Whats New in Foot and Ankle Surgery

Lin, Sheldon S. MD1,a; Yeranosian, Michael G. MD1; Bastian, Sevag A. MD1

Journal of Bone & Joint Surgery - American Volume: 19 April 2017 - Volume 99 - Issue 8 - p 700–706
doi: 10.2106/JBJS.16.01603
Specialty Update

1Department of Orthopaedics, New Jersey Medical School, Newark, New Jersey

E-mail address for S.S. Lin: linss@njms.rutgers.edu

Article Outline

This article provides a summary of recent research pertaining to orthopaedic foot and ankle surgery, from July 2015 to August 2016. It includes studies published in The Journal of Bone & Joint Surgery and Foot and Ankle International; as well as select presentations from Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), March 1 to 5, 2016, in Orlando, Florida; or at the Annual Meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), July 20 to 23, 2016, in Toronto, Canada.

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Ponseti casting has proven to be very effective in treating idiopathic clubfoot, and some have expanded its use to non-idiopathic cases. Kowalczyk and Felus retrospectively compared a cohort of Ponseti-treated arthrogrypotic clubfeet with a group that underwent traditional soft-tissue releases and talectomies1. Their intermediate-term results demonstrated improved clinical outcomes, lower complication rates, and less invasive revision surgical procedures in patients previously treated with Ponseti casting.

The decision to operate in cases of residual deformity following Ponseti casting is typically based on clinical evaluation. Recent studies have suggested that certain radiographic parameters may also be useful. Shabtai et al. found that larger tibiocalcaneal angles and smaller talocalcaneal angles on maximum dorsiflexion lateral radiographs were associated with lower functional outcome scores and were predictive of surgical intervention in patients previously treated with the Ponseti method2.

Achilles tenotomy is commonly performed in patients with <15° of ankle dorsiflexion after Ponseti casting. Kang and Park compared the ankle dorsiflexion angle with the lateral tibiocalcaneal angle as prognostic indicators of the need for percutaneous tenotomy3. Among patients who had not undergone Achilles tenotomy, sagittal relapse was never seen in those with lateral tibiocalcaneal angles of <80°. Furthermore, those with lateral tibiocalcaneal angles of >80° had a high chance of sagittal relapse even if ankle dorsiflexion was >15°. They concluded that the lateral tibiocalcaneal angle is a more reliable indicator of the need for surgical procedures than clinical ankle dorsiflexion.

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Posterior Tibial Tendon Dysfunction

Treatment of stage-II posterior tibial tendon dysfunction remains a controversial topic. A randomized controlled trial by Houck et al. investigated whether incorporating a home strengthening program to a regimen of orthotic wear and stretching provided any additional benefit4. After 12 weeks, there were no significant differences in self-reported outcomes or deep posterior compartment strength between groups.

Tendoscopy is a novel treatment alternative for posterior tibial tendon dysfunction. Gianakos et al. reviewed 12 cases of tendoscopy and compared intraoperative findings with preoperative magnetic resonance imaging (MRI) results5. Although tendoscopy and MRI diagnoses were concordant in 8 cases, diagnoses made with tendoscopy were missed on MRI in the remaining 4 cases. At the 2.5-year follow-up following tendoscopy, functional outcome scores had also improved significantly.

A retrospective study by Soukup et al. investigated the effect of obesity on clinical and radiographic outcomes following reconstruction in patients with stage-II posterior tibial tendon dysfunction6. They found that, although preoperative symptoms were worse in obese patients, short-term clinical and radiographic outcomes were not significantly different between normal-weight and overweight patients.

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Plantar Fasciitis

Conservative treatment for plantar fasciitis includes physical therapy, home stretching exercises, and corticosteroid injections. A prospective study by Celik et al. compared functional outcome scores in patients randomized to receive either joint mobilization and stretching or corticosteroid injections7. The corticosteroid injection group exhibited greater improvement at follow-ups of 3, 6, and 12 weeks than the joint mobilization and stretching group. However, sustained improvement from 12 weeks to 1 year was only seen in the joint mobilization and stretching group.

