Orthopaedic podiatry triage: process outcomes of a skill mix initiative.

BACKGROUND: The Orthopaedic Podiatry Triage Clinic (OPodTC) is a 'skill mix' model of care developed in Queensland Health to address the problem of lengthy waiting times for orthopaedic surgery on foot and ankle pathologies. It is based on the recognition that many orthopaedic surgery referrals can be identified early and treated conservatively with podiatry, averting the need for more costly and invasive surgical interventions. The model is collaborative and relies on screening and triage by the podiatrist, rather than delegation by the orthopaedic surgeon. METHODS: Screening and triage through OPodTC was trialled at three Queensland Health hospital facilities during 2009 and 2010 to improve service timeliness. Patients identified by the OPodTC podiatrist as suitable for conservative management were provided with non-surgical podiatry interventions and discharged if appropriate. Those identified as still requiring surgical intervention after the benefit of interim conservative treatment provided by the podiatrist (or who chose to remain on the list) were returned to their previous place on the orthopaedic waiting list. This paper presents a summary and description of waiting list changes in association with this trial. RESULTS: The OPodTC intervention resulted in a reduction in the non-urgent category of the waiting list across the three hospitals of between 23.3% and 49.7%. Indications from wait-list service data demonstrated increased timeliness and improved patient flow, which are core goals of these skill mix initiatives. CONCLUSIONS: This study highlights the potential of screening and triage functions in the skill mix debate. In this example, conservative treatment options were considered first, suitable patients did not have to wait long periods to receive timely and appropriate interventions, and those for whom surgery was indicated, were provided with a more targeted service.

Ankle arthrodesis.

Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early 1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion, extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of infection, deformity, avascular necrosis, and nonunion.

Effect of foot and ankle position on tarsal tunnel compartment volume.

BACKGROUND: Tarsal tunnel pressure is increased when the foot and ankle are positioned in eversion or inversion from neutral, aggravating symptoms of tarsal tunnel syndrome in some patients. Space-occupying lesions may cause tarsal tunnel syndrome. We hypothesized that positional change of the foot and ankle from neutral to eversion or inversion causes decreased tarsal tunnel compartment volume that may aggravate symptoms of posterior tibial nerve entrapment. METHODS: MRI of 13 ankles in nine healthy subjects in three positions (neutral, eversion, inversion) were obtained with respect to the malleolar-calcaneal plane; this plane was defined by the distal tip of the anterior colliculus of the medial malleolus, the medial tubercle of the posterior calcaneal tuberosity, and the lateral tubercle of the posterior calcaneal tuberosity. The borders of the tarsal tunnel noted on the MRI were traced with a computer digitizing apparatus to determine the cross-sectional area of the tarsal tunnel on each image, and the slice thickness and interspace distance for the seven central images were used to calculate tarsal tunnel volume. RESULTS: The mean tarsal tunnel volume was significantly greater when the foot and ankle were in neutral position (21.5 +/- 0.9 cm(3)) than in either full eversion (18.0 +/- 0.9 cm(3); p = or < 0.001) or inversion (20.3 +/- 1.0 cm(3); p = or < 0.001). CONCLUSIONS: The results support the hypothesis that eversion and inversion of the foot and ankle cause decreased compartment volume of the tarsal tunnel and increased tarsal tunnel pressure that may contribute to symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome. CLINICAL RELEVANCE: Neutral immobilization of the foot and ankle may relieve symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome by minimizing pressure on the nerve and maximizing tarsal tunnel compartment volume available for the nerve.

Arthroscopic treatment of anterior ankle impingement syndrome in dancers.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic treatment of anterior bony and soft-tissue impingement of the ankle in elite dancers. METHODS: The study is a case series retrospectively reviewed. In the period between 1990 and 1999, 11 elite dancers (12 ankles) had ankle arthroscopy after a diagnosis of anterior ankle impingement that markedly interfered with their dancing. Initial nonoperative treatment failed in all subjects. Previous ankle trauma was noted in all subjects. There were seven women and four men (average age 28 years). Tibiotalar exostoses were radiographically noted in six ankles. Standard anteromedial and anterolateral arthroscopic portals and instrumentation were used for resection of bone spurs and debridement of impinging soft tissues. Patients were nonweightbearing for 5 days after surgery and had postoperative physiotherapy. RESULTS: Nine dancers returned to full dance activity at an average of 7 weeks after surgery. One patient did not return to dance performance because of concurrent unrelated orthopaedic problems, but he resumed work as a dance teacher; he developed a recurrent anterior tibial spur that was successfully resected at a second arthroscopy 9 years later. Another dancer developed postoperative scar-tissue impingement and stiffness; she had a repeat arthroscopy 4 months after the initial procedure and subsequently returned to dance performance. All patients eventually had marked postoperative improvement in pain relief and dance performance. CONCLUSIONS: Arthroscopic debridement is an effective method for the treatment of bony and soft-tissue anterior ankle impingement syndrome in dancers and has minimal morbidity.

