What’s New in Foot and Ankle Surgery

Daniels, Timothy R., MD, FRCSC1; Halai, Mansur, MD, FRCSC1; Matz, Jacob, MD, FRCSC1

doi: 10.2106/JBJS.19.00052

1Division of Orthopaedic Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada

E-mail address for T.R. Daniels: danielst@smh.ca

Investigation performed at the Division of Orthopaedic Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada

Disclosure: One of the authors (T.R.D.) received a stipend for this work from JBJS. 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 (http://links.lww.com/JBJS/F265).

This article provides a summary of recent research pertaining to orthopaedic foot and ankle surgery, mainly published from September 2017 to September 2018. The included studies were published in several orthopaedic journals, including The Journal of Bone & Joint Surgery, The Bone & Joint Journal, Foot & Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, the Journal of Orthopaedic Trauma, and the American Journal of Sports Medicine.

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Syndesmotic Injury

Reduction techniques and implant choices for syndesmotic injuries remain controversial. An accurate reduction of the syndesmosis requires knowledge of the precise relationship between the distal part of the fibula and the tibial incisura. In a Level-III comparative study of 72 patients, Boszczyk et al.1 used bilateral postoperative computed tomographic (CT) scans to determine the correlation between syndesmotic anatomy and syndesmotic malreduction. Patients were at risk of overcompression if they had a deep incisura and a fibula not engaged into the tibial incisura. In contrast, patients were at risk of anterior fibular translation if they had anteverted incisurae, and patients were at risk of posterior fibular translation if they had retroverted incisurae. The authors concluded that operative attention should focus on sagittal plane malreduction, which was common (27.8%), and preoperative CT scans may aid in surgical planning to avoid syndesmotic malreduction.

In a Level-II prospective cohort study, Cherney et al.2 investigated whether accuracy of syndesmotic reduction predicts functional outcomes and pain. Forty-eight patients were reviewed at 12 months following transsyndesmotic stabilization with 1 or 2 quadricortically positioned screws. Reduction was assessed by tactile feel, closure of the tibiofibular clear space, and comparison with contralateral mortise and talar dome true lateral views. Bilateral CT scans assessed the accuracy of reduction postoperatively. Although malreduction of >3 mm or 15° rotation was observed in 30% of patients, outcome scores were equivalent compared with patients in the anatomically reduced group. Patient age, obesity, fracture pattern, and screw configuration had no effect on functional outcomes. In this American study, functional outcomes and pain scores were significantly worse in patients with state-sponsored insurance (Medicaid [n = 4]) when compared with patients with private insurance (n = 30), Medicare (n = 3), or no insurance (n = 11).

In the above studies, screws were used to reduce the syndesmotic diastasis. A point of controversy is whether suture button fixation is more physiological and allows for more natural tibiofibular rotation. In a randomized controlled trial (RCT) of 97 patients, suture button fixation achieved better American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale (non-validated) and Olerud-Molander Ankle (OMA) scores and had better radiographic outcomes than screw fixation, but daily activities were similar in both groups at 2 years3. Although suture button fixation has some advantages, implant availability, fracture pattern, and cost must be considered, as functional outcomes are acceptable in both groups.

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Lisfranc Fractures

Literature on the young patient with a low-energy Lisfranc injury is sparse. Cochran et al.4 evaluated outcomes following primary arthrodesis (n = 14) compared with open reduction and internal fixation (n = 18) in a young athletic population (mean age, 28 years) with low-energy Lisfranc fractures. At the 1-year follow-up, the primary arthrodesis cohort had significantly greater gains in their 1-mile speed than the open reduction and internal fixation group, compared with their pre-injury times. At a mean time of 35 months postoperatively, there was no difference in Foot and Ankle Ability Measure scores between the groups. Fifteen patients (83%) who underwent open reduction and internal fixation and 2 patients (14%) who underwent primary arthrodesis underwent planned removal of the transarticular screws.

The use of transarticular screws in open reduction and internal fixation of a Lisfranc injury in a young patient causes iatrogenic damage to the synovial joint articular cartilage. Kirzner et al.5 retrospectively analyzed the functional and radiographic outcomes of bridge plating, screw fixation, and a combination of both for the treatment of Lisfranc fracture-dislocations. In 108 patients (mean age, 39 years), functional outcomes were related to the quality of reduction. Patients with dorsal bridge plating (n = 45) had significantly improved clinical outcomes and a trend toward better anatomical reduction compared with the other groups at a mean follow-up of 3 years. Complications were similar across all groups, despite the bridge plating group having a higher proportion of smokers and open fractures. The confounding effect of a second operation to remove implants was less in this study, as 73% of the bridge plating cohort and 95% of the screw cohort underwent implant removal. The study authors preferred bridge plating and primarily used this technique after 2007, suggesting that selection bias may have influenced the outcomes in this study.

