantation, the infection rate was low, with the development of only one acute infection in a patient who underwent primary tibiocalcaneal arthrodesis; no patient had had a delayed amputation at the time of the latest follow-up. Because of the limited number of patients, no significant associations could be made. However, all cases involving an extruded talus in conjunction with a talar neck or body fracture subsequently were associated with the development of radiographic evidence of collapse, osteonecrosis, or arthritis. Reflecting the severity of the injuries, the average musculoskeletal functional assessment score was 29.8 (compared with the normal population value of 9.3), demonstrating permanent disability. The findings of this study suggest that the talus may be safely reimplanted, thereby preserving limb height and bone stock, joint mechanics, and the possibility of future reconstructive surgery.
In a cadaver study, Sides et al. compared the biomechanical properties of 6.5-mm partially threaded cancellous screws with those of 4 to 5-mm tapered variable pitch compression screws when used for the fixation of fifth metatarsal metaphyseal-diaphyseal junction (Jones-type) fractures12. Their goal was to determine differences between the two screws in terms of bending stiffness and pullout strength. While no differences in bending stiffness were identified, the 6.5-mm lag screw provided significantly higher resistance to thread pullout.
The complex anatomy and biomechanical properties of the distal tibiofibular ligaments are still being defined. Hoefnagels et al. were the first investigators to isolate and directly quantify the strength and stiffness of the interosseous tibiofibular ligament of the ankle, further elucidating its role in syndesmotic stability13. The interosseous ligament was found to be stronger and stiffer than the anterior inferior tibiofibular ligament, both in this study and in other investigations, underscoring the importance of the interosseous ligament in ankle syndesmotic stability. Chronic tibiofibular syndesmotic injuries present challenging diagnostic and treatment problems. The etiology of the associated ankle pain is incompletely understood but may be explained by one of two theories. The first theory equates pain with instability, whereas the second attributes the pain to impingement of hypertrophic soft tissue within the distal tibiofibular joint. In a prospective randomized study, Han et al. used a new magnetic resonance imaging technique known as contrast-enhanced, fat-suppressed, three-dimensional, fast gradient-recalled (CE 3D-FSPGR) acquisition in the steady state with radiofrequency spoiling to evaluate twenty patients with an arthroscopically diagnosed syndesmotic ankle injury for the presence of hypertrophic soft tissue in the syndesmosis14. All patients received arthroscopic marginal resection of hypertrophic tissue and then were randomized to receive transcortical syndesmotic screw fixation or marginal resection alone. Interestingly, two provocative tests of diagnostic value in acute syndesmotic injury—the external rotation stress test and the tibiofibular squeeze test—were positive in only two and three of the twenty patients, respectively. However, eighteen of the twenty patients experienced dull tenderness anteriorly over the syndesmosis on palpation. The magnetic resonance imaging technique showed a sensitivity of 90%, a specificity of 94.8%, and an accuracy of 93.4%. Patients who received syndesmotic screw fixation demonstrated improvement in AOFAS scores that was nearly equivalent to that of patients who received arthroscopic marginal resection alone. The authors concluded that the CE 3D-FSPGR magnetic resonance imaging technique may be helpful for diagnosing chronic distal tibiofibular syndesmosis injury and that pain could be related to impingement of hypertrophic soft tissue. Superficial peroneal nerve injury can cause residual morbidity following inversion ankle sprains. O'Neill et al. quantified the potential excursion and strain sustained by the superficial peroneal nerve during an inversion ankle sprain15. In a cadaver inversion ankle sprain model, they successively loaded the ankle before and after sectioning of the anterior talofibular ligament and after an impact force while measuring superficial peroneal nerve excursion and strain. They found significantly higher excursion and strain for all weights and after an impact force with the anterior talofibular ligament sectioned. The magnitude of strain recorded in the superficial peroneal nerve with the impact force was consistent with values demonstrated in other investigations to structurally alter peripheral nerves and may explain superficial peroneal nerve injury during inversion ankle sprains. Two related cadaver studies were performed to define the ligamentous attachments of the lateral talar process and to challenge the arbitrary value of 1 cm as the size of lateral talar process fractures causing ankle or subtalar joint instability. DiGiovanni et al. dissected cadaver ankles and measured the proximity of ligamentous attachments to the apex of the lateral talar process16. The results showed that only the lateral talocalcaneal, anterior talofibular, and posterior talofibular ligaments attach to the lateral talar process, contrary to the findings of some previous reports. Langer et al. excised a 1-cm3 fragment of the lateral talar process and then stressed the ankle and subtalar joints to measure radiographic signs of instability17. None of the measurements reached the value of standard accepted radiographic criteria for ankle or subtalar instability. This finding suggests that excision of lateral talar fracture fragments of 1 cm3 may not destabilize the ankle or subtalar joint nor require open reduction and internal fixation to confer stability.
Talar osteochondral lesions are commonly described as being located either anterolaterally or posteromedially on the talar dome. Raikin et al. developed an original nine-zone talar grid system by assigning three rows and three columns to the talus in an attempt to localize osteochondral lesions more accurately18. In that study, 428 lesions that had been identified with magnetic resonance imaging were reviewed, measured, and then relocalized by applying the authors' nine-zone grid system. Zone 4 (medial talar dome/middle row) was the most frequently involved location (53%), and zone 6 (lateral and middle) was the second most frequently involved location (26%). The traditional anterolateral and posteromedial locations only accounted for a combined 9% of lesions with use of the grid system. Finally, the results demonstrated that medial talar dome lesions are significantly larger and deeper than lateral lesions are. The authors proposed using their grid system as a more reproducible and accurate means of characterizing talar osteochondral lesions. Osteochondral lesions of the talus that remain symptomatic following arthroscopic débridement pose a particular therapeutic challenge. Savva et al. describe the results of repeat arthroscopic débridement alone, performed by the same surgeon applying the same technique, for twelve patients with persistent symptoms after the index procedure19. The average AOFAS score improved from 42 after the index procedure to 81 after repeat débridement, with two patients returning to professional sports. The pathologic findings at the time of repeat arthroscopy were areas of fibrocartilage that were of poor quality, partially loose, and incompletely healed. In cases of large talar osteochondral lesions, the extensive avascularity of the bone often prohibits successful transfer of autologous chondrocytes and bone plugs. Tanaka et al. reported satisfactory results for four patients with medial talar osteochondral defects (mean volume, 4.31 cm3) who were managed with a local vascularized bone graft20. Bone was harvested from the medial aspect of the calcaneus, with the calcaneal branch of the posterior tibial artery being used as the vascular pedicle. Most of the lesions required supplemental bone graft from the iliac crest to fill the void. The described technique also requires that there is residual cartilage overlying the lesion; no articular substitute is transferred into the lesion. Postoperative radiographs revealed sclerosis with no joint narrowing in all patients, and follow-up magnetic resonance imaging and computed tomography scans showed no osteonecrosis or recurrence of cysts. Finally, mean AOFAS scores improved from 60 to 83 after the procedure.
