Extract
The amount of new information in all subspecialties
of orthopaedic surgery continues to increase at an exponential rate.
It is no longer possible for one textbook to contain all of the
information necessary to practice state-of-the-art orthopaedic surgery.
To keep abreast of this tide of information, most major textbooks
are being revised more frequently. Similarly, a single specialty
journal can no longer be expected to cover all of the important
advances in all of the subspecialties.
The amount of new information in all subspecialties
of orthopaedic surgery continues to increase at an exponential rate.
It is no longer possible for one textbook to contain all of the
information necessary to practice state-of-the-art orthopaedic surgery.
To keep abreast of this tide of information, most major textbooks
are being revised more frequently. Similarly, a single specialty
journal can no longer be expected to cover all of the important
advances in all of the subspecialties.
Like other subspecialties, the field of foot and ankle surgery
is perpetually evolving. Many procedures that were considered on
the cutting edge ten years ago have become either routine or obsolete.
The purpose of this report is to review the information and ideas
presented at recent meetings of the American Orthopaedic Foot and
Ankle Society (AOFAS), the American Academy of Orthopaedic Surgeons
(AAOS), and other specialty and subspecialty associations. Pertinent
points from recent articles in Foot and Ankle International will
also be highlighted in an effort to provide an overview of new concepts
and major advances in foot and ankle surgery.
It would be difficult to identify an area of foot and ankle surgery
that has received as much intense study recently as has the pathophysiology
and treatment of posterior tibial tendon deficiency (PTTD). Clearly,
this is a condition that causes considerable morbidity. The associated
structural changes in the foot include valgus alignment of the hindfoot,
loss of the medial longitudinal arch, and abduction of the forefoot.
The resultant inability to invert the subtalar joint lessens the
rigidity of the foot during the final stages of gait. The plantar
flexion force applied by the gastrocnemius muscle is not transferred
appropriately to the forefoot and is dissipated through the midfoot.
A lateral shift then occurs in the contact forces in the ankle and
the subtalar joint, potentially accelerating degenerative changes within
these joints and often leading to a stiff planovalgus deformity.
Many techniques have recently been introduced for the treatment
of posterior tibial tendon deficiency. Most of these are intended
for the treatment of the foot that does not have stiffness or irreversible degenerative
changes within the joints of the hindfoot. Often these techniques
incorporate an osteotomy or arthrodesis to realign the
hindfoot and a tendon transfer to reestablish the function of the posterior
tibial tendon. Good results have been reported in association with calcaneocuboid
distraction arthrodesis, anterior calcaneal lengthening, medial
sliding wedge osteotomy of the calcaneal tuberosity, and opening-wedge
osteotomy of the calcaneal tuberosity. The performance of a medial sliding-wedge
osteotomy of the calcaneal tuberosity in conjunction with a flexor
digitorum longus transfer was associated with good pain relief in more
than 90% of patients at an average of forty months1. However, less than half of the patients
noted improvement in the arch of the foot. These results have prompted
an even more aggressive approach that combines this procedure with
anterior calcaneal lengthening. Good results have been observed in
a limited number of patients, but, as anticipated, a substantial
increase in surgical morbidity has also been seen2.
The traditional donor tendon used for transfer to the posterior
tibial tendon has been the flexor digitorum longus or the
flexor hallucis longus. The early experience with alternative
donor tendons, such as the peroneus brevis, has been encouraging3. This is particularly interesting
since the peroneus brevis is an antagonist to the posterior tibialis
muscle. It has been suggested that the presence of peroneal-muscle
action is necessary to produce the acquired flatfoot deformity seen
in posterior tibial tendon deficiency4.
This transfer both strengthens the support of the medial longitudinal
arch and weakens the deforming force. However, although it has not
yet been reported to be a clinical problem, the potential danger
of overstrengthening the posterior tibialis in relation to the peroneal
force should be considered.
