Clinical And Plantar Fascial Morphologic Changes After Proximal Medial Gastrocnemius Release Treatment of Recalcitrant Plantar Fasciitis.

BACKGROUND: Magnetic resonance imaging (MRI) has been used as a diagnostic and prognostic instrument to evaluate the results of conservative treatment for plantar fasciitis. However, there are scarce data available relative to changes in the plantar fascia after operative treatment. The primary objective of this study is to evaluate the imaging changes in patients with recalcitrant plantar fasciitis treated operatively by means of proximal medial gastrocnemius release. METHODS: Thirteen patients with recalcitrant plantar fasciitis were studied with MRI preoperatively and 1 year after operative treatment. Quantitative (plantar fascia thickness) and qualitative variables (hyperintensity in the plantar fascia, insertional calcaneus bone edema, a plantar fascia tear, and the presence of perifascial collections) were assessed by 2 musculoskeletal radiologists. Clinical results were also measured with American Orthopaedic Ankle & Society (AOFAS), visual analog scale (VAS) pain, and 36-Item Short Form Health Survey (SF-36) scales. RESULTS: The mean plantar fascia thickness was 6.59 mm preoperatively and 6.37 mm postoperatively (P = .972). No statistically significant differences were found in any of the qualitative variables on comparing the pre- and postoperative periods. Patients reported clinical improvements in pain VAS, AOFAS measurement, and the physical subdomains of the SF-36 scale. CONCLUSION: Quantitative and qualitative variables assessed for the plantar fascia on MRI did not show any significant change after medial gastrocnemius release despite clear clinical improvement. LEVEL OF EVIDENCE: Level II, perspective cohort study.

Proximal Medial Gastrocnemius Release Versus Open Plantar Fasciotomy for the Surgical Treatment in Recalcitrant Plantar Fasciitis.

BACKGROUND: Plantar fasciitis is a common cause of foot pain. If conservative treatment fails, there is no consensus as to the best surgical management for recalcitrant plantar fasciitis (RPF). The aim of this study was to compare the results obtained from proximal medial gastrocnemius release (PMGR) with those obtained from open plantar fasciotomy (OPF) in terms of pain, satisfaction, health-related quality of life, and American Orthopaedic Foot & Ankle Society (AOFAS) score. METHODS: This is a prospective randomized trial conducted between 2012 and 2016. Patients with RPF for at least 9 months were included. Diagnosis was clinically made. The exclusion criteria were neuropathic heel pain; a history of previous foot fracture, surgery, or deformity; rheumatoid arthritis; or the need for long-term analgesic administration. After ruling out other conditions with magnetic resonance or ultrasound imaging, patients were randomized to be operated on with OPF or PMGR independently of the Silfverskjold test. Follow-up was carried out for up to 1 year. The AOFAS, visual analog scale (VAS) for pain, SF-36, and Likert scale for satisfaction were used to evaluate the results obtained. The analysis was done with 21 patients in the OPF group and 15 in the PMGR group. The demographic data (age, sex, body mass index, duration of symptoms, and positivity to the Silfverskjold test) of the groups were comparable. RESULTS: No differences were found in terms of the AOFAS (P = .24), VAS (P = .14), or any item of the SF-36. Satisfaction was very good in 85.8% of the PMGR group and 89.5% of the OPF group (P = .27). Faster recovery was observed in the PMGR group. CONCLUSION: OPF and PMGR provided good results for patients with RPF. Neither was superior to the other relative to pain, AOFAS score, satisfaction, or the SF-36. We recommend PMGR as the first option in RPF surgical management in order to avoid potential biomechanical complications related to OPF. LEVEL OF EVIDENCE: Level I, therapeutic randomized controlled trial.

Foot and ankle infections: Debridement, early fixation and rifampicin provide earlier recovery of function and quality of life.

