Foot and Ankle Surgery - Articles in Press

Percutaneous reduction and screw fixation of fracture neck talus - Corrected Proof

Sherif Mohamed Abdelgaid, Farid Fouad Ezzat — 2012-02-15

Abstract: Background: Fracture neck talus is a rare fracture represents about 1% of all fractures and usually due to high energy trauma. These fractures are usually associated with compromised soft tissues, concomitant skeletal fractures, or life threatening injuries. Talus has a tenuous blood supply which is affected by fracture displacement. Urgent fracture reduction±fracture fixation is mandatory. The associated injuries may make the conventional open reduction and internal fixation is impossible to be done in urgent base as it may impacts the already tenuous blood supply of talus increasing the risk of AVN and non union. Percutaneous fracture reduction and fixation can overcome this problem, and decrease complications associated with conventional open reduction and internal fixation.Materials and methods: Between 2006 and 2008, 16 patients with talar neck fractures were operated on by percutaneous reduction of fracture and percutaneous fixation with 3.5mm cannulated screws. Injuries were classified according to modified Hawkins classification system. Patients were followed up over an average of 48 months.Results: 87.5% of the patients were satisfied and resumed their preoperative activities. The mean AOFAS Hind Foot Scale was 89.25 points (range: 74–100) and no poor outcomes.Conclusion: Although the number of patients in this study is small, the results showed that, percutaneous reduction and fixation is a good treatment modality in treatment of fracture neck talus, especially in cases with increased risk of soft tissue complications and open reduction should be resort only when percutaneous reduction was failed.

Metatarsal extension osteotomy without plantar aponeurosis release in cavus feet. The effect on claw toe deformity a radiographic assessment - Corrected Proof

A.K. Singh, P.J. Briggs — 2012-01-13

Abstract: Background: This study reviewed patients undergoing correction of cavus foot deformity by metatarsal extension osteotomy with preservation of the plantar aponeurosis, and assessed the correction achieved of the claw deformity of the toe by radiographic assessment.Method: 15 patients (18feet) were reviewed clinically and radiographically. All feet required extension osteotomy of the first metatarsal and four patients (5feet) had extension osteotomy of the first to fourth metatarsals. Hallux extension angle in relation to the 1st metatarsal and in relation to the ground was measured in all feet to estimate the degree of clawing of the hallux.Results: 13 patients (15feet) were satisfied with the outcome of their surgery and also the appearance of their foot. The mean radiographic change in the hallux extension angle in relation to the 1st metatarsal was 16°, and in relation to the ground was 7°. These changes were statistically significant.Conclusion: Our results indicate an improvement in the claw toe deformity and we recommend preservation of the plantar aponeurosis in corrective surgery for cavus foot.

The use of surgeon-performed ultrasound assessment in a foot and ankle clinic - Corrected Proof

K. Thomason, P.H. Cooke — 2012-01-11

Abstract: Background: We describe the first reported use of ultrasound examination performed by an orthopaedic surgeon in the setting of a foot and ankle clinic.Methods: The senior author attended a course in musculoskeletal ultrasound and performed 100 examinations each checked against the results from a consultant radiologist. Records were kept of all examinations performed in the clinic over a 6-month period with results.Results: Of the 622 patients seen, 91 had an ultrasound scan and 36 had guided injections. All patients had one hospital attendance spared, for most two. Time saved on the treatment pathway per patient was on average 6 weeks.Conclusion: Ultrasound assessment performed by a clinician during an outpatient clinic appointment reduces delay in treatment and cuts costs by reducing patient episodes.

Tarsal tunnel syndrome: A literature review - Corrected Proof

M. Ahmad, K. Tsang, P.J. Mackenney, A.O. Adedapo — 2011-12-23

Abstract: Background: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis.Conclusion: Recommendations from literature:

A comparative study of bone shortening and bone loss with use of saw blades versus burr in hallux valgus surgery - Corrected Proof

Muhammad Saleem Shahid, Paul Lee, Sam Evans, Rhys Thomas — 2011-12-16

Abstract: Background: The aim of this study was to assess bone loss and thickness of the cut with the use of a burr in percutaneous hallux valgus surgery.Methods: Twelve blocks of saw bone were used. Cuts of same depth were made in each block with two different saw blades and a burr. Each block was assessed for bone loss and thickness of the cut.Results: There was statistically significant (p<0.05) increased bone loss and thickness of the cuts with the use of a burr as compared to use of two different saw blades. The use of a burr resulted in threefold increased loss of bone material and fourfold increase in the thickness of the cut as compare to use of two different saw blades.Conclusion: The metatarsal shortening is a risk factor in percutaneous hallux valgus surgery with the use of a burr.

Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: A cadaver study - Corrected Proof

Thomas Huber, Werner Schmoelz, Andreas Bölderl — 2011-12-09

Abstract: Background: The motion of the fibula in relation to the tibia is coupled on the motion of the talus in the ankle joint. Several authors investigated this motion with different methods. An injury of the elastic fixation of the fibula to the tibia and its treatment with the syndesmotic set screw has an impact on this motion.Methods: The motion of the fibula relative to the tibia was measured in eight embalmed human above the knee amputated cadaver specimens using a 3D-motion analysis system. The relative motion was measured from 50° of plantar flexion to 30° of dorsiflexion. Experiments were performed in the following conditions: without fixation and intact ligaments, after sectioning of the four syndesmotic ligaments and the interosseous membrane, and application of either a tricortical screw, or a quadricortical screw or two quadricortical screws.Results: Concordant movements of the lateral malleolus were a medial translation during plantar flexion, external rotation around the sagittal axis during plantar and dorsiflexion. The motion of the proximal fibula was smaller and more variable than in the distal part. After sectioning of the syndesmosis the range of motion, compared to the intact state increased, particularly in translation along the transversal (118%), sagittal (160%) and the longitudinal (136%) axis and in axial rotation (145%). Syndesmotic screws reduced the range of motion in transversal (p<0.006) and sagittal translation (p<0.011) and axial rotation.Conclusion: The small relative motion of the tibia and fibula is increased by syndesmotic injuries. Syndesmosis screws significantly limit this increased relative motion below physiologic values, which makes it necessary to remove the screws before flexion in the ankle joint is performed.

Internet information quality for ten common foot and ankle diagnoses - Corrected Proof

2011-12-07

Abstract: Background: Patients use the Internet regularly to access health-related information. This study's goal was to assess the quality and content of Internet-based information for common foot and ankle diagnoses.Methods: We identified the ten most common foot and ankle diagnoses in our academic foot and ankle practice. Ten websites for each diagnosis were identified using two large Internet search engines. A custom grading form was used to determine website quality, based upon the Health On the Net Foundation (HON) principles, and information content. Four independent reviewers graded each website.Results: One hundred thirty-six unique websites were reviewed. Average HON score was 62.4 (range, 52.3–68.8) and content score was 49.7 (range, 33.8–62.1) out of a maximum of 100. Interobserver variability was low.Conclusions: The overall quality of Internet information for common foot and ankle diagnoses is variable, raising concerns about what information is currently available to patients.

A new limb-salvaging technique for the treatment of late stage complicated Charcot foot deformity: Two-staged Boyd's operation - Corrected Proof

Muzaffer Altindas, Ali Kilic, Mehmet Ceber — 2011-11-21

Abstract: Background: Depending on the stage of disease, several operative and non-operative treatment options exist for diabetic patients with Charcot foot deformity. In the early stages of the disease, the most effective treatment is total-contact cast application. In patients with multiple bone fractures and deformations, surgical interventions are generally required for the reconstruction of foot architecture. Exostectomy, osteotomy, arthrodesis, and internal–external fixation are some of these operative methods. However, recurrence of ulcer and infection is very likely following these surgical procedures. If the lesion and infection reach to midfoot and hindfoot region, a major amputation is usually required for treatment.Methods: We have been performing Boyd's operation for the last 10 years in diabetic foot patients who had complicated lesions in midfoot and hindfoot regions. Furthermore, since 2004, we have been doing the same operation for complicated Charcot foot deformities. So far, we have treated 11 patients.Results: The mean age of the patients was 53.4±10.2 years, and the mean duration of diabetes mellitus (DM) was 17.5±7.2 years. All patients had chronic infections with fractures of the tarsal bones for at least 2 years. Durable wound coverage and ankylosis were achieved in all patients with two-staged Boyd's operation. No recurrence is detected in any of the patients during mean post-operative follow-up period of 2.1±0.8 years.Conclusion: Boyd's operation is a reliable option for the treatment of patients with late stage Chatcot foot deformity.