Plantar fasciitis refractory to nonoperative management can be treated with partial plantar fascial release. Success rates of up to 80% have been reported, but a recent study by MacInnes et al. has called this into question8. Overall outcomes were poor at the 10-year follow-up. The authors found significantly worse outcomes in younger patients and those who received a steroid injection preoperatively.

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Ankle Fractures and Syndesmotic Injuries

Unstable ankle fractures require operative fixation. Although stress radiographs are most commonly utilized to detect instability in isolated fibular fractures, the ability to immediately bear weight after injury has also been suggested as a predictor of a stable mortise. A prospective study by Chien et al. demonstrated that patients with isolated fibular fractures and anatomic mortises were 3.6 times more likely to have a stable fracture if they could tolerate weight-bearing at the time of injury9. Although these findings do not preclude the need for proper imaging, they do provide additional information to aid in decision-making.

Venous thromboembolism is a well-known complication after lower-extremity trauma, although recommendations for prophylaxis in isolated foot and ankle fractures are conflicting. In a prospective study, Zheng et al. determined the incidence of venous thromboembolism in 814 patients who received either low-molecular-weight heparin or placebo for 2 weeks postoperatively10. The overall incidence of deep vein thrombosis was 0.98% in the low-molecular-weight heparin group and 2.01% in the placebo group, with no significant difference between the two. The risk factors were high body mass index (BMI) and advanced age. The authors concluded that routine chemical prophylaxis was not necessary in cases of isolated foot and ankle fractures.

Syndesmotic fixation is indicated in cases of persistent medial clear space widening after fibular fixation. However, the concern for malreduction has caused some to forego fixation of the syndesmosis. Cherney et al. investigated the relationship between incisura morphology and syndesmotic malreduction using bilateral computed tomographic (CT) scans11. They found that shallow incisurae were associated with a higher risk of anterior fibular malreduction and a lower risk of malrotation. Deeper incisurae predisposed to posterior and rotational malreductions. The authors suggested that preoperative CT scans could aid in surgical planning to avoid malreductions.

Syndesmotic overcompression has also been suggested as a cause of malreductions. A study by Haynes et al. utilized postoperative CT scans to assess syndesmotic reduction and correlated it to periarticular clamp reduction forces measured intraoperatively12. They found that mean reduction clamp forces were 88 N for the undercompressed group, 130 N for the adequately compressed group, and 163 N for the overcompressed group. Surgeons should therefore remain cognizant of the clamp forces used, as they can be a cause of malreductions.

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Calcaneal Fractures

Calcaneal fracture is the most common of the tarsal bones. CT scans are obtained in most cases, as they are integral for fracture classification, treatment decision-making, and operative planning. Roll et al. investigated whether 3-dimensional reconstructions provided any additional information to the interpreting surgeon13. They found that it significantly improved fracture pattern evaluation, especially among inexperienced surgeons and with complex fracture types.

The extensile lateral approach to the calcaneus involves sectioning the calcaneofibular ligament. A Level-II study by Wang et al. used radiographic evaluation to determine whether this technique had a negative effect on ankle joint stability14. They found no significant difference in talar tilt or anterior drawer on stress radiographs between the injured and uninjured sides at 6 months postoperatively. The authors concluded that calcaneofibular ligament repair following this approach is unnecessary.

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Ankle Arthroscopy

Ankle arthroscopy has gained favor in recent years, attributable to quicker patient recovery and preservation of local blood supply. This latter advantage is particularly beneficial in promoting fusion.

Vilá y Rico et al. compared the results of arthroscopic posterior subtalar arthrodeses for adult-acquired flatfoot deformity and posttraumatic subtalar arthritis15. Both groups demonstrated improved postoperative AOFAS scores, comparable time to union, and similar complication rates. They suggested that arthroscopic subtalar arthrodesis is a safe and reliable technique.