A Level-III review of reoperation rates following open reduction and internal fixation (n = 163) and primary arthrodesis (n = 54) for Lisfranc injuries demonstrated no difference when planned implant removal was removed from the analysis6.

In 33 recreational athletes (mean age, 31 years), most (67%) returned to participating in sport at their pre-injury level or increased frequency following Lisfranc fracture fixation with a combined screw and bridge plate technique7. Eleven patients (33%) experienced ongoing pain at the injury site; however, 80% were not limited by their injury, indicating that the pain, in most instances, was minor. Overall, 31 (94%) returned to some level of physical activity or sport.

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Ankle Fractures

Much attention has recently been paid to lateral and posterior malleolar fractures. However, the medial malleolar osteoligamentous structure is fundamental to mortise stability. Hu et al.8 retrospectively evaluated adverse radiographic outcomes following operative treatment of medial malleolar fractures in 296 patients. At a mean follow-up of 52 months, the prevalence of nonunion was 3.7%, that of malunion was 4.4%, and that of delayed union was 20.3%. The risk factors for delayed healing and poorer functional outcomes included tobacco use, vertical fractures, interposed soft tissue, and malreduction (with a >2-mm step). Sixty patients developed posttraumatic arthritis, with a prevalence of only 12.7% in patients with normal healing, suggesting that when a nonunion, malunion, or delayed union is present, the risk of posttraumatic arthritis increases.

In the Lauge-Hansen classification system, deltoid injuries are considered equivalent to medial malleolar fractures. Most nonosseous medial injuries were traditionally treated conservatively, with the deltoid ligament complex allowed to heal in a nonanatomical position with persistent medial-side pain. In a retrospective analysis of acute deltoid repairs with associated ankle fracture fixation and no medial fracture, operative management with suture anchors (n = 41) resulted in a significantly narrower medial clear space compared with conservative management (n = 37) at a minimum 1-year follow-up9. A reduced medial clear space was associated with better clinical outcomes, particularly when accompanied by a syndesmotic injury. Clinical outcomes were not significantly different between the 2 groups, suggesting that a prospective, sufficiently powered, clinical study is required to determine the necessity for acute deltoid ligament repair.

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Osteochondral Lesions of the Talus

Factors that contribute to symptomatic (painful) osteochondral lesions of the talus are poorly understood. A retrospective review of 52 patients with chronic osteochondral lesions of the talus assessed the relationship of age, body mass index (BMI), quality of life, lesion size, and anatomical location to morbidity10. Overall, a linear relationship between lesion size and BMI was identified. The authors found a higher prevalence of central lesions (24%), with a linear relationship between aging and AOFAS Ankle-Hindfoot Scale scores in this subset. The cohort’s quality of life was impacted to the same extent as patients with other orthopaedic disorders (i.e., osteoarthritis or sciatica) or non-orthopaedic disorders (i.e., diabetes or hypertension), irrespective of the lesion’s location. Further study is required to determine why some osteochondral lesions of the talus are symptomatic and others are not. In this study, symptomatic osteochondral lesions of the talus did not cause substantial morbidity.

A Level-III comparative study by Telleria et al.11 identified serum vitamin D deficiency in 25 (54%) of 46 patients with osteochondral lesions of the talus, compared with 11 (28%) of 40 patients with acute ankle sprains (p = 0.012). The authors suggested that consideration be given to screening for and treating vitamin D deficiency in patients presenting with osteochondral lesions of the talus, as is recommended for fragility fractures12.

The treatment of large or recurrent osteochondral lesions of the talus requires further investigation. A Level-III study retrospectively reviewed the effect of containment of osteochondral lesions of the talus on patient outcomes following autologous osteochondral transplantation13. Patients with contained defects (n = 31) and those with uncontained defects (n = 63) both reported improved clinical outcomes at a median follow-up of 45 months, with significantly greater improvement in Foot and Ankle Outcome Score (FAOS) pain subscores in patients with the contained-type osteochondral lesions of the talus.

Matrix-associated stem cell transplantation for the treatment of osteochondral lesions of the talus was prospectively assessed by Richter et al.14. The technique involved harvesting of stem cell-rich blood from the ipsilateral pelvic bone marrow, centrifugation, and impregnation of the resultant supernatant onto a collagen I/III matrix, which was then secured to the defect with fibrin glue. At the 2-year follow-up, the Visual Analog Scale Foot and Ankle (VAS FA) scores improved significantly in 130 patients with a mean defect size of 1.6 cm2, with no major complications. Ankle range of motion and imaging were not assessed.

