George B. Holmes

Etiologic Factors Associated with Symptomatic Achilles Tendinopathy

Background: The purpose of this study was to determine if a statistical association exists between Achilles tendinopathy (also referred to as tendinosis) and obesity, diabetes mellitus, hypertension, the supplemental use of estrogen, and exposure to local or systemic steroids. Methods: From July, 1997, to February, 2003, 82 patients with a diagnosis of Achilles tendinopathy were identified. The diagnosis of Achilles tendinopathy was confirmed by a review of medical records, radiographs, and MRI. There were 44 women and 38 men with an average age of 50 (range 27 to 77) years. For the parameters of obesity, hypertension, diabetes, steroid exposure, and the use of estrogen compounds, all patients were analyzed both cumulatively and stratified into subgroups by gender and age. Chi-square 2 times 2 tables were used to compare the observed prevalence of the parameters in patients with Achilles tendinopathy to the expected prevalence of these disorders and exposures in the population at large. Results: Cumulatively, 98% percent (43 of 44 women; 29 of 38 men) had hypertension, diabetes, obesity, and steroid or estrogen exposure. Seventy-six percent of men (29) had hypertension, diabetes, and obesity, or steroid exposure. Sixty-eight percent of women (15 of 22) had a history of hormone replacement therapy and 44% (8 of 15) had a positive history for use of oral contraceptives. When compared with published national data using Chi-square analysis, the association between tendinopathy and hormone replacement therapy and oral contraceptives was found to be statistically significant with p-values of 0.01 and 0.001, respectively. For both women and men, obesity was statistically associated with Achilles tendinopathy with p-values of 0.025 and. 001, respectively. Hypertension was statistically associated with Achilles tendinopathy only for women. Diabetes mellitus and Achilles tendinopathy were found to have a statistical association only for men younger than 44 years old Conclusions: Obesity, hypertension, and steroids have as their end-organ effect a diminution of local microvascularity. The significant correlation of these factors with Achilles tendinopathy suggests the importance of their effect on microvascularity in the development of Achilles tendinopathy.

Fractures and Dislocations of the Foot and Ankle in Diabetics Associated with Charcot Joint Changes

This study was undertaken to evaluate the occurrence of Charcot joint changes in diabetic patients after fractures and/or dislocations of the foot and ankle. There were 20 fracture/dislocations of the foot and ankle in 18 patients, with an average follow-up of 27 months (range 14–70 months). There were eight fractures of the midfoot, six fractures of the ankle, four fractures of the hindfoot, and two fractures of the forefoot. Eight fractures were followed by the development of Charcot changes: five in the midfoot and one each in the forefoot, hindfoot, and ankle. Of nine fractures recognized early and initially treated by early immobilization or ORIF, seven healed uneventfully. Two fractures, both open injuries, developed soft tissue infection and osteomyelitis, respectively. Of the 11 fractures in which there was a delay in diagnosis and treatment, eight developed Charcot changes. The early recognition and appropriate treatment of fractures in diabetic patients appears to be important in the prevention of Charcot joint changes.

Revision MTP Arthrodesis for Failed MTP Arthroplasty

Introduction. Although the gold standard to address hallux rigidus that fails conservative treatment is an arthrodesis, some surgeons have attempted to use arthroplasty to improve range of motion and to simulate a normal joint. When these implants do fail, a salvage MTP arthrodesis is the only surgical option for these patients. This research aims to outline various methods to arthrodese the MTP joint in salvage situations. Methods. We retrospectively looked at patients who underwent a first-MTP fusion after failure of an implant arthroplasty. All fusions involved either bone allograft or autograft and internal fixation. The patients were assessed clinically, radiographically, and with the Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) clinical questionnaire preoperatively and postoperatively. Results. In all, 11 patients met the inclusion criteria. The average age of patients at the time of the salvage MTP arthrodesis was 57 years. The interval time between primary surgery and revision arthrodesis was on average 84.2 months. There was a high reoperation rate, with 7 operative procedures occurring per 12 arthrodeses (58%). The average time to radiographic fusion was 6.9 ± 4.8 months; 41.7% of patients had a delayed union (>6 months to fusion). Two patients had symptomatic nonunions (16.7%). All the patients had an improvement in their AOFAS MTP-IP score. Conclusion. Although salvage arthrodeses for failed arthroplasties generally have favorable satisfaction rates and are a powerful tool in treating this painful condition, they are fraught with complications. They unite slower, have a significantly higher reoperation rate, and have lower AOFAS scores than primary fusions. Levels of Evidence: Therapeutic, Level IV—Case series

