What’s New in Foot and Ankle Surgery : JBJS

• Updated on: 2020-05-24
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Editorial
What’s New in Foot and Ankle Surgery
Daniels, Timothy R. MD, FRCSC1,a; Wilson, Ian R. BSc, MD, FRCSC1; Fu, Joyce M. MD, FRCSC1
1Division of Orthopaedic Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada
aEmail address for T.R. Daniels: Timothy.Daniels@unityhealth.to
Investigation performed at St. Michael’s Hospital, Toronto, Ontario, Canada
Disclosure: The authors indicated that no external funding was received for any aspect of this work. 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/F782 ).
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This article provides a summary of research pertaining to orthopaedic foot and ankle surgery, published from September 2018 to September 2019. The included studies were published in The Journal of Bone & Joint Surgery, The Bone & Joint Journal, Foot & Ankle International, Foot and Ankle Surgery, The BMJ, Clinical Orthopaedics and Related Research, the Journal of Pain Research, the Journal of Orthopaedic Trauma, the Journal of Orthopaedic and Sports Physical Therapy, BMC Musculoskeletal Disorders, and The American Journal of Sports Medicine.
The Forefoot
Hallux Rigidus
Midterm outcomes of a synthetic cartilage, polyvinyl hydrogel implant for the first metatarsophalangeal joint in advanced hallux rigidus were prospectively assessed for 112 patients in a noninferiority, randomized clinical trial (RCT) 1 . Measures included a visual analog scale (VAS) for pain, the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale, the FAAM Sports subscale, active great toe dorsiflexion, and radiographs. Clinical and safety outcomes observed at 2 years were maintained at 5.8 years.
A shorter operative time was demonstrated for synthetic cartilage implant compared with arthrodesis (35 and 58 minutes, respectively) in the treatment of advanced hallux rigidus 2 . The patients treated with the implant were permitted to bear weight at 1 week and recover with a soft dressing, whereas patients who had arthrodesis were immobilized in a cast or boot for ≥6 weeks.
Hallux Valgus
In a prospective cohort study, minimally invasive chevron-Akin (MICA) surgery (n = 50) and open scarf-Akin surgery (n = 48) demonstrated similar improvements with respect to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, VAS for pain, and radiographic outcomes at minimum 2-year follow-up 3 . Each group had 3 cases of moderate stiffness (range of motion [ROM], 30° to 74°). Extension increased by 10° in the MICA group. Reoperation was required for 13 (26%) of the patients in the MICA group and 4 (8%) in the scarf-Akin group, including 11 cases of hardware removal, 5 cases of secondary resection of the residual medial prominence, and 1 case of a postoperatively dislocated fracture with MICA that required reoperation.
Among groups treated with Akin osteotomy fixation with staples (n = 43), screws (n = 47), or transosseous sutures (n = 48), AOFAS Ankle-Hindfoot scores improved similarly, with no cases of delayed union or nonunion 4 . Suture fixation was advantageous regarding cost and potential complications. Scarf osteotomy with fixation using 2 screws (n = 50), 1 screw (n = 55), or no screws (n = 64, including 20 with transosseous sutures) demonstrated similar degrees of correction, AOFAS Ankle-Hindfoot Scale scores, and rates of complications 5 .
Sutherland and colleagues evaluated hallux valgus from a public-health perspective in a study of 95 patients who completed preoperative and postoperative patient-reported outcome measures (PROMs) and reported a significant difference in patient-reported health after surgery 6 . The cost per quality-adjusted life year was relatively inexpensive and changed on the basis of patient age and sex. Hallux valgus surgery was deemed cost-effective overall and offered significant health benefits to the patient. A prospective comparative study of 87 patients demonstrated that longer wait times for hallux valgus surgery were associated with smaller gains in the Foot and Ankle Outcome Score (FAOS) domains of pain and ADL, indicative of poorer postoperative outcomes 7 . Among 80 patients awaiting bunion surgery for a mean of 34.9 weeks, high pain levels and compromised foot function did not change significantly from the beginning to the end of the waiting period 8 .
Midfoot Injuries and Lisfranc Fractures
Over 5 years at a university hospital, 233 (75.9%) of 307 midfoot injuries were Lisfranc injuries, 56 (18.2%) were Chopart injuries, and the remainder were combined injuries 9 . The primary mechanism of injury was low-energy trauma. The amount of energy and mechanism of trauma were not associated with injury severity 9 , although in a previous report 10 , higher-energy trauma increased the risk of additional, adjacent foot fractures or distributed musculoskeletal injury.
Transarticular screw utilization in open reduction and internal fixation (ORIF) of Lisfranc fractures is concerning for damage to articular cartilage. Jastifer et al. determined the mean articular surface area of joints comprising the Lisfranc complex using digital imaging software in a cadaveric study 11 . Nonarticular screw trajectories large enough to allow adequate screw fixation were simulated to be plantar-medial to dorsal-lateral and approximately perpendicular to the long axis of the foot.
In a retrospective comparative study, 88 feet (189 joints) underwent arthrodesis for tarsometatarsal arthritis, with the use of screws alone (n = 105), bridge plating with all screws through the plate (n = 67), or combined bridge plating and an independent compressive lag screw (n = 17) 12 . The overall rate of nonunion was 11.4%. Significant risk factors for nonunion were the use of a plate only, nonanatomic alignment postoperatively, and smoking in the perioperative period. Seventy (79.5%) of the patients received bone graft (autograft or demineralized bone matrix), which significantly decreased the rate of nonunion (odds ratio [OR], 0.2; p = 0.006). The study included patients with diabetes and Charcot neuroarthropathy, in whom surgeons had a strong preference for using plates; these factors did not significantly affect nonunion.