Arthroscopy was also shown to be safe and reliable for ankle arthrodesis. Kendal et al. reported on a series of patients who underwent arthroscopic ankle arthrodeses for talar osteonecrosis16. They reported a 100% clinical and radiographic fusion rate, with nearly all patients reporting resolution of pain at the time of the final follow-up.

Given its increasing rate of utilization, proficiency in arthroscopy has become an important facet of surgical training. A Level-I study by Martin et al. showed that ankle arthroscopy simulation training improved basic surgical skills, efficiency, and anatomic recognition in residents in as few as four 15-minute sessions17. Future studies will focus on ways to improve training and define objective parameters to establish a curriculum with the goal of improving technical skill and maximizing patient safety.

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Ankle Arthritis and Total Ankle Arthroplasty

Surgical options for end-stage ankle arthritis include ankle arthrodesis and total ankle arthroplasty. Traditionally, ankle arthrodesis has been preferred because of cost and longevity concerns of total ankle arthroplasty, although recent refinements in implant design have shown improved outcomes with the latter.

Nwachukwu et al. performed a cost-utility analysis comparing ankle arthrodesis and total ankle arthroplasty in the treatment of end-stage ankle arthritis18. When indirect costs were considered, total ankle arthroplasty was more cost-effective and the preferred treatment, especially in younger patients. As indications for total ankle arthroplasty continue to expand, outcomes data in different demographic groups and different implant systems become especially important.

The deleterious effects of obesity on outcomes after hip, knee, and shoulder arthroplasty are well documented, but results following total ankle arthroplasty in obese patients have only recently been studied. Gross et al. found that total ankle arthroplasty is a relatively safe procedure in obese patients with no increase in postoperative complications compared with non-obese controls19. Obese patients also experienced significant functional and pain improvements following total ankle arthroplasty, although to a lesser degree than non-obese patients.

In another study, Schipper et al. found that patients with a BMI of ≥30 kg/m2 had an increased 5-year risk of implant failure, with the highest risk seen in patients with osteoarthritis compared with patients with inflammatory or posttraumatic arthritis20. The etiology of arthritis may therefore be an important consideration when counseling patients on total ankle arthroplasty compared with arthrodesis.

Concerns regarding implant survivorship in younger patients have prompted investigations on the effect of age on total ankle arthroplasty outcomes. Demetracopoulos et al. prospectively compared patient-reported outcomes and revision rates in patients who were <55 years of age, those who were 55 to 70 years of age, and those who were >70 years of age21. At the 3.5-year follow-up, patients who were <55 years of age had greater improvement in functional outcome scores than those who were >70 years of age, although no differences were observed in pain, need for reoperation, or revision rates between groups.

Lewis et al. compared clinical and radiographic outcomes in first and second-generation total ankle arthroplasty systems22. Both implant systems were composed of a fixed-bearing prosthesis utilizing a modular intramedullary stem. Patients in both groups exhibited significant improvements in pain and function and maintained improvements in coronal plane alignment. The second-generation system did demonstrate slightly better outcomes at the 1-year follow-up, with lower reoperation and implant failure rates.

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Achilles Tendon

Recent studies have investigated the role of augmented repairs in the treatment of Achilles tendinopathy and rupture.

Surgical treatment of chronic Achilles tendinopathy involves tendon debridement with calcaneal ostectomy. Decreased healing potential in patients who were >50 years of age have led some surgeons to augment the repair with a flexor hallucis longus tendon transfer. Hunt et al. evaluated the effectiveness of this strategy in a prospective randomized trial with patients who had undergone nonoperative management that had failed23. Although patients in the debridement and flexor hallucis longus tendon transfer group had increased ankle plantar flexion strength at the 1-year follow-up, no significant difference was observed in pain or functional scores compared with the debridement-only group.