Injectable Treatments for Noninsertional Achilles Tendinosis A Systematic Review

Background: Although there has been a recent increase in interest regarding injectable therapy for noninsertional Achilles tendinosis, there are currently no clear treatment guidelines for managing patients with this condition. The objective of this study was (1) to conduct a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis, (2) to identify patient-specific factors that are prognostic of treatment outcomes, (3) to provide treatment recommendations based on the best available literature, and (4) to identify knowledge deficits that require further investigation. Methods: We searched MEDLINE (1948 to March week 1 2012) and EMBASE (1980 to 2012 week 9) for clinical studies evaluating the efficacy of injectable therapies for noninsertional Achilles tendinosis. Specifically, we included randomized controlled trials and cohort studies with a comparative control group. Data abstraction was performed by 2 independent reviewers. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. Results: Nine studies fit the inclusion criteria for our review, constituting 312 Achilles tendons at final follow-up. The interventions of interest included platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). Only 1 study met the criteria for a high-quality randomized controlled trial. All of the studies were designated as having a low quality of evidence. While some studies showed statistically significant effects of the treatment modalities, often studies revealed that certain injectables were no better than a placebo. Conclusions: The literature surrounding injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies. Level of Evidence: Level II, systematic review.

Correction of Intermetatarsal Angle in Hallux Valgus Using Small Suture Button Device

Background: Hallux valgus is a common foot ailment causing pain and disability, and correction of the intermetatarsal angle (IMA) deformity is often accomplished using a first metatarsal distal or proximal osteotomy. These osteotomies can be technically challenging and may lead to complications such as loss of fixation, shortening of the first metatarsal, avascular necrosis, malunion, and nonunion. Endobuttons (Mini TightRope device) provide an alternative to first metatarsal osteotomies for correction of the IMA. The purpose of this preliminary study was to determine the short-term clinical and radiographic outcomes of hallux valgus correction using the Mini TightRope. Methods: A total of 14 cases of hallux valgus correction using the Mini TightRope technique with a 1.1-mm drill and mini-buttress plate were reviewed. Clinical examinations and radiographs were performed preoperatively and postoperatively at 1-week (non-weight-bearing), 3-month (weight-bearing), and 6-month (weight-bearing) follow-up. Results: The overall 1-week postoperative decreases in IMA and hallux valgus angle (HVA) of all cases compared with preoperative status were 9 degrees and 28 degrees, respectively. Decreases in IMA and HVA continued at 3 months postoperatively but to a lesser extent, with decreases of 7 degrees and 20 degrees, respectively. Reductions in IMA and HVA were maintained through 6 months of follow-up compared with preoperatively, with IMA and HVA decreases of 6 degrees and 19 degrees, respectively. Two minor soft-tissue complications and 1 intraoperative second metatarsal fracture were treated with a buttress plate, with uneventful healing. Conclusions: Overall short-term results demonstrated notable improvements in IMA and HVA with use of the Mini TightRope, and few early complications were associated with the procedure. Level of Evidence: Level IV, retrospective case series.

Treatments for avascular necrosis of the talus: a systematic review.

