John M. Schuberth

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Arthroscopic ankle arthrodesis: factors influencing union in 39 consecutive patients.

Background: Arthroscopic ankle arthrodesis is an effective alternative to open techniques with established advantages in select patient populations. The purpose of this study was to evaluate patients who had arthroscopic ankle arthrodesis for end-stage arthritis with minimal to no deformity of the ankle and to report factors influencing union. Methods: Thirty-nine consecutive patients had arthroscopic ankle arthrodesis between 1994 and 2003. Clinical records and radiographs were retrospectively reviewed to evaluate variables that could predispose patients to nonunion. Union outcomes were correlated with etiology of arthritis, ankle deformity, medical comorbidities, and the use of demineralized bone matrix or platelet-rich plasma. Arthroscopic ankle arthrodesis was accomplished with a consistent technique using crossed transmalleolar cannulated screw fixation. Results: Thirty-four of 39 patients (87.2%) achieved radiographic and clinical union. The average time to fusion was 47 (range 37 to 70) days. Poor bone quality and inherent positional ankle deformity were identified as risk factors for nonunion. Patients who smoked, had diabetes mellitus, peripheral neuropathy, or other medical comorbidities attained ankle union in nearly all cases. In obese patients, there was an observed trend towards ankle nonunion (relative risk 5.81, p = 0.049, Fishers Exact test). The addition of demineralized bone matrix or platelet-rich plasma did not improve the rate of ankle union. Aside from nonunion, 10 patients developed minor complications. Conclusion: Arthroscopic ankle arthrodesis achieves high union rates, facilitates short time to union, and permits rapid patient mobility. Careful patient selection is important for the procedure. Synthetic allograft or platelet-rich plasma did not enhance the fusion rate. Obese patients showed a trend towards nonunion in this series.

Minimally Invasive Arthroscopic-Assisted Reduction with Percutaneous Fixation in the Management of Intra-Articular Calcaneal Fractures: A Review of 24 Cases

UNLABELLED A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of intra-articular calcaneal fractures is presented. Collected data included articular step-off, medial wall displacement, and Boehlers angle, in addition to other descriptive characteristics of the fracture and case series. The operative technique is described in detail including the optimal screw constructs. Arthroscopic assistance was used in 10 of the cases. The articular step-off of the posterior facet, medial wall displacement, and Boehlers angle all displayed statistically significant change between the preoperative and postoperative periods (P < .0001). These results were consistent with the goal of restoration of articular congruity, calcaneal morphology, and calcaneal height. There were no soft tissue complications. The mean overall follow-up duration was 2.8 years (range 1 to 10 years). Of the 18 patients who were followed for more than 1 year (range 1.0 to 10 years), none went on to subtalar fusion. The results of this study suggest that a minimally invasive approach can improve radiographic parameters consistent with the ultimate goals of operative reduction of calcaneal fractures, and can be used to achieve satisfactory results with minimal risk of wound complication. LEVEL OF CLINICAL EVIDENCE 4.

Diagnosis and treatment of First Metatarsophalangeal Joint Disorders. Section 6: Other disorders ☆ ☆☆

If clinical examination and radiographs allow for definitive diagnosis, treatment should be directed accordingly. Nondisplaced or mildly displaced fractures, symptomatic partitions, and avascular necrosis may be initially treated with immobilization and offloading techniques. If these measures fail, or if a markedly displaced fracture is encountered, excision of the affected sesamoid(s) may be indicated. Degenerative/arthritic changes may be treated with offloading techniques, orthotics, anti-inflammatory nonsteroidal drugs, or localized injection. Surgery may be indicated if nonsurgical care is unsuccessful (2,14). Excision of a sesamoid(s) may result in a variety of postoperative problems including hallux varus, valgus, hammertoe, and/or extensus; the patient must be evaluated carefully (15).

Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity.

To identify complications that necessitated revision surgery after the primary operation, a multicenter retrospective chart review was conducted for 646 patients who received either a modified chevron-Austin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients), or closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Revision surgery for complications was calculated and compared. All surgery was performed by 1 of 5 staff foot and ankle surgeons at Kaiser Permanente medical centers. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection, and capital fragment dislocation. The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them. The total rate for re-operation was 5.56% among patients who received chevron-Austin osteotomy, 8.82% among those who had a closing base wedge osteotomy, and 8.19% for patients who received modified Lapidus arthrodesis. Among patients who had the chevron-Austin osteotomy procedure, rates of re-operation were 1.85% for recurrent hallux valgus and 1.48% for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of re-operation were 2.92% for recurrent hallux valgus and 0.29% for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94% for recurrent hallux valgus and 2.94% for hallux varus. The collected comparative complication rates should serve to provide adjunctive information for foot and ankle surgeons and patients regarding hallux valgus surgery.

