Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study.

BACKGROUND: Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS: This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS: Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION: Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE: III.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVE: To determine which treatment is superior in terms of clinical scores and adverse events. DESIGN: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). SETTING: 17 National Health Service trusts across the United Kingdom. PATIENTS: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. INTERVENTION: Patients were randomly assigned to TAR or AF surgical treatment. MEASUREMENTS: The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. RESULTS: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). LIMITATION: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. CONCLUSION: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research Heath Technology Assessment Programme.

The Use of Hindfoot Nails for Elderly Complex Distal Tibial and Ankle Fractures.

Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weightbearing. We performed a retrospective observational review of patients >65 years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, postoperative mortality, complications, and further treatment. The primary outcome was reoperation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty-three out of 70 patients were female. The average age of those who died within 1 year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days postsurgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.

Foot injuries, playing surface and shoe design: Should we be thinking more about injury prevention.

The increasing use of artificial pitches has occurred in a multitude of sports at both professional and amateur levels. Artificial turf has become an extremely attractive option as it is felt to encourage a faster, safer and more entertaining play. However these pitches are not without controversy among sporting professionals and in the media. Foot and ankle injury in sport remains incredibly common and a significant burden on health professionals, but what impact do the new artificial surfaces have on these injuries. This review article aims to establish whether artificial turf has an impact on injury rates in the foot and ankle.

Extended plantar limb (modified) chevron osteotomy versus scarf osteotomy for hallux valgus correction: A randomised controlled trial.

BACKGROUND: The purpose of this RCT was to compare the extended plantar limb (modified) chevron osteotomy with the scarf osteotomy in correcting hallux valgus deformity and improving functional scores and patient satisfaction. METHODS: Patients were randomly assigned and kept blind to surgical allocation. Cases requiring additional procedures including the Akin osteotomy were excluded. Outcomes were measured at 1 year following surgery. RESULTS: 84 patients (109 feet) were analysed (60 modified chevron; 49 Scarf). The mean age was 50.7 years (75F: 9M). Post-operative intermetatarsal angle (IMA) was significantly lower in the modified chevron group (5.8° versus 6.9°, p=0.045). Hallux valgus angle and distal metatarsal articular angle were similar. The magnitude of IMA correction with the modified chevron was also significantly greater (9.1° versus 7.1°, p=0.007). Both osteotomies produced comparable MOxFQ scores and satisfaction ratings. CONCLUSION: The modified chevron was superior to the scarf osteotomy in correcting IMA in hallux valgus deformity.

Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery.

BACKGROUND: The Manchester-Oxford Foot Questionnaire (MOXFQ) has been validated in Spanish for use in patients undergoing foot and ankle surgery. METHODS: 120 patients completed the MOXFQ and the SF-36 before surgery and 6 and 12 months postoperative. Surgeons completed the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating System. Psychometric properties were assessed for all three MOXFQ dimensions, and for the MOXFQ Index. RESULTS: The Spanish MOXFQ demonstrated consistency with Cronbach's alpha values between 0.65 and 0.90, and reliability ([ICCs] >0.95). It shows a moderate to strong correlation between the Walking/standing dimension and the related domains of the SF-36 (|r|>0.6), the AOFAS Ankle-Hindfoot Scale (|r|>0.47) and Hallux-MTP-IP Scale (|r|>0.64). Responsiveness was excellent, (effect sizes >2.1). The respective minimal detectable change (MDC90) was 14.18 for the MOXFQ Index. CONCLUSIONS: The Spanish version of the MOXFQ showed good psychometric properties in patients with foot and ankle disorders.

Donor site morbidity of the medial plantar artery flap studied with gait and pressure analysis.

BACKGROUND: The medial plantar artery flap (MPA) allows transfer of both glabrous (smooth and free from hair) and sensate tissue. It has been suggested that the non-weight bearing instep area of the foot provides tissue for transfer with minimal donor morbidity. However the abductor hallucis muscle and plantar fascia are dissected during flap harvest which may affect foot mechanics. METHODS: Patients were included who had undergone MPA flap harvest and were walking unaided. The majority of the patients studied had problems with soft tissues of their heels rather than trauma as a starting point. Laboratory normals and the patient's contralateral limb were used as controls. Gait and pressure analysis were performed using 3D gait analysis and high resolution pressure analysis. RESULTS: This study included 6 patients, with 5 chronic wounds (4 ipsilateral, 1 contralateral) and 1 traumatic ankle defect. QUESTIONNAIRE RESULTS: Enneking scores: 67.9% return to function; Foot Function Index scores: 39.1% loss of function. GAIT ANALYSIS: Significant differences were seen in kinetic and kinematic data. PRESSURE ANALYSIS: The donor site group had significantly less pressure in the great toe (38.1kPa vs. 78.1kPa, p=0.013), significantly slower transition through the midfoot (445.2ms vs. 352.07ms, p=0.016) and increased impulse in the heel (3.1kPa/s vs. 11.7kPa/s, p=0.038). CONCLUSIONS: This study demonstrates subjective and objective evidence of MPA donor site morbidity. Comparison to other studies looking at gait and pressure changes seen after flap reconstruction of the plantar region suggest that much of this difference may be attributable to ipsilateral reconstruction. As the majority had chronic problems with the soft tissues over the heel some of these biomechanical responses could be related to learned behaviour preoperatively or continued discomfort in the heel pad. Nonetheless it demonstrates accurately the effect of the technique overall on the function of the foot. The changes in the region of the great toe may be solely attributable to MPA harvest. These results suggest that MPA harvest is not free of donor morbidity.