Reliability of metatarsus adductus angle and correlation with hallux valgus - Corrected Proof

Aryan I.S. Dawoodi, Anthony Perera — 2011-11-14

Abstract: Background: Metatarsus adductus is a common congenital foot deformity. Variable prevalence values were reported using different techniques in different populations.Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods.The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus.Materials and methods: Weight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engel's angle and modified Engle's angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus.Results: Intraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45–70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatarso-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles.Conclusion: Five techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method.

Böhler's angle – What is normal in the uninjured British population? - Corrected Proof

H. Willmott, J. Stanton, C. Southgate — 2011-11-11

Abstract: Böhler's angle is a radiographic parameter widely used in the detection and assessment of fractures of the os calcis. The normal range in the uninjured British adult population has not previously been established. We analysed 128 lateral radiographs without fracture in order to establish the true value of Böhler's angle. Analysis was performed with respect to age, sex and laterality. Interobserver reliability was also assessed. The mean angle was 36.4° (SD 4.2°, range 24.7–48.9°). The normal range was 28.2–44.5°, which incorporates 95% of subjects. There was no difference with respect to age, sex or laterality. Agreement between independent observers was good (interobserver correlation coefficient=0.72), although there was disagreement of >5° in 40.9% of cases. Given the wide range of normal values we recommend a comparative radiograph of the contralateral side if the presence of fracture is ambiguous.

Owens et al. “Morton's neuroma: Clinical testing and imaging in 76 feet, compared to a control group” [Foot and Ankle Surgery 17 (September (3)) 2011] - Corrected Proof

Magdi E. Greiss — 2011-10-05

We read the above article with interest. We note that the PLP Plantar Percussion test described as one of four clinical tests is in fact a version of the DNS Digital Nerve Stretch test we described in Foot and Ankle Surgery, Vol. 12, Issue 4, January 2006.

Response to Letter to the Editor - Corrected Proof

Anthony Sakellariou — 2011-10-03

I thank Mr. Greiss for his interest in our article and for his valuable comments. We were, in fact, not aware of the DNS (Digital Nerve Stretch) test as described in FAS Vol. 12, Issue 4, January 2006. I first became aware of the PLP (Plantar Percussion) test when it was described to me, many years ago, by Ian Anderson, a North American foot and ankle surgeon. I have since successfully incorporated it into my clinical practice. Although I accept that, as the DNS test appears to be more sensitive than the PLP test (97% positive vs. 62% positive), it could be incorporated into our practice as well, what I am unsure about, is how sensitive it is with regard to identifying the pathological web space. It may be, as Mr. Greiss states in his letter, that the PLP (and DNS) tests may be very sensitive in ‘identifying’ inflammatory changes surrounding an inflamed nerve; however, I have found that the percussion component helps me (in combination with the squeeze test), to identify the actual pathological web space.

Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures - Corrected Proof

Sherif Mohamed Abdelgaid — 2011-08-26

Abstract: Background: Displaced intra-articular calcaneal fractures remain a therapeutic challenge due to fracture complexity and different treatment options. One of the adverse effects of operative treatment is secondary damage to soft tissues. To avoid soft tissue complications, several less invasive procedures have been introduced. The most frequently used minimally invasive technique is closed reduction of fracture and percutaneous cannulated screws fixation.Method: This study evaluates the medium-term outcome of a new technique of percutaneous treatment in 60 cases operated in Al-Razi orthopedic hospital in Kuwait in the period from 2007 to 2009. The described technique applies the principle of closed manipulation with new reduction method using a medial subperiosteal tunnel to manipulate the fragments. The technique involves new method of distribution of screws required to fix the fracture.Results: According to the American Orthopedic Foot and Ankle Society Hind foot Score, 38.3% of all cases (22 cases) had excellent results, 41% good (25 cases), fair results in 15% (9 cases), and poor results in 5% (4 cases). The overall satisfactory results (excellent and good) were 79.3%.Conclusion: The technique is suitable for most types of intra-articular fractures especially in patients with compromised soft tissues in which open reduction and internal fixation is contraindicated.