The diagnosis and treatment of heel pain

Mechanical heel pain is one of the most frequent conditions presented to foot and ankle specialists. Plantar heel pain is responsible for the majority of mechanical heel pain cases. Plantar heel pain is defined as insertional heel pain of the plantar fascia with or without a heel spur (Fig. 1). The most common cause cited for plantar heel pain is biomechanical abnormalities that lead to pathologic stress to the plantar soft tissues (1–7). Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (8–11). Patients usually present with isolated plantar heel pain upon initiation of weightbearing, either in the morning upon arising or after sitting for a period of rest. The pain tends to decrease after a few minutes, then returns as the day proceeds and time on the feet increases. Associated significant findings may include high body mass index, tightness of the Achilles tendon, pain upon palpation of the inferior heel, and inappropriate shoe wear (12–14). Many patients will have attempted self-remedies before seeking medical advice. A careful history is important, including time(s) of day when pain occurs, current shoe wear, activity level both at work and at leisure, and history of trauma. An appropriate physical examination of the lower extremity includes range of motion of the ankle with special attention to decreased range of motion of dorsiflexion of the ankle, palpation of the inferior medial aspect of the heel, palpation of the medial aspect of the heel, the occurrence of bilateral symptoms, and angle and base of gait evaluation. Following physical evaluation, appropriate radiographs may be considered. Radiographic identification of a plantar heel spur indicates that the condition has been present for at least 6–12 months, whether having been symptomatic or not (Fig. 2). As a rule, the longer the duration of heel pain symptoms, the longer the period to final resolution of the condition. Initial treatment options may include nonsteroidal antiinflammatory drugs (NSAIDs), padding and strapping of the foot, and corticosteroid injections for appropriate patients. Patient-directed treatments seem to be as important in resolving symptoms. They include regular stretching of the calf muscles, avoidance of flat shoes and barefoot walking, use of cryotherapy directly to the affected part, over-the-counter arch supports and heel cushions, and limitation of extended physical activities. Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If no improvement is noted, the patient should be referred to a podiatric foot and ankle surgeon. The second phase of treatment for the referred patient includes continuation of the initial treatment options with considerations for additional therapy: the use of custom orthotic devices, especially in the biomechanically malaligned patient, the use of night splints to

Complications after open reduction and internal fixation of ankle fractures in the elderly

BACKGROUND Open reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age. METHODS A retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed. RESULTS There was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications. CONCLUSIONS Overall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.

Isolated Medial Incisional Approach to Subtalar and Talonavicular Arthrodesis

Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial-incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.

The Radiographic Fate of the Syndesmosis after Trans-syndesmotic Screw Removal in Displaced Ankle Fractures

The purpose of this study was to evaluate the radiographic changes of the tibiofibular position and the ankle mortise after removal of trans-syndesmotic fixation to determine if there is loss or maintenance of correction. In addition, the effect of the type of rotational injury, early weight bearing, and the number of trans-syndesmotic screws used on the integrity of the inferior tibiofibular articulation or ankle mortise after screw removal were evaluated. An analysis was conducted of 86 patients, with an unstable rotational ankle fracture requiring open reduction with syndesmosis screw stabilization. Routine radiographic parameters were measured just after open reduction and just before syndesmotic screw removal. There was a high correlation of loss of the integrity of the syndesmotic parameters after screw removal. However, the medial clear space of the ankle changed an insignificant amount, suggesting that although there appears to be some loss of maintenance, the talus did not shift laterally at the expense of a mobile syndesmosis. Ankle injuries requiring stabilization of syndesmotic instability with use of temporary trans-syndesmotic fixation achieve a stable ankle mortise after removal. Tibiofibular diastasis is commonplace upon removal of the syndesmotic hardware, but the ankle mortise remains unchanged. Based on the radiographic criteria described in this study, the postoperative change in medial clear space or tibiofibular diastasis has no bearing on fracture type, deltoid injury, or the use of 1 or 2 cortical screws. As such, other unknown mechanisms affecting the integrity of the syndesmosis after screw removal are in place.

Cement Spacer as Definitive Management for Postoperative Ankle Infection

Background: Postoperative infection can be a devastating complication of ankle replacement and arthrodesis surgery. Management consists of eradication of the infection and either, revision of the initial surgery or some form of salvage procedure. There are instances however when the patient is asymptomatic, medically unfit, or the local tissue is too tenuous to warrant performing additional surgery. We conducted a retrospective review of the outcome of the use of an antibiotic impregnated cement spacer as the definitive procedure in this kind of patient. Methods: There were nine patients with post operative deep ankle infection following surgery who did not undergo subsequent revision surgery. The initial surgeries were either total ankle replacement (TAR) (n = 6) or ankle arthrodesis (n = 3). The indications for the retention of the cement spacer were patients who were asymptomatic following insertion of the cement spacer, did not desire further surgery, or were medically unfit for further surgery. The patients all underwent removal of hardware or implants, debridement, and insertion of an antibiotic impregnated cement spacer. Six weeks of intravenous antibiotics were administered according to culture sensitivity results. Patients were followed up closely for complications (wound dehiscence, spacer migration, bone loss), resolution of infection, functionality, and satisfaction. Results: The average time of cement spacer retention was 20.1 months, ranging from 6 to 62 months. The most common infecting organisms were Staph. Aureus (n = 3) and Staph. Epidermidis (n = 3). One patient had wound complications, possibly due to the proximity of the cement spacer to the anterior skin surface. One patient had a repeat infection at 52 months. The most common co-morbidities were rheumatoid arthritis (n = 3) and diabetes (n = 2). At final followup, seven patients still had a retained cement spacer and two had subsequent below knee amputations (BKA) performed as a result of delayed complications. Review of the X-rays revealed two patients with loosening and migration of the cement spacer. No patients had signs of excessive bone loss. All patients with a retained antibiotic cement spacer were mobile and able to perform basic activities of daily living with minimal discomfort. Conclusion: The long-term use of antibiotic impregnated cement spacers following postoperative ankle infection is a reasonable option in the low demand patient with surgical or medical co-morbidities. Level of Evidence: IV; Retrospective Case Series