Nonoperative methods are the mainstay of treatment of plantar
fasciitis. Custom orthoses are commonly prescribed as the initial
treatment. However, these devices are expensive and are no more
effective than off-the-shelf silicone, rubber, or felt heel cushions.
When first-line efforts such as stretching, heel cushions, and anti-inflammatory
medications fail, splinting the foot in a neutral position at night has
been shown to be effective. Shoe modifications, such as insertion
of a stiffener in combination with an anterior rocker bottom, also
often provide relief. Treatment involving the injection of corticosteroids into
the heel should be approached with caution. In addition to the possibility
of atrophy of the heel cushion after corticosteroid injection,
there is a considerable risk of plantar fascial rupture, which is often
chronically painful. Extracorporeal shock-wave therapy has shown
promise in the treatment of resistant plantar fasciitis, although
the duration of follow-up has been short. In one study, six of seven patients
who had received such therapy reported more than a 60% reduction
of pain, whereas four control patients showed minimal symptomatic improvement
after twelve months of follow-up5.
Surgical treatment of plantar fasciitis by either open or endoscopic
means has, in general, been reported to be highly successful, but
it should only be performed after prolonged nonoperative treatment. The
plantar fascia is important in the control of the hindfoot during
gait. Weakening of the plantar fascia by release has important biomechanical
consequences that may result in long-term problems. In vitro analyses
of cadaveric specimens after both complete and partial
plantar fasciotomy have shown redistribution of stress in the plantar
aspect of the forefoot, the metatarsal shafts, and the long plantar and
spring ligaments as well as reduction in the height of the medial
longitudinal arch. These effects may be responsible for various
clinical complaints, including lateral hindfoot and forefoot pain, sometimes
seen after plantar fasciotomy, and for the patient dissatisfaction
that has been noted after long-term follow-up.
Most techniques designed to improve the stability of the lateral
side of the ankle involve anatomic reconstruction of the anterior
talofibular ligament or the calcaneofibular ligament. However, a
clinical comparison of the results of anatomic repair of the lateral
ligaments with those of an Evans tenodesis showed no significant
difference in outcome6. When the
damaged ligament is insufficiently strong for an acceptable repair,
reinforcement is occasionally necessary. Commonly, a portion of
the peroneus brevis tendon is used for this purpose; however, this
procedure weakens a tendon that is an important dynamic lateral
ankle stabilizer. Investigation of the use of other autogenous
grafts, such as the palmaris longus, semitendinosis, and fascia
lata, has met with some early success.
Thermal capsular shrinkage, a technique already used for the
treatment of shoulder instability, has been studied as a treatment
for functional lateral ligament instability. In theory, thermal
coagulation of collagen within the fibrous tissue shortens the ligament,
thereby improving stability. The short-term results of one recent
study were good, but they should be interpreted cautiously as the
degree of preoperative instability was not defined and the amount
of residual lateral ankle laxity was not measured7.
Because of the chronic nature and abnormal mechanics of the unstable
ankle, associated injuries are often seen. Arthroscopic examination
of the ankle has revealed a high prevalence of chondromalacia, synovitis,
and osteochondral lesions of the talus in patients with lateral
ligament instability. This may explain the persistent ankle pain
reported by some patients after reconstruction. However, routine
arthroscopy concurrent with lateral ligament reconstruction for
the treatment of these associated injuries has not yet been shown
to improve the results of lateral ligament stabilization alone. Hindfoot
varus is also more commonly seen in patients with lateral ankle
instability. This deformity may predispose the ankle to failure
after soft-tissue reconstruction, and consideration should be given
to a corrective calcaneal osteotomy if the varus is severe, as in
a cavovarus foot.
Diabetes mellitus is undoubtedly the predominant cause of morbidity
of the foot and ankle and is the leading cause of amputation of
the lower extremity. It affects sixteen million people in the United
States today, and this number will increase to twenty-one million
by the year 2025. The average cost of treating a diabetic foot ulcer
exceeds $5000. The results of sensory screenings, sponsored
by the American Orthopaedic Foot and Ankle Society throughout the country,
showed that nearly a third of the diabetic participants had sensory
loss after having the disease for eight years or longer, which put
them at risk for ulceration8.