A metal resurfacing inlay implant for a revision surgical procedure for osteochondral lesions of the talus was evaluated prospectively in 38 patients15. Two patients underwent revision to ankle arthrodesis, and 21 patients required a secondary operation (i.e., metal malleolar screw removal, gutter debridement, or calcaneal realignment osteotomy). Most clinical outcome measures improved significantly at 5 years postoperatively, and 77% of patients returned to sport. The high level of reoperation is concerning; further case-controlled studies comparing other available techniques are necessary to validate this treatment option.

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Total Ankle Replacement

Numerous design improvements and technique refinements have contributed to the evolution of the modern total ankle replacement. Benich et al.16 compared outcomes of older-generation and newer-generation total ankle replacements (n = 170) with ankle arthrodesis (n = 103) in a prospective cohort study. At a 3-year follow-up, both total ankle replacement and arthrodesis resulted in improved function and reduced pain; a pooled comparison of all outcome scores revealed no differences between the procedures. In subset analyses, significantly better outcomes were observed with newer-generation implants compared with arthrodesis. Longer-term follow-up is required to establish the sustainability of these outcomes.

In a retrospective review of 109 total ankle replacements with a single fixed-bearing design, the preoperative range of motion in the sagittal plane improved by a mean of 13.6° (p < 0.001) during the first 6 months postoperatively17. Pain outcomes improved until 3 months postoperatively and functional outcomes improved until 6 months postoperatively; these improvements were maintained at 2 years postoperatively.

Restricted motion in any joint is a predictor of limited motion after arthroplasty. Brodsky et al.18 retrospectively assessed outcomes following total ankle replacement in 76 patients, subdivided into 4 groups based on preoperative sagittal range of motion. Better preoperative sagittal range of motion was a positive predictor of postoperative gait. Patients with the largest preoperative range of motion had the best overall postoperative gait function. However, patients with the least preoperative sagittal range of motion demonstrated the greatest improvement in overall gait function. The authors concluded that preoperative ankle stiffness was not a deterrent for total ankle replacement.

The limits of coronal plane deformity on total ankle replacement continue to be challenged. A retrospective study of 144 consecutive HINTEGRA (Newdeal) total ankle replacements found comparable clinical outcomes and implant survival rates among patients with neutral coronal plane deformity (<5°), valgus coronal plane deformity (5° to 20°), and varus coronal plane deformity (5° to 20°) at a mean follow-up of 7.3 years19. Ancillary procedures (i.e., Achilles lengthening, medial release, lateral ligamentous repair, and calcaneal osteotomy) were more commonly required in patients with preoperative varus deformity. The overall implant survivorship was 91.1% (97.7% in the varus group, 81.1% in the valgus group, and 90.9% in the neutral group) at 7.3 years.

Outpatient total ankle replacements have been conducted in some centers for several years. In a retrospective review of 65 consecutive patients, Borenstein et al.20 reported that outpatient total ankle replacement led to low wound infection (1.5%) and wound breakdown rates, and no patients required readmission for pain control, supporting the safety of outpatient total ankle replacement.

Total ankle replacements include mobile-bearing and fixed-bearing designs. Queen et al. updated an earlier study21 with an RCT to determine whether a fixed-bearing or mobile-bearing total ankle replacement resulted in better clinical and biomechanical outcomes22. They found no significant differences in outcomes at the 1-year follow-up, consistent with earlier studies21,23. Further studies evaluating fixed-bearing and mobile-bearing designs from the same manufacturer would be beneficial.

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Analgesia and Pain Management

Opioid abuse has reached epidemic proportions in some countries, including the United States. Surgeons are in a difficult position: they are expected to use responsible prescribing practices and to simultaneously address patients’ pain adequately. Determining the appropriate amount of opioids to prescribe following an orthopaedic surgical procedure is challenging.

Two recent studies assessed opioid utilization in orthopaedic patients. Zhu et al.24 prospectively studied opioid utilization in 1,513 patients following nonoperative treatment of various fractures and dislocations at a single center. Over 60% of patients used less than the prescribed amount of opioids, and 10% did not fill their prescription. The risk factors for increased opioid consumption included injuries of the ankle, tibia, fibula, wrist, forearm, elbow, or humerus; dislocation or displaced fractures; greater alcohol consumption; age (40 to 79 years); and Workers’ Compensation claims. In a prospective study by Saini et al.25, only 50% of prescribed opioids were utilized in 988 patients following an outpatient foot and ankle surgical procedure. The risk factors for increased opioid consumption included continuous infusion catheter or regional block anesthesia, younger age (<60 years), preoperative pain, and ankle or hindfoot procedures.