BACKGROUND: Infection after foot and ankle fractures is a major concern for orthopedic surgeons. It is widely believed that final osteosynthesis should be delayed until the infection is cured. However, there is no literature that supports this practice. In addition, the delay impairs patient function and quality of life (QoL). METHODS: In the present study, four cases of ankle infection treated with aggressive debridement, early fixation and antibiofilm antibiotics are described. It is thought that, like other implant related infections, ankle infections can be rapidly treated with the definitive fixation and by curing the infection to make for a fast recovery of QoL and function. RESULTS: The infections were caused by MSSA and Pseudomonas aeruginosa in case 1, MSSA in case 2 and MRSA as well as K. pneumonia in case 3. Case 4 was a culture negative infection. They were susceptible to antibiofilm antibiotics (the gram-negative bacilli susceptible to ciprofloxacin and the gram-positive cocci susceptible to rifampicin). Cases 1, 3 and 4 were treated with a tibio-talo-calcaneal arthrodesis and case 2 was treated with a de-rotational fibular osteotomy and a medial closing wedge supramalleolar osteotomy. All cases improved at a median time of 4 weeks in terms of quality of life (SF-36) and function (AOFAS). At 2-years follow-up, no recurrence of infection was observed in any of the cases. All the cases achieved fusion or osteotomy healing at final follow-up. CONCLUSIONS: Early fixation after debridement combined with antibiofilm antibiotics can be performed in foot and ankle inflections to provide early recovery of QoL and function in patients.

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis.

BACKGROUND: The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition. METHODS: Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients. RESULTS: In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36. CONCLUSION: The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning. LEVEL OF EVIDENCE: Level IV, case series.

Corticosteroid Injection for the Treatment of Morton's Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial.

BACKGROUND: The effectiveness of corticosteroid injection for the treatment of Morton's neuroma is unclear. In addition, most of the studies related to it are case-control or retrospective case series. The purpose of this study was to compare the effectiveness between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) for the treatment of Morton's neuroma. METHODS: Forty-one patients with a diagnosis of Morton's neuroma were randomized to receive 3 injections of either a corticosteroid plus a local anesthetic or a local anesthetic alone. The patients and the researcher who collected data were blinded to the treatment groups. The visual analog scale for pain and the American Orthopaedic Foot & Ankle Score (metatarsophalangeal/interphalangeal score) were obtained at baseline, after each injection, and at 3 and 6 months after the last injection. RESULTS: There were no significant between-group differences in terms of pain and function improvement at 3 and 6 months after treatment completion in comparison with baseline values. At the end of the study, 17 (48.5%) patients requested surgical excision of the neuroma: 7 (44%) in the experimental group and 10 (53%) in the control group ( P = 1.0). CONCLUSION: The injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and function improvement in patients with Morton's neuroma. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Influence of Hindfoot Malalignment on Hallux Valgus Operative Outcomes.

BACKGROUND: Hindfoot deformity has been described as a risk factor for poor hallux valgus (HV) surgery outcomes. However, there has been no study that demonstrates it. The purpose of this investigation was to evaluate the influence of hindfoot misalignment in HV surgery results. METHODS: All patients operated on for HV during 2010 and 2011 at 3 university hospitals were included. The preoperative and 2-year postoperative radiologic data included the HV and the intermetatarsal (IM) angles, the naviculocuboid overlap (NC), the talonavicular coverage (TN) angle, the talus-first metatarsal (T-1MT) angle, as well as the calcaneal pitch (CP) angle. Additionally, the Short Form-36 questionnaire version 2.0 (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) score, satisfaction and recurrence were also analyzed. A total of 207 met the inclusion criteria. There were 26 patients (12.6%) who could not be assessed at the 2-year follow-up. Patients were allocated to a varus, normal, or a valgus hindfoot tertile using the values for the CP, NC, TN, and T-1MT angles. RESULTS: No significant differences (P > .05) were found between the groups when the HV or IM angles, AOFAS, SF-36 Mental Composite Scale, SF-36 Physical Composite Scale, or satisfaction were compared. Similarly, no significant and strong correlations were observed (P > .05, ρ < 0.3) between any of the mentioned hindfoot measures and the outcomes scales. CONCLUSION: No influence of hindfoot misalignment on HV surgery outcomes was found in the present study in terms of correction, pain, function, satisfaction, or quality of life. Patients with hindfoot misalignment did not obtain worse outcomes in HV surgery. LEVEL OF EVIDENCE: Level II, prognostic, comparative study.

Partial lateral facetectomy plus Insall's procedure for the treatment of isolated patellofemoral osteoarthritis: survival analysis.

