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Journal Scan: Foot and Ankle

Del Gaizo, Daniel, MD1; Parekh, Selene, G., MD, MBA2, 3, a

Clinical Orthopaedics and Related Research: January 2010 - Volume 468 - Issue 1 - p 296–301
doi: 10.1007/s11999-009-1110-5

1Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA

2Division of Orthopaedic Surgery, Duke University, 3609 Southwest Durham Drive, 27707, Durham, NC, USA

3Fuqua Business School, Duke University, Durham, NC, USA


Published online: 7 October 2009

Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations: a prospective randomized trial. White BJ, Walsh M, Egol KA, Tejwani NC. J Bone Joint Surg Am. 2008;90:731-734.

Context: Ankle fracture-dislocations are common injuries whose urgent reduction in the emergency department (ED) often require the administration of analgesia. Conscious sedation often is used successfully but carries a reliance on emergency room staff and the risk of respiratory depression.

Study Design and Results: In a prospective randomized study, 42 patients requiring reduction of an ankle fracture received either an intraarticular hematoma block consisting of 12 cc 1% lidocaine without epinephrine or conscious sedation (combination of narcotics and benzodiazepines determined by an ED physician). Outcomes recorded included metrics of pain during the reduction, pain after the reduction, difficulty of the reduction, and the time elapsed before the reduction was recorded. There were no statistically significant differences between the two groups in any of these parameters. The number of repeat reductions required in the hematoma group (six) was greater than the conscious sedation group (two), but the difference was not significant (p = 0.15).

Conclusions: The authors conclude that an intraarticular hematoma block is a safe and reasonable alternative to conscious sedation for patients with ankle fracture-dislocations.

Comments: The results of this study are consistent with studies comparing hematoma block with conscious sedation for other injuries in patients such as Colles fractures or glenohumeral dislocations. There still may be some benefit to conscious sedation in certain patients as evidenced by the increased number of repeat reductions required in the hematoma block group. (Recall that p = 0.15 means that there is an 85% chance that the two groups are really distinct.)

Pearls: Conscious sedation may be particularly effective if extreme anxiety or inability to cooperate (as seen with some children or intoxicated/combative patients) is an additional impediment to reduction.

Ankle fractures in the elderly: initial and long-term outcomes. Anderson SA, Li X, Franklin P, Wixted JJ. Foot Ankle Int. 2008;29:1184-1188.

Context: Elderly patients (with weaker bones and poor reflexes, among other factors) are at risk for more severe ankle fractures for a given mechanism of injury. Also, patients in this age group often have multiple comorbidities that place them at increased risk for postoperative complications.

Study Design and Results: A retrospective review was performed on 46 patients younger than 65 years and 25 patients older than 65 years who had open reduction and internal fixation for a displaced ankle fracture. The patients older than 65 years had a significantly greater complication rate (40% vs 11%) with greater requirement for nursing home placement. At long-term followup, there were no significant functional or radiographic differences between the two groups.

Conclusions: In the early postoperative period, elderly patients were at increased risk for complications and functioned poorly. At long-term followup, patients older than 65 years had equivalent results to the patients younger than 65 years.

Comments: Anderson et al. commented that the study design of a retrospective review may have selected for higher functioning elderly patients. Elderly patients with multiple comorbidities may not have been offered or may have declined operative treatment.

Pearls: A risk of falls owing to poor vision, disturbed gait, etc, presents a risk for hip fracture. When an elderly patient presents with an ankle fracture, ask yourself, why did this patient fall?

Functional outcome after operative treatment for ankle fractures in young athletes: a retrospective case series. Porter DA, May BD, Berney T. Foot Ankle Int. 2008;29:887-894.

Context: The majority of studies evaluating functional outcomes after operative treatment of ankle fractures analyzed cohorts of patients with few athletic injuries. Athletic-related ankle fractures often involve high-energy mechanisms not seen in ankle fractures in the general population. Compared with the general population, the competitive athlete might have higher expectations regarding postinjury function.

