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Journal Reading

Whats New in Foot and


Ankle Surgery

Muhammad Luthfi Muammar

Ankle Fractures and


Syndesmosis

Mayich et al. performed a prospective


randomized study to evaluate the role of
educational handouts as related to
patient satisfaction with orthopaedic care
and outcomes in the first three months
following surgical stabilization of ankle
fractures
Patient satisfaction with the treating staff
was significantly improved as compared
with that of patients who did not receive
educational handouts

Ankle Fractures and


Syndesmosis
Femino et al. compared radiographs of varus
hindfoot positioning with those of valgus
hindfoot positioning during the external
rotation stress test for radiographic detection
of deep deltoid ligament disruption with and
without syndesmotic disruption
Only varus positioning of the hindfoot during
the external rotation stress test produced
significant radiographic medial clear space
widening in isolated deep deltoid injury

Ankle Fractures and


Syndesmosis
Phisitkul et al. demonstrated that
forceps clamp placement in a neutral
anatomical axis most accurately
reduced the syndesmosis when
compared with either an anterior or
posterior oblique clamp orientation

Ankle Fractures and


Syndesmosis
Noh et al. Compared outcomes of conventional
metallic implants to a biodegradable implant
made from polylevolactic acid for the fixation
of ankle fractures
The biodegradable implants were associated
with a longer mean operative time and a
greater number of fractures with postoperative
loss of reduction or nonunion, whereas metallic
implants were more commonly removed
postoperatively

Ankle Fractures and


Syndesmosis
Storey et al. reported on the complications
associated with suture-button stabilization
of ankle syndesmosis injuries with use of
the TightRope device
Of 102 cases reviewed by the authors,
eight patients required implant removal
for reasons related to osteomyelitis
surrounding the implant, painful aseptic
osteolysis, failed stabilization of the
syndesmosis, and unexplained pain

Ankle Fractures and


Syndesmosis
Ovaska et al. reviewed 1923 ankle
fracture operations to identify risk factors
for deep infection at the surgical site
A 6.8% deep infection rate was reported.
The significant patient related risks
factors for infection were a history of
diabetes, alcohol abuse, tobacco use,
fracture-dislocation, and soft-tissue injury

Calcaneal Fractures and Hindfoot


Trauma
The use of the sustentacular piece as a reference
or constant fragment with which to reconstruct
the displaced calcaneal fragments was challenged
in a study by Berberian et al., in which a high rate
(42%) of sustentacular displacement was
demonstrated. Overall, twenty-five of one
hundred calcanei had a sustentacular fragment
angulation of >10, twenty-four had sustentacular
translation of >3 mm, twenty had fracture
diastasis of the middle facet, and twenty-one had
a displace intraarticular fracture of the calcaneal
middle facet

Calcaneal Fractures and Hindfoot


Trauma
Gitajn et al. demonstrated that standar
calcaneal axial (Harris heel) fluoroscopic
images do not accurately assess
placement of screws into the
sustentaculum
The authors recommend obtaining the
standard Harris heel view as well as a heel
view with the fluoroscopic beam angled
10 to 20 toward the heel midline to
detect inferiorly misplaced screws

Calcaneal Fractures and Hindfoot


Trauma
Dickens et al. performed a retrospective
review of 102 consecutive combatrelated open calcaneal fractures to
identify risk factors for infection or
amputation
The overall reported amputation rate was
42%, with 15% requiring an amputation
in a delayed fashion more than twelve
weeks after the injury occurred

Calcaneal Fractures and Hindfoot


Trauma
The outcomes of foot and ankle blast
injuries following an under-vehicle explosion
resulting from improvised explosive devices
(IEDs) were reported by Ramasamy et al.
The injuries were associated with a high
amputation rate (29%) and were a source of
long-term morbidity, a symptoms were
persistent in 74% of the injured limbs and
only 14% of service members were able to
return to their pre-injury duties