Chronic Achilles tendon ruptures typically require augmentation at the time of repair. Guclu et al. investigated long-term results following the use of V-Y tendon plasty with fascia turndown in a retrospective comparative study24. At the 16-year follow-up, no patients experienced rerupture, and their clinical outcomes were comparable with those reported in the literature for chronic ruptures. The authors concluded that V-Y plasty with fascial turndown is a good, economic alternative to other methods, as it is straightforward to perform and does not require synthetic materials or allografts for augmentation.

Some surgeons have augmented primary repairs of acute tendon ruptures with fascial flaps to promote healing, to reduce rerupture risk, and to prevent tendon elongation. A Level-I study by Heikkinen et al. evaluated long-term outcomes in patients randomized to either a repair-only group or a repair and augmentation group25. At the 14-year follow-up, there were no significant differences in strength, tendon elongation, or rerupture rate between the two groups.

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Ankle Cartilage and Osteochondral Lesions of the Talus

Treatment of large or recurrent osteochondral lesions of the talus remains a controversial issue. A prospective Level-II study by Ahmad and Jones compared the use of autograft with allograft in these lesions26. Patients with either large or recurrent osteochondral lesions of the talus were randomized to a distal femoral autograft group or a fresh talar allograft group. At the 3-year follow-up, there was no significant difference in functional or radiographic outcomes between the groups. Allograft use avoids donor-site morbidity, and autograft use may demonstrate greater rates of healing.

Another question is whether repetitive microtrauma from chronic lateral ankle instability affects the development and prognosis of osteochondral lesions of the talus. A retrospective study by Lee et al. compared lesion characteristics and outcomes in patients with osteochondral lesions of the talus and concomitant chronic lateral ankle instability with those in a control group that had no chronic lateral ankle instability27. The presence of chronic lateral ankle instability increased the propensity for large osteochondral lesions of the talus, lateral-sided osteochondral lesions of the talus, and lesions at the tip of the medial malleolus. Furthermore, patients with chronic lateral ankle instability also experienced increased rates of clinical failure and inferior performance in sport and recreational activities at the time of the final follow-up.

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Hallux Rigidus

Joint-preserving arthroplasties for hallux rigidus have been proposed as an alternative to first metatarsophalangeal joint arthrodesis. However, they have shown high rates of failure with associated bone loss, rendering salvage arthrodesis a more complicated procedure with worse outcomes. A Level-I study by Baumhauer et al. investigated the use of a synthetic cartilage implant that requires less bone resection than a traditional arthroplasty28. Patients were randomized to implant and arthrodesis groups. At the 2-year follow-up, pain level, functional scores, and rates of revision surgical procedures were statistically equivalent in both groups. Secondary arthrodesis was required in <10% of the implant group and was considered to be a straightforward procedure because of preservation of bone stock.

Determining the first metatarsophalangeal joint range of motion is important for decision-making and assessing outcomes in patients with hallux rigidus. However, the reliability of clinical measurements has not been previously established. A Level-II study by Vulcano et al. compared first metatarsophalangeal joint passive dorsiflexion measurements made with a goniometer with those calculated radiographically in patients with any grade of hallux rigidus29. They found no significant difference between clinically and radiographically measured dorsiflexion.

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Outcomes following the surgical treatment of hallux valgus continue to be a heavily studied topic.

Two commonly utilized corrective procedures for hallux valgus are the scarf and chevron osteotomies. In a Level-II study, Jeuken et al. compared long-term outcomes in patients randomized to undergo either procedure, with radiographic recurrence and reoperation rate serving as primary outcome measures30. At the 14-year follow-up, the overall recurrence rate was 75%, with only 1 patient requiring a revision surgical procedure. Differences in recurrence and reoperation rates between the scarf and chevron osteotomy groups were not significant. Functional scores and radiographic results were also similar.