An RCT found no difference in pain relief between acetaminophen (n = 25) and acetaminophen with tramadol (n = 14) for breakthrough pain following an orthopaedic surgical procedure for an extremity fracture26. It is noteworthy that 9 (36%) of 25 patients assigned to the acetaminophen with tramadol arm used only acetaminophen. This study adds to the body of evidence questioning whether opioids actually improve patient satisfaction with pain management after an orthopaedic surgical procedure.

Various regional anesthesia techniques are available to help to reduce the requirement for oral medications. In a prospective study of 167 patients undergoing outpatient forefoot procedures, Schipper et al.27 reported that a single-shot popliteal block provided longer analgesia (20.9 hours) compared with an ankle block (14.5 hours). However, an ankle block is technically simpler, does not require the use of ultrasound, and may be more practical and easier to administer by the surgeon.

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Hallux Rigidus

The Coughlin and Shurnas classification for hallux rigidus is the most popular classification system, taking into account both clinical and radiographic data28. Baumhauer et al.29 evaluated whether this system correlated with intraoperative findings and outcomes in 202 patients who had been randomized to first metatarsophalangeal joint arthrodesis compared with polyvinyl alcohol hydrogel implant arthroplasty. They found no correlation between preoperative Coughlin grade and preoperative maximum dorsiflexion and pain, and only a small correlation between preoperative Coughlin grade and intraoperative cartilage loss. The authors suggested that clinical signs and symptoms may play a greater role than radiographic evaluation in decision-making for the treatment of hallux rigidus. Also, arthrodesis and polyvinyl alcohol hydrogel implant arthroplasty had similarly favorable outcomes, irrespective of preoperative hallux rigidus grade.

In a 2016 RCT, Baumhauer et al.30 demonstrated equivalence of polyvinyl alcohol hydrogel implant (Cartiva; Wright Medical) arthroplasty (n = 152) and arthrodesis (n = 50) for hallux rigidus at a 2-year follow-up. In a follow-up study by the same group, Goldberg et al.31 retrospectively analyzed the success rates relative to patient factors in each group. They confirmed equivalent positive outcomes across all grades of hallux rigidus, with hallux valgus deformity of ≤20°, and irrespective of sex, age, BMI, and preoperative stiffness, pain, or symptom duration.

In a prospective, multicenter series of 80 patients who underwent a first metatarsophalangeal joint arthroplasty with a 3-component, unconstrained, cementless implant (ROTO-glide; Implants International), Kofoed et al.32 reported significant improvements in AOFAS Ankle-Hindfoot Scale scores and range of motion at a median follow-up of 11.5 years, with 91.5% survival at 15 years. Four patients required implant removal: 2 for infections, 1 for technical error, and 1 for joint dislocation. Two patients had periprosthetic cysts on the metatarsal side and 13 patients had phalangeal cysts; the presence of cysts did not influence clinical results. Four patients had the tibial sesamoid enucleated because of loading pain. Multivariate analysis showed a correlation between reduced AOFAS Ankle-Hindfoot Scale scores and arthrosis of the metatarsosesamoid junction. The authors suggested that the sesamoid should be enucleated in the presence of substantial arthrosis, fracture, or chondromalacia.

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Hallux Valgus

Numerous hallux valgus correction techniques exist, but an optimal method has not been established. Barg et al.33 performed a systematic review of 229 studies on 9 different hallux valgus correction procedures from 1968 to 2016. The overall results involving an osteotomy or arthrodesis were good, and dissatisfaction rates were low. Comparatively, simple bunionectomy (i.e., excision of the medial eminence, lateral soft-tissue release, and medial imbrication) and joint hemiresection (i.e., excision of the proximal third of the proximal phalanx, Keller operation) had worse outcomes and higher patient dissatisfaction. Both procedures have been reported infrequently in the last 2 decades; the authors theorized that their popularity has decreased because of these poor outcomes. Most studies had a low level of evidence (66% Level IV) with limited follow-up; large, prospective, long-term trials with multiple treatment arms are needed to determine the optimal procedures for the various pathologies that present with hallux valgus (i.e., pes planus, medial column instability, congruent deformities compared with incongruent deformities, extent of deformity, stiffness, contracted Achilles tendons).

Shakked et al.34 retrospectively examined the link between depression and surgical outcomes at a mean of 23 months following a hallux valgus surgical procedure. Patients with depressive symptoms (n = 36) had lower functional scores at baseline and final follow-up than patients without depressive symptoms (n = 203). Furthermore, although patients with depression had lower pain scores postoperatively, dissatisfaction with pain was higher in patients with depression compared with patients without depression.