The Ankle and Hindfoot
Total Ankle Replacement
Total ankle replacement (TAR) continues to be refined to improve longevity and patient outcomes. Among 200 Scandinavian Total Ankle Replacement (STAR; Stryker) implants, survivorship was 90%, 83%, and 76% at 5, 10, and 15.8 years of follow-up, respectively, using revision surgery as the primary end point 13 . Among 153 INFINITY (Wright Medical Technology) TARs, the incidence of revision was 10% at 13 months 14 . Common reasons for revision were deep infection (3.8%) and tibial-component loosening (3.8%). The patient population was heterogeneous; 79% required additional procedures at the time of TAR or had preexisting arthrodeses.
In a consecutive series of 278 TARs, the overall incidence of postoperative complications was 41.7%, including amputation, deep infections, superficial infections, wound-healing delays, venous thromboembolism (VTE), fractures, osteolysis, aseptic loosening, subsidence, malpositioning, polyethylene fracture, edge-loading, soft-tissue injuries, pain, and stiffness 15 . The clinical outcome was affected in only 7.6% of the cases, as most complications were minor.
In a prospective comparative series of TARs with use of the HINTEGRA (Newdeal/Integra LifeSciences) implant, patients ≤55 years (n = 38) and patients >55 years old (n = 85) had similar rates of complications (39.5% and 41.2%, respectively), overall survivorship (97% and 87.8%, respectively), and clinical outcomes, including AOFAS Ankle-Hindfoot scores and Short Form (SF)-36 physical component summary and mental component summary scores, and a VAS for pain at a mean of 78 months of follow-up 16 .
Saito et al. performed a retrospective comparative study of patient-specific instrumentation (PSI) (n = 75) and standard referencing guides (n = 24) 17 . The groups were statistically similar regarding coronal and sagittal alignment of the tibial component; the talar component was not assessed. The PSI group had significantly shorter operative and fluoroscopy durations. Poor prediction of implant size was demonstrated for PSI (correct prediction of tibial component size in 73% of the cases and of talar component size in 51% of the cases). In 3 cases, PSI was abandoned in favor of standard referencing guides because of inaccuracy.
Schipper et al. compared wear attributes of fixed-bearing ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (HXLPE) 18 . After 5 million cycles, HXLPE showed significantly less wear and significantly smaller and rounder particles compared with UHMWPE. In a separate study, HXLPE was strong enough to withstand the demands placed on the TAR bearing surface 19 .
In a retrospective database cohort study of TAR (n = 2,993) and tibiotalar arthrodesis (n = 2,667), the 30-day readmission rate was significantly higher following arthrodesis (4.4%) compared with TAR (1.4%) 20 . Independent risk factors for having a readmission within 30 days included iron-deficiency anemia, coagulopathy, renal failure, nonprivate insurance, and tibiotalar arthrodesis.
Shofer et al. prospectively evaluated activity levels among patients who underwent TAR or ankle arthrodesis preoperatively and 6, 12, 24, and 36 months postoperatively 21 . Activity level increased in both groups, initially more following TAR, but the effects evened out by 36 months, and activity levels did not correspond to PROMs. The patients who underwent ankle arthrodesis were younger (by a mean of 6.8 years) and had a greater body mass index (BMI) (by a mean of 2.9 kg/m2) than the patients who underwent TAR.
Lazarides et al. retrospectively evaluated 32 patients with a remote periprosthetic fracture >4 weeks after TAR 22 . Implant instability was determined radiographically as evidence of osteolysis about the implant or loosening or subsidence and was confirmed operatively when feasible. Talar periprosthetic fractures were always unstable and required revision TAR or arthrodesis in every case. Periprosthetic fractures of the medial malleolus, tibial shaft, and lateral malleolus that were deemed stable were recommended for treatment with ORIF; those deemed unstable necessitated revision or arthrodesis. Nonoperative management of the periprosthetic fracture was independently associated with failure (p < 0.001), with surgery required because of osseous nonunion or malunion in >80% of the cases.
Periprosthetic Infection
In 2018, the Foot and Ankle Work Group of the International Consensus Meeting on Musculoskeletal Infection developed 40 consensus statements on the prevention, diagnosis, and treatment of periprosthetic infections following TAR as summarized in a supplemental issue of Foot & Ankle International 23 . In these consensus statements, prophylactic intravenous cefazolin administration within 60 minutes before TAR was unanimously recommended 24 . In patients with prior infection involving the ankle undergoing TAR, the addition of antibiotics to the cement was unanimously recommended 25 . Diagnosis 26 and treatment 27 algorithms for periprosthetic infections were also developed by the Foot and Ankle Work Group.
Ankle Fractures
Several studies evaluated intramedullary fibular fixation for ankle fractures. Challagundla et al. assessed the use of an intramedullary fibular rod for lateral malleolar fractures in 15 elderly patients (mean age, 74 years) 28 . At 12 months of follow-up, all fractures had healed, reduction was obtained and maintained with no infections, and the mean FAAM score was 78. Two patients eventually required hardware removal. A retrospective study of fibular nail use for 39 ankle fractures showed that the quality of reduction was good in 32 (82%) of the fractures, fair in 5 (13%), and poor in 2 (5%), with the poor fractures revised to a plate via ORIF 29 . Eight ankles required reoperation, of which 6 required fibular nail removal because of irritation and/or prominence (n = 3), deep infection (n = 1), secondary displacement (n = 1), and Charcot neuroarthropathy (n = 1). Among 342 ankle fractures managed with an intramedullary fibular nail, Carter et al. identified 20 failed cases (6%), with failure in 7 (2%) due to proximal locking-screw pull-out (device problem) and in 13 (4%) as a result of surgeon error 30 .
Coles et al. surveyed members of the Orthopaedic Trauma Association (OTA) on current practice patterns for ankle fracture management 31 , with a poor overall response rate (8.4%). Best-practice recommendations included accurate syndesmotic reduction via either fluoroscopic or open methods, not removing syndesmotic screws unless the patient is symptomatic, and VTE prophylaxis only if notable risk factors are present.
