Foot and Ankle Surgery

About the pathogenesis of the so-called adult acquired pes planus

Giacomo Pisani — 2009-06-01

Abstract: Even overlooking the scarcely significance nature of the term “flat”, in the pathogenesis of the adult acquired flat foot deformity, we must consider also the spring ligament degenerative pathology, that I called “degenerative glenopathy”, due to its reference to the glenoid, without a primitive posterior tibial tendon disease. The glenoid structure intervenes in the cotyloid structure (acetabulum) of the “coxa pedis”.In many cases the aetiological moment must be clarified finding of the accessory navicular bone. Its position between the posterior tibial tendon and glenoid explains a possible direct microtraumatic lesional mechanism.

The efficacy of the tourniquet in foot and ankle surgery? A systematic review and meta-analysis

T.O. Smith, C.B. Hing — 2009-05-28

Abstract: Tourniquets are commonly used during foot and ankle surgery. The purpose of this study was to compare the peri- and post-operative outcomes of tourniquet-assisted to non-tourniquet-assisted ankle and foot surgery. A systematic review was undertaken assessing the electronic databases Medline, CINAHL, AMED and EMBASE, in addition to a review of unpublished material and a hand search of pertinent orthopaedic journals. The evidence-base was critically appraised using the Cochrane Bone, Joint and Muscle Trauma Group quality assessment tool. Study heterogeneity was measured using χ2 and I2 statistics. Where appropriate, a random-effects meta-analysis was undertaken to pool results of primary studies, assessing mean difference or relative risk of each outcome. A total of four studies were identified. The findings of this study would suggest that hospital length of stay was significantly shorter, and that the post-operative period was less painful, with reduced swelling from the fifth post-operative day, in surgeries undertaken without a tourniquet, compared to tourniquet-assisted procedures. There may be a greater incidence of wound infection and deep vein thrombosis in tourniquet-assisted foot and ankle procedures. The methodological quality of the evidence base is limited. Further study is required to address these limitations, after which we may be able to determine whether a tourniquet should be used during ankle or foot procedures.

Closed wedge osteotomy in 66 patients for the treatment of moderate to severe hallux valgus

2009-05-18

Abstract: Background: The intention of this study was to analyze the long-term results of the proximal closing wedge osteotomy for the correction of hallux valgus deformity, modified by adding a mini L-plate for osteosynthesis.Methods: The outcome of a proximal first metatarsal closing wedge osteotomy was retrospectively evaluated after a mean follow-up of 52 months. A total of 66 female patients (86 feet) participated in this study. The AOFAS-score was used to evaluate the postoperative results. Pre- and postoperative weight-bearing radiographs were used to evaluate the osseous development.Results: 95.5% of the patients were satisfied, 3 patients (4.5%) were not satisfied with the overall result of the operation. Transfer metatarsalgia was registered in 7 of 50 cases. The mean improvement of the HV-angle was 22.1° (36.4° to 14.3°) and the intermetatarsal angle was reduced from a mean of 17.6° to a mean of 6.5°. The mean first metatarsal shortening was 3.2mm. The mean AOFAS-score was 78 points.Conclusion: The results confirm, that the closing wedge osteotomy is indicated for moderate to severe hallux valgus. The shortening of the first ray is comparable with other well-established operative procedures. The risk of transfer metatarsalgia can only be lightly reduced by this procedure.

The management and outcome of lateral process fracture of the talus

A. Perera, J.F. Baker, D.F. Lui, M.M. Stephens — 2009-05-04

Abstract: Background: Lateral process fractures of the talus are a rare injury with significant associated morbidity when missed. Only a small number of case series’ and reports are available and the appropriate management of these fractures is not really known.Methods: We reviewed available English language literature for reports and series of lateral process fractures of talus. Only papers in which the classification of fracture, management and outcome were clear were included in our analyses.Results: 109 Cases in total were identified including four cases from a personal series. 50 Type I, 17 type II and 29 type III fractures were analysed. A significant number of patients required late surgery when the diagnosis was initially missed.Conclusion: Type I fractures are best treated with ORIF, type II with excision and type III with casting. Fractures presenting late that are not united should be excised if small and internally fixed if large.

