Surgical Treatment of the Flexible, Progressive Collapsing Foot: Deformities, Definitions, and Decisions.

The complex adult acquired flatfoot deformity involves progressive collapse of the foot with attenuation of medial soft tissues such as the posterior tibialis tendon and spring ligament complex. Multiple deformities at different levels can coexist in the collapsed foot, including hindfoot valgus, midfoot abduction, forefoot varus, and valgus ankle instability. Definitions of flatfoot have evolved to encapsulate the peritalar basis of the deformity, with instability around the talus as the fulcrum. The goals of treatment are to minimize pain, dysfunction, and progressive deformity. Some treatment options directly address the pathologic areas, such as tendon transfer for posterior tibialis tendon dysfunction and spring ligament reconstruction. Others such as calcaneal osteotomies secondarily counteract the primary ligamentous dysfunction and realign the foot to neutralize deforming forces. Selective fusions of the hindfoot and medial column are also viable options to correct the deformity at the joint level when appropriate. The treatment selected depends on flexibility and locations of the deformity, and ultimately patient-specific factors.

The Impact of Concomitant LOW Back Pain (LBP) on Functional Outcomes in Total Ankle Arthroplasty (TAA).

Although numerous studies have demonstrated that concomitant low back pain (LBP) is associated with worse functional outcomes in patients undergoing total hip and knee arthroplasty, no study has analyzed its impact on patients undergoing total ankle arthroplasty (TAA). The aim of this study was to determine the prevalence of LBP in people undergoing TAA and analyze its impact on patient reported functional outcome measures (PROMs). A retrospective review was performed on data from the Vancouver End Stage Ankle Arthritis Database. In total, 87 patients undergoing TAA were studied, with patient demographics collected preoperatively, including the absence or presence of LBP. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs including the Ankle Osteoarthritis Score and Ankle Arthritis Score. The Short Form-36 was used as a secondary outcome measure to assess global function. Multivariable linear mixed-effects regression models were conducted to compare the PROM between patients with LBP with those without LBP. In total, 30 patients (35%) presented with concomitant LBP. There were no significant differences at baseline between the LBP group and no LBP group in terms of demographics or baseline primary disease-specific PROMs. At 5 years, the patients with LBP had significantly worse Ankle Arthritis Score (32 ± 23 vs 22 ± 17, p = .03), Ankle Osteoarthritis Score Total (34 ± 23 vs 22 ± 16, p = .01), and Short Form-36 physical (PCS) components summaries (33 ± 12 vs 44 ± 9, p = .001) compared to the no-LBP group. Both groups improved significantly from baseline across all outcome measures. Our study demonstrated that the prevalence of concomitant LBP in end stage ankle arthritis undergoing TAA is similar to that described in arthritic knees and hips. If present, it can be associated with worse functional outcomes in the intermediate term. However it is not a contraindication to surgery, with patients still experiencing significant improvements from baseline. Further studies are needed to evaluate if LBP influences complications, implant failure rates and survival.

Clinical outcome results of total ankle replacement and ankle arthrodesis: a pilot randomised controlled trial.

BACKGROUND: Ankle arthrodesis (AA) and replacement (TAA) are widely accepted options in managing end-stage ankle arthritis (ESAA). We hypothesize that clinical outcomes would be similar for both interventions. METHODS: We conducted a multicenter randomized controlled trial that collected data on patient demographics, complication rates, Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. We evaluated pre and postoperative scores within and between cohorts. RESULTS: The thirty-nine ankles enrolled had a mean follow-up of 5.1 ± 2.8 years. Total AOS scores improved significantly in both groups; 59.4 ± 15.9 to 38 ± 20 (p-value = 0.002) for TAA and 64.6 ± 19.7 to 31.8 ± 16.5 (p-value < 0.001) for AA at last follow-up. Complication rate was higher in the AA cohort with four major complications (20%). CONCLUSION: We observed a statistically significant benefit with TAA and AA. As a pilot trial, this study is meant to inform on design and feasibility of future RCTs. LEVEL OF EVIDENCE: II.