Syndesmosis
A meta-analysis of 3 RCTs and 5 retrospective studies (total n = 397) found that functional outcomes and complications were similar for suture-button fixation and screw fixation for syndesmotic injuries, with a faster time to full weight-bearing in the suture-button group 32 . Although the authors recommend suture-button fixation, the conclusion is drawn from retrospective studies and only 1 RCT that tracked time to weight-bearing. With the increasing cost of health care, this conclusion should be scrutinized.
Removal of syndesmotic fixation screws had no effect on ankle dorsiflexion in 21 patients 33 . Dorsiflexion was measured on radiographs intraoperatively, immediately before and following implant removal, and 3 months postoperatively. Thus, ankle range of motion should not be the sole indication for syndesmotic implant removal.
Syndesmotic reduction is considered important for achieving good clinical outcomes. A retrospective cohort study of 87 patients found that an anterior tibiofibular distance of >2 mm on computed tomography (CT) scans 2 years after syndesmotic reduction was correlated with poorer Olerud-Molander Ankle Scores and AOFAS Ankle-Hindfoot scores 34 . Approximately 20% of AOFAS and Olerud-Molander Ankle Scores were missing at the time of final follow-up.
Osteochondral Lesions of the Talus
Several studies evaluated microfracture for the treatment of osteochondral lesions of the talus (OLTs). In 64 of 70 patients treated with arthroscopic microfracture for OLT (mean lesion size [and standard deviation], 1.1 ± 0.7 cm2; no OLTs were >1.5 cm), VAS and AOFAS Ankle-Hindfoot scores improved significantly up to 2 years postoperatively, stabilized, and were maintained at 3 and 4 years of follow-up 35 . Six of 70 patients worsened or showed no improvement at the 6-month follow-up and were excluded from the analysis. The overall success of arthroscopic microfracture based on good-to-excellent AOFAS Ankle-Hindfoot scores was reported by 88.6% of patients at 2 years.
In a prospective cohort study of 101 patients with an average lesion size of <1.5 cm2 and treated with microfracture alone (n = 52) or microfracture + autologous iliac crest bone marrow aspirate concentrate (BMAC) (n = 49) 36 , both groups reported significant improvement in FAOS pain, sport, activities of daily living, and quality-of-life subscores at a minimum of 36 months of follow-up. The revision rate was 28.8% in the microfracture-only cohort compared with 12.2% in the microfracture + BMAC cohort (p = 0.0145).
Autologous matrix-induced chondrogenesis (AMIC) is a technique involving microfracture followed by implantation of a type I/III collagen bilayer membrane matrix (Chondro-Gide, Geistlich Pharma). The charts of 33 patients who had undergone AMIC for OLT were retrospectively reviewed at mean of 4.7 years of follow-up 37 . Tegner and VAS for pain scores improved significantly, and 26 (79%) of the patients returned to sport. The magnetic resonance observation of cartilage repair tissue (MOCART) score did not correlate with otherwise good clinical outcomes. A high proportion of patients (58%) required reoperation for hardware-related symptoms following medial malleolar osteotomy, but no revisions for failure of AMIC were performed. This study lacked a control group, with potential selection bias introduced with subjects lost to follow-up.
An ongoing prospective case series of matrix-associated stem cell transplantation (MAST) for OLTs was updated by Richter and Zech 38 . Autologous concentrated pelvic bone marrow combined with a collagen I/III bilayer membrane matrix (Chondro-Gide) was secured in the OLT with fibrin glue. At 5 years of follow-up, 100 (83%) of the patients remained, with an average OLT size of 1.7 cm2. Visual-Analogue-Scale Foot and Ankle scores remained stable compared with 2-year outcomes. In 49 (48%) of 102 previous lesion locations, no lesion was visible by magnetic resonance imaging (MRI) at follow-up. While promising, these results are confounded by additional simultaneous procedures and hindered by the lack of a control group.
Shimozono et al. compared outcomes between autograft (n = 16; nonarticular portion of the ipsilateral femoral condyle) and allograft (n = 25; fresh osteochondral) used to treat OLTs of >1.5 cm2 or in patients in whom previous microfracture had failed 39 . The autograft group fared significantly better on the FAOS, SF-12, and MOCART scores, and demonstrated less chondral wear, less cyst formation, and a lower rate of revision surgeries (0% compared with 25%) compared with the allograft group.
Chronic Ankle Instability
Rigby and Cottom retrospectively found that patient-satisfaction, VAS for pain, and AOFAS Ankle-Hindfoot scores were similar for an “all-inside” arthroscopic Broström repair (n = 30) and a classic open Broström-Gould repair (n = 32) 40 . The arthroscopic group had a shorter mean time to weight-bearing: 12 days compared with 22 days in the open-repair group.
At a mean follow-up of 28 months, 30 (93.8%) of 32 patients with chronic lateral ankle instability rated their outcomes as excellent or good following anatomic reconstruction of the lateral ligament using the anterior half of the peroneus longus tendon as a free tendon graft 41 . They also had decreased pain scores, and significantly reduced mean talar tilt (14.1° to 3.4°) and anterior drawer displacement (13.8 to 3.6 mm).
Intra-Articular Injections
Among 1,708 patients who received an intra-articular corticosteroid injection into the tibiotalar or subtalar joint, 99 (5.8%) developed 104 adverse events within 90 days 42 . Common adverse events were flare (75%) and skin reaction. Study limitations include the retrospective design and potential underreporting if patients visited another health-care provider.
Pes Planus
The authors of a prospective comparative study of weight-bearing CT (WBCT) reported good interobserver and intraobserver reliability for axial, coronal, and sagittal-plane measurements among 19 patients with adult-acquired flatfoot deformity, as performed by investigators with varying clinical experience after a training protocol 43 . Significant differences in measurements were observed for the medial cuneiform-first metatarsal angle and the navicular-medial cuneiform angle.
In 61 patients (63 feet) with stage-II adult-acquired flatfoot deformity who received a medial cuneiform (Cotton) osteotomy as part of their reconstruction, those with mild plantar flexion (i.e., cuneiform articular angle [CAA] of ≥−2°) had statistically and clinically better FAOS symptom, ADL, sports, and quality-of-life subscales compared with moderate plantar flexion (CAA of <−2°) at a minimum of 2 years of follow-up 44 .
