Mark S. Mizel

What's new in foot and ankle surgery.

This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2010 and July 2011. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot and Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on February 19, 2011, in San Diego, California, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), held on July 14 through 16, 2010, in Keystone, Colorado.

Evaluation and treatment of chronic ankle pain.

The evaluation and treatment of chronic ankle pain presents a challenge to the orthopaedic surgeon. A detailed history helps to determine causative factors resulting from earlier trauma or surgery. A careful physical examination and radiographic studies also are helpful in making an accurate diagnosis, which is the basis for choosing a specific and effective treatment regimen.

Value of radiographs in the initial evaluation of nontraumatic adult heel pain.

Background: Adult patients with nontraumatic plantar heel pain often present to orthopaedic surgeons for evaluation. A thorough history and physical examination are often sufficient for diagnosis, yet radiographs usually are ordered during the initial evaluation. The purpose of this study was to evaluate the value and cost-effectiveness of these radiographs. Methods: A retrospective chart and radiographic review of 157 consecutive adults (215 heels) presenting with nontraumatic heel pain was done to evaluate the utility of routine radiographs in the initial evaluation. Results: The most common diagnosis was plantar fasciitis (80.9%, 174 of 215). Radiographs were normal in (17.2%, 37 of 215), and incidental radiographic findings were observed in 81.4% (175 of 215). The most common incidental findings were plantar calcaneal spurs (59.5%, 128 of 215) and Achilles spurs (46.5%, 100 of 215). Only (2%, 4 of 215) of all patients had abnormal findings that prompted further evaluation. Conclusions: Routine radiographs are of limited value in the initial evaluation of nontraumatic plantar heel pain in adults and were not necessary in the initial evaluation. Radiographs should be reserved for patients who do not improve as expected or present with an unusual history or confounding physical findings.

Cuboid-navicular tarsal coalition - Presentation and treatment: A case report and review of the literature

A 15-year-old boy complained of left foot pain that had been present for 2 to 3 years. His medical history was negative for any rheumatologic disorders, diabetes mellitus, or trauma. The patient’s pain was localized to the midfoot and ankle regions, with exacerbation noted during extended periods of activity. Nonsteroidal antiinflamatory medications, rest, and nonweightbearing provided only minor relief. Heel lifts and a University of California Berkeley Laboratory (UCBL) insert failed to provide relief. Physical examination of the foot and ankle region identified decreased subtalar and transverse tarsal joint motion and a fixed pes planus deformity. Radiographs were negative for fracture, dislocation, soft-tissue injury, degenerative changes, and talar beaking (Figure 1). Magnetic resonance imaging revealed a bony tarsal coalition between the plantar aspect of the lateral navicular and the medial aspect of the cuboid (Figure 2). The patient was treated with a 6-week period of immobilization in a short-leg walking cast, which initially

Technique tip: Revisit to a surgical approach to allow direct fixation of fractures of the posterior and medial malleolus

The treatment of trimalleolar fractures and the fixation of the posterior malleolar fragment have been discussed and recommended under certain circumstances1,2 (Fig. 1). This is sometimes necessary when reduction of the lateral malleolar fracture does not lead to adequate reduction of the posterior malleolar fragment.2 There are, however, few surgical techniques3,4 described to facilitate this fixation. The authors present a surgical approach to the posterior and medial malleoli previously described by Edgar L. Ralston1 in 1951. This description was published when open reduction and internal fixation of displaced medial and posterior malleolar fractures was relatively uncommon. This approach allows fixation of these two fractures under direct vision, through the same incision, while at the same time allowing direct examination of the distal articular surface. It then involves posterior dissection, mobilization, and anterior retraction of the tendons of the posterior tibialis and flexor digitorum longus. The posterior fracture fragment is then visible and can be treated under direct vision.

Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis.

Background: The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. Methods: The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. Results: Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. Conclusions: Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.

Measurement of isolated subtalar range of motion: a cadaver study.

Fifteen fresh-frozen cadaveric lower extremities were studied to evaluate the reliability of measuring subtalar motion using a bubble inclinometer. There was high intra-observer reliability for manual inversion and eversion of the subtalar joint with the tibiotalar joint locked and unlocked. Poor correlation of radiographic and clinical measurements questioned the validity of bubble inclinometer measurements. The contribution of the tibiotalar joint to apparent subtalar motion, as measured clinically and radiographically, was found to be one-third of the arc of motion, as compared to motion measured clinically and radiographically with the tibiotalar joint locked.

Ipsilateral arthrodesis of the metatarsophalangeal and interphalangeal joints of the hallux.

Background: Arthrodesis of the metatarsophalangeal joint of the hallux is frequently used for treatment of a variety of disorders. However, occasionally patients who have complex deformities or degenerative changes of the hallux require reconstruction of both the metatarsophalangeal and interphalangeal joints. There is concern that arthrodesis of both the metatarsophalangeal and ipsilateral interphalangeal joints could be problematic, interfering with the toe-off phase of gait or with shoewear. Methods: A retrospective evaluation of seven feet in five patients who had simultaneous arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux was undertaken. These cases represented all the patients who had this procedure within the practice of three orthopaedic foot and ankle specialists, totaling over 50 surgeon-years of experience. The indication for surgery in all patients was moderate to severe pain with ambulation with severe fixed deformity of both the interphalangeal and metatarsophalangeal joints of the hallux. All patients had pain that limited their ambulation and interfered with their daily activities. All patients required modified shoewear to accommodate their foot deformity. The mean age of patients was 53 years. The patients were evaluated by questionnaire and radiographic examination. Results: At an average of 46 months followup, all patients had resolution of their pain and were able to wear nonprescription shoes. All had limitations that interfered with full athletic activities but had no limitation of daily activities. Three patients who were employed returned to their occupations and two who were not employed were able to continue housework. Conclusion: Arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux results in painless function in patients with moderate demands.

Intravascular papillary endothelial hyperplasia: a pseudotumor presenting on the plantar foot.

Intravascular papillary endothelial hyperplasia is an unusual lesion typically seen in the upper extremity, trunk, head, and neck.4 Masson9 described it in 1923 and regarded it as a hyperplasia of endothelial cells. Several investigators have suggested more recently that it represents an exuberant reparative response to vascular injury.1,6 It is important to differentiate this benign lesion from malignant processes to avoid overly aggressive surgical management.

Lesser metatarsophalangeal joints: Intra-articular distension, volumetric measurements, and changes of position

Plantarflexion of the second metatarsophalangeal (MTP) joint with intra-articular injection has previously been observed and commented upon, and the purpose of this study was to determine motion of the lesser toes with direct fluid infusion into the lesser MTP joints. Fluid distension was found to cause variable postural changes in all lesser toes; the most consistent change was plantarflexion of the second metatarsophalangeal joint. Dorsiflexion of the third, fourth, and fifth MTP joints was observed, but less reliable than plantarflexion of the second MTP joint. The average volume in each of the lesser MTP joints was less than 1 cc. Plantarflexion of the second MTP joint was usually, but not always, indicative of intra-articular distention. Aspiration of these joints (given their small volume capacity) may not be a reliable or therapeutically useful technique.