Lai et al.35 retrospectively determined that percutaneous chevron-Akin osteotomies (n = 29) for correction of hallux valgus deformities had clinical and radiographic outcomes comparable with open-technique scarf and Akin osteotomies (n = 58) at a 24-month follow-up. The percutaneous group demonstrated less perioperative pain, shorter operative time, and fewer wound complications. The mean hallux valgus angle (and standard deviation) improved significantly more in the percutaneous group (8.8° ± 5.9° compared with 13.8° ± 7.6°); the intermetatarsal angle improved similarly in both groups.

The risk of damage to anatomical structures with percutaneous techniques needs to be considered. In a cadaveric study, surgeons inexperienced with minimally invasive techniques damaged the dorsomedial cutaneous nerve in 15% of specimens during minimally invasive dorsal cheilectomy36.

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Achilles Tendon

Schipper et al.37 retrospectively evaluated 28 patients, including 12 professional athletes, with Achilles tendon sleeve avulsions. A history of pain was observed in 7 (44%) of 16 general patients and 11 (92%) of 12 elite athletes. The authors excised any osseous prominence including a Haglund deformity in 81% of patients, any diseased tendon, and avulsed bone fragments. Transosseous tunnels or suture anchors were used for tendon fixation in 81%, and 44% underwent flexor hallucis transfer. Wound-healing complications requiring reoperation were observed in 3 patients. All athletes returned to play at a mean time of 13.4 months. They demonstrated good clinical outcomes at a mean time of 8 years following primary repair. The authors recommended suture anchor repair and Haglund excision in this patient population and preemptive Haglund excision and secondary Achilles reconstruction in elite athletes with symptoms of a ≥9-month duration and evidence of distal disease on magnetic resonance imaging (MRI).

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Pes Planus

Symptomatic stage-II posterior tibial tendon dysfunction often presents in older patients, in whom operative management compared with nonoperative management is a greater consideration. In a retrospective review of 140 feet, patients were divided into 3 age cohorts: young (mean, 36.8 years), middle-aged (mean, 57.1 years), and older (mean, 70.5 years)38. The procedures utilized included flexor digitorum tendon transfer, medializing calcaneal osteotomy, lateral column lengthening, Cotton osteotomy, first tarsometatarsal fusion, and spring ligament reconstruction. The authors did not clarify whether gastrocnemius lengthening was part of the operative procedure. Older patients were more likely to require lateral column lengthening. Improvements in FAOS scores were equivalent across all age cohorts at a mean time of 3 years following reconstruction. Reoperation rates were not higher in the older cohort; however, a detailed description of postoperative complications in each cohort was not reported. The authors did not provide insight into what clinical parameters influenced which surgical procedures were chosen.

Tendoscopy has been suggested as a reasonable intermediate step for stage-II posterior tibial tendon dysfunction39, but it has rarely been reported. In a retrospective review of 16 patients, posterior tibial tendoscopy with synovectomy and debridement demonstrated improvements in pain and function, with 13 patients (81%) reporting good satisfaction at the 26-month follow-up40. Three patients underwent a standard flatfoot reconstruction at 2 to 5 months following tendoscopy. Although the authors suggested that tendoscopy is an effective intermediate step in treating stage-II posterior tibial tendon dysfunction, their study did not take into consideration the natural history of this disease process, as symptoms from tendon inflammation can diminish with nonoperative management. A comparative study is required to effectively assess the role of tendoscopy in stage-II posterior tibial tendon dysfunction. In this study, 2 of 9 patients who underwent preoperative MRI had unreported spring ligament ruptures, whereas the MRI description of the posterior tendon correlated with the operative findings in 12 (92%) of 13 cases.

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The Pediatric Foot

The Ponseti method has become the mainstay of clubfoot treatment. Zionts et al.41 prospectively followed 101 consecutive children treated with Ponseti manipulation and casting. Patients were graded with the Dimèglio score, and laterality was noted. If the patient experienced a relapsed deformity during the first 4 years, bracing was recommended until the patient reached 5 years of age. The mean Dimèglio score was 13.2 ± 2, and 67% of patients experienced ≥1 relapse, with 38% requiring an additional surgical procedure (i.e., anterior tibial tendon transfer and soft-tissue release). Despite these shortcomings, 62% of children achieved a good outcome, and 38% of children achieved a fair outcome. Almost all had a cosmetically acceptable foot with minimal complications at the mean 81-month follow-up.

The recurrence of deformity following Ponseti casting is commonly treated surgically, often with an anterior tibial tendon transfer. Van Praag et al.42 employed repeat casting and bracing for recurrent clubfoot in a comparative cohort study and reported acceptable outcomes at 7 years of age following repeat casting in 26 (74%) of 35 patients. They suggested that repeat casting can be used successfully to avoid a surgical procedure in many children and should be the first-line intervention in relapsed deformity.