The use of appropriate shoewear by high-risk patients can lessen
the risk of development of neuropathic ulcers. The AOFAS screening
also demonstrated that both physicians and patients are widely unaware
that financial assistance for the purchase of therapeutic shoes
and inserts is available to patients with diabetes through the Medicare
Therapeutic Shoe Bill. To enhance awareness of these issues, the
AOFAS launched Diabetes 2000, a public-education program with the
goal of preventing diabetic foot problems. This campaign included free
community diabetic foot screenings, a presentation on relevant national
policies and research issues at the Society’s Annual Winter
Meeting, a diabetic foot survey, and the initiation of a multicenter
research study on one of the major complications associated with
the diabetic foot, Charcot fracture.
The tenets of treatment of neuropathic ulcers resulting from
diabetes include reduction of weight-bearing over the ulcer, establishment
of adequate local blood flow, and débridement of necrotic
and infected tissue. Modulation of other systemic factors through
control of the diabetes, cessation of smoking, and avoidance of
vasoconstrictors such as caffeine is also necessary. Becaplermin
gel, a topical medication containing recombinant human platelet-derived
growth factor, has recently been introduced as an adjuvant treatment
for neuropathic ulcers. This is one of the first widespread uses
of recombinant growth factors for the modulation of tissue-healing.
Initial studies have shown significant improvement in both the percentage
of ulcers healed and the time to healing.
Total-contact casting and the use of wedge weight-relief shoes
are nonoperative measures that are often used to reduce local pressure
over an ulcer. Surgical treatment is also sometimes necessary. Metatarsal
head resection and other forms of ostectomy can reduce
pressure points on osseous prominences. In addition, dorsiflexion
metatarsal osteotomy can be considered. In a recent review, this
procedure was associated with a rate of success of 95% in
the treatment of neuropathic ulcers9.
However, Charcot arthropathy developed after 32% of the
procedures and deep wound infection, after 14%. In general,
the use of corrective osteotomies and arthrodeses should be approached
with caution in patients with diabetic neuropathy, since a high
prevalence of complications can be expected.
Potential complications of the treatment of ankle fractures in
diabetic patients include the compromise of peripheral nerve and
vascular function and immunodeficiency. The rates of infection and
loss of fixation following the treatment of unstable ankle fractures
in diabetic patients are substantially higher than those in nondiabetic
patients10. While the indications
for operative fixation in diabetic patients are still unclear, it
is clear that these patients require longer courses of treatment
and more aggressive immobilization than do nondiabetic patients.
Intense interest in the development of a durable total ankle
arthroplasty that provides results comparable with those of knee
and hip arthroplasty is reflected in the wealth of articles, presentations, and
discussions in the recent literature. Nearly all of the data are
on ankle prostheses that have been recently introduced to the American
market, and therefore the durations of follow-up have been relatively
short. The learning curve associated with this procedure
is steep. Saltzman et al.11 presented
the results of total ankle arthroplasty in the initial ten patients
treated by three surgeons. Intraoperative complications included
malleolar fractures and lacerations of the long flexor and posterior
tibial tendons. Postoperative complications included wound dehiscence,
deep infection, nonunion of the syndesmosis, and arthrofibrosis.
At thirty-nine months, two patients required an arthrodesis, and
one of the two eventually had an amputation. In spite of these complications,
the patients who retained the implant reported a high rate of increased
function and pain relief. Similarly, use of the Agility total ankle
prosthesis (DePuy Orthopaedics, Warsaw, Indiana) has provided a
high rate of pain relief but also has been associated
with frequent complications. In one series, four of twenty-five
patients reported that they would not elect to undergo
the procedure again12.