Current topics review: Charcot neuroarthropathy of the foot and ankle.

Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Instability or deformity may limit the ability to use standard footwear. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Historically, treatment had included nonweightbearing immobilization for the acute phase, and surgery had been reserved only for infection, unresolved skin ulceration, or deformity that precluded the use of therapeutic footwear. Current controversies include weightbearing in the acute or reparative phases and early surgical stabilization. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population.

The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction.

In 32 consecutive intra-articular calcaneal fractures (28 patients, 4 bilateral), open treatment was done using the modified Palmer lateral approach and the reduction was assessed with postoperative radiography and computed tomography (CT) (coronal and axial images, 1-2 days after surgery). Retrospective analysis of the available radiographs and CT scans was done in 27 fractures (25 patients, 2 bilateral) to assess accuracy of reduction achieved; in five fractures the studies were not available. Sanders classification was type I in 2 (7%), type II in 20 (74%), and type III in 5 (19%) fractures; the calcaneocuboid joint was involved in 9 (33%) fractures. Reduction included elevation of the depressed lateral side of the posterior facet, reduction of the neck (anterior third of calcaneus) to the body (middle third of calcaneus), realignment of the posterior tuberosity, and reduction of lateral wall blowout; internal fixation was done with cannulated screws. Mean (+/-SD) values of the following displacement parameters were significantly improved after surgery: Böhler's angle, posterior facet angle, lateral posterior facet articular depression, heel width (coronal CT), and calcaneal height. There was no significant difference between preoperative and postoperative values of mean angle of Gissane, posterior tuberosity position, and body width and length on axial CT. One (3%) of the 32 fractures was associated with preoperative (traumatic) full-thickness skin necrosis at the sinus tarsi that required free muscle flap coverage. One (3%) postoperative wound healing complication occurred, consisting of wound dehiscence and drainage at the central portion of the surgical wound in a smoker, which resolved with dressing changes and antibiotics. In conclusion, the modified Palmer lateral approach enabled open reduction of major features of calcaneal fractures with less soft-tissue risk than more extensile approaches.

Microscopic metallic wear and tissue response in failed titanium hallux metatarsophalangeal implants: two cases.

The membranes present at the implant-bone interface were retrieved from two patients with titanium single stem hallux implants that had failed. Both patients had pain and valgus deformity of the hallux, and radiographs showed a radiolucent shadow around the implant stem, with thinning of the dorsal cortex of the proximal phalanx in one patient. After removal of the implants, arthrodesis of the first metatarsophalangeal (MP) joint was performed. Histologic analysis of the membrane tissue at the implant-bone interface showed a synovial-like appearance. There was a fibrous tissue stroma adjacent to the bone surface, with multiple regions of scalloping covered by mononuclear cells. Fine metallic debris was seen throughout the fibrous tissue. Multinucleated foreign body giant cells were sparsely observed associated with fine particulate metallic wear debris similar to observations from failed total hip arthroplasties. The histologic appearance is evidence that foreign-body granulomatous infiltration associated with metallic wear debris may be a causative factor of peri-implant osteolysis leading to aseptic loosening and failure of titanium single stem hallux implants.

Toe flexor forces in dancers and non-dancers.

Toe flexor force (hallux and second toe) was determined in the right and left feet of 24 dancers and 29 non-dancers (sitting and standing positions) using a commercially-available pressure sensor connected to a voltmeter. For the hallux and second toe combined (all trials combined), average toe flexor force was slightly greater for dancers than non-dancers (dancers, 7 +/- 4 N; non-dancers, 6 +/- 4 N; P<0.049). For dancers and non-dancers combined (all trials), the average toe flexor force of the hallux was more than twice that of the second toe (hallux, 9 +/- 4 N; 2nd toe, 4 +/- 1 N; P<0.0001); average toe flexor force was slightly greater in standing than sitting positions (standing, 7 +/- 4 N; sitting, 6 +/- 3 N; P<0.0001); and the average toe flexor force was slightly greater for the right than left foot (right, 7 +/- 4 N; left, 6 +/- 4 N; P<0.012). The average toe flexor force was greatest for the first repetition and slightly decreased for the second and third repetitions (first repetition, 7 +/- 4 N; second and third repetitions each, 6 +/- 4 N; P<0.0013). Toe flexor force measurement may potentially be applicable to clinical practice as a guide to rehabilitation after injury or as a screening parameter for readiness to advance dance or other athletic training, performance, or competition.

First ray disorders in athletes.

Athletes who participate in contact sports (American football, soccer, rugby) or who are involved in high-impact sports (dancing, running, gymnastics) are susceptible to first ray forefoot injuries. Common first ray disorders in athletes include hallux rigidus, turf toe, sand toe, sesamoid disorders, and fractures. First ray disorders in athletes frequently are treated by nonoperative methods including relative rest, ice, elevation, activity modification, shoe modification, and insoles.