Brian G. Donley

Complications of Ankle Fracture in Patients With Diabetes

Abstract Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to practicing clinicians. Complications of impaired wound healing, infection, malunion, delayed union, nonunion, and Charcot arthropathy are prevalent in this patient population. Controversy exists as to whether diabetic ankle fractures are best treated noninvasively or by open reduction and internal fixation. Patients with diabetes are at significant risk for soft‐tissue complications. In addition, diabetic ankle fractures heal, but significant delays in bone healing exist. Also, Charcot ankle arthropathy occurs more commonly in patients who were initially undiagnosed and had a delay in immobilization and in patients treated nonsurgically for displaced ankle fractures. Several techniques have been described to minimize complications associated with diabetic ankle fractures (eg, rigid external fixation, use of Kirschner wires or Steinmann pins to increase rigidity). Regardless of the specifics of treatment, adherence to the basic principles of preoperative planning, meticulous soft‐tissue management, and attention to stable, rigid fixation with prolonged, protected immobilization are paramount in minimizing problems and yielding good functional outcomes.

The Efficacy of Oral Nonsteroidal Anti-Inflammatory Medication (NSAID) in the Treatment of Plantar Fasciitis: A Randomized, Prospective, Placebo-Controlled Study

Background: Plantar fasciitis frequently responds to a broad range of conservative therapies, and there is no single universally accepted way of treating this condition. Modalities commonly used include rest, ice massage, stretching of the Achilles tendon and plantar fascia, nonsteroidal anti-inflammatory medications (NSAIDs), corticosteroid injections, foot padding, taping, shoe modifications (steel shank and anterior rocker bottom), arch supports, heel cups, custom foot orthoses, night splints, ultrasound, and casting. To our knowledge, no prospective, randomized, placebo controlled double-blind study has evaluated the efficacy of oral NSAIDs in the treatment of plantar fasciitis. Methods: Twenty-nine patients with the diagnosis of plantar fasciitis were treated with a conservative regimen that included heel-cord stretching, viscoelastic heel cups, and night splinting. They were randomly assigned to either a placebo group or an NSAID group. In the NSAID group, celecoxib was added to the treatment regimen. Results: Pain and disability mean scores improved significantly over time in both groups, although there was no statistical significance between the placebo and NSAID groups at 1, 2, or 6 months. There was a trend towards improved pain relief and disability in the NSAID group, especially in the interval between the 2 and 6-month followup. Pain improved from baseline to 6 months by a factor of 5.2 and disability by 3.8 in the NSASID group compared to 3.6 and 3.5, respectively, in the placebo group. Even though at baseline the pain and disability scores were higher in the NSAID group, the final pain and disability scores were subjectively lower in the NSAID group than in the placebo group (1.43 for pain and 1.16 for disability in the NSAID group, compared to 1.86 and 1.49, respectively, in the placebo group). Conclusions: These results provide some evidence that the use of an NSAID may increase pain relief and decrease disability in patients with plantar fasciitis when used with a conservative treatment regimen.

Implantable electrical stimulation in high-risk hindfoot fusions

The risk of nonunion in both the ankle and subtalar joints has been reported as high as 41% and 16%, respectively. Several factors have been reported to significantly increase the incidence of nonunion: smoking, previous nonunion, osteonecrosis, history of infection, fracture type, and major medical problems. A single surgeons experience is retrospectively reviewed. Thirteen patients who were identified as high risk for non-union had an implantable electrical stimulator placed at the time of their ankle or hindfoot fusion along with bone grafting. Three ankle, two subtalar, six tibiotalocalcaneal, and two tibiocalcaneal fusions were performed. All 13 patients had a minimum of two major risk factors for non-union. Of the 13 patients, 11 were active smokers and five of 13 had three or more major risk factors. At a minimum of one year follow-up (average, 24.6 months), successful fusion was achieved in 12 of 13 (92%) patients. Pain scores improved from a mean of 8.5 points preoperatively (range, 7 to 10) to a mean of 1.9 points postoperatively (range, 1 to 6), while the preoperative mean modified AOFAS score of 31.2 points (range, 15 to 55) improved to 85.4 points (range, 45 to 100) postoperatively. The improvement was statistically significant at p<0.01. Eleven of 13 patients (85%) ranked their pain as a 1 or 2 out of 10, and achieved a modified AOFAS score of 80 or better. No additional procedures were done to achieve fusion. Four patients developed superficial wound infections requiring local wound care. The subcutaneous battery pack was bothersome to eight of 13 patients, painful to one, and removed in four patients. The results suggest that electrical implantable stimulation may be a useful adjunct to rigid internal fixation and bone grafting for ankle and hindfoot fusions in high-risk patients.

Finite element modeling of the first ray of the foot : A tool for the design of interventions

Disorders of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical force was extracted from experimental data, and a posterior force of 0.18 times the vertical force was assumed to represent loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously. The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least 18% and 43% under metatarsal head and hallux, respectively, were possible.