Study Design and Results: Twenty-seven athletes (defined as one who participated in an organized team sport or was involved in regular competition) underwent operative treatment for various isolated ankle fractures. Fractures of the medial and/or lateral malleolus underwent open reduction internal fixation. Injuries to the syndesmosis were addressed with screws. Deltoid ligament tears were repaired. The postoperative protocol consisted of immobilization wearing a walking boot with weightbearing as tolerated initiated at the first postoperative visit. Full return to athletics was allowed on completion of a sport-specific functional progression program. Subjective outcome data were obtained with AAOS questionnaires at a minimum of 1 year followup. Objective clinical and radiographic data also were obtained at this visit. The average percentage rating of the ankle compared with preinjury status was 96.4% with 12 athletes rating their ankle 100%. All athletes were able to resume their previous level of competition except for one patient who feared reinjury.

Conclusions: Anatomic open reduction with rigid internal fixation, repair of ruptured ligaments, early weightbearing, and early range of motion resulted in excellent outcomes in this group of patients.

Comments: The psychology of athletes may be different than that of other patients, which may influence the subjective scoring.

Pearls: General conditioning and range of motion activities should be used throughout the rehabilitative process, even for nonathletes.

The Achillon achilles tendon repair: is it strong enough? Ismail M, Karim A, Shulman R, Amis A, Calder J. Foot Ankle Int. 2008;29:808-813.

Context: The Achillon is a relatively new device that allows for minimally invasive repair of a ruptured Achilles tendon with a purportedly decreased risk of wound complications compared with open repair. Unlike previously reported percutaneous techniques, the Achillon device/technique does not appear to present an increased risk of sural nerve injury. However, the configuration of the stitches used in the Achillon repair may lacerate the tendon (via “cheese-wiring”).

Study Design and Results: A sheep tendon model was used in this biomechanical comparative study. All tendons underwent a transverse tenotomy 40 mm proximal to the calcaneal insertion. Eight tendons were repaired with the three-strand Achillon device/technique and eight tendons were repaired with a two-strand Kessler repair. In both groups, the suture used was No. 2 Ticron. The tendons then were loaded in tension to failure. All specimens in the Achillon group failed owing to the sutures cutting through the tendon. Five of the Kessler sutures cut through the tendon whereas three failed at the knots. The mean load to failure for the Kessler repair was 123 N +/−24. The mean load to failure for the three Achillon technique repairs was 153 N +/−60. The difference was not statistically significant.

Conclusions: The Achillon technique had a comparable repair strength to the traditional open Kessler technique.

Comments: The transverse tenotomy used in this study is a limitation in that it fails to replicate the more common clinical scenario of frayed mop-end tendon often seen in acute Achilles tendon ruptures.

Pearls: For surgeons who are just starting to use this technique, it is reasonable to perform initial surgeries with a more traditional incision to ensure proper placement of the device in the paratenon, and passage of the sutures.

Emergency brake response time after first metatarsal osteotomy. Holt G, Kay M, McGrory R, Kumar CS. J Bone Joint Surg Am. 2008;90:1660-1664.

Context: Hallux valgus correction involving an osteotomy of the first metatarsal is a common elective orthopaedic procedure. Patients often will inquire when they can safely return to driving.

Study Design and Results: A prospective observational study was conducted with 28 patients who had a right-sided first metatarsal osteotomy (chevron, Scarf, or basal) for symptomatic hallux valgus. A soft tissue release was performed when needed. Fixation was obtained with screws and/or plates. A driving simulator was used to assess total brake response time, reaction time, and brake time. Data were collected preoperatively and at 2 and 6 weeks after surgery. These data were compared with data from a control group that was matched for age, driving status, and gender. At 2 weeks, only seven patients (25%) were able to tolerate the driving simulator. By 6 weeks, total brake response time was markedly improved and reaction and brake times were comparable to preoperative and control values.

Conclusions: This study supports waiting 6 weeks to return to driving after undergoing a first metatarsal osteotomy for symptomatic hallux valgus.

Comments: The authors note that reaction time and brake time are measurements that may improve with practice and that some improvement seen at 6 weeks after surgery may represent a learning response.

Pearls: It is important to counsel patients preoperatively on anticipated driving restrictions so they can make the necessary work/lifestyle adjustments. If the improvements seen at 6 weeks postoperative represent a learning response, it would be wise to advise patients to practice driving in an empty parking lot before returning to highway driving.