Saltzman et al. used validated outcome instruments to assess the degree of physical impairment associated with ankle osteoarthritis and the influence of systemic and unrelated musculoskeletal comorbidities on the perception of ankle pain and function21. Patients with primary and posttraumatic ankle osteoarthritis completed the Short Form-36 Physical Component Summary and Mental Component Summary questionnaire as well as Ankle Osteoarthritis Scale forms for comparison with matched controls. The results revealed that ankle osteoarthritis produced physical impairment equivalent to that reported for patients with severe medical problems such as end-stage renal disease, congestive heart failure, or cervical spine pain and radiculopathy. Patients with posttraumatic osteoarthritis had impairment similar to that of patients with primary ankle osteoarthritis but were an average of ten years younger. The number of concomitant unrelated musculoskeletal comorbidities was linked in a nearly linear fashion to the patient's perception of ankle pain and impairment. The authors suggested the need for future studies, using these outcome measures adjusted for unrelated musculoskeletal comorbidities, in order to discern the true impact of the disease being evaluated. The disability associated with end-stage ankle arthritis was compared with that associated with end-stage hip arthritis in a prospective study by Glazebrook et al.22. Two large cohorts of patients waiting for surgery for the treatment of either ankle or hip osteoarthritis were evaluated with the Short Form-36 questionnaire. All symptom-related and functional scores for both cohorts were significantly below normal population values. The ankle group was significantly worse in terms of mental component scores, physical limitation with work and daily activities, and general health. These results further underscored the severe disability of ankle osteoarthritis despite higher resource allocation for the treatment of hip osteoarthritis.
Interest in total ankle arthroplasty has increased as the search for viable alternatives to ankle arthrodesis continues and as newer generations of prostheses aim to improve on the failures of earlier models. Coetzee evaluated the three-year results associated with the Agility total ankle replacement (DePuy, Warsaw, Indiana)23. For the sixty-four ankles with complete data, the average AOFAS score improved from 44 preoperatively to 79 at the time of the three-year follow-up, the average total musculoskeletal functional assessment injury and arthritis survey scores improved from 38 to 18, and visual analog pain scores improved from 8 to 2. Ankle range of motion improved on average by 5°, and 95% of the patients reported satisfaction with the procedure. However, the overall complication rate was 24%, and more than half of the complications were considered to be serious and required a second major operation. The most common complication was nonunion of the syndesmosis, but some patients required revision or fusion. In the group of forty-six patients who had incomplete data at three years, six additional complications occurred, including the necessity for amputation. These data suggest that, in properly selected patients, the Agility total ankle replacement can relieve pain and improve function at the time of the three-year follow-up, but the complication rate is high. The results of 200 total ankle arthroplasties with use of the Scandinavian total ankle replacement (STAR; Waldemar Link, Hamburg, Germany) were reported by Prem and Wood24. The average age of the patients was sixty-one years, 119 subjects had rheumatoid arthritis, and eighty-one subjects had osteoarthritis. The rate of implant survival was 93% at five years and 79% at ten years. Twenty-four ankles required revision because of failure resulting from infection, fracture of the medial malleolus, polyethylene fracture, aseptic loosening, or progressive malalignment. The average AOFAS pain score improved from 0 to 35, the average function score improved from 31 to 40, and survivorship was comparable with that reported for the Agility total ankle prosthesis. Brodsky et al. prospectively analyzed the gait pattern of forty-nine patients before and after total ankle arthroplasty with use of the STAR25. Three-dimensional gait analyses were performed preoperatively and then annually for up to six years. Significant increases were found in velocity, ankle range of motion during gait, and peak sagittal ankle joint power at push-off. The study demonstrated objective improvement in gait function when compared with the preoperative condition and demonstrated superior results in comparison with those in previous studies of gait analysis following ankle arthrodesis. Schneiderbauer et al. reported a 3.1% infection rate after primary ankle replacement in a study of 386 ankles26. Infection was diagnosed on culture of tissue specimens that had been collected during revision surgery. Four of the twelve infected ankles had a history of infection or open fracture. The most common infecting organism was Staphylococcus aureus, followed by coagulase-negative staphylococci and anaerobes. The median time from primary implantation to infection was nine months. Treatment consisted of surgical débridement and either liner or component exchange in addition to six weeks of antibiotics. Three patients required flap coverage. The reported 3.1% infection rate was higher than rates reported in the literature for primary knee and hip arthroplasty.