Arthroscopic triple fusion joint preparation using two lateral portals: a cadaveric study to evaluate efficacy and safety.

BACKGROUND: Arthroscopic triple fusion has several advantages over open techniques, but its use has yet to become widespread. Preliminary published techniques use five portals with neurovascular risk. Our aim was to assess the safety and efficacy of an alternative lateral two portal technique. METHODS: Four cadaveric hindfeet were arthroscopically prepared for a triple fusion using two lateral portals. The distance to relevant subcutaneous nerves was measured as well as the prepared joint surface percentage. RESULTS: Mean distance from mid-lateral portal to the nearest sural nerve branch was 22.3mm (range 20-24mm) and from the dorsolateral portal to the intermediate branch of the superficial peroneal nerve was 7.8mm (range 4-11mm). Mean percentages of joint preparation were 63% (talar head), 62% (navicular), 75% (calcaneum) and 74% (cuboid). CONCLUSIONS: Two lateral arthroscopic portals allow adequate joint preparation for triple fusion procedures. The proximity of subcutaneous nerves is important to appreciate when using these portals.

Arthroscopic resection of talocalcaneal coalitions--a bicentre case series of a new technique.

BACKGROUND: Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. We describe an arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). METHODS: Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. RESULTS: Pain and SAFAS improved in 7 patients. Subtalar movements were improved in all feet. All patients achieved early good function but one relapsed requiring subsequent fusions. One posterior tibial nerve was damaged. CONCLUSIONS: Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. Patient selection and preoperative planning are crucial to avoid relapse and complication. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

Ground Reaction Force Calcaneal Offset: A new measurement of hindfoot alignment.

BACKGROUND: The tibio-calcaneal angle (TCA) does not measure individual forefoot contributions to the overall foot balance. Using standard radiographs we calculated the ideal hindfoot alignment based on ground reaction force (GRF), independently from the tibial axis. METHODS: Thirty-six patients (40ft.) were included. Mean age was 56. Weight bearing radiographs were taken. Calcaneal offsets were measured using tibio-calcaneal angles and GRF algorithms. Measurements were compared using the Bland-Altman method. FINDINGS: Both methods agreed (p>0.05) but individual discrepancies were found. Mean measured offsets were -11.5mm (SD: 10.2) using TCA and -8mm (SD: 9.3) using GRF. Mean bias between the methods was -0.88mm. INTERPRETATION: The GRF algorithm successfully measured hindfoot alignment. The absence of a previous gold standard and radiographic variability are a limit. The TCA underestimated calcaneal offset. Discrepancies showed that forefoot position data provided increased accuracy. This could be of particular relevance for surgical planning.

Extended lateral approach for elective hind foot surgery--a safe and versatile incision.

AIM: The aim of our study was to review our experience of the extended lateral approach to the hind foot in treatment of non-traumatic foot disorders with particular reference to wound complications. MATERIALS AND METHODS: We retrospectively reviewed 51 consecutive patients who under went extended lateral approach to the hind foot for treatment of various non traumatic foot disorders. We documented the indication for surgery, co-morbidity, quality of wound healing and other wound related problems. RESULTS: The mean age was 47.9. There were three superficial wound infections (5.8%). One had slight sensory loss close to the scar, one developed hypersensitivity over the scar. There was no wound break down or any deep infection. No sural nerve deficit was noted. Six patients had the calcaneal screw removed due to prominent metal work (11.7%). CONCLUSION: The extended lateral approach to hind foot is safe in the surgical treatment of a wide variety of non-traumatic foot conditions. Despite the larger deep dissection, the arterial anatomy ensures reliable wound healing and a low incidence of wound complications.

Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes.

Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.

Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail.

BACKGROUND: Tibiotalocalcaneal fusion with a straight rod has a risk of damaging the lateral plantar neurovascular structures and may interfere with maintaining normal heel valgus position.We report the results of a prospective study of tibiotalocalcaneal (TTC) arthrodesis with a short, anatomically curved interlocking, intramedullary nail. MATERIAL AND METHODS: Forty-five arthrodesis in 42 patients, performed between Jan 2003 and Oct 2008, were prospectively followed. The mean followup was 48 (range, 10 to 74) months. The main indications for the procedure were failed ankle arthrodesis with progressive subtalar arthritis, failed ankle arthroplasty and complex hindfoot deformity. The outcome was measured by a combination of pre and postoperative clinical examination, AOFAS hindfoot scores, SF-12 scores and radiological assessment. RESULTS: Union rate was 89% (40/45). Eighty-two percent (37/45) reported improvement in pain and 73% (33/45) had improved foot function. Satisfactory hindfoot alignment was achieved in 84% (38/45). Postoperatively there was a mean improvement in the AOFAS score of 37. Complications included a below knee amputation for persistent deep infection, five nonunions, and three delayed unions. Four nails, six proximal and six distal locking screws were removed for various causes. Other complications included two perioperative fractures, four superficial wound infections and one case of lateral plantar nerve irritation. CONCLUSION: With a short, anatomically curved intramedullary nail, we had a high rate of tibiotalocalcaneal fusion with minimal plantar neurovascular complications. We believe a short, curved intramedullary nail, with its more lateral entry point, helped maintain hindfoot alignment.

Bone graft harvest from the proximal tibia in foot and ankle arthrodesis surgery.

BACKGROUND: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control. METHODS: A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction. RESULTS: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing CONCLUSIONS: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.