Hallux valgus surgical procedures are commonly performed under spinal, epidural, or regional anesthesia. Although peripheral nerve blocks have become increasingly popular with the advent of ultrasound, the associated learning curve has limited more widespread use. A Level-I study by Karaarslan et al. compared the efficacy of ultrasound-guided popliteal sciatic nerve blocks with spinal anesthesia in patients undergoing hallux valgus correction31. The popliteal block group demonstrated decreased pain scores at every time point up to 12 hours postoperatively, longer time to first analgesic requirement, and increased patient satisfaction scores compared with the spinal anesthesia group, and the popliteal block group did not experience the adverse effects of hypotension, bradycardia, and urinary retention occasionally seen with spinal anesthesia.

Many surgeons believe that patients with hindfoot valgus have worse outcomes due to increased pressure on the medial side of the foot. However, a comparative Level-II study by Ginés-Cespedosa et al. called this assumption into question32. Radiographs were used to group patients into categories of hindfoot varus, valgus, or neutral. After a 2-year follow-up in 181 patients, the authors found no significant correlation between hindfoot alignment and radiographic or functional outcomes.

Lesser toe deformities have also been the topic of recent study. A randomized clinical trial by Schrier et al. investigated whether proximal interphalangeal joint resection or arthrodesis leads to superior outcomes following a hammer-toe surgical procedure33. Patients were randomized to either proximal interphalangeal joint resection or proximal interphalangeal joint arthrodesis. At a follow-up of up to 1 year, both procedures resulted in good to excellent outcomes, with no significant differences in pain or activity scores between the two.

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Orthobiologics continue to generate considerable interest in the orthopaedic community, as evidenced by the increasing number of high-quality studies investigating their use as adjuvants for healing.

A prospective study by Jones et al. assessed the safety and effectiveness of cellular bone allograft in foot and ankle arthrodesis34. Although traditional allograft only provides osteoconductive scaffolding, cryopreserved cellular bone allograft also contains viable osteogenic cells. At 12 months postoperatively, fusion rates were 71.1% for all patients and 86.8% for all joints. Moreover, fusion rates in patients at high risk for nonunion (e.g., diabetic or obese) were comparable with those in normal patients.

Platelet-rich plasma and hyaluronic acid have also been investigated as adjuncts to promote healing. In a Level-I study, Görmeli et al. randomized patients to receive platelet-rich plasma, hyaluronic acid, or saline solution injections following arthroscopic debridement and microfracture of talar osteochondral lesions35. At the intermediate-term follow-up, the platelet-rich plasma and hyaluronic acid groups exhibited a significant increase in AOFAS scores and decrease in pain scores compared with the control group, with the platelet-rich plasma group showing the greatest improvement.

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Surgical-Site Infection and Wound-Healing

Surgical-site infection is often cited as a common complication following foot and ankle surgery. A Level-I study by Hunter et al. investigated whether the use of different preoperative preparation solutions had any effect on the incidence of wound infection or rate of positive bacterial cultures intraoperatively36. Patients were randomized to either isopropyl alcohol (4% chlorhexidine application followed by alcohol rinse) or chlorhexidine gluconate (alcohol followed by chlorhexidine) groups. Wound infection rates were equivalent in both groups, although the chlorhexidine group demonstrated lower positive culture rates.

One of the most common complications of open ankle fractures is postoperative wound necrosis. Ovaska et al. examined risk factors for necrosis in primarily closed wounds in these patients37. They found that the most important predictors were American Society of Anesthesiologists (ASA) class ≥2, Gustilo grade-III open fractures, and the use of pulsatile lavage. That study did not make any recommendations for primary or delayed wound closure, but did recommend reevaluating the use of pulsatile lavage.