Arthroscopic ankle arthrodesis is typically recommended for ankles with minor deformities, with reported fusion rates of >90%. The results of seventy-eight arthroscopic ankle arthrodeses for both minor (<15°) and major (>15°) varus-valgus deformity were retrospectively reviewed by Gougoulias et al.27. No difference in fusion rates was noted between ankles with (97%) and without (98%) major deformity. All fused ankles were considered to have restoration of normal alignment radiographically. Patients with poor bone quality or posttraumatic deformity may require more rigid fixation to achieve union at the site of an ankle arthrodesis. Tarkin et al. performed biomechanical testing on cadaver ankles with use of a low-profile anterior plate to supplement screw fixation at the site of an arthrodesis28. Less motion occurred at the tibiotalar interface in all tested planes of motion after plate supplementation. Percutaneous posterolateral screw placement is commonly used to augment fixation at the site of an ankle arthrodesis. Keeling and Schon assessed the risk to the sural and tibial nerves in association with percutaneous placement of the posterolateral screw in a study of cadaver ankles29. After the guide-pin had been placed, dissection was carried out to determine its proximity to local neurovascular structures. The guide-pin did not contact either the sural or the tibial nerve in any specimen, but the average distance to these structures was 0.9 and 6.5 mm, respectively. Adjacent tarsal joint degeneration is a long-term sequela of the altered kinematics and load transfer that occurs after tibiotalar arthrodesis. Jung et al. used pressure-sensitive sensors in a cadaver ankle dorsiflexion loading model to measure adjacent-joint contact and peak pressures before and after screw fixation of the tibiotalar joint30. Their results suggested a significant increase in pressure in the talonavicular and calcaneocuboid joints in association with ankle dorsiflexion, corresponding to the late stance phase of gait. Limiting the number of joints that are included in an arthrodesis may preserve more normal foot mechanics and theoretically may decrease the risk of future adjacent-joint degeneration. Sammarco et al. applied this concept by performing a modified double arthrodesis in lieu of a triple arthrodesis31. The calcaneocuboid was excluded from sixteen procedures that were undertaken to correct symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis, in which the calcaneocuboid joint was not involved in the primary disease. AOFAS scores and all radiographic parameters improved significantly. However, after an average duration of follow-up of forty-seven months, five feet demonstrated clinically asymptomatic but radiographically evident progression of degeneration at the calcaneocuboid joint. Glanzmann and Sanhueza-Hernandez performed a prospective study to evaluate the clinical and radiographic results of arthroscopic subtalar fusion with autologous bone-grafting32. The authors used the anterolateral and posterolateral portals for débridement of the posterior, middle, and anterior facets and the interosseous ligament as well as for the insertion of bone graft into the sinus tarsi. The average AOFAS score improved from 53 points preoperatively to 84 of 94 points (accounting for 6 points that were lost because of subtalar fusion) postoperatively. The radiographic fusion rate was 100%, and 96% of the procedures had a good to excellent clinical result. Amendola et al. reported on their early experience with posterior arthroscopic subtalar arthrodesis33. With the patient in a prone position, three posterior portals were established, including in posteromedial and posterolateral sites. Débridement was performed posterior to the interosseous ligament and to the extent of anterior visualization from the posterior portals. Two cannulated 6.5-mm cancellous screws were then placed across the posterior facet for fixation. No complications were reported. The average AOFAS score improved from 36 points preoperatively to 86 points (maximum, 94 points) postoperatively, and ten of eleven joints demonstrated radiographic and clinical union by ten weeks. The results suggested that posterior arthroscopic subtalar arthrodesis is a safe procedure that offers reliable fusion rates and high patient satisfaction.
Total contact casting remains the gold standard treatment with which to offload Wagner grade-1 and 2 diabetic foot ulcers. Frigg et al. reported ulcer recurrence rates of 57% after primary total contact casting treatment at an average of 4.6 months34. The authors found that most recurrences were caused by underlying foot deformities that, when operatively corrected, resulted in a significantly longer ulcer-free interval or prevented ulcer recurrence entirely. Total contact casting was effective for healing primary ulcer recurrences, but new recurrences developed in 50% of those patients. On the basis of their experience, the authors recommended aggressive surgical correction of all existing underlying deformities after the primary ulcers heal. In a study investigating the optimal placement of metatarsal pads on total contact shoe inserts for reducing peak plantar pressure under the middle metatarsal heads, Hastings et al. recorded peak plantar pressure and used computed tomography scans to verify the pads' position35. Metatarsal pads were placed proximal and distal relative to the center of the second metatarsal head. The greatest reduction in peak plantar pressure (57%) was registered when the distal aspect of the pad was 10.6 mm proximal to the center of the second metatarsal head, whereas consistent reduction in pressure occurred if the pad was placed between 6.1 and 10.6 mm proximal to the center of the second metatarsal head. However, the authors found an inherent inaccuracy in the placement of the pads; for this reason, they recommended that the patient's foot be checked shortly after the orthosis is worn to check for redness, callus, and signs of skin breakdown. Ankle stiffness and limited dorsiflexion range of motion are factors that are thought to contribute to the development of plantar ulcers in patients with diabetes. Rao et al. confirmed this theory with use of the Iowa Ankle Range of Motion Device, which has established validity and interobserver reliability36. In a study that compared twenty-five diabetic patients with sixty-four nondiabetic individuals, the authors demonstrated significantly lower peak dorsiflexion range of motion and higher passive ankle stiffness in the diabetic group. Additionally, they found an association between poor glycemic control, as measured on the basis of HbA1c levels, and the duration of diabetes mellitus with ankle stiffness. Diagnosing osteomyelitis in the feet of diabetic patients presents a major challenge. Most imaging techniques are highly sensitive for detecting inflammation but lack the specificity to differentiate noninfective inflammation from infection. It is thus difficult, if not impossible, to rule out associated neuroarthropathy, healing fracture, diabetic osteopathy, or soft-tissue inflammation from the differential diagnosis. In a prospective study, Dutta et al. combined a technique with 100% sensitivity (99mTc methylene diphosphonate triple-phase bone scanning) with one of high specificity (99mTc-ciprofloxacin scintigraphy) to diagnose osteomyelitis in diabetic feet37. A total of nineteen patients with Wagner class-III diabetic foot ulcers and six control patients with only superficial ulcers received both scans. Osteomyelitis was confirmed by means of bone biopsy and histopathological studies or cultures. Combining these scans was effective for the diagnosis of diabetic foot osteomyelitis, demonstrating a sensitivity of 100% and a specificity of 85.7%. Nonetheless, bone biopsy and histopathology remains an essential diagnostic tool because the combination of these scans was unable to differentiate osteomyelitis from soft-tissue infection.