One of the most troublesome hurdles in the development of a durable
and predictable total ankle implant is loosening. Newly
implemented changes in the design of the prostheses on the market
have the potential to reduce loosening and osteolysis. A trend away
from cemented implants has been seen recently. The Scandinavian
Total Ankle Replacement (STAR) is a cementless implant that is used
in Europe. It has a mobile congruent high-density polyethylene insert
that is reported to reduce wear. Limited series have shown a high
rate of clinical and radiographic osseointegration at short-term
follow-up13.
However, in light of the problems encountered with previous
designs, it must be assumed that many patients will survive longer
than the life of the ankle prosthesis despite the design improvements. Salvage
of these extremities is challenging because the bone stock is often
insufficient for revision ankle replacement and arthrodesis may
result in substantial shortening of the extremity. Often, because
of osteolysis and bone erosion, the subtalar joint must be included
in order to obtain stable fixation at the site of the resulting
arthrodesis. Therefore, until reliable long-term results are available, ankle
replacement must still be considered experimental.
Ankle arthrodesis is currently the gold standard for the treatment
of end-stage ankle arthrosis. After ankle arthrodesis, nearly half
of the sagittal motion of the hindfoot may remain because of the
contribution of the Chopart joint. Short-term and intermediate-term
results have shown a high rate of patient satisfaction and pain
relief. Complications, however, are also frequent, with a substantial
prevalence of infection and nonunion seen in association with all
methods. Most worrisome is that long-term follow-up has revealed
significant and symptomatic arthrosis of the subtalar, midtarsal,
tarsometatarsal, and first metatarsophalangeal joints14.
Arthroscopic arthrodesis, both of the ankle and the subtalar
joint, has shown promising results, with high rates of union and
reductions in hospital stay, when overall alignment of the ankle
is near normal. However, few well-controlled studies comparing open
arthrodesis with arthroscopic arthrodesis are available. These techniques
are relatively difficult technically, and a substantial learning
curve can be expected.
The association between cigarette smoking and nonunion at the
site of hindfoot arthrodesis has been found to be quite strong.
In one study, the rate of nonunion in smokers was more than twice
the rate in nonsmokers. Patients who had recently quit smoking had
an intermediate risk of nonunion. This study provided excellent
evidence that patients should be encouraged to quit smoking prior
to hindfoot fusion. With the data available, no link was found between
smoking and infection or wound dehiscence15.
A recent retrospective evaluation of 635 displaced intra-articular
fractures of the calcaneus that had been treated through a lateral
exposure demonstrated that the severity of fracture comminution and
the adequacy of articular reconstruction were prognostically important16. In patients with highly comminuted
fractures, the results of primary arthrodesis of the subtalar joint were
significantly better than those of reduction and internal fixation.
Nonunion after primary arthrodesis was rare. The postoperative complication rate
was 8%, with twenty-nine cases of wound dehiscence and
twelve cases of osteomyelitis. Open calcaneal fractures were associated
with considerably higher morbidity. Internal fixation in the presence
of severe damage of the soft-tissue envelope is not recommended.
Syndesmotic injuries are often treated with screw fixation between
the tibia and the fibula, without compression. Traditionally, great
care has been taken to place the ankle in a neutral or dorsiflexed position
during this fixation to ensure that the syndesmosis is not overcompressed.
Compression previously was thought to potentially limit ankle motion, especially
dorsiflexion. However, cadaveric experiments in which the syndesmosis
was fixed when the ankle was in maximum plantar flexion have not
shown subsequent restriction of ankle motion17.
This finding suggests that the position of the ankle during syndesmotic
fixation does not limit ankle motion postoperatively.