Ankle and Hindfoot Arthritis


Schaefer et al. studied the unique
morphologic characteristics of
arthritic ankle joints as compared
with normal ankles. The results of the
investigation suggested that arthritic
ankle joints have a flatter surface
with less stability, depth,and
containment and have reduced
articular constraint and support

Ankle and Hindfoot Arthritis


San Giovanni et al. evaluated protein
biomarkers obtained from ankle arthrocentesis
fluid and correlated the concentration of those
biomarkers to intra-articular pathology found
in the joint. Differences were found in the
amounts of fibronectin-aggrecan complex and
monocyte chemotactic protein-1. Increasing
grades of severity of ankle intra-articular
pathology were associated with a significantly
higher concentration of fibronectin-aggrecan
complex and monocyt chemotactic protein

Ankle and Hindfoot Arthritis


Townshend et al. compared the results of
open and arthroscopic ankle arthrodesis
in patients who had end-stage ankle
arthritis and two years of follow-up. Both
open and arthroscopic ankle arthrodesis
significantly reduced pain and improved
function, although the arthroscopic
approach resulted in a shorter hospital
stay and better outcomes at one and two
years

Total Ankle Arthroplasty


Schweitzer et al. reported the early
clinical results of sixty-seven patients
treated with the fixed-bearing Salto
Talaris total ankle prosthesis (Tornier
U.S., Edina, Minnesota) at a mean
2.8 years of follow-up. The implant
survival rate was 96%, with only
three implants requiring revision

Total Ankle Arthroplasty


Ajis et al. performed a retrospective
review of 119 total ankle replacements
(three different prosthetic designs) to
determine how ankle range of motion
changes over time following surgery
The mean ankle dorsiflexion improved
by 5.4 while plantar flexion decreased
by 3.7 when compared with the
preoperative values

Ankle Arthroscopy
Van Bergen et al. reported the longterm
outcomes of fifty patients treated with
arthroscopic debridement and marrow
stimulation for primary osteochondral
lesions of the talus
This study suggests that the good initial
results reported following arthroscopic
treatment of osteochondral lesions of the
talus were durable over time. No
prognostic factors were identified.

Diabetes and Lower-Extremity


Amputation
Hastings et al. prospectively followed fifteen
patients with Charcot osteoarthropathy and
nineteen patients with diabetic peripheral
neuropathy without Charcot neuropathic
osteoarthropathy for up to two years to assess
the natural history of deformity progression
In patients with Charcot neuropathic
osteoarthropathy, the initial foot malalignment
at the onset of the study progressively worsened
over the first and second years, whereas the
uninvolved feet did not change in alignment

Belatti and Phisitkul queried the Medicare Part


B claims database (2000 to 2010) to identify
trends in treatment for diabetic foot ulcers
Lower-extremity amputation rates declined
over the decade, with the rates of proximal
amputations declining the greatest as
compared with those for more distal limbsparing levels. The use of total contact casting,
gastrocnemius recession, and Achilles tendonlengthening increased during the same period

Keeling et al. reviewed the self-reported


functional outcomes for two surgical
techniques for transtibial amputation in a
young, active-duty military population: the
bridge synostosis (modified Ertl)
technique, and the non-bone-bridging
(modified Burgess) technique
Residual limb length was significantly
longer (by 2.5 cm) in the modified Ertl
cohort

The outcomes of twenty-one patients


who underwent elective transtibial
amputation as treatment for therapyresistant type-I complex regional
pain syndrome were retrospectively
evaluated by Krans-Schreuder et al
19 patient
reduction in pain
17 patient
improved mobility
18 patient
undergo the procedure
again

Flatfoot Deformity
Mosca and Bevan retrospectively reviewed
eight patients with thirteen symptomatic
talocalcaneal tarsal coalitions treated with
a lateral column calcaneal lengthening
osteotomy with or without coalition
resection
The authors reported excellent deformity
correction and pain relief by addressing
flatfoot with the calcaneal lengthening
osteotomy

Flatfoot Deformity
Oh et al. performed a cadaver study
evaluating the alteration in pressure
across the lateral part of the forefoot with
incremental increases in lateral column
calcaneal lengthening. With progressive
increases in lateral column lengthening,
the plantar lateral forefoot pressure
consistently increased and talonavicular
abduction was consistently reduced