Preliminary results of 97 percutaneous gastrocnemius muscular lengthening operations in neurologically healthy children with an equinus contracture - Corrected Proof

2011-08-22

Abstract: Background: We report a gastrocnemius lengthening in neurologically healthy children, whose gastrocnemius equinus could not be corrected non-operatively.Methods: Fifty-five children with an equinus contracture were included in this study. Ninety-seven operations were performed in these patients. The mean age was 11.5 years and sixty percent of the patients were male. After 12 weeks we measured dorsiflexion post-surgery and after one year all parents of patients were telephoned and asked about their satisfaction with the result of the surgical treatment. Persistence of pre-operative complaints and complications were evaluated.Results: Ankle dorsiflexion significantly improved by more than 11° post-surgery compared with preoperative (p=0.01). The mean satisfaction was 8.0 on a 10-point VAS scale. Except one complication of ankle fracture during surgery, no other clinically relevant complications were observed. At follow up 50% of the patients have no complaints, 47% reported an improvement but some persisting complaints and 3% of the patients report no improvement.Conclusion: Percutaneous muscular gastrocnemius lengthening can be used to correct gastrocnemius equinus in otherwise healthy children, who have not benefited from prior nonsurgical treatment.

Prospective analysis of a first MTP total joint replacement. Evaluation by bone mineral densitometry, pedobarography, and visual analogue score for pain - Corrected Proof

Eva Wetke, Bo Zerahn, Hakon Kofoed — 2011-08-12

Abstract: Background: We hypothesized that a total replacement of the first metatarsophalangeal joint (MTP-1) would alter the walking pattern with medialisation of the ground reaction force (GRF) of the foot and subsequently cause an increase in bone mineral density (BMD) in the medial metatarsal bones and a decline of BMD in the lateral metatarsal bones.Methods: Twelve patients receiving total joint replacements (Roto-Glide®) of MTP-1 were enrolled in a prospective cohort. BMD and pedobarography of the heel bone and the metatarsal heads were performed preoperatively and at least 12 months postoperatively.Results: BMD in the lateral metatarsals and GRF under the lateral column of the operated feet decreased significantly on the operated feet.Conclusions: Total joint replacement of MTP-1 tends to reduce GRF under the lateral column of the foot causing a corresponding decline in BMD and pedobarographic measures. Our findings support the further use of the Roto-Glide® prosthesis for osteoarthritis of the first metatarsophalangeal joint.

Surgeon administered regional blocks for day case forefoot surgery - Corrected Proof

Julian Foote, Richard Freeman, Samer Morgan, Andrew Jarvis — 2011-08-12

Abstract: Introduction: The aim was to see if as surgeons we were providing safe, efficient and effective, regional blocks for patients undergoing day case, forefoot surgery. We also assessed the costs of, providing this service.Methods: 63 consecutive patients were recruited prospectively for local anaesthetic block. Blocks were, performed by the orthopaedic team. Efficacy of block was assessed intra-operatively with a visual, analogue score (VAS) of 0–10. Satisfaction with the anaesthetic procedure was also assessed.Results: Average time to perform the block was 6min. Mean VAS for knife to skin was 0.44 (95%, confidence 0.07–0.81) and for ankle tourniquet was 1.39 (95% confidence 0.85–1.39). Patients were, highly satisfied with the blocks. No complications were reported.Conclusions: These blocks are quick and easy to perform by orthopaedic surgeons. They are well, tolerated and effective. They result in considerable cost savings to the Hospital.

The rheumatoid foot and ankle: Current evidence - Corrected Proof

David T. Loveday, Gillian E. Jackson, Nick P.J. Geary — 2011-08-01

Abstract: The management of rheumatoid patients is a complex process due to the chronic, systemic, multi-joint and extra-articular nature of the disease. In comparison, osteoarthritis and post-traumatic arthritis usually involve a single joint and are hence not comparable to rheumatoid pathology. This review sets out to specifically look at studies on rheumatoid patients with interventions for foot or ankle disease. MEDLINE, EMBASE, the Cochrane databases, Current Controlled Trials and the WHO International Clinical Trials Registry Platform are all searched for relevant studies.