Arthroscopic management of osteochondral lesions of the talus
is well accepted. Drilling, microfracture, débridement,
and abrasion have led to satisfactory results in patients with small
lesions. Two newer techniques—retrograde drilling and osteochondral
transplantation—have the potential to improve the results
of treatment of these difficult problems. Retrograde drilling of
osteochondral lesions of the medial part of the talus through the sinus
tarsi with use of an arthroscopic drill-guide allows preservation
of any intact cartilage, in contrast to traditional methods. Bone
graft is then impacted through the drill-hole to facilitate healing. The
short-term results of this procedure have been encouraging18. Osteochondral transplantation,
a relatively established technique for the treatment of full-thickness cartilaginous
defects of the femoral condyles, is being investigated for the treatment
of large osteochondral lesions in the talus19.
The donor osteochondral plugs are harvested from the lateral condyle
of the knee and are inserted arthroscopically or through
a medial malleolar osteotomy. The short-term results have been encouraging,
with relief of ankle pain and improvement in function, and second-look
arthroscopic evaluation has shown incorporation of the grafts.
Bioabsorbable pins and, more recently, screws have been introduced
for the surgical treatment of ankle fractures. Products made from
polyglycolic acid have been associated with complications such as sterile
drainage and osteolysis. Newer products made from polylactic acid
(PLA) have been associated with fewer problems. Bioabsorbable implants are
less stiff than metallic screws, but good results have been reported
when these implants have been used for the treatment of malleolar
fractures, syndesmotic disruptions, and Lisfranc fractures.
The increased initial cost of these implants is considerable but
must be compared with the total costs of metal implants, including
the cost of hardware removal.
Careful measurements on the radiographs of normal feet and feet
with hallux valgus have shown that, in hallux valgus, the distance
between the second metatarsal head and the base of the proximal phalanx
of the hallux remains constant but the center of the metatarsal
head of the hallux deviates medially relative to the second metatarsal20. This suggests that the adduction
of the first metatarsal is the primary event in the development
of hallux valgus. Abduction of the proximal phalanx of the hallux
may occur secondarily.
The Scarf osteotomy, a z-osteotomy encompassing nearly the entire
length of the first metatarsal, has received attention recently.
This osteotomy is designed to preserve the inferior vascular supply
to the metatarsal head while allowing greater displacement than
is possible with the distal chevron osteotomy. By tilting the osteotomy
inferiorly, plantar displacement of the metatarsal head can be achieved.
Fixation of the osteotomy site with two screws provides more rigid
stabilization than is possible with other proximal osteotomies.
This procedure may be a useful option in the treatment of more severe
deformities.
The treatment of hallux valgus in the presence of an increased
distal metatarsal articular angle continues to be discussed, although
it should be stressed that this problem is uncommon. The biplanar
osteotomy, a simple modification of the distal chevron osteotomy,
can effectively redirect the articular surface. Other methods include
combination osteotomies of two or more sites along the medial column of
the foot, such as the medial cuneiform, proximal metatarsal, distal
metatarsal, or proximal phalanx. These are also effective, but a
greater morbidity should be anticipated and these procedures are probably
rarely indicated.
One recent study was performed to investigate whether the nerves
of patients with Morton neuroma are structurally abnormal21. Histologically, surgical specimens
from patients with a diagnosis of Morton neuroma were not distinguishable
from cadaveric (normal) specimens. The surgical specimens tended
to be slightly larger in diameter than the cadaveric specimens,
but there was substantial overlap between the groups. A prospective
trial on the treatment of interdigital neuroma showed comparable
results when resection of the interdigital nerve was compared with
incision and release of the transverse metatarsal ligament. A higher
prevalence of postoperative pain was found in the group
of patients who had resection of the interdigital nerve22.
A multitude of operations have been used for the treatment of
intractable metatarsalgia. The advantages of the Weil osteotomy,
a horizontal shortening osteotomy of the metatarsal neck that is
stabilized with screw fixation, are that it does not elevate the metatarsal
head excessively, it is easy to control, and stable fixation is
possible. Clinical trials of this procedure have shown promising
results with regard to the control of pain, the elimination of calluses,
and the reduction of metatarsophalangeal subluxation and dislocation.
However, extension contractures have been noted to occur.
