The following is a brief overview of recent studies related to foot and
ankle surgery that were published or presented between July 2005 and July
2006. The sources of these studies included The Journal of Bone and Joint
Surgery (American Volume), Foot and Ankle International, and the
proceedings of the Winter and Summer meetings of the American Orthopaedic Foot
and Ankle Society (AOFAS) (held on March 25, 2006, in Chicago, Illinois, and
on July 14 through 16, 2006, in La Jolla, California).
Since the introduction of the newer generation of total ankle prostheses
for the treatment of ankle arthritis, surgeons have been evaluating their
intermediate-term results and refining their techniques. With a substantial
learning curve, experienced surgeons are better able to define clinical pearls
Horton et al. reviewed the records of eighty patients who underwent a
Scandinavian Total Ankle Replacement
implant survival rate was 78% at 8.3 years. Fifteen patients had to have a
second procedure, such as exchange of the polyethylene mobile bearing,
osteotomy, ligament reconstruction, or irrigation and débridement. In
addition, four patients had a categorical failure that required revision or
removal of the metallic prosthetic components. Two of these four patients had
a revision to fusion because of aseptic loosening. The fusions were performed
at an average of 2.8 years after implantation. The third patient underwent
revision to a different prosthesis because of chronic unresolved pain of
unclear etiology. The fourth patient had revision of the talar component
because of aseptic loosening.
Haddad et al. performed a meta-analysis and systematic review of total
ankle arthroplasty and ankle
noted that the mean AOFAS ankle-hindfoot score was 78.6 for patients managed
with total ankle arthroplasty and 76.3 for those managed with arthrodesis.
Overall, 30% of the patients who had been managed with total ankle
arthroplasty had an excellent result; 32%, a good result; 14%, a fair result;
and 24%, a poor result. In the arthrodesis group, the corresponding numbers
were 31%, 37%, 19%, and 13%, respectively. The five and ten-year survival
rates were 79% and 77%, respectively. The revision rate following total ankle
arthroplasty was 6%, with the primary reason for revision being loosening or
subluxation. The revision rate following ankle arthrodesis was 9%, with the
main reason for revision being nonunion. Below-the-knee amputation was
necessary in 1% of the patients who had been managed with total ankle
arthroplasty, compared with 5% of patients who had been managed with ankle
arthrodesis. On the basis of these findings, the authors concluded that total
ankle arthroplasty and ankle arthrodesis appear equivalent. Prospective direct
comparison studies are needed to strengthen this conclusion.
Doets et al. performed a prospective observational study of the results of
total ankle arthroplasty with two mobile-bearing
preoperative diagnosis in all of the patients was inflammatory arthritis. The
mean overall survival rate at eight years was 84%. A significantly increased
failure rate was encountered in ankles with a preoperative deformity in the
frontal plane and in ankles in which an undersized tibial component had been
implanted. The most common mode of failure requiring revision was aseptic
loosening, which occurred after fifteen of the ninety-three ankle
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 medical journals were
reviewed to identify these articles, which all have high-quality study design.
In addition to articles published previously in this journal or cited already
in this Update, five additional level-I articles were identified that were
relevant to foot and ankle surgery. A list of those titles is appended to this
review after the standard bibliography. We have provided a brief commentary
about each of the articles to help to guide your further reading, in an
evidence-based fashion, in this subspecialty area.
The Sports Injuries of the Foot and Ankle course will be held on May 3
through 5, 2007, in Oak Brook, Illinois. The AOFAS Twenty-third Annual Summer
Meeting will be held on July 12 through 15, 2007, in Toronto, Ontario, Canada.
The Arthroscopy Association of North America and AOFAS Foot and Ankle
Arthroscopy Course will be held September 8 and 9, 2007, in Rosemont,
Illinois. The AOFAS Complete Foot Care Course will be held September 13
through 15, 2007, in Las Vegas, Nevada. The AOFAS Complications in Foot and
Ankle Surgery course will be held October 26 and 27, 2007, in New Orleans,
Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH,
Donell ST. Randomised controlled trials of immediate weight-bearing
mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br.
This report describes two independent, randomized controlled trials that
assessed the potential benefit of immediate weight-bearing after rupture of
the Achilles tendon. One trial was performed after operative treatment of
Achilles tendon ruptures, and the other was performed after nonoperative
treatment. The results of the two trials demonstrated that patients who were
managed operatively had an improved functional outcome when made
weight-bearing immediately postoperatively in a functional brace, as opposed
to those who were kept non-weight-bearing in a cast. The patients who were
managed nonoperatively did not appear to gain any functional benefit from
early weight-bearing, but they also were noted not to experience a higher
complication rate. The importance of this study is that it is the first to
compare casting and non-weight-bearing with immediate loading of a ruptured
Achilles tendon protected by an off-the-shelf orthosis. This study also
provides excellent evidence that immediate weight-bearing is safe and
potentially beneficial for operatively managed patients. More experience with
this method of operative repair and immediate weight-bearing hopefully will
confirm this study result.
Tom WL, Peng DH, Allaei A, Hsu D, Hata TR. The effect of
short-contact topical tretinoin therapy for foot ulcers in patients with
diabetes. Arch Dermatol. 2005;141:1373-7.
This randomized, double-blind, placebo-controlled trial evaluated the
efficacy and safety of short-contact application of topical tretinoin for the
treatment of diabetic foot ulcers. The results demonstrated that tretinoin
therapy was well tolerated and that it improved the healing of ulcers in
patients with diabetes who did not have evidence of peripheral arterial
disease or infection. This appears to be a promising method of resolving
diabetic foot ulcers.
Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative
pressure wound therapy after partial diabetic foot amputation: a multicentre,
randomised controlled trial. Lancet. 2005;366:1704-10.
Patients with adequate perfusion and open wounds after partial foot
amputation at or distal to the transmetatarsal level were randomized to either
wet-to-dry dressing changes or wound vacuum-assisted closure therapy. The
wounds were treated until healing or for 112 days of active treatment. The
study demonstrated that negative pressure wound therapy does appear to improve
wound-healing rates in this setting; however, the overall healing rates in
this study were low (56% in the wound vacuum-assisted closure group, compared
with 39% in the wet-to-dry dressing group). This study reinforces the improved
wound-healing associated with vacuum-assisted closure that has been noted
previously on the basis of anecdotal experience.
Costa ML, Shepstone L, Donell ST, Thomas TL. Shock wave therapy for
chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin
Orthop Relat Res. 2005;440:199-204.
This randomized, double-blind, placebo-controlled trial demonstrated no
difference in pain relief between the shock wave therapy group and the control
group. Two patients in the treatment group sustained an Achilles tendon
rupture. These results provide no support for the use of shock wave therapy
for the treatment of chronic Achilles tendon pain. This study joins others in
demonstrating a lack of success in association with the use of shock wave
therapy for the treatment of chronic inflammatory problems of the foot and
ankle. A final definitive conclusion regarding the effectiveness of shock wave
therapy has yet to be reached.
Mologne TS, Lundeen JM, Clapper MF, O'Brien TJ. Early screw fixation
versus casting in the treatment of acute Jones fractures. Am J Sports
In this controlled trial, eighteen patients were randomized to cast
treatment and nineteen were randomized to screw fixation of an acute fracture
at the base of the fifth metatarsal. The time to union and the time to return
to sport in the screw fixation group were half of those in the casting group.
In addition, there was a 44% rate of failure of cast treatment. This study
provides strong evidence for the treatment of acute Jones fractures with
intramedullary screw fixation.