In the first phase of a prospective randomized study on the treatment of plantar fasciitis, plantar fascia-specific stretching demonstrated superior results to Achilles tendon-stretching at eight weeks of follow-up. Digiovanni et al. reported these two-year outcomes after patients who were initially managed with the Achilles tendon-stretching protocol were switched to the more effective plantar fascia-specific stretching program38. Patients were taught to stretch the plantar fascia by dorsiflexing the metatarsophalangeal joints while palpating the area of maximal tenderness a total of ten times per session, with at least three sessions per day. At the time of the two-year follow-up, all patients showed significant improvement from baseline in terms of the experience of pain with the first steps in the morning and in terms of the severity of heel pain at its worst. Additionally, once patients were switched at eight weeks from Achilles tendon-stretching to plantar fascia-specific stretching, they improved at a faster rate and showed no difference at two years in comparison with those who had been initially started on plantar fascia-specific stretching. Overall, the long-term data indicated that 90% of patients will be satisfied and will experience a reduction in heel pain, that there is a 75% chance of returning to full activity, that no further treatment will be needed, and that the majority of patients will achieve their best results by six months. Plantar fasciitis is commonly treated with an orthotic device, yet few well-designed studies with sufficient power to demonstrate significance have evaluated the short and long-term efficacy of orthotic devices. Landorf et al. conducted a participant-blinded, randomized trial comparing the benefit of prefabricated and customized orthotic devices with that of a sham treatment39. Patients with chronic plantar fasciitis were randomly selected to use one of the three devices while abstaining from other treatments (anti-inflammatory medications or corticosteroid injections). Both the prefabricated and customized orthoses produced short-term benefits. Significant improvement in function was found at three months, while only a trend was noted in terms of pain reduction. These benefits compared with sham treatment were lost by one year. The results support orthotic treatment for short-term relief of plantar fasciitis. Additionally, the customized orthoses had no advantage over lower-cost prefabricated orthotic devices. While extracorporeal shock wave therapy has been approved by the Food and Drug Administration for the treatment of plantar fasciitis, the question of its effectiveness remains. Dorotka et al. evaluated whether the location of the shock waves influences outcomes40. Patients received fluoroscopically guided shock wave therapy either at the location of a heel spur or at the patient-directed area of maximum tenderness. While all patients improved from baseline, the results indicated that the location of therapy had no effect on outcome. Because of the increased exposure to radiation and the longer time necessary for fluoroscopic localization, the authors recommend focusing extracorporeal shock wave therapy at the area of maximum tenderness. Bazaz and Ferkel reported the results of a two-portal endoscopic plantar fascia release41. This technique provided significant improvement in terms of symptoms: the average AOFAS and Maryland Foot scores improved by 22 and 21 points, respectively. Factors associated with inferior outcomes included more severe symptoms, a duration of symptoms of longer than two years prior to endoscopic plantar fascia release, Workers' Compensation, and male gender.
To evaluate the suggestion that degenerative Achilles tendinopathy may be associated with systemic diseases such as obesity, diabetes, and hypertension, as well as with exposure to steroids, Holmes and Lin performed an epidemiologic study of patients in whom Achilles tendinopathy had been diagnosed clinically and confirmed with magnetic resonance imaging42. Overall, 98% of the patients had hypertension, diabetes, obesity, and steroid or estrogen exposure, which demonstrated an increased aggregate association with symptomatic Achilles tendinopathy. A significant correlation was found between Achilles tendinopathy and hormone replacement therapy, oral contraceptive use, obesity, hypertension in women, and diabetes mellitus in men younger than forty-four years of age. These results suggested a possible end-organ effect causing a decrease in local microvascularity at the Achilles tendon. Wagner et al. reported on seventy-five patients (eighty-one heels) who were managed for insertional Achilles tendinosis43. The Achilles tendon was operatively débrided and the insertion completely detached from the calcaneus if >50% of the tendon was found to be diseased. The tendon was reattached with three four-prong suture anchors with number-2 polyester sutures with use of a modified Krakow technique. A V-Y lengthening of the Achilles tendon was performed through the aponeurosis proximal to the musculotendinous junction to provide length lost from excision of diseased tendon. Detaching the tendon did not significantly affect short or long-term satisfaction rates or any parameter evaluated in the study, and the authors proposed routine detachment of the Achilles tendon with proximal V-Y lengthening in cases of insertional Achilles tendinosis. Two randomized controlled trials were performed by Costa et al. to evaluate the potential benefits of immediate weight-bearing mobilization after surgical repair and nonoperative treatment of the ruptured Achilles tendon44. Patients in each group were managed with non-weight-bearing immobilization in an equinus short leg cast or immobilization with immediate weight-bearing in an orthosis with heel rises. In the operative group, there was a more rapid return to normal walking and stair-climbing with immediate weight-bearing immobilization in an orthosis than with immobilization in a cast. In the nonoperative group, no difference was found between the two treatment groups. The results supported immediate weight-bearing immobilization in an orthosis after surgical repair of the ruptured Achilles tendon. Traditionally, postoperative treatment of the surgically repaired Achilles tendon rupture includes immobilization of the ankle in plantar flexion. This is thought to decrease the tensile stress across the repair site, which relies on the strength of the suture material until healing is adequate. Serial reduction of the equinus position is performed at the time of follow-up until a neutrally positioned foot is achieved. Labib et al. measured the static tension in the Achilles tendon at varying degrees of plantar flexion before and after surgical repair45. The tendon was repaired with number-2 braided polyester sutures with use of the Krakow locking technique reinforced with a running baseball stitch of 4.0 monofilament polypropylene. Static tension in the repaired Achilles tendon group was equal to that of the intact tendon at all positions of plantar flexion. Additionally, the tension in the repaired tendon at the neutral position was only a small percentage of the tension observed at failure of the repair. This study suggested that positioning the ankle in plantar flexion after secure surgical repair of the ruptured Achilles tendon may not be necessary. Several small intestinal submucosa extracellular matrix scaffold products are currently available on the market for the repair of musculotendinous tissues and other applications. Gilbert et al. evaluated the rate of degradation, the fate of the degradation products, and the temporal histologic changes exhibited by these scaffolds when used as an interpositional graft in the canine Achilles tendon46. The results showed that the graft degrades rapidly, losing approximately 60% of its mass by one month, and resorbs completely by three months. Host cells infiltrate the graft, peaking at fourteen days as new host tissue begins ingrowth. By one month, the graft-native tissue interface was difficult to discern and the remodeled extracellular matrix showed signs of organization. By three months, the scaffold was replaced by organized host tissue that appeared histologically similar to that of native Achilles tendon. Degradation products were excreted primarily in urine and were not found in parenchymal organs. The application of these biologic scaffolds holds promise for the repair of Achilles tendons.