Successful fifth metatarsal bulk autograft reconstruction of thermal necrosis post intramedullary fixation.

Reamed intramedullary (IM) screw fixation for proximal fifth metatarsal fractures is technically challenging with potentially devastating complications if basic principles are not followed. A case of an iatrogenic fourth-degree burn after elective reamed IM screw fixation of a proximal fifth metatarsal fracture in a high-level athlete is reported. The case was complicated by postoperative osteomyelitis with third-degree soft-tissue defect. This was successfully treated with staged autologous bone graft reconstruction, tendon reconstruction, and local bi-pedicle flap coverage. The patient returned to competitive-level sports, avoiding the need for fifth ray amputation. Critical points of the IM screw technique and definitive reconstruction are discussed. Bulk autograft reconstruction is a safe and effective alternative to ray amputation in segmental defects of the fifth metatarsal.Level of evidence V.

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

BACKGROUND: End-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care. METHODS: This study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay. RESULTS: Among the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants' LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS. CONCLUSIONS: This study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.

Validating the Foot and Ankle Outcome score for measuring foot dysfunction among hallux valgus surgery patients using item response theory.

BACKGROUND: There is an absence of high quality research validating instruments that measure foot and ankle related quality of life among hallux valgus (bunion) patients' perspectives. The Foot and Ankle Outcome Scale is a patient-reported outcome instrument, that when administered to patients with symptomatic hallux valgus, provides a patient-centric perspective of their foot function. The aim of this study is to assess the psychometric properties of the instrument's five subscales among preoperative bunion surgery patients. METHODS: The Foot and Ankle Outcome Scale instrument measures Pain, Symptoms, Activities of Daily Living, Sport and Recreational Activities and Foot/Ankle Related Quality of Life. Preoperative data is collected from a sample of patients scheduled for surgical treatment of their condition in Vancouver, Canada. Classical and item response theory methods are used to report on reliability, validity and differential item functioning among subgroups. RESULTS: This study included 249 surveys, representing an overall response rate of 44.1% among 564 eligible patients. The instrument demonstrated high reliability for all subscales, though 18 items across subscales, exhibited poor discrimination between item levels. Four items score differently according to patients' sex and one item scored differently by age. CONCLUSIONS: The instrument measures five domains of health important to bunion patients. These findings suggest that the current instrument can be used with an understanding of its limitations, including redundant questions and sex-based differences. Future research should revise a number of items. The results highlight the importance of the psychometric analyses of instruments in specific patient populations.

Nonanimal Hyaluronic Acid for the Treatment of Ankle Osteoarthritis: AProspective, Single-Arm Cohort Study.

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. Nonanimal hyaluronic acid (NASHA) is a cross-linked hyaluronic acid product that has a prolonged intra-articular residence time. The authors report the first study of NASHA for the treatment of ankle OA. Thirty-seven patients with Kellgren-Lawrence grade II or III ankle OA received an intra-articular injection of NASHA (1 mL). Outcomes included visual analogue scale (VAS) scores for pain and disability. At baseline, the mean VAS pain score was 50.1 ± 14.5mm. During the 26-week follow-up period, the least squares (LS) mean change from baseline in the ankle OA VAS pain score was -20.5mm (95% confidence interval [CI] -25.5 to -15.6 mm), an LS mean percentage reduction of 40.0% (95% CI 30.2% to 49.9%). The LS mean change from baseline in the VAS disability score during 26 weeks was -19.2mm (95% CI -24.8 to -13.6 mm), a percentage reduction of 34% (95% CI 22.3% to 45.7%). Five participants experienced a total of 7 adverse events considered to be related to study treatment (injection site pain, n = 3; injection site joint pain, n = 3; plantar fasciitis, n = 1). This study shows promise for viscosupplementation with NASHA in the treatment of ankle OA. A single injection was associated with clinically meaningful reductions in pain and disability during a 26-week period and, in general, was well tolerated.

Osteochondral Defects of the Talus: Current Management Dilemmas.