Soft Tissues
Achilles Tendon
In a retrospective chart review, eligible patients underwent open (n = 560) or minimally invasive surgical (n = 55) repair of acute Achilles tendon ruptures. One in 9 developed a postoperative complication including wound-healing problems (5.0%), symptomatic VTE (5.7%), and sural nerve injury (1.9%) 45 . The rate and type of complications were similar between the 2 groups. Patients treated by trauma surgeons were more likely to have complications compared with those treated by subspecialty surgeons. Tobacco use and advanced patient age were also associated with higher complication risk.
Plantar Fasciitis
In a prospective study of 2 patient cohorts with plantar fasciitis in whom 6 months of nonoperative treatment was unsuccessful, the authors analyzed the effect of a single methylprednisolone injection (n = 20) or two 4-mL injections of platelet-rich plasma (PRP) concentrate (n = 20) 46 . VAS pain and AOFAS Ankle-Hindfoot scores improved significantly (p < 0.0001) in the PRP group at a mean of 33 months of follow-up. The steroid group had worse AOFAS Ankle-Hindfoot scores compared with the PRP group at 6 months of follow-up. Plantar fascia thickness decreased in both groups as evaluated on ultrasound and MRI, attributed to a reduction in overall inflammation.
Molund et al. conducted an RCT evaluating stretching alone (n = 20) compared with stretching and proximal medial gastrocnemius recession (n = 20) in patients with chronic (>12 months) plantar heel pain 47 . The operative group demonstrated significantly greater improvements (p < 0.05) in AOFAS Ankle-Hindfoot, SF-36, and VAS pain scores compared with the nonoperative group at 12 months of follow-up. Ankle dorsiflexion increased by a mean of 4.5°. The groups were similar regarding Achilles function and calf weakness. Pedobarography demonstrated increased forefoot plantar pressure in the operative group.
Patient-Reported Outcomes
Liu et al. validated the Ankle Osteoarthritis Scale (AOS) in a prospective comparative study and found that the AOS was a strong measure of pain and dysfunction for preoperative evaluation of patients with end-stage ankle arthritis 48 .
Hung et al. determined that the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and FAAM Sports subscales were sensitive and responsive to changes in patient-reported health in a foot and ankle orthopaedic patient population (n = 785) 49 . A Level-I diagnostic study of 3,069 foot and ankle orthopaedic patients determined that the minimal clinically important difference (MCID) for the PROMIS PF ranged from 3 to 30 (median, 11.3); for the PROMIS PI, it ranged from 3 to 25 (median, 8.9); and for the FAAM Sports subscale, it ranged from 9 to 77 (median, 32.5) 50 . For high-stakes decisions in clinical practice (e.g., surgery referrals), the median values should be used. Bernstein et al. found that the PROMIS PI domain was superior to both the PROMIS PF and the traditional numeric pain rating scale (NPRS) for preoperative assessment of pain level and functional ability in foot and ankle patients 51 .
An AOFAS position statement supported the use of validated PROMs for the assessment of general health, function, and treatment outcomes 52 . The AOFAS support use of the PROMIS PF or Lower Extremity (LE) domains in combination with other domains, such as the PROMIS PI, as well as disease-specific measures.
Clubfoot
In a retrospective case series, the authors reviewed the cases of 145 Nepalese children (220 feet) who had been treated for idiopathic clubfoot with the Ponseti method between the ages of 1 year and 5 years 53 . At a minimum of 10 years of follow-up, 138 (95%) of the 145 children demonstrated lasting results, with 210 (95%) of the 220 feet achieving a plantigrade foot. Only 3% complete relapses occurred, although residual deformities were common. Surgical treatment, most typically a percutaneous Achilles tendon release, was required in 96% of the feet.
A commentary by Wright 54 on the above study suggested that clubfoot deformity might prompt unnecessary surgery in “high-income settings,” as some deformity is compatible with good function.
Diabetes and Charcot Neuroarthropathy
Ford et al. retrospectively evaluated 25 patients with midfoot Charcot neuroarthropathy treated with intramedullary beams 55 . At a minimum of 1 year of follow-up, 21 (84%) of the patients achieved an ulcer-free, stable, plantigrade foot with use of 2 beams. Fifteen (60%) of the patients required reoperation for deep infection (n = 6), recurrent ulceration (n = 4), recurrent deformity (n = 3), wound dehiscence (n = 1), or hardware failure (n = 1). Six patients (all with preoperative ulceration) developed deep infections postoperatively; 4 went on to amputation. An open ulcer at the time of surgery had an increased incidence of infection, and was predictive of postoperative infection (p = 0.04). Midfoot Charcot arthropathy is a difficult clinical problem, and comparative studies of fixation methods are needed.
The diagnosis and treatment of foot infections and osteomyelitis in patients with diabetes are challenging. Pinzur found that an erythrocyte sedimentation rate (ESR) of 60 mm/hr had a sensitivity of 74% and a specificity of 56% and a C-reactive protein (CRP) level of 7.9 mg/dL had a sensitivity of 49% and a specificity of 80% for the diagnosis of osteomyelitis in patients with diabetes-related foot infections in a receiver operating characteristic (ROC) curve analysis 56 . While the ESR was better for ruling out osteomyelitis initially, the CRP level helped distinguish osteomyelitis from soft-tissue infections in those with a high ESR value.
Mijuskovic et al. prospectively determined that culture of biopsy specimens obtained from patients requiring toe or forefoot amputations overestimated the incidence of osteomyelitis, with a 41% false-positive rate (i.e., positive culture with negative histological analysis) attributed to cross-contamination from adjacent soft tissue 57 .
Upcoming Educational Events
Events related to foot and ankle surgery sponsored by the AOFAS include the AOFAS Annual Meeting, September 9 to 12, 2020, in San Antonio, Texas.
Evidence-Based Orthopaedics
The editorial staff of JBJS 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 this update, 27 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.