RISK OF SURAL NERVE INJURY WITH INTRAMEDULLARY SCREW FIXATION OF FIFTH METATARSAL FRACTURES : A CADAVER STUDY

The risk of injury to the sural nerve and its branches during operative procedures performed on the lateral foot and ankle is well recognized; however, there have been no anatomic studies demonstrating the proximity of the sural nerve branches to the head of an intramedullary screw used for fixation of fractures of the proximal fifth metatarsal. Dissection of 10 cadaver specimens, after insertion of 4.5-mm screws, demonstrated that the screw head was within 2 mm of the dorsolateral branch of the sural nerve in five specimens and within 3 mm of eight specimens. Irritation of or injury to the nerve during screw insertion may explain the persistence of pain after screw removal in some patients. Furthermore, patients could sustain injury to the sural nerve at the time of screw removal. Careful surgical technique, including the use of drill guides and tissue protectors, may help lessen the risk of sural nerve injury and subsequent neuroma formation.

Magnetic resonance imaging of the foot and ankle.

&NA; Magnetic resonance (MR) imaging of the foot and ankle is playing an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities, as well as in planning for their surgical treatment. For an optimal MR study of the foot and ankle, it is necessary to obtain high‐resolution, small‐fieldof‐view images using a variety of pulse sequences. The most common indication for MR imaging of the foot and ankle is for the evaluation of tendon and bone abnormalities, such as osteomyelitis, occult fractures, and partial and complete tears of the Achilles, tibialis posterior, and peroneal tendons. Magnetic resonance imaging has also been shown to be helpful in the diagnosis of several softtissue abnormalities that are unique to the foot and ankle, such as plantar fasciitis, plantar fibromatosis, interdigital neuromas, and tarsal tunnel syndrome.

Peroneus Quartus Muscle A Rare Cause of Chronic Lateral Ankle Pain

A prolonged recovery with persistent pain after a lateral ankle injury is not uncommon in athletes. The most frequent causes include undertreated lateral ligament injuries, syndesmotic sprains, tears of the peroneal tendons, anterolateral impingement, fractures of the distal fibula, osteochondral fractures of the talar dome, and fractures of the anterior process of the os calcis. We report an unusual case of an adolescent athlete with chronic ankle pain caused by the presence of a supernumerary peroneus quartus muscle in the lateral compartment. The peroneus quartus muscle is rarely involved in pathologic processes of the foot and ankle, but the rare peroneocuboidan insertion variant presented here frequently causes lateral ankle stenosis.

Selective Atrophy of the Abductor Digiti Quinti: An MRI Study

OBJECTIVE Entrapment of the first branch of the lateral plantar nerve is a well-recognized but diagnostically elusive cause of heel pain. The MR finding of selective atrophy of the abductor digiti quinti (ADQ) muscle has been reported as a marker of such entrapment. We performed a prospective study of consecutive patients undergoing foot and ankle MRI to determine the prevalence of ADQ atrophy and to examine the clinical symptoms of patients found to have ADQ atrophy. SUBJECTS AND METHODS A prospective study of all patients referred for ankle and foot MRI examinations was performed. Six hundred two patients were included in the study: 387 females and 215 males. All images were evaluated for the presence of selective fatty atrophy of the ADQ muscle. The clinical notes on all patients with findings of ADQ atrophy were analyzed for descriptions of symptoms leading to the MR examination, the presence of symptoms that might be related to nerve entrapment, and the influence on clinical management related to the MR finding of ADQ atrophy. RESULTS Thirty-eight of the 602 patients had selective fatty atrophy of the ADQ, 29 females and nine males. Only one patient had a clinical diagnosis of possible nerve entrapment before MR examination. MRI findings of ADQ atrophy altered clinical management in only one patient. CONCLUSION Selective fatty atrophy of the ADQ is not a rare finding on MR examination of the foot and ankle, being seen in 6.3% of all studies and in 7.5% of all studies in females. The clinical relevance of selective ADQ atrophy seen on MRI is uncertain.

Lesser metatarsal osteotomies: A biomechanical approach to metatarsalgia

As with most other orthopedic conditions, a firm understanding of the normal and pathologic biomechanics of the lesser metatarsals is essential when contemplating treatment of metatarsalgia. Despite its prevalence, metatarsalgia remains a technically demanding surgical challenge. Some of the difficulty with treatment of this problem arises because of some of the controversies discussed previously. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Alleviating the correct amount of pressure underneath the metatarsal head without adversely affecting the biomechanics of the region demands an exacting osteotomy that is stable and readily heals. Much of the research done to date has not proved which procedure can achieve these goals reproducibly for patients. It is hoped that future investigations will guide treatment choices and allow patients to obtain relief from this difficult problem with greater success.

Foot and ankle infections after surgery.

Infection after foot and ankle surgery or trauma can range from the common superficial cellulitis to the less common deep soft tissue or bone infections that can have disastrous consequences. The emergence of antibiotic-resistant organisms has made treatment of infection more difficult, even though promising new antibiotics are being developed. Prevention of infection, through proper patient selection and meticulous surgical technique, is essential to satisfactory outcomes.