Osteochondral defects or lesions of the talus represent a management challenge. Arthroscopic débridement is the treatment of choice for patients with an osteochondral lesion of the talus in whom nonsurgical treatment fails. Although surgeons have a better understanding of the risk factors for failed débridement in patients with an osteochondral lesion of the talus, the treatment of patients in whom a high risk for failed débridement exists and patients in whom débridement fails is controversial. Surgeons should understand the current adjunct therapies available for the management of osteochondral lesions of the talus, including cartilage preparations, platelet-rich plasma, bone marrow aspirate, bone graft or bone graft substitutes, and whole bone cartilage transfer (osteochondral autograft transfer); however, evidence for the use of one adjunct therapy more than another is lacking.

Treatment of first metatarsophalangeal joint arthritis using hemiarthroplasty with a synthetic cartilage implant or arthrodesis: A comparison of operative and recovery time.

BACKGROUND: First metatarsophalangeal joint (MTPJ1) hemiarthroplasty using a novel synthetic cartilage implant was as effective and safe as MTPJ1 arthrodesis in a randomized clinical trial. We retrospectively evaluated operative time and recovery period for implant hemiarthroplasty (n=152) and MTPJ1 arthrodesis (n=50). METHODS: Perioperative data were assessed for operative and anaesthesia times. Recovery and return to function were prospectively assessed with the Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) subscales and SF-36 Physical Functioning (PF) subscore. RESULTS: Mean operative time for hemiarthroplasty was 35±12.3min and 58±21.5min for arthrodesis (p<0.001). Anaesthesia duration was 28min shorter with hemiarthroplasty (p<0.001). At weeks 2 and 6 postoperative, hemiarthroplasty patients demonstrated clinically and statistically significantly higher FAAM Sport, FAAM ADL, and SF-36 PF subscores versus arthrodesis patients. CONCLUSION: MTPJ1 hemiarthroplasty with a synthetic cartilage implant took less operative time and resulted in faster recovery than arthrodesis. LEVEL OF EVIDENCE: III, Retrospective case control study.

A study to evaluate the safety of platelet-derived growth factor for treatment of osteochondral defects of the talus.

PURPOSE: An arthroscopic procedure for the treatment of osteochondral defects using platelet-derived growth factor (PDGF) carried out in a matrix of tricalcium phosphate was developed. This prospective, case-series-based study was designed to evaluate the safety and clinical utility of this procedure. METHODS: Patients with an isolated osteochondral defect larger than 5 mm long, 3 mm wide, and 5 mm deep and smaller than 30 mm long, 25 mm wide, or 20 mm deep were considered for enrolment. Only patients with chronic lesions were enroled. Arthroscopic debridement was followed by the placement of recombinant human PDGF in a matrix of tricalcium phosphate. The Ankle Osteoarthritis Scale (AOS), visual analogue scale (VAS) for pain, and SF-36 questionnaires were administered at 0, 2, 6, 12, and 24 weeks. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were taken before and after surgery. RESULTS: Five patients were ultimately enroled in this proof-of-concept trial. All outcome measures demonstrated marked improvement from baseline to final follow-up: The mean weight bearing VAS pain score improved by 49%, and the mean AOS functional score improved by 28%. Bone healing was seen on CT, and reduction in oedema signal was seen on MRI. CONCLUSION: This new procedure may offer a promising alternative for the treatment of osteochondral defects. Further high-quality studies are needed to confirm these results and to analyse the long-term effects of the procedure. The clinical relevance of this study is that the procedure may provide a less invasive option with improved bone healing compared to standard techniques . LEVEL OF EVIDENCE: IV.

Technique for Measuring Limb Occlusion Pressure that Facilitates Personalized Tourniquet Systems: A Randomized Trial.