Evidence-Based Orthopaedics
Albin SR, Koppenhaver SL, Marcus R, Dibble L, Cornwall M, Fritz JM. Short-term effects of manual therapy in patients after surgical fixation of ankle and/or hindfoot fracture: a randomized clinical trial. J Orthop Sports Phys Ther. 2019 May;49(5):310-9. Epub 2019 Feb 13.
Approximately 3.8 months following ORIF for an ankle and/or hindfoot fracture, patients receiving standard physiotherapy with exercise and gait training were randomized to additionally receive either manual therapy (fracture-specific adjacent joint mobilization to decrease stiffness, n = 40) or sham manual therapy (control, nonspecific, light soft-tissue mobilization, n = 32). Only 3 treatments of similar duration for both groups were performed over 7 to 10 days. At the time of final follow-up 7 to 10 days after the last treatment, both groups had similar range of motion, gait, and balance outcomes. The control group had significantly greater gastrocnemius muscle stiffness compared with the manual therapy group.
Alvarez CM, Wright JG, Chhina H, Howren A, Law P. Botulinum toxin type A versus placebo for idiopathic clubfoot: a two-center, double-blind, randomized controlled trial. J Bone Joint Surg Am. 2018 Sep 19;100(18):1589-96.
Sixty-six infant patients with idiopathic clubfoot underwent onabotulinum toxin A (BTX-A) injection (n = 33) or placebo injection (n = 33) into the gastrocnemius-soleus muscle at the time of hindfoot stall; two-thirds responded to treatment (i.e., ≥15° of dorsiflexion) at 6 weeks post-injection. The remainder (including placebo cohort) received a rescue BTX-A injection at 12 weeks after the first injection, followed by a third BTX-A rescue injection or surgery (Achilles tendon lengthening [3 feet] or posteromedial release [2 feet]) if no response after 2 doses. All participants demonstrated ≥15° of dorsiflexion at 2 years of follow-up. This study highlights the potential for BTX-A injections to improve ankle dorsiflexion in idiopathic clubfoot, but more frequent follow-up is required. The lowest minimum dose of injection still needs to be identified.
Arcângelo J, Guerra-Pinto F, Pinto A, Grenho A, Navarro A, Martin Oliva X. Peri-prosthetic bone cysts after total ankle replacement. A systematic review and meta-analysis. Foot Ankle Surg. 2019 Apr;25(2):96-105. Epub 2017 Nov 29.
In 21 studies representing 2,430 TARs, osteolytic periprosthetic cysts developed in 430 (18%) of the cases. Significantly higher proportions of cysts were associated with nonanatomic implant designs (due to increased shear stress), mobile-bearing articular surfaces (increased polyethylene wear), hydroxyapatite-coated implants (elevated calcium levels found in osteolytic lesions), and nonstemmed tibial implants (possibly because of less overall stability). The main limitations of the assessed studies included the lack of a specific definition of a periprosthetic cyst, inconsistent reporting of revision surgery due to periprosthetic cysts, and variability in diagnostic imaging used to quantify and diagnose the cysts.
Bahrami MH, Raeissadat SA, Barchinejad M, Elyaspour D, Rahimi-Dehgolan S. Local ozone (O2-O3) versus corticosteroid injection efficacy in plantar fasciitis treatment: a double-blinded RCT. J Pain Res. 2019 Jul 24;12:2251-9.
Patients with plantar fasciitis symptoms of at least 3 months’ duration and not relieved by first-line conservative therapies were randomized to receive methylprednisolone (n = 23) or oxygen-ozone solution (n = 21) injection. The corticosteroid group demonstrated significantly greater improvements in VAS pain, FAAM score, and pressure-pain threshold than the ozone group at 1 week post-injection. At 1 month, VAS pain and FAAM scores showed no significant differences between the groups, but the pressure-pain threshold remained significantly higher in the corticosteroid group. By 3 months of follow-up, none of the scores showed significant differences between groups.
Cazzell S, Stewart J, Agnew PS, Senatore J, Walters J, Murdoch D, Reyzelman A, Miller SD. Randomized controlled trial of micronized dehydrated human amnion/chorion membrane (dHACM) injection compared to placebo for the treatment of plantar fasciitis. Foot Ankle Int. 2018 Oct;39(10):1151-61. Epub 2018 Jul 30.
This multicenter, prospective, single-blinded, RCT involved injection of dehydrated human amnion/chorion membrane (dHACM) (n = 73) or saline solution placebo (n = 72) for plantar fasciitis pain resistant to nonoperative treatment. At 3 months, VAS pain scores were 76% lower and Foot Function Index scores were 60% lower than baseline in the dHACM group compared with 45% and 40% decreases, respectively, in the control group. No adverse events apart from post-injection pain and pruritus were attributed to the dHACM injection.
Cho BK, Park JK, Choi SM, SooHoo NF. A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability. Foot Ankle Surg. 2019 Apr;25(2):137-42. Epub 2017 Oct 18.
In this randomized comparison study, female patients with chronic lateral ankle instability underwent either a suture-tape augmentation procedure (n = 28) or a modified Broström-Gould (MBG) procedure (n = 27) and were followed for 2 years. FAOS and FAAM scores, recurrence of instability (2 cases in the suture-tape group, 1 case in the MBG group; p = 0.385), and stress radiographs were similar between the 2 procedures. The overall cost of suture-tape intervention (including implant cost, nursing fee, and use of fluoroscopy) was significantly higher than that of MBG, although the overall operative time was shorter. This study was controversial, as it did not report complications related to the use of suture tape (a potential foreign body), or the average time to return to sport or activities of daily living. The study population was entirely female; results are not generalizable to a male population.
Elshazly O, Abdel Rahman AF, Fahmy H, Sobhy MH, Abdelhadi W. Scarf versus long chevron osteotomies for the treatment of hallux valgus: a prospective randomized controlled study. Foot Ankle Surg. 2019 Aug;25(4):469-77. Epub 2018 Mar 7.