The safety profile of a retrospective Accessory Postero-Lateral hind foot portal: The risk of sural nerve damage during visualisation of the Achilles tendon insertion - Corrected Proof

M.R. Carmont, R. Stroud, H. Bjorndalen, J. Crowther, W.J. Ribbans, D. Griffin — 2011-06-27

Abstract: Introduction: The Accessory Postero-Lateral (AccPL) portal has recently been described to improve the visualisation for the endoscopic debridement of Haglund's tubercle. The safety of using this portal has been considered previously for posterior ankle arthroscopy. We performed a study to determine the proximity of the AccPL portal to the sural nerve.Methods: We compared the distances between AccPL and PL portals to the sural nerve in 17 cadaveric specimens.Results: The AccPL portal was significantly closer (mean 12.0mm, range 6–19mm, SD=3.64) to the sural nerve than the PL portal (mean 14.1mm, range 11–18mm, SD=2.34) (t(16)=−2.34, p=0.03). In two cases the sural nerve was in contact with the clip but on close inspection, the nerve had not been damaged in any of the specimens.Conclusions: We conclude that the AccPL portal is a safe method to allow visualisation during endoscopic debridement of the Achilles tendon insertion. We also recommend that the portal is used for visualisation rather than instrumentation.

Glomus tumor of the hallux. Review of the literature and report of two cases - Corrected Proof

C. Polo, D. Borda, D. Poggio, J. Asunción, L. Peidro — 2011-06-22

Abstract: A glomus tumor is a rare and benign vascular tumor. It can originate in multiple locations on the body, although it has most frequently been found in subungeal areas of the hand. This two cases report describes a glomus tumor of the hallux, including a recurrence and a review of the related literature. We believe this case study might be of interest due to the unusual location of this tumor.

UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts - Corrected Proof

Hafiz Javaid Iqbal, Raef Dahab, Simon Barnes — 2011-06-13

Abstract: Background: Ankle fractures are one of the commonest orthopaedic injuries. A substantial proportion of these are treated non-operatively at outpatient clinics with cast immobilization. We conducted this survey to assess the current practice in UK regarding thromboembolism prophylaxis in these patients.Methods: A telephonic survey was carried out on junior doctors within orthopaedic departments of 56 hospitals across the UK. A questionnaire was completed regarding venous thromboembolism risk assessment, prophylaxis, hospital guidelines, etc.Results: 84% (n=47) hospitals did not routinely use any prophylaxis for these patients, while 7% (n=4) hospitals used chemo-prophylaxis. Only 5.3% (n=3) hospitals had DVT prophylaxis guidelines regarding these patients while other 9% (n=5) hospitals were in process of developing such guidelines. In 64% (n=36) hospitals, no formal DVT risk assessment was carried out.Conclusion: A large variation exists across NHS hospitals and a poor risk assessment is being carried out in these patients. Development of local guidelines and extension of national guidelines to include high risk outpatients may improve the situation.

Molded arthrodesis of the hallux metatarsophalangeal joint using the crossed-screw technique: Surgical technique, results and functional outcomes - Corrected Proof

R. Mohammed, A. Gadgil — 2011-06-13

Abstract: Background: We describe the surgical technique, results and functional outcomes of molded arthrodesis of hallux metatarsophalangeal (MTP) joint using crossed-screw fixation.Methods: 23 Toes in 21 consecutive patients operated between September 2007 and January 2010 were included for the retrospective study. Average age was 60.0 years (range 31–84 years) with male female ratio being 3:4. Differential pitch cannulated crossed screw technique was used in all cases. At the latest follow-up, the radiological findings, the hallux-forefoot AOFAS scores and patient satisfaction questionnaires were used to assess outcomes.Results: Overall fusion rate was 91% with a mean hallux valgus angle of 13.6° (range 8–22°) and a mean dorsi-flexion angle of 25° (range 18–30°). Complication rate was 13% that included two superficial wound infections and one failed fusion that underwent a successful fusion after revision surgery. At a mean follow-up of 17 months (range 6–34 months), the mean AOFAS score was 79 (out of a maximum of 90). 92% of the patients were satisfied with the final outcome and 83% mentioned that they would have the procedure again.Conclusions: Crossed-screw technique of arthrodesis of the first MTP joint is successful for relief of pain, allowing a high level of function and good patient satisfaction.

