E. Greer Richardson

Current Concepts Review: Total Ankle Arthroplasty

Many orthopaedic surgeons had abandoned the use of first and second generation total ankle arthroplasties due to unacceptably high complication and failure rates as compared to arthrodesis. Recently, there has been renewed interest in ankle joint replacement as longer term outcome studies have become available, and the FDA has approved several more designs. With the introduction of two new FDA approved implants in November 2006, options for surgeons interested in total ankle arthroplasty have greatly expanded. There continues to be much debate within the orthopaedic community as to indications, patient selection, and optimal component design. This review aims to provide orthopaedists with an overview of the currently available implants and literature.

Thromboembolism after foot and ankle surgery : A multicenter study

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

Injuries to the Hallucal Sesamoids in the Athlete

The sesamoids of the great toe, which are small and seemingly insignificant bones, can be the site of disabling pathology for the athlete. Sesamoiditis, osteochondritis, partite sesamoids with stress fractures, displaced fractures, and osteomyelitis have all been reported in the athlete. Bursitis beneath the tibial sesmoid and flexor hallucis brevis tendonitis also occur in the athlete and may be confused with sesamoid injury. Excision of the involved bone is the recommended treatment for displaced fractures and for less severe conditions such as sesamoiditis, osteochondritis, and nondisplaced fractures, if conservative management fails to relieve symptoms.

First Metatarsal Head-Shaft Angle: A Method of Determination

The distal metatarsal angle (DMAA) is a measurement of the relationship between the longitudinal axis of the first metatarsal and the articular surface of the metatarsal head. We measured the DMAA on radiographs with and without markers on the articular edges and compared them with measurements of the anatomic specimens. Based on the studies, the significance of the radiographic measurements to the actual DMAA and the normal distribution of the measurement were determined.

Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year Followup:

Background: There are few long-term studies on the non-operative treatment of Stage II Posterior Tibial Tendon Dysfunction (PTTD). The purpose of this study is to describe the natural history and determine the efficacy of non-operative treatment of Stage II PTTD using clinical outcome scores. Materials and Methods: Patients with Stage II PTTD treated with a Double Upright Ankle Foot Orthosis (DUAFO) with a minimum followup of 7 years were identified retrospectively. Patients were evaluated with the AOFAS Ankle/Hindfoot Score, SF-36, Foot Function Index (FFI), Visual Analog Scale (VAS) for pain, and a custom questionnaire in addition to a comprehensive physical examination. Results: Thirty-three feet in 32 patients were included with an average followup of 8.6 years. Success defined as being brace-free and avoiding surgery was 69.7%. Five patients (15.2%) were unable to completely wean from a brace. Five patients went on to surgery. The mean AOFAS and FFI score was 78.4 and 18.4, respectively. Compared to national norms, SF-36 subscores for each age sub-category showed no significant difference in any of the age groups (p < 0.05). Average VAS pain scale score was 1.9. Satisfaction was rated as “satisfied” in 20 patients (60.6%), “satisfied with minor reservations” in 11 patients (33.3%), partially satisfied in one (3.0%), and “unsatisfied” in one (3.0%). None of the patients rated as “satisfied with major reservations”. Conclusion: Treatment of Stage II PTTD with a DUAFO has been shown to be a viable alternative to surgery with a high likelihood of adequate function, avoidance of surgery, and being brace-free at 7- to 10-year followup.