Patients with hallux valgus who were randomized to treatment with scarf osteotomy (n = 21) or long distal chevron osteotomy (n = 22) demonstrated a similar degree of intermetatarsal angle correction and similar radiographic outcomes for the intermetatarsal angle and hallux valgus angle. American College of Foot and Ankle Surgeons scores were also comparable between the groups.
Gao L, Orth P, Cucchiarini M, Madry H. Autologous matrix-induced chondrogenesis: a systematic review of the clinical evidence. Am J Sports Med. 2019 Jan;47(1):222-31. Epub 2017 Nov 21.
This systematic review assessed 28 articles, 12 of which pertained to ankle cartilage defects and included a total of 214 patients. Studies evaluating the use of AMIC, a proprietary technique involving microfracture followed by implantation of a type I/III collagen bilayer membrane matrix (Chondro-Gide) in the ankle noted a substantial decrease in VAS for pain and improved AOFAS Ankle-Hindfoot scores. No ankle-related studies compared AMIC and more established microfracture or autologous chondrocyte implantation techniques, highlighting the paucity of such literature. The evidence to recommend AMIC was insufficient, although it appeared safe overall.
Grassi A, Amendola A, Samuelsson K, Svantesson E, Romagnoli M, Bondi A, Mosca M, Zaffagnini S. Minimally invasive versus open repair for acute Achilles tendon rupture: meta-analysis showing reduced complications, with similar outcomes, after minimally invasive surgery. J Bone Joint Surg Am. 2018 Nov 21;100(22):1969-81.
This meta-analysis of 8 RCTs that compared outcomes of patients treated with minimally invasive repair (total n = 182) or open repair (total n = 176) of acute Achilles tendon rupture found no significant differences between the groups for rerupture, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The group treated with minimally invasive repair had a significantly decreased risk of overall complications and wound infections. The authors noted a high level of heterogeneity and considerable risk of bias.
Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019 Jun 12. [Epub ahead of print].
Seven RCTs comparing dynamic (total n = 168) and static (total n = 167) stabilization of the syndesmosis were analyzed. Dynamic-stabilization methods included the use of suture buttons (5 RCTs), cerclage wire (1 RCT), and elastic hook plates (1 RCT). Dynamic stabilization had fewer complications and significantly better AOFAS Ankle-Hindfoot and VAS for pain scores, whereas reoperation rates and Olerud-Molander scores were similar between the dynamic and static stabilization at 2 years of follow-up. Conclusions drawn from this meta-analysis are clouded by the poor overall quality of evidence because of small sample size, lack of blinding, heterogeneity of treatment, and the use of nonvalidated outcome scores.
Green T, Willson G, Martin D, Fallon K. What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review. BMC Musculoskelet Disord. 2019 Aug 31;20(1):394.
Only 7 clinical practice guidelines (CPGs) on the treatment of acute lateral-ligament ankle sprains published between 2006 and 2013 were identified for analysis. The overall lack of CPGs for this common soft-tissue injury was concerning, and many were outdated. The CPGs were clearly presented with well-defined scope and purpose. However, the applicability (discussion of facilitators and barriers to application, advice for practical use, consideration of resurface implication, and monitoring/auditing criteria) was demonstrably low for all CPGs. The rigor of guideline development was moderate to low, with poor consistency in reporting levels of evidence. Many recommendations were based on expert-opinion consensus, rather than high-quality evidence.
Hollander K, Liebl D, Meining S, Mattes K, Willwacher S, Zech A. Adaptation of running biomechanics to repeated barefoot running: a randomized controlled study. Am J Sports Med. 2019 Jul;47(8):1975-83. Epub 2019 Jun 5.
The effects of habituation (8-week intervention) to barefoot running (n = 19) versus shod running (n = 18) on running biomechanics were compared with passive controls (n = 16). After habituation, barefoot participants demonstrated more anterior foot placement, increased foot-strike index, and increased vertical loading.
Jain SK, Dar MY, Kumar S, Yadav A, Kearns SR. Role of anti-oxidant (vitamin-C) in post-operative pain relief in foot and ankle trauma surgery: a prospective randomized trial. Foot Ankle Surg. 2019 Aug;25(4):542-5. Epub 2018 May 24.
Patients with single malleolar, bimalleolar, or trimalleolar ankle fractures, single or double metatarsal fractures, or calcaneal avulsion fractures underwent ORIF and then were randomized to either diclofenac and vitamin C (500 mg orally, twice daily; n = 30) or diclofenac and placebo (orally, twice daily; n = 30). The vitamin-C group had significantly less pain than the control group at 2 (p = 0.008) and 6 (p = 0.003) weeks of follow-up and also consumed a significantly lesser amount of analgesics (p = 0.002) at 6 weeks of follow-up. The vitamin-C group had a significantly better mean American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcome Instrument (FAI) core score at 3 months of follow-up (p < 0.001).
Katzap Y, Haidukov M, Berland OM, Itzhak RB, Kalichman L. Additive effect of therapeutic ultrasound in the treatment of plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2018 Nov;48(11):847-55. Epub 2018 Jul 11.
In a double-blinded RCT involving patients with plantar fasciitis, the effect of therapeutic ultrasound in addition to a standard, self-directed stretching regimen (n = 28) was evaluated in comparison to the same stretching exercises and sham ultrasound (control group, n = 26). After 8 treatments over 4 weeks, both groups experienced a significant improvement in pain and results of foot and ankle computerized adaptive testing and an algometric test. No significant differences between the groups were observed. Ultrasound should not be added to nonoperative treatment regimens for plantar fasciitis.
Kortekangas T, Haapasalo H, Flinkkilä T, Ohtonen P, Nortunen S, Laine HJ, Järvinen TL, Pakarinen H. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ. 2019 Jan 23;364:k5432.
