John G. Anderson

Stage IV posterior tibial tendon insufficiency: the tilted ankle

Stage IV PTTD is the most challenging of the posterior tibial tendon deficiencies. The combination of a flattened longitudinal arch and a tilted ankle make successful management unpredictable. Conservative management universally fails and surgical options have been limited to pantalar and tibiotalocalcaneal arthrodesis. Alternatives to surgical management included herein are unproven, but provide a potential solution beyond that of arthrodesis.

Total ankle arthroplasty: A historical perspective

The ideal total ankle prosthesis has yet to be determined, but much has been learned from early experiences in ankle arthroplasty. Modern implants are typically more respectful of anatomic concerns, have found a happy medium of constraint, and have found novel approaches to decrease interface stress. Biologic fixation has improved on cemented results. Surgical techniques and understanding of wound healing and ligamentous deficiency have advanced. Current series still have varied results, and longer-term follow-up is needed. Despite this, some modern ankle replacements represent significant progress, with improved results and survival challenging those of arthrodesis. Further, benefits of preserved motion and avoidance of foot arthritis outstrip this traditional gold standard. Today, tempered enthusiasm for the future of total ankle arthroplasty is again apparent. A diverse, international effort is underway to create a lasting joint implant. Building on the lessons of the past, different investigators in different countries, using markedly different prostheses, continue to work toward this goal.

Heel Overload Associated with Heel Cord Insufficiency

Background: Heel cord lengthening is a common component of foot and ankle surgery. If the tendon is anatomically or functionally over lengthened patients may develop plantarflexion weakness and heel overload problems such as symptomatic plantar heel callosities and heel ulceration. Methods: Nine patients who developed heel overload or heel ulcer after a heel cord lengthening or an irreparable rupture were identified. Initial foot injury, risk factors, treatment, and followup were reviewed. Results: Five of the nine patients had diabetes and an insensate heel. The ulcer healed in two of five patients with a dorsiflexion stop brace, two with a tendon transfer, and one required a below knee amputation. There were four patients with heel overload with normal sensation and no diabetes. One improved with strengthening exercises, two with tendon transfer, and one required a below knee amputation. Conclusions: Heel cord insufficiency can lead to an overload callus or a heel ulcer. Patients with diabetes and an insensate heel are at highest risk, but this problem also can occur in patients with normal sensation. Obesity and ipsilateral first toe amputation also may be risk factors.

Joint preservation procedures for ankle arthritis.

This Current Concept Review is presented by the American Academy of Orthopaedic Surgeons (AAOS) Ankle Arthritis Clinical Guideline Work Group. Its purpose was to review the evidence on the surgical procedures available to treat ankle arthritis while preserving the joint. This included open and arthroscopic debridement, realignment osteotomies of the distal tibia and foot, distraction arthroplasty, interpositional arthroplasty, and allograft arthroplasty. This report was based on a recent systematic review of the published English language literature performed by members of the AAOS Ankle Arthritis Work Group. The work group was comprised of AAOS research staff and volunteer physicians.

Tibial Compartment Syndrome and the Cavovarus Foot

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed (scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 (P = .034) as well as use regional nerve blocks for scenario 2 (P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.