Epidemiologic investigation of 1394 feet: Coincidence of hindfoot malalignment and Achilles tendon disorders - Corrected Proof

Ute Waldecker, Gerd Hofmann, Saskia Drewitz — 2011-06-06

Abstract: Background: The aim of this epidemiologic study was to evaluate the incidence of the Achilles tendinopathy in non athletes and the coincidence with varus alignment of the hindfoot.Methods: Six hundred ninety-seven patients (1394 feet) have been analysed. The tibiocalcaneal axis was goniometrically measured. The presence of a non insertional and insertional Achilles tendinopathy was clinically determined.Results: Achilles tendinopathy was found in 5.6% of the patients (4% insertional, 3.6% non insertional, 1.9% both forms). The average tibiocalcaneal angle was calculated with −0.76° for the tendinopathy group and −0.96° for the insertional tendinopathy whereas the control group showed an average angle of 1.77°. For the total group the average tibiocalcaneal axis was calculated with 1.62°. Out of 1394 feet 38.3% showed a varus axis of the hindfoot and 61.7% a valgus alignment.Conclusions: The coincidence of varus alignment and Achilles tendinopathy could be validated.

Functional outcome of ankle fracture patients treated with biodegradable implants - Corrected Proof

Sushil Rangdal, Daljit Singh, Narendra Joshi, Ashwani Soni, Radheshyam Sament — 2011-06-06

Abstract: Background: Biodegradable devices have been developed to overcome the disadvantages of metallic implants especially the need for their subsequent removal, though they have their own drawbacks like poor mechanical properties and tissue reactions. Aim of this prospective study was to access the outcome of bimalleolar fractures fixed with biodegradable plates and screws.Methods: A prospective study was conducted between July 2006 and November 2008 comprising of sixteen patients with unilateral bimalleolar fractures. Fibula fractures were fixed with biodegradable plates and medial malleoli with screws. Patients were followed at two weeks, six weeks, three months, six months, twelve months and eighteen months. Final evaluation was done using Olerud Molander ankle score.Results: Six patients had excellent results; four patients had good results and six patients had fair performance. No patient in this series had a poor outcome. One patient had both pain and swelling at 14 weeks postoperatively which settled down with debridement and antibiotics. None of the patients needed implant removal.Conclusion: Biodegradable plates and screws when used to fix bimalleolar fracture along with restricted weight bearing, provide satisfactory fracture healing, good functional results and reduce the need of implant removal.

Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy - Corrected Proof

Christopher J. Pearce, James Carmichael, James D. Calder — 2011-05-27

Abstract: Background: The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months.Methods: A consecutive series of 11 patients with a minimum of 2 years follow up.Results: The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p=0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p=0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied.Conclusions: The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.

The primary arthrodesis for severely comminuted intra-articular fractures of the calcaneus: A systematic review - Corrected Proof

T. Schepers — 2011-05-25

Abstract: Background: Although open reduction and internal fixation via the extended lateral approach is currently considered gold-standard, severely comminuted calcaneal fractures might not be amendable for reconstruction. The primary aim of the current review study was to assess the functional outcome of the primary arthrodesis in the management of comminuted displaced intra-articular calcaneal fractures.Methods: The literature was searched for studies published between January 1st 1990 and December 1st 2010, to identify studies in which a primary arthrodesis was utilized for the treatment of displaced intra-articular calcaneal fractures between. The methodological quality of the included studies was assessed using the Coleman Methodology Score.Results: Seven case series and one abstract were identified, reporting on 120 patients with 128 severely comminuted calcaneal fractures. Average follow-up time was 28 months and union rate 97%. Functional outcome was assessed using the modified AOFAS score in seven studies; with a weighted average of 77.4 (range 72.4–88). One study reported a 75% good to excellent outcome on the Paley score. Three studies reported on return to work, ranging from 75 to 100%. Overall reported wound complications occurred in 19.4%. The average Coleman Methodology Score was 56 (range 38–68) points.Conclusions: The primary arthrodesis for the treatment of Sanders type-IV comminuted displaced intra-articular calcaneal fractures provides overall good results considering the severe nature of the injury. Therefore, in the process of choosing the best treatment modality for a severely comminuted calcaneal fracture, the primary arthrodesis should receive full consideration.

