Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis.

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I2 statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia.

Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.

Cost-Effectiveness Analysis of Primary Arthrodesis Versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries.

The purpose of the present study was to determine whether surgical intervention with open reduction internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries is more cost effective. We conducted a formal cost-effectiveness analysis using a Markov model and decision tree to explore the healthcare costs and health outcomes associated with a scenario of ORIF versus PA for 45 years postoperatively. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. ORIF was always associated with greater costs compared with PA and was less effective in the long term. When calculating the cost required to gain 1 additional QALY, the PA group cost $1429/QALY and the ORIF group cost $3958/QALY. The group undergoing PA overall spent, on average, $43,192 less than the ORIF group, and PA was overall a more effective technique. Strong dominance compared with ORIF was demonstrated in multiple scenarios, and the model's conclusions were unchanged in the sensitivity analysis even after varying the key assumptions. ORIF failed to show functional or financial benefits. In conclusion, from a healthcare system's standpoint, PA would clearly be the preferred treatment strategy for predominantly ligamentous Lisfranc injuries and dislocations.

Forefoot Adduction Is a Risk Factor for Jones Fracture.

Jones fractures are among the most common fractures of the foot; however, much remains unknown about their etiology. The purpose of the present study was to further examine the risk factors of forefoot and hindfoot alignment on Jones fractures using an epidemiologic study design. We used a retrospective, matched, case-control study design. Cases consisted of patients with acute, isolated Jones fractures confirmed on plain film radiographs seen at our institute from January 2009 to December 2013. Patients presenting with pain unrelated to metatarsal fractures served as controls. Controls were matched to cases by age (±2 years), gender, and year of presentation. Weightbearing foot radiographs were assessed for 13 angular relationships by a single rater. Conditional multivariable logistic regression was used to identify important risk factors. Fifty patients with acute Jones fractures and 200 controls were included. The only significant variables in the final multivariable model were the metatarsus adductus angle (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.08 to 1.25) and fourth/fifth intermetatarsal angle (OR 0.69, 95% CI 0.57 to 0.83)-both measures of static forefoot adduction. The presence of metatarsus adductus (defined as >15°) on foot radiographs was associated with a 2.4 times greater risk of a Jones fracture (adjusted OR 2.4, 95% CI 1.2 to 4.8). We have concluded that the risk of Jones fracture increases with an adducted forefoot posture. In our population, which consisted primarily of patients presenting after a fall (10 of 50; 20%) or misstep/inversion injury (19 of 50; 38%), the hindfoot alignment appeared to be a less important factor.

American College of Foot and Ankle Surgeons' clinical consensus statement: risk, prevention, and diagnosis of venous thromboembolism disease in foot and ankle surgery and injuries requiring immobilization.

The purpose of this document is to provide guidance for physicians regarding the risk, prevention, and diagnosis of venous thromboembolism disease after foot and ankle surgery and while caring for lower extremity injuries that require ankle immobilization. A panel composed of all authors of this document reviewed the published evidence and, through a series of meetings, reached consensus regarding the viewpoints contained herein. We conclude that routine chemical prophylaxis is not warranted; rather, patients should be stratified and have a prevention plan tailored to their individual risk level. An effective venous thromboembolism prevention program is typically multimodal and focuses on addressing any modifiable risk factors, use of mechanical prophylaxis, early mobilization, and careful consideration of the use of chemical prophylaxis. The final decision regarding use and method(s) of prophylaxis adopted should be agreed upon by both the clinician and patient after a discussion of the potential benefits and harms as they relate to the individual. This should take place preferably during the preoperative visit or in the immediate post-injury setting, and it may need to be revisited during the course of care if the patient's risk level changes. Prompt recognition of the signs and symptoms of deep venous thrombosis following surgery or injury is important. Patients suspected of deep venous thrombosis should receive further work-up with either a D-dimer test or duplex venous ultrasound of the symptomatic leg, depending on their pretest probability for the disease. The latter can be determined using a validated clinical decision-making tool (e.g., Well's criteria).