Toe-walking in children is of great concern for many parents and a frequent reason for pediatric orthopaedic surgery consultation. Information on the natural history of this condition is limited. In a retrospective cohort study of 63 patients followed from birth to 10 years of age, 79% of children diagnosed with toe-walking without ankle contracture had spontaneous resolution by the age of 10 years43. Approximately 50% of children whose toe-walking did not resolve by the age of 10 years were diagnosed with a neurodevelopmental disorder between 5.5 and 10 years of age. This study is useful in setting expectations with contemporary treatment.

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Diabetes and Charcot Neuroarthropathy

Limb salvage in diabetic foot infections often entails multiple osseous and soft-tissue procedures requiring substantial time and cost. Despite best efforts, limb salvage attempts can fail, resulting in a below-the-knee amputation. Hong et al.44 retrospectively studied 41 patients with diabetes who underwent a below-the-knee amputation, either due to failure of limb salvage or as a primary procedure. Cases that required multiple salvage procedures prior to below-the-knee amputation, such as abscess drainage, debridements, minor amputations, and reconstructive operations, were defined as creeping amputation. Twenty-four patients (59%) underwent primary below-the-knee amputation, and 17 patients (41%) had creeping amputations performed. Sixteen (94%) of 17 patients who underwent multiple procedures and 9 (38%) of 24 patients who underwent primary amputation indicated that they preferred to do everything possible (i.e., undergo multiple procedures) to save the affected limb. There was no significant difference in outcome parameters or the ability to return to normal living between the groups. A health-care cost comparison between the 2 cohorts was not conducted.

Achieving fusion in a Charcot neuropathic ankle can be challenging and prone to complications. El-Mowafi et al.45 used an ankle arthrodesis nail and external fixation simultaneously in 24 patients with diabetic Charcot neuroarthropathy and achieved 92% union, with no broken implants or deep infections. This strategy increased stability of the reconstructed ankle, shortened time in the fixator, and prevented refracture after frame removal.

In the patient with Charcot neuroarthropathy, the goal of reconstruction is to create a stable foot for independent ambulation in appropriate shoe wear, orthotic wear, and/or brace wear. Modern internal and external fixation greatly assists the stability of Charcot reconstruction techniques. Pinzur and Schiff46 found that 173 (78%) of 223 feet of patients with Charcot neuroarthropathy who underwent a corrective surgical procedure achieved a favorable clinical outcome. Favorable outcomes were more likely in valgus deformity than varus deformity.

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Upcoming Educational Events

Several courses and events related to foot and ankle surgery are sponsored and/or are cosponsored by the American Academy of Orthopaedic Surgeons (AAOS) and the AOFAS. These include the AOFAS Annual Meeting, September 12 to 15, 2019, in Chicago, Illinois.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 14 other articles with a higher Level of Evidence grade relevant to foot and ankle surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Orthopaedics

Ahmad J, Lynch MK, Maltenfort M. Comparison of screws to plate-and-screw constructs for midfoot arthrodesis. Foot Ankle Int. 2018 Aug;39(8):922-9. Epub 2018 Apr 5.

Patients with severe midfoot arthritis of the medial and/or middle column undergoing fourth and fifth tarsometatarsal joint arthrodesis were randomized to receive either screws (n = 25) or a plate-and-screw construct (n = 25). Patients with Charcot neuroarthropathy, large areas of bone loss, and prior surgical procedure were excluded. At 6 months postoperatively, 21 (84%) of the 25 patients with screws and 23 (92%) of the 25 patients with a plate and screws achieved complete fusion. Foot and Ankle Ability Measures and VAS pain scores improved significantly in both groups, with no difference between the groups, at a mean final follow-up of 44 months. The plate-and-screws cohort (6 patients) had more wound complications than the screw cohort (3 patients) (p = 0.03).

Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED, Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI, Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. JAMA. 2017 Dec 26;318(24):2438-45.

This Level-I, double-blinded, multicenter study randomized patients who were undergoing removal of orthopaedic implants used for the treatment of foot and ankle fractures to receive preoperative intravenous 1,000-mg cefazolin (n = 228) or saline solution (n = 242). Immunocompromised patients were excluded, but patients who had diabetes, were smokers, or were obese were not. At 1 month, there was no significant difference in surgical site infections between the groups (12.9% for the cefazolin group compared with 14.9% for the saline solution control group).

Braito M, Dammerer D, Schlager A, Wansch J, Linhart C, Biedermann R. Continuous wound infiltration after hallux valgus surgery. Foot Ankle Int. 2018 Feb;39(2):180-8. Epub 2017 Oct 27.

The prospective, double-blinded trial randomized 50 patients undergoing a hallux valgus surgical procedure to receive continuous wound infiltration with either ropivacaine or saline solution (placebo) for the first 24 hours after the surgical procedure. At multiple time points up to 6 weeks postoperatively, pain scores, narcotic consumption, range of motion of the first metatarsophalangeal joint, and patient satisfaction were similar in both groups. Catheter-related complications occurred in 7 patients, with the authors discouraging its routine use.