Patients with stable Weber B-type ankle fractures (defined as a medial clear space of <4 mm and <5 mm under external rotation stress) were randomized to treatment with either 6 weeks of traditional cast immobilization (n = 84) or 3 weeks of immobilization in a cast (n = 83) or a removable, commercially available, simple orthosis (n = 80). Three weeks of immobilization in a cast or simple orthosis was noninferior to the traditional 6-week period of casting. At 1 year post-intervention, Olerud-Molander Ankle Score values were equivalent in all groups. The 3-week orthosis group demonstrated an increased ankle plantar flexion range compared with the 6-week cast group. An increased rate of deep vein thrombosis was observed in the 6-week cast group (6%) compared with the 3-week cast (3.6%) and orthosis (0%) groups. Instituting 3-week immobilization relies on the ability to correctly diagnose stable versus unstable Weber B-type ankle fractures.
Louwerens JKG, Mensch DT, Verhoof OJW, de Reuver PR, Bijlsma TS, van Noort A, van den Bekerom MPJ. Functional treatment for acute ankle sprains: Softcast wrap versus MOK-cast. A prospective randomized single-center trial. Foot Ankle Surg. 2019 Aug;25(4):482-7. Epub 2018 Mar 26.
Patients were randomized to receive either a semi-rigid polyester wrap (Softcast; Delta-Cast Conformable, BSN medical; n = 48) or a removable version of the same wrap material held with Velcro straps (MOK-cast; n = 52) after sustaining a grade-II or III lateral ankle sprain diagnosed on physical examination 5 to 7 days post-injury. At 4 months of follow-up, no significant difference in overall function on the basis of the Karlsson scoring scale was noted between the groups. The Softcast wrap group demonstrated a small but significantly greater improvement in VAS pain from 10 days postoperative onward, but the MOK-cast group had greater patient satisfaction. Both modalities were considered effective functional treatment options for acute lateral ankle ligament injuries.
Marson BA, Deshmukh SR, Grindlay DJC, Ollivere BJ, Scammell BE. A systematic review of local antibiotic devices used to improve wound healing following the surgical management of foot infections in diabetics. Bone Joint J. 2018 Nov;100-B(11):1409-15.
Thirteen studies (1 RCT, 2 case-controlled studies, 10 case series) of implantable antibiotic delivery methods as an adjunct to surgery in diabetic foot infections were reviewed. The overall quality of evidence was poor. The single trial found a shorter time-to-healing with use of gentamicin-impregnated sponge (3 weeks) versus no sponge (4.9 weeks) (p < 0.05) in minor forefoot amputation. Other studies found no significant differences in rates of reoperation, major amputation, and mortality between groups using different implanted antibiotics. The authors concluded that antibiotic-eluting devices cannot be advocated until high-quality evidence can justify their use.
McIntyre JA, Jones IA, Han B, Vangsness CT Jr. Intra-articular mesenchymal stem cell therapy for the human joint: a systematic review. Am J Sports Med. 2018 Dec;46(14):3550-63. Epub 2017 Nov 3.
Twenty-eight studies of mesenchymal stem cell (MSC) injection of the hip (n = 5), knee (n = 523), or foot and ankle (n = 61) for osteoarthritis (14 studies) or focal chondral defects (14 studies) were reviewed. The studies evaluated included 3 RCTs, 10 prospective and 5 retrospective cohort studies, and 8 prospective and 2 retrospective case series. The most common sources of MSCs were bone marrow and adipose tissue. The overall quality of the literature surrounding this topic was poor, there was substantial heterogeneity, and the studies lacked reproducibility. Regardless, all studies demonstrated that at least 1 clinical outcome measure improved from baseline, that no major adverse events were experienced related to MSC injection, and that ultimately, intra-articular MSC injection is safe.
Nemeth B, van Adrichem R, Nelissen R, le Cessie S, Cannegieter SC. Individualized thromboprophylaxis in patients with lower-leg cast immobilization – a validation and subgroup analysis in the POT-CAST trial. Thromb Haemost. 2019 Sep;119(9):1508-16. Epub 2019 Jul 28.
In the original POT-CAST (Prevention of Thrombosis following lower leg CAST immobilization) trial, the risk of VTE was 1.6% within 3 months of lower-leg cast immobilization, and prophylactic low-molecular-weight heparin was not effective for VTE prevention. In the current subgroup analysis, risk factors for VTE included a BMI of >30 kg/m2 (relative risk [RR], 3.8) and a family history of VTE (RR, 2.4). The incidence of VTE was 8.5% following cast immobilization for Achilles tendon rupture, 19.0% following surgery for Achilles tendon repair versus 5.5% following conservative treatment, 1.1% for immobilization for metatarsal fractures, and 1.2% for immobilization for ankle fractures. The VTE risk was higher for surgically treated injuries (absolute risk [AR], 3.5%) versus conservatively treated injuries (AR, 1.3%; OR, 2.7).
Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 7;364:k5120.
This systematic review and meta-analysis of 10 RCTs (944 patients) and 19 observational studies (14,918 patients) found no significant difference in rerupture rate following operative (2.3%) compared with nonoperative (3.9%) treatment of acute Achilles tendon rupture, and no significant difference in effect estimates between RCTs and observational studies. The authors recommended shared decision-making based on patient-specific factors. They emphasized the importance of employing accelerated functional rehabilitation with early range-of-motion exercises for patients undergoing nonoperative therapy for acute Achilles tendon rupture. If adherence to this protocol is of concern, then the risk of surgical complications should be weighed.
Porter M, Shadbolt B, Ye X, Stuart R. Ankle lateral ligament augmentation versus the modified Broström-Gould procedure: a 5-year randomized controlled trial. Am J Sports Med. 2019 Mar;47(3):659-66. Epub 2019 Jan 30.
This RCT compared outcomes of active patients with chronic lateral ligament instability who underwent the modified Broström-Gould procedure (n = 21) or a primary repair with a ligament augmentation reconstruction system (LARS; n = 20). The primary repair/LARS group had better FAOS and Tegner activity scores compared with the modified Broström-Gould group at 5 years of follow-up.
Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture button versus syndesmotic screw for syndesmosis injuries: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019 Sep;47(11):2764-71. Epub 2018 Nov 26.