Changes in length of the first ray with two different first MTP fusion techniques: a cadaveric study. Singh B, Draeger R, Del Gaizo DJ, Parekh SG. Foot Ankle Int. 2008;29:722-725.

Context: When performing a first metatarsophalangeal joint (MTP) fusion, it is important to minimize shortening of the first ray which could result in symptomatic forefoot disorders such as transfer metatarsalgia to the lesser toes.

Study Design and Results: A cadaveric study was performed to compare the degree of shortening in first MTP fusion between two commonly used techniques: flat cuts and conical reaming. Six matched pairs of frozen cadaver feet were divided into two groups. Specimens in Group I underwent MTP fusion with flat bone cuts. Specimens in Group II underwent MTP fusion with a conical reaming system. Preprocedure and postprocedure calibrated radiographs were obtained and the degree of shortening of the first ray was determined. The average shortening of the first ray was 7.1 mm in the flat cut group and 5.7 mm in the conical reaming group. This difference was not statistically significant.

Conclusions: Both techniques resulted in shortening of the first ray, but there was no significant difference between the two groups.

Comments: A larger sample size may have detected a small difference between the two techniques; but even if it did, a 1.4-mm difference would be of questionable clinical relevancy.

Pearls: The flat-cut method appears to be a simple, quick, and effective means of providing reliable fusion with acceptable alignment. That alone may be worth the 1.4 mm of shortening.

Incidence of chondral lesions of talar dome in ankle fracture types. Aktas S, Kocaoglu B, Gereli A, Nalbantodlu U, Guven O. Foot Ankle Int. 2008;29:287-292.

Context: Although ankle fractures are common injuries, the presence of concomitant chondral injuries has not been well studied. In particular little data are available regarding correlation between ankle fracture types and the type and severity of cartilage injury.

Study Design and Results: This is a retrospective review of 86 ankle fractures that underwent arthroscopic assisted open reduction internal fixation. Ankle arthroscopy was performed before and after repair of the fractures. All fractures were supination external rotation injuries that were repaired with standard AO technique. Fractures were classified according to the Weber classification system. Almost 28% of all fractures had a talar dome chondral lesion. Isloated Weber B distal fibular fractures had the highest rate (70%) of chondral injuries. There was no correlation between fracture severity and incidence of chondral injury.

Conclusions: There is a sizeable incidence of chondral lesions associated with ankle fractures. The severity of the fracture is not useful in determining which ankles are more likely to have a chondral injury.

Comments: The authors of this study recommend ankle arthroscopy for all ankle fractures. There is currently no evidence that arthroscopic interventions would improve the overall clinical outcome in these patients.

Pearls: Although we do not routinely perform ankle arthroscopy for acute ankle fractures, it is critically important to observe the joint for any loose cartilaginous bodies if there is any block to anatomic restoration of the talus in the ankle mortise.

Ankle replacement versus arthrodesis: a comparative gait analysis study. Piriou P, Culpan P, Mullins M, Cardon JN, Pozzi D, Judet T. Foot Ankle Int. 2008;29:3-9.

Context: In patients with end-stage arthritis of the ankle, arthrodesis offers reliable initial pain relief but alters gait mechanics that lead to degenerative changes in adjacent joints. Total ankle arthroplasty (TAA) provides pain relief and maintains some motion at the ankle. By preserving motion, TAA provides the theoretical benefit of avoiding excessive stress and subsequent degeneration of neighboring joints.

Study Design and Results: Gait analysis was performed on 12 patients with a successful ankle arthrodesis, 12 patients with a successful TAA, and 12 age-matched healthy control subjects. Neither TAA nor ankle arthrodesis restored normal ankle movement or speed when compared with the age-matched control group. Patients who had arthrodesis had a faster gait with a longer step length than patients with TAA. Although slower, patients who had TAA had a more physiologic and symmetric gait with more normal timing and transmission of ground reactive forces.

Conclusion: Patients with ankle arthrodesis had a faster gait than patients with TAA. This gain in speed was at the expense of timing, symmetry, and altered ground reaction forces that were more physiologically maintained in the TAA group.

