This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2007 and July 2008. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot and Ankle International, and the proceedings of Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on March 8, 2008, in San Francisco, California, and the summer meeting of the American Orthopaedic Foot and Ankle Society (AOFAS), held on June 25 through 28, 2008, in Denver, Colorado.
There are several upcoming courses and events relevant to foot and ankle surgery sponsored or cosponsored by the AAOS, AOFAS, and Arthroscopy Association of North America (AANA).From the Playground to the Stadium: A Comprehensive Update on Sports Injuries of the Foot and Ankle; May 28 through 30, 2009; Durham, North Carolina.The AOFAS Twenty-fifth Annual Summer Meeting (AOFAS Fortieth Anniversary); July 15 through 18, 2009; Vancouver, British Columbia, Canada.AAOS Hot Topics in Ankle and Hindfoot Surgery (Course #3320); September 10 through 12, 2009; Rosemont, Illinois.AOFAS/AANA Masters Experience: Foot and Ankle Arthroscopy; September 26 and 27, 2009; Rosemont, Illinois.AAOS Top 15 Foot and Ankle Problems (Course #3328); December 4 through 6, 2009; Houston, Texas.
From the Playground to the Stadium: A Comprehensive Update on Sports Injuries of the Foot and Ankle; May 28 through 30, 2009; Durham, North Carolina.
The AOFAS Twenty-fifth Annual Summer Meeting (AOFAS Fortieth Anniversary); July 15 through 18, 2009; Vancouver, British Columbia, Canada.
AAOS Hot Topics in Ankle and Hindfoot Surgery (Course #3320); September 10 through 12, 2009; Rosemont, Illinois.
AOFAS/AANA Masters Experience: Foot and Ankle Arthroscopy; September 26 and 27, 2009; Rosemont, Illinois.
AAOS Top 15 Foot and Ankle Problems (Course #3328); December 4 through 6, 2009; Houston, Texas.
van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121:324-31.e6.
Acute lateral ankle sprains are one of the most common musculoskeletal injuries, yet their clinical course following conservative treatment remains poorly described and therefore not well understood. This systematic review of the literature sought to shed light on the course of recovery after an acute lateral ankle injury and to evaluate potential factors for nonrecovery and repeat sprains. Thirty-one studies met the methodologic quality criteria for inclusion in the review, of which twenty-four were considered to be of high quality. The review showed a rapid decrease in pain in the first two weeks following an acute lateral ankle injury. Improvement continued at a slower pace following the initial two weeks; however, 5% to 33% of patients still continued to experience pain after one year. At three years of follow-up, residual symptoms remained for some patients, and the factors influencing those persistent complaints remain unknown. A wide variation was noted in the reported symptoms of subjective instability, repeat sprains, and subjective recovery. Although substantial research has been dedicated to understanding this injury, there remains a need for studies of high methodologic quality to investigate the prognostic factors and variables that contribute to incomplete recovery of acute lateral ankle sprains.
van Rijn RM, van Os AG, Kleinrensink GJ, Bernsen RM, Verhaar JA, Koes BW, Bierma-Zeinstra SM. Supervised exercises for adults with acute lateral ankle sprain: a randomised controlled trial. Br J Gen Pract. 2007;57:793-800.
In this randomized controlled trial, conventional treatment alone was compared with conventional treatment combined with a progressive training program supervised by a physiotherapist for the management of acute lateral ankle sprains. The group that received conventional treatment alone received information about early ankle motion and advice on home exercises and early weight-bearing. The group that received conventional treatment along with supervised physical therapy had a mean of 6.1 treatment sessions, within a period of three months, emphasizing balance exercises, walking, running, and jumping. After three months and one year of follow-up, no significant difference was found between the two groups in terms of subjective recovery or the occurrence of repeat sprains. This study does not support supplementing conventional treatment with a supervised physical therapy program for the treatment of acute lateral ankle sprains.
Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35:2033-8.