The relationship between pes planus and injuries to the lower extremity is unclear. Levy et al. performed a prospective study over forty-six months to evaluate the incidence of lower extremity injuries in association with pes planus in a physically active population47. With use of a standardized objective measure (Harris mat footprints) to define pes planus, the researchers identified significant relationships between the degree of pes planus (large midfoot ratio), larger foot size (total foot area), and the total number of injuries sustained. Left foot pes planus was found to be correlated with left and right midfoot injuries and left knee injuries. Women were found to have significantly smaller feet and lesser degrees of pes planus but sustained more injuries than men did. These results suggest that having larger feet and pes planus may predispose patients to lower extremity injuries. The natural history of nonoperative treatment for stage-II posterior tibial tendon dysfunction has yet to be elucidated. Lin et al. reported the results of conservative treatment of stage-II posterior tibial tendon dysfunction on the basis of clinical outcomes scores48. Treatment consisted of six weeks of immobilization in a short leg weight-bearing cast followed by the use of a double upright ankle-foot orthosis for an average of fifteen months. The rate of success, defined as being brace-free and avoiding surgery, was 70% after an average duration of follow-up of 8.62 years. Overall, 94% of the patients reported satisfaction or satisfaction with minor reservations following the conservative treatment, and none of the patients who were managed operatively regretted initial treatment with the double upright ankle-foot orthosis. Finally, no difference was found between national norms and the values for patients who were managed with a double upright ankle-foot orthosis in terms of any Short Form-36 subcategory scores at the time of follow-up of seven to ten years. Stage-II posterior tibial tendon dysfunction encompasses the spectrum of disease severity, ranging from mild to severe. Identifying variants of stage-II posterior tibial tendon dysfunction on the basis of severity may guide operative treatment decisions; for example, the more severe form likely requires additional procedures to adequately correct the deformity. Vora et al. recreated mild and severe flatfoot deformities in cadaver models to evaluate the correction achieved when a medializing calcaneal osteotomy was combined with a flexor digitorum longus transfer and then a subtalar arthroereisis procedure was added49. They found that the combined medializing calcaneal osteotomy and flexor digitorum longus transfer adequately treated mild deformity but undercorrected more severe flatfoot. When arthroereisis was added, the increased correction was effective for treating severe flatfoot without adverse biomechanical consequences, but it overcorrected mild flatfoot. The results support the concept of subcategorizing stage-II posterior tibial tendon dysfunction into mild and severe variants to help surgeons to determine which procedures to apply for appropriate correction. Dolan et al. performed a prospective randomized study to evaluate the effectiveness of using tricortical iliac crest autograft as opposed to allograft for the lateral column lengthening component of the operative correction of adult acquired flatfoot deformity50. The study included thirty-three feet with stage-II posterior tibial tendon dysfunction, and the lateral column was lengthened through the anterior process of the calcaneus with use of a single 3.5-mm fully threaded cortical screw that was introduced from the distal to the proximal aspect. All feet demonstrated clinical and radiographic union by the twelve-week follow-up. The rate of radiographic union at eight weeks was 94% in the allograft group, compared with only 60% in the autograft group. Two patients in the autograft group continued to have donor site pain at three months. The findings of the study suggested that union rates between tricortical iliac crest allograft and autograft are equivalent for the lateral column lengthening component of correction of stage-II posterior tibial tendon dysfunction and that the use of an allograft may avoid the associated morbidity and increased cost of autograft harvest.
Raikin et al. reported on the outcome of a newly described form of peroneal tendon pathology51. In a group of fifty-seven patients with painful snapping of the peroneal tendons, fourteen were found to have no subluxation from the retrofibular groove with a dorsiflexion-eversion maneuver. Dynamic ultrasound examination of the tendons demonstrated two types of peroneal tendon pseudosubluxation. The first type involved subluxation of the peroneus longus through a longitudinal tear in the peroneus brevis tendon, and the second type involved snapping of the peroneus longus over the brevis tendon, which reversed their relative anatomic positions. Surgical repair of tendon tears combined with a peroneal groove deepening procedure improved the average AOFAS score from 61 preoperatively to 93 postoperatively, and 93% of the patients demonstrated no persistent pseudosubluxation at the time of follow-up. Intrasheath pseudosubluxation of the peroneal tendons must now be considered in the differential diagnosis for patients with retrofibular pain and clicking with no reproducible subluxation on examination. Dynamic ultrasound examination of the peroneal tendons may be a useful study to confirm this diagnosis. A modified technique of superior peroneal retinaculoplasty for the operative stabilization of recurrent dislocating peroneal tendons was reported by Adachi et al.52. The false pouch created by the attenuated superior peroneal retinaculum was incised; the incision began at the anterior attachment and extended to the fibular periosteum. Drill-holes were created on the lateral edge of the peroneal groove. After the redundant false retinacular tissue was resected, the rest of the pouch was sutured through the drill-holes with the aid of a tensioning device. The authors reported full postoperative ankle range of motion and no redislocation in twenty patients who were managed in this manner.
Kadakia et al. initiated a prospective study to evaluate the effectiveness of correcting mild to moderate hallux valgus deformity with use of a percutaneous distal metatarsal osteotomy53. This technique was used in thirteen consecutive patients; however, at three months, the study was suspended because of the high frequency of complications. Although initial postoperative radiographs showed significant improvement in the hallux valgus angle and the first-second intermetatarsal angle, a significant loss of reduction was noted in terms of mean radiographic parameters after additional follow-up. Additionally, one case of metatarsal head osteonecrosis, one nonunion, one case of superficial cellulitis, five cases of recurrent hallux valgus, and nine dorsal malunions were observed. The study was discontinued, and the percutaneous distal metatarsal osteotomy is no longer performed at the authors' institution. Scarf and chevron osteotomies are two techniques that are commonly used for the correction of symptomatic hallux valgus. The scarf osteotomy achieves larger corrections through the metatarsal shaft and is thought to be more effective for the treatment of moderate to severe deformities. The chevron osteotomy is limited in potential by its more distal location and typically is indicated for mild to moderate hallux valgus. Deenik et al. conducted a prospective randomized study in which the two procedures were compared in terms of deformity correction, function, and complication rates54. No significant differences were found with respect to the hallux valgus angle, the intermetatarsal angle, AOFAS scores, or complication rates. The authors recommended the use of the chevron osteotomy because the procedure is technically less demanding. Gallentine et al. used locking plates for fixation at the sites of proximal metatarsal chevron osteotomies that were performed for the treatment of symptomatic large hallux valgus deformities55. All osteotomy sites subsequently demonstrated radiographic union without clinical evidence of transfer lesions or hardware-related