PURPOSE: The purpose of this study was to report the survival analysis of partial lateral facetectomy and Insall's procedure in patients with isolated patellofemoral osteoarthritis, and to assess the risk and protective factors for failure of this procedure. METHODS: From 1992 to 2004, all subjects with isolated patellofemoral osteoarthritis who met the inclusion criteria and underwent this procedure were enrolled. Risk and protective factors for failure (failure considered as the need for total knee arthroplasty) were assessed by comparing obtained baseline data between failed and non-failed cases. Eighty-seven cases (mean (SD) age 61.8 (7.7) years, mean (SD) follow-up 9.6 (3.2) years) were included. RESULTS: Twenty-three failed cases were found. Mean (SD) survival time was 13.6 (0.5) years. At 13 years (last failure case), the cumulative survival was 59.3 %. Baseline medial tibiofemoral pain, genu flexum, and worst grade of tibiofemoral osteoarthritis were significant risk factors for failure (p < 0.0001, p = 0.02, p < 0.0001, respectively). In contrast, higher anatomical (p = 0.02) and total (p = 0.03) knee society score (KSS) scores, absence of knee effusion (p = 0.03), higher value of the Caton-Deschamps index (p = 0.03), and lateral position of the patella (p = 0.01) were all protective factors against failure. CONCLUSION: The treatment for isolated patellofemoral osteoarthritis through partial lateral facetectomy and Insall's procedure demonstrated good long-term survival. The presence of preoperative medial tibiofemoral pain, genu flexum, and incipient tibiofemoral osteoarthritis increased the risk of failure of this procedure. In contrast, higher anatomical and total KSS scores, absence of knee effusion, higher value of the Caton-Deschamps index, and lateral position of the patella were found to protect against failure.

Influence of common associated forefoot disorders on preoperative quality of life in patients with hallux valgus.

BACKGROUND: Hallux valgus (HV) is frequently associated with other forefoot disorders, but its influence on preoperative quality of life (QOL) has not been well characterized. The main purpose of this study was to assess the influence of common associated forefoot disorders (metatarsalgia and lesser toe deformities) on preoperative QOL in patients with HV. METHODS: Preoperative QOL assessed through the Short Form-36 (SF-36, version 2) was obtained from 94 patients with HV from a database. Patients were classified according to their condition: HV alone, HV and metatarsalgia, HV and lesser toe deformities, and HV and both metatarsalgia and lesser toe deformities. Values of each domain were compared among groups. In addition, a correlational study between SF-36 and radiographic severity of HV was performed. The mean age of the 94 patients was 62.6 ± 12.3 years. There were 42.6% patients with HV alone, 30.8% with HV and metatarsalgia, 16% with HV and lesser toe deformities, and 10.6% with HV and both metatarsalgia and lesser toe deformities. RESULTS: Patients with HV and associated metatarsalgia and lesser toe deformities had significantly worse physical function (P = .029), role-physical (P = .017), bodily pain (P = .045), role-emotional (P = .016), mental health (P = .001), and mental component summary (P = .003) compared to patients with HV alone. There were no significant correlations between radiographic HV and intermetatarsal angles and any of the domains or summaries of the SF-36. CONCLUSION: Patients with HV and both metatarsalgia and lesser toe deformities have significantly worse QOL compared to patients with HV alone. The presence of associated forefoot deformities may be a discriminating factor for the prioritization of surgical treatment of HV. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Correlation of dorsiflexion angle and plantar pressure following arthrodesis of the first metatarsophalangeal joint.