Comments: Followup comparative studies are needed to determine if the improved gait kinematics in the arthroplasty group will result in less degenerative changes in the adjacent joints.

Pearls: The results of conversion of a failed TAA to arthrodesis are inferior to results from primary arthrodesis. Therefore, it is critical to make an informed choice for the primary operation.

Proprioception after total ankle arthroplasty. Conti SF, Dazen D, Stewart G, Green A, Martin R, Kuxhaus L, Carl Miller M. Foot Ankle Int. 2008;29:1069-1073.

Context: Total ankle arthroplasty (TAA) preserves motion relative to arthrodesis, which is not necessarily synonymous with normal gait. Analysis of proprioception after TAA allows for assessment of the procedure to replicate normal ankle function and for development of effective postoperative rehabilitation protocols.

Study Design and Results: Thirteen patients who had a unilateral arthroplasty with the Agility total ankle prosthesis (DePuy, Warsaw, IN) were recruited for this study. All patients had a satisfactory outcome at 2 years as determined with radiographs and clinical examination. A device was constructed that measured the ability of blindfolded/seated subjects to reproduce computer-controlled positioning of the foot. Data from the operative ankle were compared with data from the subject's contralateral unaffected ankle. There were no significant differences in ankle proprioception between the side with the TAA and the contralateral unaffected side.

Conclusions: TAA with the Agility total ankle prosthesis did not result in a measurable deficit in proprioception.

Comments: Study limitations include a small sample size resulting in a low value of power to confirm the absence of difference between the compared groups. Also, differences at points earlier than Year 2 may be clinically important.

Pearls: Proprioception is necessary for normal gait. Exercises to restore it are helpful even after relatively minor ankle sprains.

Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results. Ferkel RD, Zanotti RM, Komenda GA, Sgaglione NA, Cheng MS, Applegate GR, Dopirak RM. Am J Sports Med. 2008;36:1750-1762.

Context: Chronic osteochondral lesions of talus (OLT) can be treated with arthroscopy. Although well studied in the knee, the long-term outcome of these treatments in the ankle has yet to be defined.

Study Design and Results: A retrospective review of 50 patients (average age, 32 years; range, 12-72 years) who had undergone arthroscopic treatment for OLT was performed. Treatment consisted of retrograde transtibial or transtalar drilling if the lesion was stable (four), excision with drilling if the lesion was loose (40) or abrasion arthroplasty for “extensive” lesions (six). The average followup was 71 months (range, 24-152 months). At followup, patients were evaluated clinically with the Alexander, modified Weber, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot scores. Postoperative radiographs also were evaluated and compared with preoperative imaging for the presence of arthritis. The average postoperative AOFAS score was 84 (range, 34-100). The modified Weber score revealed 38% excellent, 26% good, 30% fair, and 6% poor results whereas the Alexander scale revealed 32% excellent, 40% good, 20% fair, and 8% poor postoperative results. Thirty-three patients (66%) showed no change in arthritis grade, 15 (30%) decreased by one grade, one (2%) decreased by two grades, and one (2%) decreased by five grades. There were seven (14%) complications reported. These consisted of peripheral neuropathies and portal pain, all of which resolved by 6 months after surgery. There was significant correlation between clinical outcomes and arthroscopic but not radiologic classification of the lesions.

Conclusions: At an average of 71 month followup, 64% to 72% of patients had good to excellent results from arthroscopic treatment of their OCL. Although the majority of patients in this series benefited from the procedure, patients with unstable chondral defects observed during arthroscopy were at increased risk for persistent pain and/or disability.

Comments: Multiple treatment modalities were used in this study. There were insufficient numbers of patients in each group to perform statistical analysis between these modalities. In the realm of evidence-based practice, this retrospective review can serve as a springboard for a robust trial.

Pearls: In our experience, the size of the lesion is a critical determinant of prognosis. Patients with large lesions still might be offered arthroscopy, but with a guarded prognosis. In the setting of failed microfracture of a large lesion, patients may be candidates for new alternative treatments such as synthetic, allograft, or autologous chondrocyte implantation.

Autologous chondrocyte implantation of the ankle: a 2- to 5-year follow-up. Nam EK, Ferkel RD, Applegate GR. Am J Sports Med. 2009;37:274-284.