Buckley R, Kwek E, Duffy P, Korley R, Puloski S, Buckley A, Martin R, Rydberg Moller E, Schneider P. Single-screw fixation compared with double screw fixation for treatment of medial malleolar fractures: a prospective randomized trial. J Orthop Trauma. 2018 Nov;32(11):548-53.

The authors randomized patients to either 1-screw fixation (n = 61) or 2-screw fixation (n = 66) of a medial malleolar fracture. Fracture patterns and operative time were similar for both groups; all but Type A (avulsion) fractures were randomized. Short Form-36 (SF-36) and AOFAS Ankle-Hindfoot Scale scores were similar for both groups at all time points up to 2 years. In 14 patients (21%) randomized to receive 2 screws, the surgeons decided intraoperatively to use only 1 screw because of fracture size and configuration. These crossover patients had similar outcomes to the other groups. No nonunions were reported in either group.

Eliasson P, Agergaard AS, Couppé C, Svensson R, Hoeffner R, Warming S, Warming N, Holm C, Jensen MH, Krogsgaard M, Kjaer M, Magnusson SP. The ruptured Achilles tendon elongates for 6 months after surgical repair regardless of early or late weightbearing in combination with ankle mobilization: a randomized clinical trial. Am J Sports Med. 2018 Aug;46(10):2492-502. Epub 2018 Jul 2.

Seventy-five patients were divided into 3 groups with less and more aggressive rehabilitation regimens, and 70 patients were included in the final analysis. Early compared with late weight-bearing and variations in ankle joint mobilization did not significantly alter outcome parameters, including tendon elongation, as measured with tantalum beads. Strength, endurance, and functional scores did not reach maximal values until at least 12 months postoperatively, suggesting that this is the required time frame for recovery from Achilles tendon rupture.

Fernández-Rodríguez T, Fernández-Rolle Á, Truyols-Domínguez S, Benítez-Martínez JC, Casaña-Granell J. Prospective randomized trial of electrolysis for chronic plantar heel pain. Foot Ankle Int. 2018 Sep;39(9):1039-46. Epub 2018 May 17.

A treatment regimen of ultrasound-guided percutaneous needle electrolysis of the plantar fascia for chronic heel pain, once a week for 5 weeks (n = 38), was compared with a placebo needle puncture (n = 29) in a double-blinded RCT. At 12 and 24 weeks after treatment, pain levels (p < 0.001) and function levels (p < 0.002) were significantly better in the electrolysis cohort compared with the placebo cohort.

Gottlieb IJ, Tunick DR, Mack RJ, McCallum SW, Howard CP, Freyer A, Du W. Evaluation of the safety and efficacy of an intravenous nanocrystal formulation of meloxicam in the management of moderate-to-severe pain after bunionectomy. J Pain Res. 2018 Feb 16;11:383-93.

This randomized, double-blinded, controlled study evaluated the safety and efficacy of intravenous meloxicam (nanocrystal formulation) administered as a 30-mg bolus and a 60-mg bolus compared with a placebo injection in 59 patients with moderate to severe pain after bunionectomy. There were no major adverse events in any of the groups. Meloxicam provided significantly greater pain reductions compared with placebo at all time intervals in the 48-hour test period, with less use of rescue medication. A once-daily meloxicam injection provided a rapid onset of analgesia that was maintained up to 2 days postoperatively.

Grubhofer F, Catanzaro S, Schüpbach R, Imam MA, Wirth S. Compressive stockings after hindfoot and ankle surgery. Foot Ankle Int. 2018 Feb;39(2):210-8. Epub 2017 Dec 1.

The benefit of postoperative compressive stockings after a hindfoot and ankle surgical procedure was investigated in this single-center RCT. Interestingly, the study also included a sensor in the stockings to monitor compliance, and patients were only retrospectively informed of this. Patients (n = 37) were prescribed to wear the stockings for at least 8 hours per day for 12 weeks; the patients in the control group (n = 39) did not wear compressive stockings. At 12 weeks, ankle swelling, VAS for pain, SF-36, and AOFAS Ankle-Hindfoot Scale scores showed no significant differences between the 2 groups. Furthermore, in the compression group, patients with high compliance had equivalent outcomes compared with those with low compliance.

Kim JW, Kim HU, Oh CW, Kim JW, Park KC. A prospective randomized study on operative treatment for simple distal tibial fractures-minimally invasive plate osteosynthesis versus minimal open reduction and internal fixation. J Orthop Trauma. 2018 Jan;32(1):e19-24.