Introduction: Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature. Methods: We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. Results: 19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is “very low”. Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN. Discussion: Given the “very low” GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN. Level of Evidence: Level II

Quantitative Determination of Intermetatarsal Pressure

Pain, plantar to the metatarsophalangeal joints, is a common location for the presentation of pain in the forefoot. In the absence of fractures or specific inflammatory conditions common causes of pain in this area include: (1) nonspecific metatarsalgia, (2) plantar fat pad atrophy, and (3) interdigital (intermetatarsal) neuroma. The aggravation and possibly the etiology of these forms of forefoot pain may be related to acute or chronic extrinsic pressure to the forefoot. The role of nonweightbearing, compression of the metatarsal heads, weightbearing, and toe-stance (on the metatarsal heads) on the intermetatarsal pressure of the third interspace was measured in eleven asymptomatic volunteers. Intermetatarsal pressures were recorded using the Stryker Miniaturized Digital Fluid Pressure Monitor. Intermetatarsal pressures for nonweightbearing, nonweightbearing with medial-lateral compression of the metatarsal heads, weightbearing, and toe stance averaged 21 mm Hg, 22 mm Hg, 29 mm Hg, and 36 mm Hg, respectively. In comparison to nonweightbearing, significant increases in intermetatarsal pressures were measured with weightbearing (P = .0027) and toe stance (P = .0002). The change noted from weightbearing to toe-stance was also significant (P = .0005). These findings support the proposition that increases in forefoot plantar pressures convey greater pressures to the intermetatarsal space and metatarsal heads. Increased pressures to the intermetatarsal space may likewise lead to or exacerbate the symptoms of patients with fat pad atrophy, nonspecific metatarsalgia and Mortons neuroma.

Treatment of Osteonecrosis of the Talus

More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis.Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis.In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.

Clinical tip : Eccentric in-situ inlay bone graft for delayed unions and nonunions of the base of the fifth metatarsal

Inlay bone grafting has been demonstrated to be a useful technique for the treatment of nonunions and failed arthrodeses of the foot.1,3 A significant advantage in the use of this technique is that it creates an immediate bone bridge across the nonunion site. Union is enhanced by the greater ease of incorporation of the proximal and distal ends of the graft as well as the early establishment of stability by the corticocancellous strut. On the other hand, a disadvantage of this technique is that bone must be harvested from distant donor sites, such as the tibia or the iliac crest, with the risks of postoperative pain, hypertrophic scarring, and incisional neuroma. This technical tip modifies the traditional bone inlay graft technique, achieving the advantages of the inlay bone graft without the morbidity associated with graft harvesting from a distant donor site. This technique has been found to be relatively simple to perform and reduces the overall operative time when compared to harvesting the graft from a distant donor site. This technique should be added to the options of bone grafting techniques available to achieve union for delayed unions, nonunions, and failed arthrodeses.

Factors Influencing Patient Selection of a Foot and Ankle Surgeon

An increasingly consumer-centric health insurance market has empowered patients to select the providers of their choice. There is a lack of studies investigating the rationale by which patients select a foot and ankle surgeon. In the present study, 824 consecutive new patients seeking treatment from 3 foot-ankle surgeons were consecutively administered an anonymous questionnaire prior to their first appointment. It included rating the importance of 15 factors regarding specialist selection on a 1 to 10 scale, with 10 designated “Very important” and 1 designated “Not important at all.” The remaining questions were multiple choice regarding patient perspectives on other surgeon aspects (appointment availability, waiting room times, clinic proximity, etc). Of 824 consecutive patients administered the survey, 305 (37%) responded. Patients rated board certification (9.24 ± 1.87) and on-site imaging availability (8.48 ± 2.37)—on a 1 to 10 scale, with 10 designated “Very important— as the 2 most important criteria in choosing a foot and ankle surgeon. Patients rated advertisements as least important. Among the patients, 91% responded that a maximum of 30 minutes should elapse between clinic check-in and seeing their physician; 61% responded that a maximum of 20 minutes should elapse between clinic check-in and seeing their physician. In the context of an increasingly consumer-driven paradigm of health care delivery and reimbursement, it is important to understand patients’ preferences in specialist selection. Levels of Evidence: Level III: Prospective questionnaire