BACKGROUND: The correlation between angle of fusion of the first metatarsophalangeal (1MTTP) joint and pressures under metatarsal heads and hallux has not been well characterized. The main purpose was to investigate the correlation between fusion dorsiflexion angle of the 1MTTP joint and plantar pressures under the first metatarsal head and hallux during gait. METHODS: Patients who underwent arthrodesis of the 1MTTP joint from 2005 to 2010 were seen for a follow-up examination. Of 27 patients, 15 (22 feet) with a mean follow-up of 26.2 months were evaluated in the study. Main outcomes included the fusion clinical and radiological dorsiflexion angles and the mean and maximum dynamic plantar pressures under all 5 metatarsal heads and under the hallux. Plantar pressures were measured through an in-shoe system while patients walked normally along a corridor. RESULTS: The dorsiflexion angle was positively correlated with mean dynamic plantar pressures under the first metatarsal head: P = .02 (r = 0.5) for clinical angle, and P = .01 (r = 0.58) for radiological angle. Patients with 15 degrees or more of clinical dorsiflexion angle demonstrated higher mean dynamic plantar pressure under the first metatarsal head (P = .05) and higher maximum dynamic plantar pressure under the second metatarsal head (P = .04) compared with patients with less than 15 degrees. In contrast, the latter patients demonstrated higher mean dynamic plantar pressure beneath the hallux (P = .04). Patients with 30 degrees or more of radiological dorsiflexion angle demonstrated significantly higher mean dynamic plantar pressure under the first metatarsal head (P = .04) compared with patients with less than 30 degrees. CONCLUSION: Higher dorsiflexion angles correlate with higher plantar pressures under the first metatarsal head. Lower dorsiflexion angles increase plantar pressures beneath the hallux during gait. CLINICAL RELEVANCE: Significant increase in plantar pressure under the first metatarsal head may be avoided by performing the arthrodesis of the 1MTTP joint below 30° and 15° for the radiological and clinical dorsiflexion angles, respectively.

Treatment of isolated patellofemoral osteoarthritis with lateral facetectomy plus Insall's realignment procedure: long-term follow-up.

PURPOSE: To assess the long-term results of lateral facetectomy plus Insall's realignment procedure to treat isolated patellofemoral osteoarthritis. METHODS: All consecutive patients undergoing this procedure with a follow-up between 10 and 14 years were included in this study. Subjects were excluded if they had previous patellar dislocation, patellar fracture, tibiofemoral osteoarthritis (except mild cases) or follow-up <10 or >14 years. Failure cases (need for total knee arthroplasty) of this surgical procedure before 10 years of follow-up were considered in the overall failure rate. Clinical, functional and radiographic outcomes were obtained at baseline and compared to postoperative values. RESULTS: Forty-three patients (mean (SD) age 59.7 (8.1) years) had a follow-up between 10 and 14 years and were finally included in this study. The failure rate in the whole series and included patients was 26.4 and 16.3 %, respectively, for a mean (SD) follow-up of 9.2 (3.2) years and 11.7 (1.4) years, respectively. Patellofemoral pain (p < 0.0001), need for NSAIDs (p < 0.0001), longitudinal (p < 0.0001) and transversal (p < 0.0001) patellar glide tests, Zholen's sign (p = 0.0007) and knee effusion (p = 0.02) significantly improved in the follow-up. Postoperative Knee Society Score (KSS) anatomical (p < 0.0001), functional (p < 0.0001) and total (p < 0.0001) scores and Kujala's score (p = 0.001) were significantly higher compared to preoperative values. The patellar tilt (p = 0.001) and shift (p = 0.04) significantly improved postoperatively, whereas the patellofemoral osteoarthritis was not modified (n.s.) with respect to preoperative assessment. CONCLUSIONS: The lateral facetectomy plus Insall's realignment procedure was a successful treatment for isolated patellofemoral osteoarthritis from a clinical, functional and radiographic point of view in the long-term follow-up.

Effects of an educational audiovisual videodisc on patients' pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study.

PURPOSE: To investigate the effectiveness of an educational videodisc in modifying pre-operative patients' expectations with total knee arthroplasty (TKA) and to find a biophysical profile of subjects in whom this videodisc could be most effective. It was hypothesized that patients receiving standard information plus additional medical information through audiovisual videodiscs would modify their pre-operative expectations more than those only receiving the standard information through medical interviews. METHODS: Ninety-two patients (age, 50-90 years) with knee osteoarthritis waiting for TKA were randomized into two groups. All patients received general verbal information about this procedure. Forty-two patients (study group) additionally viewed an educational videodisc related to the whole process of TKA, whereas 50 patients did not view it (control group). Patients completed baseline and post-videodisc questionnaires regarding their expected results after TKA. RESULTS: Expectations with TKA were not modified by the audiovisual videodisc, except for knee range of motion and use of stairs. There were no differences in change of expectations between groups depending on demographic, functional, health, emotional, and cognitive variables, except for body mass index. The overall pre-operative, pre-intervention expectations were not modified by the audiovisual videodisc. CONCLUSIONS: Based on these results, the use of this complementary tool may not be systematically recommended. In addition, it was not possible to identify a biophysical profile of patients in whom the intervention could be most effective.