The effect of platelet-rich plasma administration on wound-healing has also been the subject of recent study. In a randomized controlled trial, SanGiovanni and Kiebzak demonstrated that administration of autologous platelet-rich plasma in patients undergoing foot and ankle surgery had no effect on the rates of surgical-site infection or delayed wound-healing compared with untreated controls38. They concluded that, although future studies may identify a subset of patients who may benefit from autologous platelet-rich plasma administration, its routine use for prevention of wound complications is not recommended at this time.

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Diabetes and Charcot Arthropathy

Peripheral neuropathy and Charcot arthropathy cause severe morbidity among diabetics, often leading to ulceration, infection, and amputation.

Peripheral artery disease is a known risk factor for foot ulceration in the diabetic population. Wukich et al. evaluated the sensitivity and specificity of the ankle brachial index and toe brachial index in diagnosing peripheral artery disease in diabetic patients39. Although a decreased ankle brachial index had a greater specificity for peripheral artery disease, normal or elevated values in the setting of calcified distal arteries limited its sensitivity. The toe brachial index was more reliable in diabetic patients with non-compressible arteries, end-stage renal disease treated with dialysis, and/or neuropathy. The authors concluded that combining the ankle brachial index with the toe brachial index improved the ability to diagnose peripheral artery disease in diabetic patients.

Offloading ulcers is vital to healing and the prevention of further morbidity. Piaggesi et al. prospectively compared the efficacy and safety of walking boots with those of total contact casts in 60 patients40. Patients were randomized to a total contact casting group, a removable walking boot group, or an irremovable walking boot group. All 3 groups showed significant ulcer size reduction and no difference with respect to healing time. Patients’ acceptance and costs were significantly better in the removable walking boot group.

Charcot arthropathy is often distinguished from infection using MRI, although correlation with systemic inflammatory markers has also been suggested. Because Charcot arthropathy is considered a local inflammatory process, it is thought that C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are less likely to be elevated. However, a recent study by Hingsammer et al. casts doubt on this assumption41. They found elevated CRP and ESR levels in non-infected patients with Charcot arthropathy, with higher levels correlating with acute stages of the disease. Although elevated inflammatory markers may not be reliable exclusion criteria for Charcot arthropathy, they may be useful in distinguishing between acute and subacute stages of the disease.

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Upcoming Educational Events

Several courses and events related to foot and ankle surgery are sponsored and/or co-sponsored by the AAOS and the AOFAS. Among these is the AOFAS Annual Meeting, July 12 to 15, 2017, in Seattle, Washington.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 12 other articles with a higher Level of Evidence grade were identified that were relevant to foot and ankle surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Articles Related to Foot and Ankle Surgery

Akimau PI, Cawthron KL, Dakin WM, Chadwick C, Blundell CM, Davies MB. Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal: a prospective, randomised, single-blinded non-inferiority controlled trial. Bone Joint J. 2016 Jun;98-B(6):806-11.

Cast immobilization was compared with elastic bandaging for the treatment of fifth metatarsal base fractures. Patient-reported outcomes were not significantly different between groups at 4 weeks and 6 months following injury. Loss to follow-up was noted to be 43% at 6 months.

Campbell CM, Diamond E, Schmidt WK, Kelly M, Allen R, Houghton W, Brady KL, Campbell JN. A randomized, double-blind, placebo-controlled trial of injected capsaicin for pain in Morton’s neuroma. Pain. 2016 Jun;157(6):1297-304.

The efficacy, tolerability, and safety of a 0.1-mg capsaicin injection for Morton neuroma were investigated in a randomized controlled trial. At weeks 1 and 4 post-injection, greater improvement in pain and decrease in analgesic use were noted in the capsaicin group than in the control group. These findings suggest that capsaicin injections may be efficacious treatment options for painful intermetatarsal neuroma.

Ding DY, Manoli A 3rd, Galos DK, Jain S, Tejwani NC. Continuous popliteal sciatic nerve block versus single injection nerve block for ankle fracture surgery: a prospective randomized comparative trial. J Orthop Trauma. 2015 Sep;29(9):393-8.