Context: Favorable results have been seen with autologous chondrocyte implantation (ACI) for focal chondral lesions of the knee. The use of ACI for focal chondral lesions of the talus has not been well studied.

Study Design and Results: This is a prospective study of 11 patients (mean age, 33 years; range, 21-47 years) who had undergone ACI for focal lesions of the talus (nine medial, two lateral). Previous operative treatment, including debridement, drilling, pinning, or abrasion arthroplasty, had failed in all patients. The average lesion size was 21 mm long × 13 mm wide (range, 10-28 mm long × 8-15 mm wide). Six patients with subchondral cyst formation of 8 mm or greater underwent a “sandwich” procedure consisting of curetting the cyst, bone grafting the defect, and then “sandwiching” the cultured cells between two layers of harvested periosteum. The average followup was 38 months, at which time significant improvement was noted in Tenger activity, Finsen, and American Orthopaedic Foot and Ankle Society ankle hindfoot scores. Ten patients underwent repeat arthroscopy at which time complete coverage of the tissue with reparative cartilage was seen.

Conclusions: ACI resulted in significant functional improvement in a cohort of 11 patients with talar chondral injuries that had failed previous operative intervention.

Comments: On second-look arthroscopy, the lesions were covered with repair cartilage that was higher in intensity than the surrounding articular cartilage. Without a comparative group it is unclear that these results could not have been replicated via repeat microfracture and/or the sandwich procedure without ACI.

Pearls: The reported results of ACI for chondral lesions of the talus have been promising but more long-term followup is needed. Unlike microfracture or drilling that can be performed arthroscopically, ACI requires an open approach often requiring an osteotomy of one or more malleoli. Furthermore, there can be associated donor-site morbidity. For these reasons we use synthetic plugs for patients in whom the more tested and less invasive treatments of microfracture and/or arthroscopic drilling have failed.

Hallux valgus and first ray mobility: surgical technique. Coughlin MJ, Smith BW. J Bone Joint Surg Am. 2008;90(suppl 2 pt 2):153-170.

Context: There have been few prospective studies evaluating outcomes after proximal crescentic osteotomy with distal soft tissue repair of the first metatarsophalangeal joint for hallux valgus.

Study Design and Results: 103 patients with moderate to severe hallux valgus underwent proximal crescentic osteotomy and distal soft tissue reconstruction. At a followup at a minimum of 2 years after surgery, outcomes were assessed via the American Orthopaedic Foot and Ankle Society (AOFAS) scores, objective clinical measurements, and radiographic analysis. The average AOFAS scores increased from 57 to 91. One hundred fourteen feet (93%) were rated as having good to excellent results after surgery. Of the 23 feet that were noted to have hypermobility of the first ray, only two remained with increased mobility after surgery.

Conclusions: Proximal crescentic osteotomy with distal soft tissue reconstruction was successful in treating moderate to severe hallux valgus. Arthrodesis of the first metatarsocuneiform joint was not required in the majority of these patients.

Comments: This study was not a head-to-head comparison, and such a study might not be apt in any case: in our practice, for instance, proximal crescenteric osteotomies have been successful for treatment of moderate and serve hallux valgus deformities.

Long-term evaluation of interdigital neuroma treated by surgical excision. Womack JW, Richardson DR, Murphy GA, Richardson EG, Ishikawa SN. Foot Ankle Int. 2008;29:574-577.

Context: Morton's neuroma is one of the most common causes of forefoot pain. Excision of the neuroma usually is successful, but recurrence is possible. Although numerous factors have been suggested to lead to recurrence or persistence of pain, none have been shown conclusively to effect outcome.

Study Design and Results: A retrospective chart review was performed to identify 232 patients who had neuroma excision after failure of conservative management. One hundred twenty (52%) patients completed and returned a survey used to assess the neuroma clinical evaluation score and visual analog score. Sixty-one feet (51%) had good or excellent results, 12 (10%) had fair results, and 48 (40%) had poor results. Second webspace neuromas had significantly worse outcomes than third webspace neuromas.

Conclusions: Neuroma excision in this series was not as successful as previously reported. Location of the neuroma in the second webspace was a poor prognostic indicator.