Flatfoot Deformity
Kang et al. compared radiographic
measurements of the length of the
lateral column among patients with
established adult acquired flatfoot
deformity and a control population
The authors determined that flatfoot
deformity is therefore not due to
shortening of the lateral column

Achilles Tendon
Soroceanu et al. review of highquality randomized controlled trials
that compared surgical to
nonsurgical treatment of acute
Achilles tendon ruptures included
several newer trials that have
employed functional bracing and
rehabilitation protocols for
nonsurgical treatment

Achilles Tendon
If functional rehabilitation was
utilized, the rerupture rates were
equal for surgical and nonsurgically
treated patients, but if early range of
motion was not utilized, then surgery
reduced absolute risk of rerupture by
8.8%. Surgery was associated with an
absolute risk increase of 15.8% for
complications other than rerupture

Achilles Tendon
A systematic meta-analysis of trials that
evaluated the effectiveness of
extracorporeal shock wave therapy in
the treatment of chronic insertional and
non-insertional Achilles tendinopathy
was performed by Al-Abbad and Simon
Results improved when extracorporeal
shock wave therapy was combined with
an eccentric Achilles stretching program

Achilles Tendon
Schon et al. reviewed their experience with
fifty-eight cases of Achilles tendon
debridement combined with a flexor hallucis
longus tendon transfer for treatment of
chronic insertional or non-insertional Achilles
tendinosis. A significant improvement was
noted in Achilles tendon function, physical
function, and pain intensity. This procedure
remains a reliable surgical option with
minimal sequelae of hallux plantar flexion
weakness

Hallux Rigidus
OMalley et al. Reported significant
improvements in AOFAS scores and
dorsiflexion of the
firstmetatarsophalangeal joint with a
combined cheilectomy and great toe
proximal phalangeal extension osteotomy
at a mean follow-up of 4.3 years. This
may offer another joint-sparing
alternative to fusion for treatment of
advanced hallux rigidus.

Hallux Rigidus
McNeil et al. to analyze the quality of
evidence supporting different surgical
interventions. Although 586 articles on hallux
rigidus were identified at the timeof the
study, only surgical arthrodesis had fair
evidence to support its use as treatment for
this condition. Cheilectomy, osteotomy,
implant arthroplasty, resection arthroplasty,
and interpositional arthroplasty had only poor
evidence to support its use for treatment of
hallux rigidus

Hallux Valgus and Lesser Toe


Deformities
Nery et al. prospectively evaluated
arthroscopic findings of the
metatarsophalangeal joint and the
results of magnetic resonance imaging
(MRI) in grading plantar plate tears
using an anatomic grading system
Accuracy of the interpretation of the
MRI improved with prior knowledge of
the anatomic grading system

Hallux Valgus and Lesser Toe


Deformities
Mazzuca et al. prospectively compared
fluoroscopic arthrography and magnetic
resonance arthrography in the detection of
plantar plate tears and correlated them with
intraoperative
Magnetic resonance arthrography was more
accurate; however, fluoroscopic
arthrography was more cost-effective and
was as reliable as magnetic resonance
arthrography if additional views were utilized

Morton Neuroma
Thomson et al. performed a patient-blinded
randomized clinical trial comparing the effect
of a corticosteroid injection (1 mL of
methylprednisolone [40mg], and 1mL
2%lignocaine) to an anesthetic injection alone
(2 mL 1% lignocaine)
Compared with the control group, patients
receiving the corticosteroid injection scored
significantly better in terms of global
assessment of foot health at one and three
months

Bone-Grafting
Hyer et al. Prospectively evaluated bonemarrow aspirates from the iliac crest, the
distal part of the tibia, and the calcaneus
to determine which would yield the
highest quantity of osteoblastic
progenitor cells. While osteoblastic
progenitor cells were present at each
location, the bone-marrow aspirate from
the iliac crest had the highest mean
concentration.

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