complications. The authors reported a mean improvement of 16° in the hallux valgus angle, 7.6° in the intermetatarsal angle, and only 0.8° in first metatarsal elevation. They concluded that locking plates may improve stability at the site of a proximal metatarsal chevron osteotomy that is performed for the correction of hallux valgus. Pinney et al. sought to determine the most common choice of operative procedures for the correction of hallux valgus among academic foot and ankle surgeons56,57. A hypothetical case of symptomatic mild deformity (an intrametatarsal angle of 11° and hallux valgus of 22°) that was resistant to nonoperative treatment was sent to surgeons who teach orthopaedic residents and devote 50% or more of their practice to the treatment of foot and ankle problems56. The majority of respondents (87%) chose to perform a distal chevron osteotomy, of whom 10% also performed an Akin proximal phalangeal closing-wedge osteotomy and another 8% of whom indicated that they would add the Akin osteotomy if the chevron osteotomy provided inadequate correction. A hypothetical case of symptomatic severe hallux valgus deformity (an intermetatarsal angle of 20° and a hallux valgus angle of 42°) that was resistant to nonoperative treatment also was sent to the same population of surgeons57. The responses for the preferred method of correction varied widely. For osseous correction, 52% of the respondents chose to perform a metatarsal osteotomy, 26% chose to perform a first metatarsal phalangeal joint arthrodesis, and 24% chose to perform a Lapidus procedure. Even among the fifty-two respondents who chose a metatarsal osteotomy, the type of osteotomy varied considerably: twenty-four chose a Ludloff osteotomy, sixteen chose a proximal crescentic osteotomy, eight chose a proximal chevron osteotomy, two chose a scarf osteotomy, and two chose a distal chevron osteotomy. Most surgeons included some sort of medial capsulorrhaphy and lateral soft-tissue release. Forty-three percent preferred an L-shaped capsular incision medially, and 90% used a lateral capsular and adductor release. The responses indicated that no consensus exists with regard to the treatment of severe hallux valgus deformity and that treatment continues to depend on surgeon preference. Arthrodesis of the first metatarsophalangeal joint has served as a salvage procedure following the failure of hallux valgus repair. Grimes and Coughlin reported on thirty-three symptomatic feet that were treated with arthrodesis of the first metatarsophalangeal joint after the failure of hallux valgus surgery58. The causes of failure were numerous and represented many types of surgical corrective attempts. Overall, 73% of the patients reported a good to excellent result at the time of long-term follow-up. Arthrodesis of the first metatarsophalangeal joint can be a reliable salvage procedure following the failure of hallux valgus correction.
In a prospective blinded study, Pons et al. compared a single injection of intra-articular sodium hyaluronate with a single injection of intra-articular triamcinolone acetonide for the treatment of grade-I hallux rigidus59. One dose was injected into the first metatarsophalangeal joint in forty feet, and the patients were followed for three months. Both types of injections resulted in significant improvements in terms of pain at rest, dorsiflexion and plantar flexion pain, visual analog pain scores on walking 20 m, and AOFAS hallux scores. Significantly better pain scores after walking 20 m were found in the sodium hyaluronate group. At one year, 47% of the hyaluronate injection group and 53% of the triamcinolone injection group required surgery for the treatment of persistent pain and reduced function. Goucher and Coughlin reported on the one-year outcomes of fifty-four arthrodeses of the hallux metatarsophalangeal joint60. Male and female reamers were used for preparation of the hallux metatarsal head and the base of the first phalanx for arthrodesis. A precontoured low-profile plate was applied dorsally and was secured with 3.0-mm screws. The reported fusion rate was 92%, with a 96% rate of good to excellent results. Only four nonunions occurred, and no failures of the plate or screws were reported. Arthroplasty and hemiarthroplasty are appealing theoretical alternatives to fusion of the metatarsophalangeal joint in cases of severe hallux rigidus; however, intermediate and long-term data on outcomes are currently lacking. Konkel and Menger evaluated the intermediate-term results of thirteen titanium hemi-great toe implants used for replacement of the articulating surface of the proximal phalanx61. All prostheses demonstrated subsidence and radiolucency, with the most rapid rate occurring within the first two years following implantation. One implant was removed after a fracture of the phalanx caused shifting of the prosthesis when the fracture went on to nonunion. The average AOFAS score was 86, and all but two patients reported satisfaction with the results. Despite encouraging reports of patient function and satisfaction, implant longevity and long-term functionality remain a concern. Botto-van Bemden and SanGiovanni reported on the early follow-up results of twenty-four first metatarsal head resurfacing procedures that were performed with use of the hemi-contoured articular prosthesis (HemiCAP; Arthrosurface, Franklin, Massachusetts) for the treatment of advanced hallux rigidus62. Concomitant osseous and soft-tissue procedures were included for the correction of deformity and improvement of dorsiflexion motion. After an average duration of follow-up of twelve months, the average AOFAS score improved from 54.7 preoperatively to 70 postoperatively, the average visual analog pain score improved from 6.4 to 3.5, and average dorsiflexion increased from 20.2° to 51°. While the authors considered this prosthesis to be a reliable alternative for the treatment of advanced hallux rigidus, the device was recommended primarily for the treatment of arthritis pain and not for the restoration of motion. Long-term results remain to be determined.
The capital oblique Weil osteotomy is an osseous correction that is commonly used to treat intractable plantar keratosis and lesser toe metatarsalgia. As originally described, the osteotomy cut should be angled parallel to the plantar surface of the foot; this is thought to prevent plantar displacement of the capital fragment after final positioning. However, the biomechanics and ideal technique of this osteotomy remain controversial. Grimes and Coughlin performed a cadaver study to evaluate the osseous anatomy of the lesser metatarsals, the geometry of the Weil osteotomy, and the effect of saw-blade thickness on the final position of the capital fragment63. The metatarsal inclination, defined as the angle formed between a line parallel to the dorsal metatarsal cortex and the plantar surface of the foot, was found to vary widely for each metatarsal, decreasing in amount for the more lateral metatarsals. Metatarsal head sizes also showed wide variability but were large enough that 12-mm screw fixation should be acceptable for the second, third, and fourth metatarsals in nearly all individuals. Plantar displacement of the capital fragment depended on the angle of the osteotomy and the metatarsal inclination. The saw cut removes additional bone from the osteotomy site, thereby compensating for some plantar displacement of the capital fragment. The authors recommended using 1-mm-thick saw blades for most osteotomies, but in cases of shortening of >5 mm or with metatarsal inclination of <19°, a 2-mm-thick saw blade should be used.
Su et al. performed a retrospective review of 674 consecutive primary interdigital neurectomies to survey the frequency of digital artery removal64. Assessment of pathologic specimens revealed that 38.9% included the digital artery. No difference was observed between dorsal and plantar surgical approaches used for excision. No complications related to vascular perfusion to the digits were reported. The study indicated that extensive collateralization of digital vessels maintains vascular perfusion of the toes following digital artery excision but that caution should be observed in patients with decreased vascularity to the toes and those with adjacent interdigital neuromas.