We developed a technique for measuring patient limb occlusion pressure (LOP) through a tourniquet cuff that overcomes many limitations of existing LOP measurement techniques. The purpose of the study is to determine whether the LOP measured by the proposed technique is statistically or clinically different from that measured by the gold standard Doppler ultrasound technique. The study used randomized crossover multicenter trials. 143 pre- and post-surgical patients with a mean age of 54 years (range 17-86 years) were enrolled in the study. Pneumatic cuffs were applied to the non-operative upper and lower limbs and LOP was measured using the proposed technique and the Doppler ultrasound technique. From a total of 252 usable measurements for each technique (134 for upper limbs and 118 for lower limbs), the mean difference in LOP between the two techniques was 1 ± 8 mmHg for the upper limbs, 0 ± 15 mmHg for the lower limbs, and 1 ± 12 mmHg overall. The differences between the proposed technique and the Doppler technique were neither statistically nor clinically significant. The simplicity, effectiveness, and accuracy of the proposed technique should lead to broader clinical usage and acceptance of LOP measurement, thus leading to safer, personalized pressures in surgical tourniquet applications.

Preoperative and Postoperative Imaging and Outcome Scores for Osteochondral Lesion Repair of the Ankle.

Cartilage lesions to the ankle joint are common and can result in pain and functional limitations. Surgical treatment aims to restore the damaged cartilage's integrity and quality. However, the current evidence for establishing best practices in ankle cartilage repair is characterized by limited quality and a low level of evidence. One of the contributing factors is the lack of standardized preoperative and postoperative assessment methods to evaluate treatment effectiveness and visualize repaired cartilage. This review article seeks to examine the importance of preoperative imaging, classification systems, patient-reported outcome measures, and radiological evaluation techniques for cartilage repair surgeries.

A Novel Update on the Management of Müller-Weiss Disease: Presentation of a Treatment Algorithm.

OBJECTIVE: Müller-Weiss disease (MWD) is a challenging condition involving the perinavicular region in the initial stages and subsequently the entire foot in the later stages. The goal of this article is to describe the pathomechanics, clinical evaluation, and nonoperative and operative treatment, including a treatment algorithm, based on current evidence and the combined authors' experience. DESIGN: We review the related articles and summarize the information about this condition. RESULTS: A number of related articles reveal that the treatments should focus on the management of degenerative regions and deformity correction to restore normal foot alignment and provide pain relief. CONCLUSION: This systematic review proposes a treatment algorithm that is comprehensive and practical to apply for the management of MWD.

Inconsistency in the Reporting Terminology of Adverse Events and Complications in Hallux Valgus Reconstruction: A Systematic Review.

Surgical complications are inevitable in any surgical subspecialty. Throughout the years, many classification systems have been developed to better understand and report such complications. The aim of this systematic review is to investigate the variability and frequency of reporting terms used to describe adverse events and complications in hallux valgus reconstruction. We hypothesized that the terms used would be highly inconsistent, which further promotes a need for a standardized terminology reporting system. Studies related to hallux valgus reconstruction outcomes that met our predetermined inclusion criteria were investigated to identify and report the related adverse terms and complications. Adverse terms and complications were grouped into 9 categories. Of the 142 studies included, 376 distinct terms that described adverse events or complications related to hallux valgus reconstruction were identified. Of these, 73.4% (276/376) were mentioned only once in their respective studies. Five of 376 terms were mentioned in at least 25% of the papers, and only 2 of 376 were mentioned in at least 50%. The most frequently reported adverse events were "Recurrence," mentioned in 77 of 142 studies (54%), followed by "Nonunion," mentioned in 76 of 142 studies (53%). The most reported category was "Bone/Joint" with 135 related terms, mentioned in 135 of 376 of the papers (95.1%). The terminology used in reporting adverse events and complications in surgical hallux valgus correction was highly inconsistent and variable. This represents yet another barrier in accurate reporting of these terms, and subsequently a difficult analysis of the outcomes related to hallux valgus reconstruction. To overcome these challenges, we suggest developing a standardized terminology reporting system.Levels of Evidence: Level III; systematic review of Level III studies and above.

Shared Decision Making in Hallux Valgus Surgery: A Prospective Observational Study.

Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value < 0.05). There was no association between SDM scores and postoperative outcome scores. In this study, patients with depressive symptoms and lower socioeconomic status had worse perceptions of SDM. There was no difference in postoperative outcomes among participants based on SDM scores. Level of Evidence: Level III, prospective observational study.

A prospective pilot study of B2A-coated ceramic granules (Amplex) compared to autograft for ankle and hindfoot arthrodesis.