Synthetic osteochondral grafting of ankle osteochondral lesions - Corrected Proof

Christopher J. Pearce, Louise E. Gartner, Adam Mitchell, James D. Calder — 2011-05-18

Abstract: Background: The treatment of osteochondral lesions, especially those with a cystic component or those that have failed the standard arthroscopic procedures can be challenging. Synthetic grafts have several potential advantages over other second line treatments including the fact that only one operation is required and no other joint is violated.Method: We report the results of the first series of synthetic grafts used in the treatment of osteochondral lesions of the ankle with a minimum of one year follow up.Results: There was significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot and Ankle Osteoarthritis Scale (AOS) scores and all patients were satisfied with the results of surgery. Magnetic Resonance Imaging (MRI) scans at one year have demonstrated resolution of the bony cysts and surrounding bone marrow oedema but, worryingly, continued to show high signal on the T2 weighted images within the plugs themselves. Qualitative T2 mapping has suggested a fibrous rather than hyaline appearance of the cartilage portions of the plugs.Conclusions: The clinical results have been encouraging but more patients and longer follow up are required before firm conclusions can be drawn.

Headless compression screw fixation prevents symptomatic metalwork in arthroscopic ankle arthrodesis - Corrected Proof

Adekoyejo A. Odutola, Barnaby D. Sheridan, Andrew J. Kelly — 2011-05-10

Abstract: Background: Arthroscopic ankle arthrodesis (AAA) is a recognised salvage procedure for end-stage arthritis. Its reported disadvantages include a high rate of re-operation for symptomatic prominence of metalwork. We propose that the use of a headless screw would reduce this re-operation rate.Methods: We reviewed 32 AAAs, using the Acutrak™6/7mm headless screw fixation system, to determine peri-operative parameters and complication rates.Results: At an average of 22 months follow-up, 28 (88%) had united radiologically. There were 2 stable fibrous non-unions not requiring further intervention. Of the other 2, one was successfully revised using an open technique, and the other patient died of unrelated causes.There were no other complications in this series, with no cases of metalwork removal for prominence or pain.Conclusions: Using a headless screw fixation for arthroscopic ankle arthrodesis prevents symptomatic metalwork prominence and the requirement for removal.

Complications after open reduction and internal fixation of ankle fractures in the elderly - Corrected Proof

Michael J. Lynde, Travis Sautter, Graham A. Hamilton, John M. Schuberth — 2011-05-02

Abstract: Background: Open reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age.Methods: A retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed.Results: There was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications.Conclusions: Overall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.

A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: A preliminary investigation - Corrected Proof

J. Attard, D. Singh — 2011-04-18

Abstract: Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFOs). This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in a plantigrade position.Method: Each participant was given a questionnaire to fill in to evaluate how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was the pain decreased.Results: Two-thirds of all participants confirmed that morning pain and stiffness was less after wearing the AFO; both types were relatively easy to don and doff, but the posterior orthosis was more uncomfortable and disrupted sleep. On average, the anterior AFO reduced heel pain more significantly than the posterior orthosis.Conclusion: Plantar fasciitis night AFOs are poorly tolerated orthoses but their use can be justified in that the pain levels are reduced. The anterior AFOs are more comfortable and more effective than posterior AFOs.

Footwear and orthopaedics - Corrected Proof

H.V. Kurup, C.I.M. Clark, R.K. Dega — 2011-04-18

Abstract: Footwear is the oldest known fashion accessory in use. Footwear is often implicated in orthopaedic problems affecting lower limbs and back. Hence footwear modifications have a major role in management of these pathologies as well. This review explores footwear and its role in causation and management of orthopaedic problems. Based on our observations we recommend that children with flexible flatfeet should be encouraged to walk barefoot to help in developing their arches. Women with risk factors for secondary arthritis of knee or back pain may be advised to avoid heels. Commercial shoes which decrease hind foot loading may be used in symptomatic management of hindfoot and mid foot problems. Similarly shoes which decrease forefoot loading may be useful in managing forefoot pathology. Flip-flops should be avoided by diabetics as they do not protect from injuries.

Fibula lengthening osteotomy to correct valgus mal-alignment following total ankle arthroplasty - Corrected Proof

Benjamin Thomas Brooke, Nick John Harris, Samer Morgan — 2009-12-18

Abstract: Total Ankle Arthroplasty (TAA) is increasing in popularity following the development of the, next generation of implants and improved surgical technique giving better long-term results. Significant mal-alignment of the ankle pre-operatively has always provided a challenge to the surgeon, to regain anatomical alignment to reduce subsequent wear. We present a series of two cases of TAA, who developed post-operative valgus deformity requiring salvage procedure in the form of a fibula, lengthening osteotomy.