Maximalist Shoes: Separating Science From Hype.

One of the most discussed but misunderstood topics in foot and ankle is shoe wear choices and the purported benefits of each type of shoe versus their actual scientific advantages. All foot and ankle care providers should be familiar with the various shoe wear types available to patients to improve their overall foot health. Recently, mainstream popularity and media coverage of maximalist shoes has created increased interest in the science and potential clinical benefits of maximalist shoes. The purpose of this review is to present the current biomechanical evidence of maximalist shoes and to help inform the foot and ankle community of their potential therapeutic applications.Levels of Evidence: Level V.

Periprosthetic Fracture After Hindfoot Fusion Nail Treated With Spanning Antegrade Tibial Nail.

LEVEL OF EVIDENCE: Level V.

Foot and Ankle Injections in Athletes.

CONTEXT: Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety. EVIDENCE ACQUISITION: An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results. CONCLUSIONS: Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Knotless Reconstruction of Chronic Achilles Tendon Ruptures With <3-cm Defects: Technique Tip.

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation. Level of Evidence: Level V, Expert Opinion.

Fractures of the Talus: Current Concepts.

Talus fractures continue to represent a challenging and commonly encountered group of injuries. Its near-complete articular cartilage surface, and its role in force transmission between the leg and foot, makes successful treatment of such injuries a mandatory prerequisite to regained function. Familiarity with the complex bony, vascular, and neurologic anatomy is crucial for understanding diagnostic findings, treatment indications, and surgical techniques to maximize the likelihood of anatomic bony union. This review details the structure and function of the talus, a proper diagnostic workup, the treatment algorithm, and post-treatment course in the management of talus fractures. LEVEL OF EVIDENCE: Level V, expert opinion.

Repair of Combined Insertional and Midsubstance Achilles Tendon Ruptures.

Complex combined tears of the insertion and midsubstance of the Achilles tendon are rare injuries that are challenging to diagnose and treat. The author describes a novel technique for combined insertional and midsubstance Achilles repair that decreases proximal soft tissue dissection, restores musculotendinous length, and directly fixes tendon to bone in a strong, knotless fashion to allow for early mobilization and functional recovery. [Orthopedics. 2020; 43(1):e57-e64.].

Advances in the Surgical Management of Ankle Fractures.

Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair. LEVEL OF EVIDENCE: Level V, expert opinion.

Complex Ankle and Hindfoot Arthrodesis Using Circular External Fixation.

Surgical reconstruction of the ankle and hindfoot in patients with diabetes, Charcot neuroarthropathy, osteomyelitis, deformity, and/or bone loss can be challenging and often results in amputation. In these patients, conventional internal fixation with plates, screws, and intramedullary nails is often not feasible because of ongoing infection or poor bone stock and soft tissue quality. The Ilizarov method of ankle and hindfoot arthrodesis is a well-established technique for limb reconstruction that uses circular external fixation to achieve solid bony fusion, optimal leg length, and eradication of infection in cases of complex pathology. This article discusses indications, contraindications, pearls, and pitfalls of performing ankle and hindfoot arthrodesis using the Ilizarov technique.

Transfemoral Amputation Adductor Myodesis Using FiberTape and Knotless Anchors.

Transfemoral amputation is considered the last treatment option for severe infection, vascular disease, trauma, and malignant tumors of the lower extremity that have failed limb salvage. Unopposed pull of the hip abductors causes a flexion-abduction thigh deformity that results in abnormal biomechanics and increased oxygen consumption during ambulation. Myodesis of the adductor tendons is a critical component of transfemoral amputation that creates dynamic muscle balance, enhances prosthetic fitting and function, and improves clinical outcomes. Traditional adductor myodesis uses locking sutures passed through cortical drill holes along the anterolateral aspect of the distal femur that are tensioned and tied by hand. In this report we describe a novel technique for adductor myodesis using FiberTape suture and knotless anchors that we have found to be quick, easy, and reproducible with strong tendon-bone fixation. LEVEL OF EVIDENCE: Level V, expert opinion.

Management of a Tibial Plafond Lung Cancer Metastasis Using an Intramedullary Hindfoot Fusion Nail.

Metastatic disease to the tibial plafond is rare with few reports in the literature. No consensus exists regarding surgical reconstruction of large structural defects of the ankle due to these lesions, as each treatment must be tailored to the individual patient's goals and prognosis. Cancer metastases pose a unique challenge to limb salvage as there is often bone loss and poor soft tissue quality combined with the need for postoperative adjuvant therapy. The goal of surgery is to obtain early weightbearing, pain relief, and a durable reconstruction that will outlive the patient. In this report, we present the case of an intraarticular fracture of the tibial plafond with severe bone loss due to a lung carcinoma metastasis. The patient was successfully treated with en bloc tumor excision, curettage, argon beam coagulation, tibiotalocalcaneal arthrodesis using an intramedullary hindfoot fusion nail, and bone cementation with postoperative chemotherapy and radiation. One year after surgery, the patient was able to bear full weight on the extremity without a brace or assistive device and had no pain in the ankle with no local tumor recurrence. LEVELS OF EVIDENCE: Level V: Expert opinion.