BACKGROUND: To reduce fusion nonunion, autogenous bone graft is often incorporated into foot and ankle fusion procedures. B2A peptide-coated ceramic granules, with encouraging results in pilot studies of transforaminal lumbar interbody fusion, were here reformulated into Amplex with a coating concentration of 225 µg B2A/cm(3) ceramic granules (B2A-granule) with the goal of eliminating autogenous bone graft in foot and ankle arthrodesis. The purpose of this study was to perform a multicenter prospective randomized pilot clinical trial designed to compare the safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. METHODS: This study was a multicenter, prospective, randomized, pilot clinical trial designed to compare safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. Twenty-four patients were enrolled and randomized (1:1) into 2 groups: autogenous bone graft control and B2A-granule. Primary outcome measures at 6 months (with follow-up at 9 and 12 months) included radiographic fusion assessed by computerized tomography and Ankle Osteoarthritis Scale scores for pain and disability. RESULTS: Radiographic fusion success rates were similar in both groups (100% in the B2A-granule group, 92% autograft). Both the B2A-granule group and the autograft group had improvements in the pain and disability scores over the course of the study. Graft harvest-site pain affected only autograft-treated patients. There were no adverse events attributed to the graft material in either the B2A-granule or autograft group. CONCLUSION: The results of this pilot study are supportive of a larger clinical trial to assess the safety and efficacy of B2A-granule as a bone graft substitute in foot and ankle fusions. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Deltoid ligament injury and repair.

The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament.The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.

Level of Evidence for the Treatment of Chronic Noninsertional Achilles Tendinopathy.

BACKGROUND: Noninsertional Achilles tendinopathy affects both athletes and sedentary individuals, and its incidence is rising. Conservative management is the mainstay of treatment, but a variety of operative techniques have been described to treat recalcitrant cases. We seek to outline the current available evidence for surgical management of noninsertional Achilles tendinopathy. STUDY DESIGN AND METHODS: A systematic review was performed using the MEDLINE and EMBASE databases, and all articles were reviewed by at least 2 authors. Each article was assigned a level of evidence in accordance with the standards of Journal of Bone and Joint Surgery. The available data were reviewed and a level of evidence was assigned to each intervention of interest, based on the revised classifications of Wright. RESULTS AND CONCLUSION: A total of 46 articles met inclusion and exclusion criteria. There is fair evidence (grade B) in support of open debridement with 1 level II study, 1 level III study, and 8 level IV studies. There is fair evidence (grade B) in support of arthroscopic or minimally invasive surgical techniques. There is poor evidence (grade C) in support of flexor hallucis longus transfer, longitudinal tenotomy, peritenolysis, gastrocnemius recession, and plantaris excision. There is insufficient evidence (grade I) to provide a recommendation about other surgical treatment methods for noninsertional Achilles tendinopathy.Levels of Evidence: Level III: Systematic review.

Responsiveness and validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in end stage ankle arthritis.

BACKGROUND: We examined four commonly used scores, the SF-36, the Ankle Osteoarthritis Scale (AOS), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Score, and the Foot Function Index (FFI) to determine their responsiveness and validity. METHODS: Patients with end stage ankle arthritis were recruited into a prospective multicenter cohort study and baseline and one year outcome scores were compared. The Standardized Response Mean and Effect Size for the AOS, AOFAS, and FFI were calculated and the three region- or disease-specific scores were compared with the SF-36 to determine their criterion validity. RESULTS: All four scores showed acceptable responsiveness, and when using the validated SF-36 as the standard the three region or disease specific scores all showed similar criterion validity. CONCLUSION: All four scores are responsive and can be considered for use in this population. The objective component of the AOFAS Ankle Hindfoot Score may make it harder to perform than the other three scores which have subjective components only, and as yet its objective component has not been shown to demonstrate reliability. We recommend use of a purely subjective score such as the Ankle Osteoarthritis Scale or Foot Function Index as the region- or disease-specific score of choice in this population. As the SF-36 shows acceptable responsiveness, using it alone could also be considered.