Foot pressure differences in men and women

A.B. Putti, G.P. Arnold, R.J. Abboud — 2009-05-14

Abstract: Background: Women and men are anatomically and physiologically different in a number of ways. Anthropometric studies have shown considerable differences in the foot bones of both genders. These differences could potentially mean different foot pressures in men and women.Objective: The aim of our study was to investigate any potential foot pressure differences between males and females using the Pedar®-M (Novel gmbh, Germany) in-shoe foot pressure measurement system.Methods: Twenty-eight subjects (16 females and 12 males) were recruited. Peak pressure, contact area, contact time, pressure–time integral, force–time integral, instant of peak pressure, maximum force and mean force were recorded and subsequently analysed.Results: In males, contact area was significantly larger in all regions of the foot compared with females. There were no significant between gender differences in peak pressure, contact time, pressure–time integral and instant of peak pressure. Force–time integral was significantly greater in males than females under the 1st, 3rd, and 4th metatarsal heads. Maximum force was also significantly higher in males under the heel, 1st and 3rd metatarsal heads. Mean force was greater in males under the 3rd metatarsal head.Conclusion: There were no peak pressure differences; however the contact area of the male foot was larger than that in females.

Survivorship of the bio-action metatarsophalangeal joint arthroplasty for hallux rigidus: 5-year follow-up

S. Sinha, P. Mcnamara, M. Bhatia, L. Louette, I. Stephens — 2009-05-14

Abstract: Background: Metatarsophalangeal joint arthroplasty is an accepted treatment for hallux rigidus. There are few reports of the long-term results of this procedure.Methods: A series of 15 consecutive bio-action first metatarsophalangeal total joint replacements were retrospectively reviewed after a minimum follow-up of 5 years. The patients were assessed using the American Orthopaedic Foot and Ankle Society Score. Patient satisfaction and standard radiographs were also examined.Results: Subjectively, just over half the patients were satisfied with the results of the surgery. Objectively, however mechanical failure of the implant was universal, as determined radiographically.Discussion: Despite some success in relieving symptoms in patients, we have abandoned this procedure because of the high and increasing rate of failure, as demonstrated both clinically and radiologically.

Surgical tip: Repair of acute Achilles rupture with Krackow suture through a 1.5cm medial wound

T.H. Lui — 2009-05-18

Abstract: Acute Achilles tendon ruptures is one of the commonest tendon injury of the foot and ankle. The management of this problem is still controversial. Treatment can be classified into non-surgical and surgical types. Surgical management can be subdivided into open repair, percutaneous with or without adjunct of arthroscopy. In compare with non-surgical management, surgical management will decrease the tendon re-rupture rate. However, the possible surgical complications including wound breakdown and sural nerve injury are still quite significant. Percutaneous repair technique has the advantage of less chance of wound breakdown, but the rate of tendon re-rupture is higher than that after open tendon repair, because the repair is usually weaker than that achieved in open repair. Lui have described an endoscopic assisted repair with the Krackow locking suture. However, the technique is complicated and six portal wounds are needed. A simpler way of applying the Krackow suture through the portal wound has been described for reattachment of Achilles tendon insertion after endoscopic calcaneoplasty. We describe a mini-open approach of Achilles tendon repair with the Krackow locking suture. By means of release of the medial edge of the investing fascia, the Achilles tendon can be mobilized easily and the Krackow locking suture can be applied through a 1.5cm medial wound. Hopefully, this can improve the strength of repair and maintaining the advantage of minimally invasive tendon repair.

Arthrodesis of the first metatarsophalangeal joint with ball and cup reamers and osteosynthesis with pure titanium staples: Radiological evaluation of a continuous series of 54 cases

Jean-Luc Besse, J. Chouteau, D. Laptoiu — 2009-06-03

Abstract: Background: In a continuous series of 54 MTP-1 arthrodeses using ball and cup reamers, fusion and great toe position were analyzed.Materials and methods: The population was mainly female (46 versus 8). Mean age at operation was 61 years. Arthrodesis was for four conditions of symptomatic degenerative disease: 36 severe hallux valgus (>35°), 7 recurrences of hallux valgus, 9 hallux rigidus and 2 hallux varus. Arthrodesis used a medial approach, articular surface preparation by ball and cup reamers (plus perforation by Kirschner wire), and osteosynthesis with three titanium staples. Pre- and postoperative big toe positions were analysed with the Footlog™ semi-automated X-ray assessment software.Results: All patients were followed up for a mean 38.6 months (22–56). Overall fusion rate was 94.4%, and 99% for primary arthrodesis. Mean time to union was 56 days (74% in 6 weeks), with 3 non-unions (5.6%), including 2 after hallux valgus recurrence. Mean pre-operative toe valgus was 40° and 14.1° at revision for all groups. 95% of arthrodeses fused at a mean lateral metatarsophalangeal angle of 22.6 (18–26°). Metatarsus varus exceeded 20° in 8 cases, mainly in the severe hallux valgus group; at revision, the mean first intermetatarsal angle was 10.6° (9–12°).Conclusion: Arthrodesis of the first metatarsophalangeal joint with ball and cup reamers is a reliable and reproducible technique, giving total correction of big toe valgus. The first intermetatarsal angle was corrected without supplementary osteotomy. Using three pure titanium staples for fixation, rate and time of fusion were in line with reference techniques.