Comments: Limitations of the study include lack of preoperative data to assess for improvement, no objective clinical followup, and risk of recall bias.

Pearls: Ordinarily, patients lost to followup (nearly half in this study) typically do worse than those studied; the missing patients were lost to followup when they searched for a better doctor for better treatment. However, in the case of a neuroma excision (where no long-term followup is needed if the operation works), it may be fair to suggest that perhaps the patients lost to followup did well.

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. Suchak AA, Bostick GP, Beaupré LA, Durand DC, Jomha NM. J Bone Joint Surg Am. 2008;90:1876-1883.

Context: Various postoperative rehabilitation protocols following surgical repair of the ruptured Achilles tendon have been described. Controversy remains regarding optimal postoperative management including time to return to full weightbearing.

Study Design and Results: One hundred ten patients were treated by 14 surgeons who performed open operative repair using various suture materials and techniques. All patients wore a posterior splint and were nonweightbearing for the first 2 weeks after surgery. At the 2-week postoperative visit, the posterior splint was removed and the patient wore a hinged ankle-foot orthosis at 20° plantar flexion. The patients were taught active dorsiflexion exercises and instructed to advance the fixed angle hinge to neutral over the subsequent 2 to 3 weeks. The patients were randomized blindly to either remain nonweightbearing for an additional 2 weeks or to discard their crutches as soon as possible and begin weightbearing as tolerated. At 6 weeks followup, the patients who were weightbearing as tolerated reported significantly better physical functioning, vitality, social functioning, and role-emotional and fewer limitations of daily living. By 6-months there were no significant differences between the groups. There was no difference in complication rate between the groups and there were no reruptures in either group.

Conclusions: The patients who began weightbearing as tolerated 2 weeks after surgery reported better initial results in multiple domains compared with patients who were nonweightbearing for 6 weeks. This benefit was achieved without an increased complication rate.

Comments: Two caveats are in order: first, this was not early weightbearing without protection (there was a specific postoperative protocol that included at least 6 weeks of immobilization wearing an AFO, initially in plantar flexion); and second, patients with diabetes, ipsilateral injury, and a history of Achilles tendinitis were excluded. Surgeons should be cautious when applying the data from this study to other postoperative protocols or to patients with conditions that required exclusion.

Pearls: The final decision regarding early postoperative weightbearing should be made intraoperatively, depending on the subjective assessment of the quality of the Achilles tendon tissue and the repair.

Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Kane TP, Ismail M, Calder JD. Am J Sports Med. 2008;36:1160-1163.

Context: Noninsertional Achilles tendinopathy is a common condition with an unclear etiology, debated pathophysiology, and wide range of proposed treatments, many of which lack a strong evidence base. There has been some initially promising evidence to support the use of topical glyceryl trinitrate (GTN).

Study Design and Results: This is a randomized controlled trial of 40 patients with a clinical diagnosis of noninsertional Achilles tendinopathy confirmed with MRI and ultrasound. The control group consists of 20 patients who received a standard physical therapy program. The experimental group was given a daily transdermal patch of GTN over the area of maximal tenderness in addition to the same physical therapy program as the control group. The Ankle Osteoarthritis Scale (AOS) was used for outcome analysis at 6 months after initiation of treatment. Patients in whom nonoperative treatment failed (three in the control and four in the GTN group) underwent open decompression, at which time tissue samples were obtained for histopathologic analysis. There were no statistical differences between the groups as measured with the AOS or seen during histologic analysis of tissue obtained during open decompression. There was a significant increase in the prevalence of headaches in the GTN group.

Conclusions: The addition of topical GTN to a standard physical therapy protocol failed to provide clinical benefit or provide histologic evidence of improvement in this group of patients with noninsertional Achilles tendinopathy.

Comments: The data from this study conflict with earlier evidence that showed beneficial effects of topical GTN. The scoring system used in this study (AOS questionnaire) has not been validated for Achilles tendinopathy and without the measurement of physical parameters, some benefits of GTN treatment may have been overlooked.

Pearls: GTN may have a placebo effect as well. A well-designed study would have control patients apply a patch with comparable physical properties as well.

© 2010 Lippincott Williams & Wilkins, Inc.