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations.

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.

Spontaneous bilateral ankle and midfoot sepsis in a nonimmunocompromised patient.

We describe a 70-year-old nonimmunocompromised woman with spontaneous bilateral ankle and midfoot sepsis and a deep-space abscess of the right lower leg. Salvage of both limbs was achieved by aggressive bilateral soft-tissue and osseous debridement, including a four-compartment fasciotomy of the right lower leg, antibiotic-loaded polymethyl methacrylate bone cement implantation, delayed allogeneic bone grafting of the osseous defects impregnated with autologous platelet-rich plasma bilaterally, and external fixation immobilization, implantable bone growth stimulation, and split-thickness skin graft coverage of the right lower leg, ankle, and foot. Osseous incorporation of the bone grafts bilaterally occurred 8 weeks after surgery. No soft-tissue or osseous complications occurred during the postoperative period or at 18-month follow-up except for arthrofibrosis in the right ankle; there was no evidence of recurrent abscesses, sequestrum, or wound-related problems. A review of the literature regarding bilateral pedal sepsis and the techniques used for limb salvage in this patient are presented in detail.

Effects of Swimming and Cycling Exercise Intervention on Vascular Function in Patients With Osteoarthritis.

Swimming exercise is an ideal and excellent form of exercise for patients with osteoarthritis (OA). However, there is no scientific evidence that regular swimming reduces vascular dysfunction and inflammation and elicits similar benefits compared with land-based exercises such as cycling in terms of reducing vascular dysfunction and inflammation in patients with OA. Forty-eight middle-aged and older patients with OA were randomly assigned to swimming or cycling training groups. Cycling training was included as a non-weight-bearing land-based comparison group. After 12 weeks of supervised exercise training, central arterial stiffness, as determined by carotid-femoral pulse wave velocity, and carotid artery stiffness, through simultaneous ultrasound and applanation tonometry, decreased significantly after both swimming and cycling training. Vascular endothelial function, as determined by brachial flow-mediated dilation, increased significantly after swimming but not after cycling training. Both swimming and cycling interventions reduced interleukin-6 levels, whereas no changes were observed in other inflammatory markers. In conclusion, these results indicate that regular swimming exercise can exert similar or even superior effects on vascular function and inflammatory markers compared with land-based cycling exercise in patients with OA who often has an increased risk of developing cardiovascular disease.

Improved Function and Reduced Pain after Swimming and Cycling Training in Patients with Osteoarthritis.

OBJECTIVE: Arthritis and its associated joint pain act as significant barriers for adults attempting to perform land-based physical activity. Swimming can be an ideal form of exercise for patients with arthritis. Yet there is no information on the efficacy of regular swimming exercise involving patients with arthritis. The effect of a swimming exercise intervention on joint pain, stiffness, and physical function was evaluated in patients with osteoarthritis (OA). METHODS: Using a randomized study design, 48 sedentary middle-aged and older adults with OA underwent 3 months of either swimming or cycling exercise training. Supervised exercise training was performed for 45 min/day, 3 days/week at 60-70% heart rate reserve for 12 weeks. The Western Ontario and McMaster Universities Arthritis Index was used to measure joint pain, stiffness, and physical limitation. RESULTS: After the exercise interventions, there were significant reductions in joint pain, stiffness, and physical limitation accompanied by increases in quality of life in both groups (all p < 0.05). Functional capacity as assessed by maximal handgrip strength, isokinetic knee extension and flexion power (15-30% increases), and the distance covered in the 6-min walk test increased (all p < 0.05) in both exercise groups. No differences were observed in the magnitude of improvements between swimming and cycling training. CONCLUSION: Regular swimming exercise reduced joint pain and stiffness associated with OA and improved muscle strength and functional capacity in middle-aged and older adults with OA. Additionally, the benefits of swimming exercise were similar to the more frequently prescribed land-based cycling training. TRIAL REGISTRATION: clinicaltrials.gov NCT01836380.