Long-Term Evaluation of Interdigital Neuroma Treated by Surgical Excision

Background: We examined a large cohort of patients who had interdigital neurectomy and evaluated their clinical outcomes by using a previously developed scoring system as well as a visual analog scale (VAS). In addition, we wanted to identify risk factors that may lead to poorer outcomes. Materials and Methods: A retrospective review identified 232 patients who had neuroma excision between 1994 and 2004, after failure of conservative treatment. Each patient was contacted via mail and given a Neuroma Clinical Evaluation Score survey as well as a visual analog score. Each patient received a unique identification number, allowing the evaluation process to be single-blinded. Results: Of the 232 patients contacted, 120 (52%) returned their completed surveys. The average Giannini neuroma score was 53: 61 feet (51%) had good or excellent results, 12 (10%) had fair results, and 48 (40%) had poor results. The average VAS score was 2.5. The only significant (p = 0.027) difference in outcome was the location of the neuroma: second webspace had worse outcomes than third webspace neuromas on both the VAS and neuroma score. Conclusion: This retrospective review identified location in the second webspace as a possible prognostic indicator of poor outcome, but the more important finding may be that outcomes of neuroma excision do not appear to be as successful at long-term followup as previously reported

Radiographic Changes in the First Metatarsal Head after Distal Chevron Osteotomy Combined with Lateral Release Through a Plantar Approach

The purpose of this study was to evaluate the development of clinically significant avascular necrosis of the head of the first metatarsal after: (1) distal metatarsal osteotomy of the chevron configuration beginning apically at the center of the metatarsal head and extending into the head metatarsal neck junction and (2) release of the adductor hallucis muscle, the lateral capsulosesamoid ligament, and the lateral head of the flexor hallucis brevis via fibular sesamoidectomy in the majority of procedures (71/77). Although there were initial radiographic findings suspicious of avascular necrosis, subchondral lucencies (28 feet), mottling (40 feet), and focal lucencies (29 feet) in 76% of the feet, at final follow-up (12–43 months, average 25 months) this figure had fallen to 25%. The range of motion of the first metatarsophalangeal joint and articular symptoms were important in this study because of the assumption that these two parameters of evaluation would correspond to the severity of radiographic evidence of avascular necrosis. Only those patients (8 feet) with persistent mottling at final follow-up had a statistically significant decrease in the average range of motion (P = .013), with 51° total arc of motion compared with 64° total arc of motion for the remainder. There were no patients with persistent radiographic changes suggesting avascular necrosis who complained of pain. We concluded from the radiographic and clinical data that if the primary blood supply to the capsule and head of the metatarsal (the first dorsal intermetatarsal artery) is preserved, an extensive lateral release combined with a distal metatarsal osteotomy of the chevron configuration are unlikely to cause clinically significant avascular necrosis of the first metatarsal head. By clinically significant, we refer to range of motion and articular pain.

The Chevron bunionectomy: a trigonometric analysis to predict correction.

A trigonometric analysis was developed in an attempt to predict the postoperative hallux valgus angles and inter-metatarsal angles after Chevron bunionectomy. This analysis was used in 20 feet to predict postoperative angles, and these predicted values were compared with actual measured roentgenographic values. The postop erative intermetatarsal angles were evaluated to deter mine their correction to postoperative hallux valgus angles of 20° or less. Using the trigonometric analysis, the post operative intermetatarsal angles were highly predictable, but the hallux valgus angle could not be reliably predicted for individual patients. The intermetatarsal angle obtained at surgery, however, was indicative of the final hallux valgus angle: 75% of feet with intermetatarsal angles of more than 11° had postoperative hallux valgus angles of more than 20°. Thus, when an intermetatarsal angle of 11° or less can be obtained surgically, the hallux valgus angle can be corrected to 20° or less in most patients.

Dysplasia Epiphysealis Hemimelica (Trevor Disease) Presenting as Peroneal Spastic Flatfoot Deformity: A Case Report

Trevor disease (dysplasia epiphysealis hemimelica) involving the foot and ankle is not uncommon, but its presentation as a progressive spastic flatfoot deformity is unusual. The patient reported had an isolated lesion in the medial facet of the subtalar joint. In addition to the unusual presentation and location, the lesion recurred 1 year after surgical excision.

Special Report: Highlights of the 23rd Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Toronto, Ontario, Canada, July 13–15, 2007:

The 23rd Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 13–15 July 2007 at the Westin Harbour Castle Hotel in Toronto, Ontario, Canada. There were 538 registrants in attendance, including 182 individuals from 29 countries outside the United States. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.