Intraoperative Ultrasound Guidance for the Removal of Nonmetallic Foreign Body from the Foot.

Ultrasound has become an increasingly valuable diagnostic tool throughout all areas of medicine. The role of diagnostic ultrasonography has an evolving role in orthopaedic surgery and particularly in the field of foot and ankle. Whether in the clinic or hospital setting, ultrasound has proven to be pivotal in the identification and localization of foreign bodies. The inherent limitations of plain films in identifying nonmetallic penetrating foreign bodies of the foot can be overcome or enhanced with the assistance of diagnostic ultrasound. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Limited-Incision Knotless Achilles Tendon Repair.

Acute midsubstance Achilles tendon ruptures, which are increasingly common among athletes, can result in significant functional limitations and decreased quality of life when not managed appropriately. The various surgical techniques for treating Achilles ruptures include open repair with Krackow locking sutures, percutaneous repair, and limited-incision repair with suture-passing jigs. Less invasive techniques have been developed to optimize the functional benefits of surgery while reducing delayed wound healing, infection, and other postoperative complications. An important albeit subjective aspect of Achilles tendon repair is suture knot tying and tensioning around the rupture site. Recently, a limited-incision knotless Achilles tendon repair technique (Achilles Midsubstance SpeedBridge; Arthrex) was developed to minimize soft-tissue dissection, restore musculotendinous length, and directly fix tendon to bone to allow for early mobilization and more rapid functional recovery. The indications, contraindications, details, pearls, and pitfalls of this surgical technique are discussed in this article.

Foot and Ankle Injuries in American Football.

Physicians need to be aware of a variety of foot and ankle injuries that commonly occur in American football, including turf toe, Jones fractures, Lisfranc injuries, syndesmotic and deltoid disruption, and Achilles ruptures. These injuries are often complex and require early individual tailoring of treatment and rehabilitation protocols. Successful management and return to play requires early diagnosis, a thorough work-up, and prompt surgical intervention when warranted with meticulous attention to restoration of normal foot and ankle anatomy. Physicians should have a high suspicion for subtle injuries and variants that can occur via both contact and noncontact mechanisms.

Posteromedial Approach for Open Reduction and Internal Fixation of Talar Process Fractures.

UNLABELLED: Fractures of the posteromedial process of the talus are frequently the result of high-energy trauma to the lower extremity. The treatment of these uncommon injuries may be unfamiliar and challenging to many surgeons. Significant pain and disability can result if these injuries are not recognized or treated appropriately. Open reduction and internal fixation via a posteromedial approach with screws is a mainstay of operative treatment for simple fractures. In cases of fracture impaction and/or comminution, a medial uniplanar external fixator may be used to improve intraoperative fracture visualization and mini-fragment plates and screws can be used to secure areas of comminution. LEVEL OF EVIDENCE: Level V, expert opinion.

Preliminary Treatment of Achilles Tendinopathy Using Low-Intensity Pulsed Ultrasound.

BACKGROUND: Achilles tendinopathy is a degenerative process of the tendon associated with diminished vascularity, microtrauma, and aging. Nonoperative treatments such as activity modification, immobilization, night splints, and physical therapy have good outcomes for the majority of patients. However, there are cohorts of patients that remain symptomatic despite use of all nonoperative measures that eventually require surgical intervention. The present study reports the preliminary short-term clinical outcomes of low-intensity pulsed ultrasound (LIPUS) for treatment for Achilles tendinopathy. MATERIALS AND METHODS: Fourteen patients with clinically diagnosed Achilles tendinopathy who failed previous nonoperative treatments underwent LIPUS stimulation directly over the area of maximum tendon tenderness for 20 min/d for 8 weeks total. No other treatment modalities were used during the period of LIPUS stimulation. All patients had serial clinical exams and evaluations with an average follow-up of 12 months (range, 6-50 months). RESULTS: Excellent clinical outcomes with complete resolution of pain and other symptoms were obtained in 7 patients (50%). Two patients (14%) had good outcomes with mild tendon irritation and stiffness not requiring further intervention. Five patients (36%) had minimal benefit with continued pain, swelling, and tenderness over the Achilles and functional deficits. No patients had worsening pain or progression of disability requiring surgery. CONCLUSIONS: LIPUS is an additional noninvasive treatment modality for chronic Achilles tendinopathy that may potentially help improve clinical symptoms and delay and/or prevent the need for surgical intervention. While LIPUS is easy to use, well-tolerated, and has promising early clinical results, further research is needed to determine the long-term benefits, disadvantages, and cost-effectiveness of this alternative treatment for tendinopathy. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Return to Play in National Football League Players After Operative Jones Fracture Treatment.