Single-shot and continuous-infusion popliteal sciatic nerve blocks for ankle fracture surgery were compared in this prospective randomized trial. Patients in the continuous infusion group had significantly lower pain scores at 12 hours and 2 weeks postoperatively. They also had a lower opioid requirement in the first 72 hours postoperatively compared with the single-shot group.

Ewald TJ, Holte P, Cass JR, Cross WW 3rd, Sems SA. Does ankle aspiration for acute ankle fractures result in pain relief? A prospective randomized double-blinded placebo controlled trial. J Orthop Trauma. 2015 Sep;29(9):399-403.

This study was a randomized, double-blinded, placebo-controlled trial investigating the therapeutic effect of aspiration for acute ankle fractures. Patients were randomized between ankle aspiration and sham procedure groups. There were no significant differences in pain scores acutely in the emergency department or within 72 hours after injury.

Mahadevan D, Attwal M, Bhatt R, Bhatia M. Corticosteroid injection for Morton’s neuroma with or without ultrasound guidance: a randomised controlled trial. Bone Joint J. 2016 Apr;98-B(4):498-503.

The need to perform corticosteroid injections for Morton neuroma under ultrasound guidance was investigated in this randomized controlled trial. Patients underwent injection of triamcinolone and lidocaine either with or without ultrasound guidance. Both groups showed improvement in functional outcomes from baseline, but no significant differences were detected between groups at any time point up to the 12-month follow-up.

Menz HB, Auhl M, Tan JM, Levinger P, Roddy E, Munteanu SE. Effectiveness of foot orthoses versus rocker-sole footwear for first metatarsophalangeal joint osteoarthritis: randomized trial. Arthritis Care Res (Hoboken). 2016 May;68(5):581-9.

Patients with first metatarsophalangeal joint osteoarthritis were randomized to receive prefabricated foot orthoses or rocker-sole footwear. Pain scores improved in both groups, with no difference between the two. The footwear group was less compliant with treatment and less likely to report global improvement in symptoms compared with the orthosis group.

Monahan AM, Madison SJ, Loland VJ, Sztain JF, Bishop ML, Sandhu NS, Bellars RH, Khatibi B, Schwartz AK, Ahmed SS, Donohue MC, Nomura ST, Wen CH, Ilfeld BM. Continuous popliteal sciatic blocks: does varying perineural catheter location relative to the sciatic bifurcation influence block effects? A dual-center, randomized, subject-masked, controlled clinical trial. Anesth Analg. 2016 May;122(5):1689-95.

This study examined whether the effectiveness of popliteal sciatic blocks varies depending on the location of catheter relative to the sciatic bifurcation. Patients were randomized to undergo catheter placement either at the bifurcation or 5 cm proximal to it. The primary outcome measure was pain level on the morning after the surgical procedure. For continuous infusion blocks, catheters placed 5 cm proximal to the bifurcation provided superior postoperative analgesia compared with those placed at the bifurcation.

Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CWC; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.

This randomized clinical trial investigated whether formal physical therapy in conjunction with patient education provided any additional benefit following immobilization of ankle fractures compared with patient education alone. The authors found that there was no difference in functional outcomes between the 2 groups at the 1, 3, and 6-month time points. They concluded that the routine use of supervised exercise programs after removal of immobilization for isolated and uncomplicated ankle fractures was not warranted.

Reilingh ML, van Bergen CJA, Gerards RM, van Eekeren IC, de Haan RJ, Sierevelt IN, Kerkhoffs GM, Krips R, Meuffels DE, van Dijk CN, Blankevoort L. Effects of pulsed electromagnetic fields on return to sports after arthroscopic debridement and microfracture of osteochondral talar defects: a randomized, double-blind, placebo-controlled, multicenter trial. Am J Sports Med. 2016 May;44(5):1292-300. Epub 2016 Feb 22.