Complete subtalar release for older children who had recurrent clubfoot deformity

Freih Odeh Abu Hassan, Samir Jabaiti, Tarek El tamimi — 2009-06-08

Abstract: Background: Neglected idiopathic clubfoot deformities, and severe recurrent deformity after previous surgery presents technical difficulties for correction and challenges for surgeons to achieve primary skin closure.Methods: Between 2000 and 2006, 18 children (30 feet), had complete subtalar release (CSTR) for failed previous surgery in 28 feet and severe neglected congenital talipes equinovarus (CTEV) in 2 feet followed by cross leg fasciocutaneous flaps for reconstruction of residual defect at the ankle and foot after full correction of the deformity.Mean patients followed up were 4.5 years (average 2–8 years). 23 feet were classified as Dimeglio III and 7 feet as Dimeglio IV.Results: All cases achieved a plantigrade foot, better walking ability (p<0.03), and parental satisfaction with the result (p<0.001).Ankle joint doriflexion increased from mean (−21.33°) preoperatively to (12.5°) postoperatively. All cases showed postoperative improvement in their radiographic findings. The mean preoperative talocalcaneal angle increased from (15.7° to 30.03°). The talo-first metararsal angle improved from a preoperative mean of −16° mean of 5.53° postoperatively. At the final follow-up cosmetically acceptable plantigrade foot was achieved in all feet. Four legs (14.28%) developed hypertrophic scars at the donar flap site. One patient developed 1.5cm marginal necrosis of the flap, which did heal after debridement by secondary intention. None of the feet had recurrence at the final follow up. Despite the enormous improvement clinically and radiologically, their was no statistical significant difference between preoperative and postoperative radiological angles (p<0.069).The number of previous surgical interventions had no influence on the outcome. All the previously treated feet had inadequate release of important tethered soft tissue.Conclusion: This is indicative of the enormous value of complete subtalar release combined with cross leg fasciocutaneous flap without the need for bony intervention in previously operated failed feet or neglected deformities.

Overuse ankle injuries in professional Irish dancers

R.J. Walls, S.A. Brennan, P. Hodnett, J.M. O’Byrne, S.J. Eustace, M.M. Stephens — 2009-06-29

Abstract: Background: Overuse ankle injuries have been described in elite athletes and professional ballet dancers however the spectrum of injuries experienced by professional Irish dancers has not been defined.Methods: A troupe of actively performing dancers from an Irish-dance show were recruited (eight male, ten female; mean age, 26 years). The prevalence of overuse injuries in the right ankle was determined from magnetic resonance imaging. Foot and ankle self-report questionnaires were also completed (AOFAS and FAOS).Results: Only three ankles were considered radiologically normal. Achilles tendinopathy, usually insertional, was the most frequent observation (n=14) followed by plantar fasciitis (n=7), bone oedema (n=2) and calcaneocuboid joint degeneration (n=2). There were limited correlations between MRI patterns and clinical scores indicating that many conditions are sub-clinical. Dancers with ankle pain had poor low (p=0.004) and high (p=0.013) level function.Conclusions: Overuse ankle injuries are common in Irish dancers. Incorporating eccentric exercises and plantar fascia stretching into a regular training program may benefit this population.

Role of early surgical revascularization in the management of refractory diabetic foot ulcers in patients without overt ischemic limbs

2009-05-28

We enthusiastically read the interesting article by Rose et al. which have been published in the “Foot and Ankle Surgery”. The authors evaluated the clinical outcome in patients with diabetic foot managed in a tertiary care diabetic foot clinic. Below, we want to discuss some points about this article.

Elly Trepman, John M. Embil, Joshua Koulack — 2009-06-18

The authors appreciate the thoughtful review and comments. Chronic diabetic foot ulcers may be refractory to treatment because of ongoing mechanical pressure, ischemia, or infection. Evaluation of ischemia may include history (claudication and rest pain), physical examination (dependent rubor and palpation of pedal pulses) and ancillary studies including measurement of ankle-brachial index (ABI), angiography, transcutaneous oxygen tension, and toe blood pressure studies.

Corrigendum to: “Long-term follow-up on microsurgical free-tissue transfer in foot and ankle reconstruction” [Foot Ankle Surg. 14 (2008) 82–88]

Ramzi Moucharafieh, Joseph Wehbe, Ghassan Maalouf, Bishara Atiyeh — 2009-05-18

The corresponding author of the above paper would like to point out that his name was incorrectly spelled Musharafieh in the above paper. The authors name is correctly spelled Moucharafieh above.