A review of the long-term results of treatment of fixed hammertoe
deformity with a proximal interphalangeal arthrodesis
demonstrated fusion of the joint in 81% of the toes and
a high rate of pain relief 23.
Dissatisfaction with the procedure was most frequently related to
postoperative numbness and malalignment of the toes.
Tarsal coalition is a common cause of rigid flatfoot and often
becomes symptomatic near the time of adolescence when restrained
intertarsal articulations develop. It is an inherited autosomal
dominant disorder that sometimes remains asymptomatic throughout
life. When symptomatic talocalcaneal coalition in the
skeletally immature foot is resistant to nonoperative treatment,
it may be successfully treated with surgical excision of the osteochondral bar.
Most patients report an improvement of symptoms postoperatively,
but the time to maximal improvement may be as long as eighteen months. Contraindications
to excision of the bar include severe planovalgus
deformity and extensive involvement of the subtalar joint.
In these instances, subtalar arthrodesis in a neutral position is
recommended. In children, calcaneonavicular coalitions also
respond well to excision.
Symptomatic tarsal coalition in adults has not been studied as
closely and is probably less common, but data from a recent study
shed light on the treatment of this entity24. Because of the maturity of the
synostosis and the poor development of the remainder of the subtalar joint,
most of the patients with a talocalcaneal coalition underwent hindfoot
realignment through arthrodesis of the subtalar joint. The majority
of these patients had excellent control of their symptoms. Resection
of the calcaneonavicular coalition with interposition of the extensor
digitorum brevis can successfully restore subtalar motion and reduce pain
even in adult patients.
Flexible flatfoot is extremely common in children, and surgical
treatment has been advocated for the prevention of an assortment
of problems of the knee, foot, and back that often have been attributed to
pes planovalgus. The Viladot implant is a silicone prosthesis that
is inserted into the sinus tarsi with concomitant imbrication of
the posterior tibial tendon to control eversion of the subtalar
joint. While Viladot reported encouraging results in his original
series25, with 100% clinical
improvement, more recent data do not support this finding. In a
study of twenty-two patients who had an asymptomatic flexible
flatfoot treated with a combination of posterior tibial tendon imbrication
and insertion of the Viladot implant, 73% of the feet were
chronically painful and only 14% were reported to be improved radiographically26. Implant removal was necessary in
14% of the feet. The use of this and similar implants to
control flexible pediatric planovalgus deformity should be discouraged
at the present time.
The American Orthopaedic Foot and Ankle Society promotes the
presentation of new research through biannual meetings. The summer
meeting will be held in San Diego, California, on July 19 through 21,
2001. In addition, Regional Review Courses will be held in a number
of cities across the country throughout the year. They will offer
an overview of the treatment of diseases of the foot and ankle. More
information may be obtained from the American Orthopaedic Foot and
Ankle Society at www.aofas.org or by calling 1-800-235-4855.
The American Academy of Orthopaedic Surgeons and the AOFAS will
jointly sponsor a course entitled "Comprehensive Foot
and Ankle: Current Concepts and Practical Solutions" on
November 8 through 11, 2001, on Marco Island, Florida. More information
on this course may be obtained from the AAOS at www.aaos.org or
by calling 1-800-626-6726.
Guyton GP, Mann RA. Flexor
digitorum longus transfer and medial displacement calcaneal osteotomy
for posterior tibial tendon dysfunction: a middle-term
clinical follow-up. Read at the Annual Summer Meeting of the American
Orthopaedic Foot and Ankle Society; 2000 July 13-15; Vail, CO.
Mosier-LaClair S, Pomeroy G, Manoli
A. Immediate follow-up on the durable osteotomy and tendon
transfer procedure for grade II posterior tibial tendon insufficiency.
Read at the Annual Summer Meeting of the American Orthopaedic
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Song S, Deland JT. The use
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Rosenbaum D; Engelhardt M; Becker HP; Claes L; and Gerngross H: Clinical and functional outcome after anatomic
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