This Level-I study investigated whether pulsed electromagnetic fields following arthroscopic debridement and microfracture of talar osteochondral lesions can hasten recovery. Patients were randomized to either pulsed electromagnetic field or control groups and were followed for 1 year postoperatively. There was no difference between groups with respect to the percentage of patients returning to sports and median time to sport resumption. There were also no observed differences in bone repair as seen on CT scans.

Serinken M, Eken C, Elicabuk H. Topical ketoprofen versus placebo in treatment of acute ankle sprain in the emergency department. Foot Ankle Int. 2016 Sep;37(9):989-93. Epub 2016 May 19.

The efficacy of topical ketoprofen in treatment acute ankle sprains in the emergency department was evaluated in this Level-I study. A total of 100 patients were randomized to either a 2.5% ketoprofen gel or placebo group. Ketoprofen was found to be superior to placebo in alleviating pain at 15 and 30 minutes following administration. No adverse events were noted in either group.

Witteveen AGH, Hofstad CJ, Kerkhoffs GMMJ. Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle. Cochrane Database Syst Rev. 2015 Oct 17;10:CD010643.

The efficacy of hyaluronic acid and other conservative treatment modalities for ankle osteoarthritis was investigated in this systematic review. The authors concluded that there were insufficient data on which to base future guidelines for ankle osteoarthritis, although non-opioid analgesics are a reasonable initial treatment. The authors could not assess the benefit or harm of hyaluronic acid because of low-quality evidence, although they could conditionally recommend hyaluronic acid if there were no response to simple analgesics.

Zhang W, Lin F, Chen E, Xue D, Pan Z. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Orthop Trauma. 2016 Mar;30(3):e75-81.

Clinical outcomes of operative and nonoperative treatment of displaced intra-articular calcaneal fractures were compared in this meta-analysis of 908 patients in 7 randomized controlled trials. Appropriate reduction and fixation resulted in fewer problems with shoe wear and improved walking ability, although overall complication rates were higher than with nonoperative treatment. There was no significant difference in functional outcome scores between groups.

Investigation performed at the Department of Orthopaedics, New Jersey Medical School, Newark, New Jersey

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: One author of this work (S.S.L.) received a stipend from JBJS for writing this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/C265).

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1. Kowalczyk B, Felus J. Ponseti casting and Achilles release versus classic casting and soft tissue releases for the initial treatment of arthrogrypotic clubfeet. Foot Ankle Int. 2015 ;36(9):1072–7. Epub 2015 Apr 29.
2. Shabtai L, Hemo Y, Yavor A, Gigi R, Wientroub S, Segev E. Radiographic indicators of surgery and functional outcome in Ponseti-treated clubfeet. Foot Ankle Int. 2016 ;37(5):542–7. Epub 2015 Dec 23.
3. Kang S, Park SS. Lateral tibiocalcaneal angle as a determinant for percutaneous Achilles tenotomy for idiopathic clubfeet. J Bone Joint Surg Am. 2015 ;97(15):1246–54.
4. Houck J, Neville C, Tome J, Flemister A. Randomized controlled trial comparing orthosis augmented by either stretching or stretching and strengthening for stage II tibialis posterior tendon dysfunction. Foot Ankle Int. 2015 ;36(9):1006–16. Epub 2015 Apr 9.
5. Gianakos AL, Ross KA, Hannon CP, Duke GL, Prado MP, Kennedy JG. Functional outcomes of tibialis posterior tendoscopy with comparison to magnetic resonance imaging. Foot Ankle Int. 2015 ;36(7):812–9. Epub 2015 Mar 10.
6. Soukup DS, MacMahon A, Burket JC, Yu JM, Ellis SJ, Deland JT. Effect of obesity on clinical and radiographic outcomes following reconstruction of stage II adult acquired flatfoot deformity. Foot Ankle Int. 2016 ;37(3):245–54. Epub 2015 Nov 5.
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