Previous studies on acute Achilles tendon ruptures have demonstrated increased strength and lower rerupture rates when surgery combined with controlled early motion has been compared with no surgery and prolonged cast immobilization. The authors of this prospective randomized study extrapolated on research demonstrating the benefits of motion on tendon-healing in order to investigate the influence of controlled early motion on nonoperatively treated Achilles tendon ruptures. Patients in both the operative and nonoperative treatment groups abided by the same rehabilitation protocol, which included ten days of treatment with an equinus cast followed by the use of a below-the-knee orthosis. After removal of the cast, patients were allowed to perform active ankle dorsiflexion and passive plantar flexion. The orthosis was placed in a neutral position by four weeks, weight-bearing was progressed by six weeks, and toe-raises were encouraged at eight weeks. No significant difference was found between the two groups in terms of range of motion, calf circumference, or outcomes scores measured at two, eight, twelve, twenty-six, or fifty-two weeks. No complications occurred in the operative treatment group, and both groups had similarly low rerupture rates. These results suggest that controlled early motion may be the most important part of the treatment of an acutely ruptured Achilles tendon instead of operative repair; however, larger studies with longer follow-up must be performed to corroborate these findings.
Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop. 2008;79:249-56.
The effect of low-energy extracorporeal shock-wave therapy (ESWT) as a supplement to conservative treatment of chronic Achilles tedinopathy was investigated in this double-blind, randomized clinical trial. Patients received either extracorporeal shock-wave therapy or placebo therapy in which the same machine device was used to deliver a sham dose as a supplement to conservative treatment (stretching and eccentric training). Both groups demonstrated improvement in terms of the mean AOFAS score, but the intervention group demonstrated significantly greater improvement over time than the control group did. Visual analog pain scale scores improved for both groups; however, no difference in improvement was detected between the treatment groups. Extracorporeal shock-wave therapy appears to improve outcomes when used as a supplement to stretching and eccentric training in the treatment of chronic Achilles tendinopathy.
Kane TP, Ismail M, Calder JD. Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med. 2008;36:1160-3.
Topical glyceryl trinitrate has been used with some success for the treatment of chronic extensor and supraspinatus tendinopathies. Glyceryl trinitrate also has been extended to the treatment of noninsertional Achilles tendinopathy, despite limited supporting evidence. This randomized, single-blinded study compared the outcomes of treatment with glyceryl trinitrate and physical therapy with those of treatment with physical therapy alone in patients with noninsertional Achilles tendinopathy. Although improvement was noted in both groups, glyceryl trinitrate did not offer any additional clinical benefit over standard nonoperative treatment. Three patients in the physiotherapy group and four patients in the glyceryl trinitrate plus physiotherapy group had a failure of conservative treatment and underwent surgical débridement of the Achilles tendon. Histologic examination of the diseased tendon following surgery did not demonstrate any detectable neovascularization, fibroblast activity, or collagen synthesis in either group. These results do not support the continued use of glyceryl trinitrate patches for the treatment of noninsertional Achilles tendinopathy.
Leese G, Schofield C, McMurray B, Libby G, Golden J, MacAlpine R, Cunningham S, Morris A, Flett M, Griffiths G. Scottish foot ulcer risk score predicts foot ulcer healing in a regional specialist foot clinic. Diabetes Care. 2007;30:2064-9.
The authors of this study used the Scottish Care Information-Diabetes Collaboration (SCI-DC) ulcer risk score in a retrospective fashion to determine if the risk score predicted ulcer development and could predict ulcer healing. Overall, 221 ulcers were included in the analysis. Sixty-eight percent of the patients were previously categorized as being at high risk for ulcer formation, and 98% were categorized as being at high or moderate risk. The healing rate was significantly lower in high-risk patients as compared with the low and moderate-risk patients (68% compared with 93%). Factors associated with poor healing were absent pulses, neuropathy, increased patient age, and the presence of deep rather than superficial ulcers. The results of this study suggest that the SCI-DC risk score can be useful for the prediction of ulcer development and healing rates.