Five RCTs comparing dynamic stabilization of the syndesmosis with suture-button fixation (total n = 143) or static syndesmotic screw fixation (total n = 142) were evaluated. Patients who underwent suture-button fixation had higher postoperative AOFAS Ankle-Hindfoot scores at a mean of 20.8 months (95.3 versus 86.7; p < 0.001) and a lower rate of broken implants (0% versus 25.4%; p < 0.001), implant removal (6% versus 22.4%; p = 0.01), and joint malreduction (0.8% versus 11.5%; p = 0.05). The quality of the trials included was considered moderate for 3 RCTs, high for 1 RCT, and low for 1 RCT. Heterogeneity among studies was high. The authors gave suture-button stabilization of the syndesmosis a grade-A recommendation; however, the highest-quality RCT included in this meta-analysis had only 1 year of follow-up with 70 patients.
Stiegelmar C, Li Y, Beaupre LA, Pedersen ME, Dillane D, Funabashi M. Perioperative pain management and chronic postsurgical pain after elective foot and ankle surgery: a scoping review. Can J Anaesth. 2019 Aug;66(8):953-65. Epub 2019 Apr 24.
The authors evaluated 7 RCTs on postoperative pain-management strategies for elective midfoot, hindfoot, and ankle surgery that met strict inclusion criteria for the scoping review. Regional anesthesia was the focus of all studies assessed, with substantial methodological variation among the studies regarding continuous versus single-shot blocks, use of ultrasound versus nerve stimulation, and the nerve targeted, i.e., popliteal sciatic, femoral, or saphenous. The ability to assess the primary outcome of chronic postoperative pain was limited, as only 1 study examined outcomes beyond 48 hours. That study noted decreased pain with activity at 6 months of follow-up after using both a femoral and popliteal catheter for pain control postoperatively. Ultimately, no conclusions could be made because of the lack of evidence on this topic.
Vannabouathong C, Del Fabbro G, Sales B, Smith C, Li CS, Yardley D, Bhandari M, Petrisor BA. Intra-articular injections in the treatment of symptoms from ankle arthritis: a systematic review. Foot Ankle Int. 2018 Oct;39(10):1141-50. Epub 2018 Jun 18.
This systematic review of 27 studies (7 RCTs, 1 prospective cohort study, 19 case series) evaluated the efficacy of intra-articular injections (19 hyaluronic acid, 4 corticosteroid, 3 PRP, and 1 MSC) for ankle arthritis. Intra-articular injection for ankle arthritis, particularly of hyaluronic acid, may be effective in improving clinical outcomes. However, direct comparisons of treatments were lacking, and most evidence was of low quality because of small sample sizes, short follow-up periods, and heterogeneity in patient populations. Large-scale controlled trials directly comparing different interventions and evaluating the long-term efficacy and safety of these modalities are needed.
Whittaker GA, Munteanu SE, Menz HB, Bonanno DR, Gerrard JM, Landorf KB. Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019 Aug 17;20(1):378.
Forty-seven RCTs assessing corticosteroid injection compared with placebo or active treatment for plantar fasciitis (total n = 2,989) were evaluated. Substantial heterogeneity among the trials was noted, with several methodological limitations, including small sample sizes, a lack of participant and investigator blinding, and a lack of a priori sample-size calculations. Only 1 trial was at low risk of bias; 41 were at high risk. The limited conclusions based on low-quality evidence were that corticosteroid injection is more effective than autologous blood injection and foot orthoses for pain reduction and functional improvement in the short-term, but these therapies are equivalent in the medium term (7 to 12 weeks) and longer term (13 to 52 weeks). The authors noted that placebo injection is similar to corticosteroid injection for pain and function.
Whittaker GA, Munteanu SE, Menz HB, Gerrard JM, Elzarka A, Landorf KB. Effectiveness of foot orthoses versus corticosteroid injection for plantar heel pain: the SOOTHE randomized clinical trial. J Orthop Sports Phys Ther. 2019 Jul;49(7):491-500. Epub 2019 May 26.
In this assessor-blinded RCT, participants received either corticosteroid injection (n = 50) or prefabricated foot orthoses (n = 53) for plantar fasciitis. The corticosteroid group experienced a significant reduction in pain based on the Foot Health Status Questionnaire foot pain subscale at week 4 compared with the foot orthosis group. At week 12, results favored the orthosis. The difference, although significant, did not meet the previously calculated minimal clinically important difference.
Wu Y, Mu Y, Yin L, Wang Z, Liu W, Wan H. Complications in the management of acute Achilles tendon rupture: a systematic review and network meta-analysis of 2060 patients. Am J Sports Med. 2019 Jul;47(9):2251-60. Epub 2019 Feb 19.
This systematic review and Bayesian network meta-analysis of 29 RCTs compared 6 combinations of treatment for Achilles tendon rupture: open, minimally invasive, or nonoperative therapy, with either accelerated rehabilitation and weight-bearing within 2 weeks of injury or early immobilization. Nonoperative therapy with early immobilization had a significantly higher risk of overall complications and rerupture compared with the other 5 treatment protocols. Minimally invasive surgery with an accelerated rehabilitation protocol was superior for major complication risks. However, the lowest complication rate and risk of rerupture observed with this protocol did not differ significantly from the other protocols. Three RCTs included in the analysis had only 3 to 6 months of follow-up, which may be too short to detect major complications such as rerupture.
Note: The authors thank Dagmar Gross for assistance with the literature search and preparation of this manuscript.
References
1. Glazebrook M, Blundell CM, O’Dowd D, Singh D, de Vries G, Le ILD, Nielsen D, Pedersen ME, Sakellariou A, Solan M, Wansbrough G, Younger ASE, Baumhauer JF, Daniels TR. Midterm outcomes of a synthetic cartilage implant for the first metatarsophalangeal joint in advanced hallux rigidus. Foot Ankle Int. 2019 Apr;40(4):374-83. Epub 2018 Dec 3.