BACKGROUND: Jones fractures commonly occur in professional athletes and operative treatment remains the standard of care in this patient population. In our clinical experience, an aggressive postoperative rehabilitation protocol for National Football League (NFL) players with an average return to play (RTP) between 8 and 10 weeks can have successful outcomes with few complications. The purpose of this study was to quantify RTP and rate of complications, including nonunion, refracture, and reoperation among a cohort of NFL players with operatively treated Jones fractures. METHODS: Between 2004 and 2014, 25 consecutive NFL players who underwent acute Jones fracture fixation by a single surgeon were reviewed. Operative treatment for the majority of patients involved fixation with a Jones-specific intramedullary screw and iliac crest bone marrow aspirate with demineralized bone matrix injected at the fracture site. Additionally, our protocol involved the use of noninvasive bone stimulators, application of customized orthoses, and an aggressive patient-specific rehabilitation protocol. Patient demographics were recorded along with position played, seasons played after surgery, RTP, and complications. RTP was defined as the ability to play in a single regular-season NFL game after surgery. At the time of surgery, average age for all patients was 24.0 years and BMI 31.0. RESULTS: Player positions included 8 wide receivers, 4 linebackers, 4 tight ends, 2 defensive tackles, 2 cornerbacks, 1 offensive tackle, 1 center, 1 tackle, 1 defensive end, and 1 quarterback. Seventy-six percent of players underwent operative fixation during their first 3 seasons. Forty-eight percent were diagnosed before or during their rookie (first) season.RTP was 100% for all players and 80% were still playing at time of publication. Three patients (12.0%) refractured and required revision surgery. Time until RTP was influenced by other variables and difficult to measure because many surgeries were performed early in the offseason. All 9 players who underwent surgery between July and October, and were therefore eligible to return to play in the same season, had an average RTP of 8.7 weeks (range 5.9-13.6). CONCLUSION: With an appropriately placed intramedullary screw and an aggressive rehabilitation protocol, early RTP was achievable with a low refracture rate in professional athletes. All NFL players in this series were able to return to play after surgery. We observed that these injuries were more likely to occur in the first 3 seasons of play and in wide receivers, linebackers, and tight ends. This at-risk subset of players may benefit from improved preventative measures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Intermediate and Long-Term Outcomes of the Modified Brostrom-Evans Procedure for Lateral Ankle Ligament Reconstruction.

UNLABELLED: Background This case series evaluated the clinical and functional outcomes of patients with lateral ankle instability treated with a primary modified Brostrom-Evans.Methods Nineteen patients who underwent the modified Brostrom-Evans procedure for lateral ankle instability with a minimum follow-up of 5 years were reviewed. Physical exams were performed and weight-bearing ankle radiographs taken at final follow-up. Clinical outcomes were evaluated using Short Form Health Survey (SF-36), Foot Function Index (FFI), and Visual Analog Scale (VAS) scores. Functional outcomes were assessed using a goniometer for ankle range of motion (ROM) and dynamometer for ankle strength compared to the non-operative extremity.Results Average age at time of surgery was 34 ± 11 years (range 17-58 years) and average follow-up was 8.7 ± 2.8 years (range 5.1-15.4 years). At final follow-up, average total SF-36 and FFI scores were 83 ± 18 and 11% ± 18%, respectively. Average VAS at rest was 1 ± 1 and during activities 2 ± 2. There were no significant differences in ankle eversion ROM or strength between operative and non-operative extremities. Ankle eversion strength in operative extremities was 91 ± 12% of non-operative ankles. Ankle ROM was similar in all planes except for a 41% decrease in ankle inversion in surgically treated extremities compared to the contralateral side (p = .01).Conclusions Patients treated with the modified Brostrom-Evans procedure for lateral ankle ligament reconstruction have minimal loss of peroneal strength, decreased inversion ROM, and no recurrent instability or progressive symptomatic subtalar arthritis requiring re-operation at long-term follow-up. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

Reduction in Wound Complications After Total Ankle Arthroplasty Using a Compression Wrap Protocol.

BACKGROUND: The purpose of this study was to evaluate the clinical differences in wound complications after total ankle arthroplasty (TAA) between a cohort of patients that received a compression wrap protocol and a historical control group treated with cast immobilization. METHODS: Patient charts and postoperative wound pictures were reviewed for 42 patients who underwent a compression wrap protocol and 50 patients who underwent circumferential casting after primary TAA from 2008 to 2013. A blinded reviewer graded each wound using a novel postoperative wound classification system, and recorded whether the wound was completely healed by or after 3 months. A second blinded review was performed to determine intraobserver reliability. Mean patient age was 55 years (range, 24-80) and all patients had at least 6-month follow-up. RESULTS: There were significantly more total wound complications (P = .02) and mild wound complications (P = .02) in the casted group compared to the compression wrap group. There were no significant differences in the number of moderate and severe complications between each group. A significantly higher proportion of TAA incisions took longer than 3 months to heal in the casted group (P = .02). CONCLUSIONS: Based on our clinical experience with postoperative wound care after TAA, use of a compression wrap protocol was safe and effective at reducing wound-related complications, and well tolerated by patients. Further prospective, randomized clinical trials are warranted to evaluate the utility and cost-effectiveness of a compression wrap protocol after TAA.