The authors conducted an adequately powered RCT to identify the rate of soft-tissue complications following minimally invasive plating osteosynthesis compared with minimal open reduction and internal fixation. Minimal open reduction and internal fixation involved opening the fracture site and utilizing lag screws, whereas minimally invasive plating osteosynthesis involved a distal and a proximal incision with bridge plating of the fracture site. There were no cases of malunion or nonunion in the 2 groups and 1 superficial infection in each group, with no deep infections. This study found no difference between the groups, but indicated that a larger, multicenter trial is required to fully understand the benefits and detriments of minimally invasive plating osteosynthesis.

Marty P, Rontes O, Chassery C, Vuillaume C, Basset B, Merouani M, Marquis C, Bataille B, Chaubard M, Mailles MC, Ferré F, Delbos A. Perineural versus systemic dexamethasone in front-foot surgery under ankle block: a randomized double-blind study. Reg Anesth Pain Med. 2018 Oct;43(7):732-7.

Patients undergoing metatarsal osteotomy with a single-shot, perineural, ultrasound-guided, ropivacaine ankle nerve block were randomized to receive dexamethasone either as part of their perineural block (n = 50) or intravenously (n = 50). The groups were equivalent for time to first rescue analgesia, duration of postoperative analgesia, and maximum patient-reported pain during the first 48 hours postoperatively. Less nausea and vomiting were reported in the intravenous dexamethasone group (p = 0.03). The authors suggested that intravenous dexamethasone may be advantageous, as the potential neurotoxicity of perineural dexamethasone is not fully established.

Stéfani KC, Ferreira GF, Pereira Filho MV. Postoperative analgesia using peripheral anesthetic block of the foot and ankle. Foot Ankle Int. 2018 Feb;39(2):196-200. Epub 2017 Nov 21.

This prospective, randomized, and patient-blinded trial investigated whether peripheral nerve blockade after foot and ankle surgical procedures affected analgesia time and pain intensity. With operations ranging from the hindfoot to the forefoot, 57 patients (59 feet) received spinal anesthesia and either an ankle block using ropivacaine or nothing else. Patients who received a supplemental nerve block reported reduced pain and longer analgesia time (14.5 hours compared with 4.4 hours for the control group) in the immediate postoperative period and a more comfortable first night’s sleep, with the authors suggesting that a supplemental nerve block may help postoperative pain control and physical therapy initiation.

Tsikopoulos K, Mavridis D, Georgiannos D, Vasiliadis HS. Does multimodal rehabilitation for ankle instability improve patients’ self-assessed functional outcomes? A network meta-analysis. Clin Orthop Relat Res. 2018 Jun;476(6):1295-310.

The authors performed a meta-analysis of 19 randomized trials of nonoperative interventions on chronic ankle instability with a total of 789 ankles (mean patient age, 18 to 34 years) and follow-up from 1 to 6 months after therapy ended. They concluded that a 4-week, supervised, multimodal rehabilitation program (i.e., balance training, strengthening, functional tasks, and range-of-motion exercises) was supported with moderate strength and that compliance was critical for success. A 4-week balance training program was the only stand-alone intervention that provided superior results, suggesting that balance training should be the cornerstone of multimodal rehabilitation protocols.

Wang Y, Gu Y, Chen J, Luo W, He W, Han Z, Tian J. Kinesio taping is superior to other taping methods in ankle functional performance improvement: a systematic review and meta-analysis. Clin Rehabil. 2018 Nov;32(11):1472-81. Epub 2018 Jul 18.

The authors performed a meta-analysis of 10 controlled clinical trials that compared the effect of Kinesio taping with the effects of other elastic taping methods on functional performance in a total of 233 patients, with or without ankle sprain. The Kinesio taping cohort had superior dynamic balance and vertical jumping outcomes over the cohorts with other taping methods in both healthy adults and those with chronic ankle instability.

Xu C, Li M, Wang C, Li H, Liu H. Perioperative analgesia with a buprenorphine transdermal patch for hallux valgus surgery: a prospective, randomized, controlled study. J Pain Res. 2018 Apr 26;11:867-73.

In this RCT, patients who underwent a routine hallux valgus surgical procedure were randomized into 3 groups: transdermal buprenorphine patch (n = 30), intravenous flurbiprofen axetil (n = 30), and oral celecoxib (n = 30). Patient demographic characteristics, radiographic severity of hallux valgus, and surgical time were similar for all groups. The patch alleviated pain significantly better than oral celecoxib and was equivalent to flurbiprofen axetil the night before the surgical procedure and the first postoperative day. Patient satisfaction with pain management was significantly higher in the patch group.

Note: The authors thank Dagmar Gross for assistance with preparation of this manuscript.

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