Retrospective analysis of the survivability of absorbable versus nonabsorbable subtalar joint arthroereisis implants.

Subtalar joint arthroereisis is a surgical modality that has been shown to be an effective procedure for flexible flatfoot in both pediatric and adult populations. Despite advances in understanding its mechanics and function, complication and implant removal rates remain as high as 30% to 40%. Analysis was performed to determine the survivability of 2 subtalar joint arthroereisis implants, absorbable and nonabsorbable, used alone and in combination with other procedures in both the adult and pediatric populations. The 95 total arthroereisis procedures were analyzed in several major categories: absorbable implants versus nonabsorbable implants and adult versus pediatric patients. Each major group was then further subdivided to create further subgroups: absorbable isolated procedures, absorbable combined procedures, nonabsorbable isolated procedures, and nonabsorbable combined procedures. The overall survival rates were 83% for absorbable implants and 81% for nonabsorbable implants. A total of 11 (17%) absorbable implants and 6 (19%) nonabsorbable implants were removed, respectively, at an average of 9 months and 23 months postoperatively. When used alone and in combination with other procedures, 36% and 13% of absorbable implants and 18% and 19% of nonabsorbable implants, respectively, were removed. When comparing adult versus pediatric populations, the overall survival rates of the absorbable and nonabsorbable implants were 81% for absorbable implants and 79% for nonabsorbable implants in the adult population and 85% for absorbable implants and 100% for nonabsorbable implants in the pediatric population.

Retrospective analysis of mini-open repair versus open repair for acute Achilles tendon ruptures.

PURPOSE: Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA). METHODS & RESULTS: Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 - 68); MOA: 46 + 2.5 years (range 33 - 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 - 30); MOA: 15 + 2 days (range 2 - 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 - 98) and 92 + 5 (range 66 - 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 - 46); MOA: Post op day 19 + 2 (range 7 - 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 - 11); MOA: Post op month 5 + 0.6 (range 4 - 11)]. CONCLUSION: These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair.

Bivalved fiberglass cast compared with plaster splint immobilization for initial management of ankle fracture-dislocations: a treatment algorithm.

UNLABELLED: The initial management of ankle fracture-dislocations is the crucial step in the treatment of these emergent traumatic injuries. A stepwise approach is necessary to properly evaluate, diagnose, and treat ankle fracture-dislocations. The goal of initial management is to evaluate the vascular status of the extremity and then restore proper alignment of the talus underneath the tibia. A retrospective review was performed on 40 patients, who presented to a community-based hospital emergency room, treated by the foot and ankle service for ankle fracture-dislocation. An analysis of patient demographics, injury pattern/classification, number of reduction attempts, and immobilization method was performed and evaluated. This analysis was correlated with a review of the literature to develop an algorithm for the initial management of ankle fracture-dislocations recommending the use of a bivalved below-the-knee fiberglass cast for maintained stabilization post reduction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Aggressive management of necrotizing fasciitis through a multidisciplinary approach using minimal surgical procedures: a case report.

Necrotizing fasciitis is an aggressive, destructive infection of the soft tissue and fascia and is a life-threatening surgical emergency. A case study is presented of necrotizing fasciitis in the right lower extremity of a 53-year-old male resident of a long-term skilled nursing facility. Limb salvage was achieved through a multidisciplinary approach with early surgical management and aggressive postoperative management. Through 3 surgical procedures, the combined efforts of podiatric surgery, orthopaedic surgery, general/trauma surgery, and infectious disease provided early wound closure and limb salvage. An aggressive multidisciplinary approach to the management of necrotizing fasciitis in the lower extremity is necessary for limb salvage. Use of this multidisciplinary approach will minimize the number of surgical procedures and decrease the potential morbidity and mortality seen in patients with this infection.