In a randomized, controlled study, Goucher and Coughlin analyzed whether covering the toes with a sterile surgical glove during foot and ankle surgery had an effect on infection rates65. Forty patients were randomized to two groups on the basis of whether the toes were covered with a sterile glove or were left uncovered prior to surgical preparation with chlorhexidine gluconate followed by painting with 70% isopropyl alcohol. Cultures of specimens from the second web space were taken before preparation, after preparation, and before dressing placement. Cultures of specimens that were obtained before surgical scrubbing were positive for 87.5% of patients and most commonly grew coagulase-negative staphylococcus. Only one sample showed growth on culture of specimens obtained after scrubbing, and two samples demonstrated positive growth on culture of specimens obtained before final dressing placement. Seven patients (including three patients from the group in which the toes were covered and four patients from the group in which the toes were left uncovered) demonstrated clinical signs of superficial infection. All infections resolved with antibiotic administration and local wound care. No significant difference was noted between the two groups in terms of the rate of infection. These results suggest that covering of the toes during foot and ankle surgery with a sterile glove following appropriate surgical scrubbing with chlorhexidine gluconate and painting with 70% isopropyl alcohol provides no added benefit in the prevention of postoperative infection. The trend of regional anesthesia has not been fully embraced by the foot and ankle community because of concerns over block failure and possible complications associated with anesthetic administration. Qureshi et al. performed a retrospective review of 372 consecutive foot and ankle procedures in which a popliteal regional anesthetic block was administered66. The block was successful in 97% of the patients; only eight patients required conversion to general anesthesia. Success of the anesthetic block was independent of the type or duration of surgery. No popliteal artery injuries, infections, seizures, or cardiopulmonary complications occurred. The lone complication was a case of postoperative neuralgia that spontaneously resolved within one week. Herr et al. investigated the safety and efficacy of lateral transtendinous popliteal blocks performed after the induction of general anesthesia for intraoperative and postoperative pain control in patients undergoing elective foot and ankle surgery67. A review of the charts of 475 consecutive patients who received a popliteal block following the induction of general anesthesia demonstrated that 83.7% had a complete block and 16.2% had an incomplete block. The average block duration was 16.5 hours, and no adverse effects were documented. Lateral popliteal nerve block after the induction of general anesthesia appears to be a safe and effective method for controlling intraoperative and postoperative pain in patients undergoing elective foot and ankle surgery.
The detectability of orthopaedic implants in security screening devices in airports and elsewhere is a question commonly posed to the orthopaedic surgeon. Bluman et al. investigated the detectability of specific implants that are typically used by foot and ankle surgeons68. A wide variety of implants were tested, from metallic screws to total ankle prostheses representing titanium and stainless steel metals. The implants were either placed in a plastic bag or wrapped in a 2.5-cm sleeve of steak to simulate body tissue and then were strapped to a volunteer near the anatomic location of implantation. The volunteer stepped through a gate-type detector, and then a wand-type detector was passed over the implants. None of the implants in the plastic bag were detected with the gate-type detector, but a significant number of implants were detected with the wand-type detector. The majority of the implants that were identified with the wand remained detectable after they had been wrapped in steak. The steak prevented only the stainless steel 6.5-mm cannulated screw and the simulated construct of four stainless steel 4.0-mm cannulated screws from being identified with the wand. Because of the increased sensitivity of security detection devices since 2001, patients with metallic implants may benefit from carrying documentation identifying them as having orthopaedic surgical hardware. To facilitate the screening process, the authors suggested a credit card-sized identification card with a passport-type photo that lists the location of the hardware.
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, all of which have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, nine additional level-I articles were identified that were relevant to foot and ankle surgery. A list of those titles is appended to this review following 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 Advanced Foot and Ankle Course will be held on May 1 through 3, 2008, in San Francisco, California; the Twenty-fourth Annual AOFAS Summer Meeting and Pre-meeting Course will be held on June 25 through 28, 2008, in Denver, Colorado; and the Complete Foot Care Course will be held on October 2 through 4, 2008, in Boston, Massachusetts.
Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 2006;34:1401-12. This well-designed prospective, randomized clinical investigation analyzed the short-term outcomes of first-time clinical grade-I, II, and III inversion sprains of the lateral ligaments of the ankle using different treatment modalities. The primary objective of the study was to compare early, controlled mobilization with use of different types of external support known as functional treatment (Air-Stirrup brace, elastic wrap, and Air-Stirrup brace combined with an elastic wrap) with immobilization (walking cast) for patients with first-time inversion ankle sprains. The results at six months of follow-up corresponded with the findings of previous studies in that the type of treatment that was employed appeared to have no effect on eventual restoration of function or the frequency of reinjury. The evidence suggested that, in the long term, lateral ankle sprains heal with excellent or good outcomes, irrespective of the treatment received. However, the short-term results provided evidence supporting the treatment of first-time grade-I and II inversion ankle sprains with an Air-Stirrup brace combined with an elastic wrap. This treatment provided earlier return to pre-injury function compared with treatment with the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for ten days followed by the use of an elastic wrap. In the first-time grade-III sprain group, there were insufficient numbers to compare different types of functional treatment. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. 2007;455:169-72. The authors used PubMed to perform a systematic review of the literature in order to identify randomized, controlled trials in which immobilization was compared with some form of functional treatment for the acute treatment of inversion ankle sprains. Nine studies were ultimately identified for review. The outcomes of interest were whether any differences existed in the time to return to the pre-injury level of activity, the level of patient satisfaction, the presence of subjective instability, and the rate of re-injury. Significant variation existed in the reviewed articles between the type and duration of immobilization, the mode of functional treatment employed, the number of subjects included, and outcome measures. However, there were trends toward earlier return to pre-injury activity in patients receiving early functional treatment. No substantial difference was found between the treatment groups in terms of recurrent instability and re-injury, whereas slightly greater satisfaction was reported by patients managed with immobilization. Additional studies need to be performed to better evaluate the optimum method of treatment. Dalton JD Jr, Schweinle JE. Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains. Ann Emerg Med. 2006;48:615-23. Lateral ankle sprains are one of the most common musculoskeletal injuries, and treatment of the associated acute pain and swelling is of important therapeutic interest. Previous double-blinded controlled trials have established the efficacy of ibuprofen as compared with placebo for treatment of the pain and swelling associated with lateral ankle sprains. In this multi-center, randomized, double-blinded, parallel-group study, the efficacy of extended-release acetaminophen (3900 mg daily) was compared with that of ibuprofen (1200 mg daily) for the treatment of pain associated with grade-I or II lateral ankle sprains during a nine-day study period. The study utilized a noninferiority design to demonstrate that this dose of acetaminophen is not inferior to ibuprofen at a dosage of 1200 mg daily for the treatment of lateral ankle sprains. Thus, as ibuprofen has been previously shown to be more efficacious than placebo for the treatment of lateral ankle sprains, this study established that acetaminophen can produce similar effects. Therefore, extended-release acetaminophen can be used to manage acute pain associated with grade-I or II lateral ankle sprains in a manner comparable with that of ibuprofen. Middleton F, Coakes J, Umarji S, Palmer S, Venn R, Panayiotou S. The efficacy of intra-articular bupivacaine for relief of pain following arthroscopy of the ankle. J Bone Joint Surg Br. 2006;88:1603-5. The intra-articular injection of bupivacaine for the control of postoperative pain has been proved to be safe and effective following arthroscopy of the knee but not arthroscopy of the ankle. In this prospective, randomized, double-blind clinical trial, the authors compared intra-articular injection of 20 mL of 0.5% bupivacaine to injection of 20 mL of normal saline solution. The analgesic effect was assessed with use of a visual analog scale as well as by measuring the amount of additional analgesic medication required in the recovery room and after discharge. Significantly lower visual analog scores (indicating less pain) on the day of operation at thirty minutes, sixty minutes, and 120 minutes after the procedure and less intravenous tramadol use for postoperative analgesia was noted in the bupivacaine group. A trend toward lower visual analog scale scores at twelve hours following arthroscopy was noted, whereas no significant difference occurred on the day after the operation. These results suggest that intra-articular injection of 20 mL of 0.5% bupivacaine significantly reduces the initial levels of pain and the requirement for analgesics after ankle arthroscopy. de Vries JS, Krips R, Sierevelt IN, Blankevoort L. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2006;4:CD004124. The authors reviewed seven randomized trials of interventions for chronic ankle instability involving 308 patients in order to compare different nonoperative and operative treatments. No definitive conclusions could be drawn because of a lack of significance and poor methodological quality. Patient outcomes in terms of the time to return to work and sports were found to be superior following functional rehabilitation as compared with immobilization. Therefore, the authors recommended functional postoperative rehabilitation for patients with chronic ankle instability, emphasizing early mobilization of the ankle joint instead of six weeks of immobilization. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;2:CD000380. The authors reviewed twenty randomized or quasi-randomized trials involving a total of 2562 patients to compare operative and nonoperative methods for the treatment of acute injuries of the lateral ligament complex of the ankle. Data for pooling of individual outcomes were available for only twelve trials and <60% of participants. There was insufficient evidence from the pooled data to determine the relative effectiveness of operative and nonoperative treatment of acute injuries of lateral ligaments of the ankle. There was some evidence of stiffness and restrictions in ankle mobility as well as a longer time to return to work associated with surgery. Until adequately powered, high-quality, and appropriately reported randomized trials supporting either treatment are done, the best current option remains nonoperative treatment with close follow-up to identify patients with persistent symptoms. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. 2007;35:59-64. This randomized clinical trial evaluated the effect of contrasting postoperative regimens after surgical repair of Achilles tendon ruptures. Intratendinous metallic markers were placed on both sides of the ruptured Achilles tendon ends after a standard Achilles tendon rupture repair. Patients were then randomized into postoperative treatment with either a below-the-knee dorsal rigid plaster splint that allowed active plantar flexion but restricted dorsiflexion to neutral or a below-the-knee plaster splint with the ankle in a neutral position. Patients were followed functionally and with standardized radiographs to reproducibly measure and accurately track postoperative elongation of the repaired tendon. Significant Achilles tendon elongation occurred in both postoperative regimens, although it was somewhat less in the early motion group. Elongation increased up to six weeks after repair in both groups, at which time the Achilles tendon preserved its length or even shortened slightly in the early motion group. A significant correlation was also found between Achilles tendon elongation and functional outcome. Patients with less shortening achieved significantly better clinical outcomes. These results suggest that protected functional rehabilitation after Achilles tendon repair may reduce postoperative tendon elongation and thereby improve clinical outcomes. Gobbi A, Francisco RA, Lubowitz JH, Allegra F, Canata G. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy. 2006;22:1085-92. Arthroscopic chondroplasty, microfracture, and osteochondral autologous transplantation are common surgical techniques for the treatment of osteochondral lesions of the talus. However, scarce evidence exists providing guidelines to aid the surgeon in the selection of technique. This prospective randomized study compared outcomes following these surgical modalities for the treatment of arthroscopically accessible anterior and lateral osteochondral lesions of the talus. The results demonstrated no difference in outcomes at the time of the two-year follow-up between chondroplasty, microfracture, and osteochondral autologous transplantation. The only significant difference between treatment groups was increased postoperative pain at twenty-four hours in patients receiving osteochondral autologous transplantation. On the basis of these results, chondroplasty and microfracture may be the preferred treatment for arthroscopically accessible osteochondral lesions of the talus on the basis of comparable outcomes, lower postoperative pain, and the more extensive nature of osteochondral autologous transplantation. Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, Leporati E, Scire V, Teobaldi I, Del Prato S. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care. 2007;30: 586-90. Total contact casting is the gold standard for the treatment of superficial neuropathic diabetic foot ulcers, yet it remains an expensive, time-demanding, and resource-consuming treatment option. The authors of this prospective randomized clinical trial sought to determine the efficacy of an off-the-shelf off-loading walker device (the Optima Diab walker). The device is designed to be irremovable by the patient but can be removed at clinical visits by cutting a securing plastic lace with a specific tool. The purpose of the study was to find a more practical, less expensive, safe, and comparably effective alternative to total contact casting. Two groups of patients with superficial diabetic foot ulcers were randomized to receive total contact casting or the Optima Diab walker. The Optima Diab walker was found to be significantly less expensive, required significantly less time to apply and remove, and resulted in higher patient satisfaction scores. Additionally, in both treatment groups, the ulcers healed at an average of approximately 6.5 weeks with a comparable number of minor adverse events. The Optima Diab walker may present a reasonable alternative to total contact casting for the treatment of superficial neuropathic diabetic foot ulcers on the basis of cost reduction, ease of application, lower resource expenditure, and comparable efficacy.
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