N. Cullen

Levels of evidence in foot and ankle surgery literature: progress from 2000 to 2010?

BACKGROUND The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. METHODS All of the articles in the literature from the years 2000, 2005, and 2010 in Foot & Ankle International and Foot and Ankle Surgery, as well as all foot and ankle articles from The Journal of Bone and Joint Surgery (JBJS, American [A] and British [B] Volumes) were analyzed. Animal, cadaver, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence were excluded. Articles were ranked by a five-point level-of-evidence scale, according to guidelines from the Centre for Evidence-Based Medicine. RESULTS A total of 720 articles from forty-three different countries were analyzed. The kappa value for interobserver reliability showed very good agreement between the reviewers for types of evidence (κ = 0.816 [p < 0.01]) and excellent agreement for levels of evidence (κ = 0.869 [p < 0.01]). Between 2000 and 2010, the percentage of high levels of evidence (Levels I and II) increased (5.2% to 10.3%) and low levels of evidence (Levels III, IV, and V) decreased (94.8% to 89.7%). The most frequent type of study was therapeutic. The JBJS-A produced the highest proportion of high levels of evidence. CONCLUSION There has been a trend toward higher levels of evidence in foot and ankle surgery literature over a decade, but the differences did not reach significance.

The demand incidence of symptomatic ankle osteoarthritis presenting to foot & ankle surgeons in the United Kingdom.

BACKGROUND Ankle arthritis is a cause of major disability; however reports in the literature on the incidence of ankle osteoarthritis are rare. OBJECTIVES To explore the methodological challenges in obtaining an incidence of ankle osteoarthritis and to estimate the incidence of symptomatic osteoarthritis presenting to Foot & Ankle specialists in the UK. METHODS We searched available national diagnosis databases and also sent out a questionnaire-based survey to all Consultant members of the British Orthopaedic Foot & Ankle Society (n=180). RESULTS 123 completed survey questionnaires were returned (68%) with each surgeon seeing on average 160 cases of symptomatic ankle arthritis and performing on average 20 definitive procedures for end-stage ankle osteoarthritis per year. There are no internationally agreed diagnostic or treatment codes specific for ankle osteoarthritis. CONCLUSION There are an estimated 29,000 cases of symptomatic ankle osteoarthritis being referred to specialists in the UK, representing a demand incidence of 47.7 per 100,000. 3000 definitive operations to treat end stage ankle osteoarthritis take place in the UK annually. We recommend that specific codes pertaining to ankle arthritis and its treatment be included in any future revisions of the WHO International Classification of Diseases (ICD) and operative procedure coding systems.

Fixation of an Akin osteotomy with a tension suture: Our results

An Akin osteotomy is a closing wedge varus osteotomy of the proximal phalanx, usually performed as part of a hallux valgus correction surgery to complement the metatarsal correction. Numerous fixation techniques have been described; most provide good and stable fixation, but involve permanent and sometimes protruding hardware. A retrospective cohort study has been carried out of 115 feet in 109 patients using a technique with an absorbable suture fixation of the medial cortex of the proximal phalanx while preserving the lateral cortex. All the osteotomies united completely with no loss of position. HV angles and IM angles were within acceptable parameters. In comparison to others methods, the technique presented in this study is technically simple, provides good results, requires no specialized instrumentation, is cost effective and has a very low complication rate.

Patient satisfaction and function after bilateral ankle arthrodeses

BACKGROUND The optimum way to manage patients with bilateral ankle arthritis (AA) is unclear. METHODS This review was performed to report the midterm satisfaction and functional outcome of a series of patients who have undergone bilateral staged ankle arthrodesis. RESULTS Eight patients, median age 68.5 yrs (range 59-80) were followed-up for a median of 58.5 months (range 24-100). All fusions united in a median time of 12.8 weeks (range 10-19) Their median AOFAS hindfoot score was 79.5 (range 71-90). Six patients (75%) were very satisfied, one was satisfied, and the other neither satisfied nor dissatisfied. Two patients developed symptomatic subtalar arthritis requiring subtalar fusion. CONCLUSIONS This is the first study to report the outcome of bilateral AA independent to that of unilateral AA. Bilateral AA appears to give patients a good functional result with high patient reported satisfaction into the medium term.

Destructive Pseudo-neuroarthropathy Associated With Calcium Pyrophosphate Deposition

Background: Calcium pyrophosphate deposition (CPPD) disease is a metabolic disorder characterized by soft tissue calcific deposits formed primarily in articular cartilage. What can result is a crystal-induced arthropathy often referred to as pseudogout, which is variable in both presentation and severity. A particularly destructive and deforming arthritis is an uncommon but well-recognized subtype of this disease. Radiologically resembling the neuroarthropathy described by Charcot, a pattern of joint fragmentation and structural collapse occurs in the absence of peripheral neuropathy. This pseudo-neuroarthropathy is rarely reported in the foot and ankle. Methods: A total of 15 cases of pseudo-neuroarthropathy involving some previously unreported joints within the foot and ankle are described in this case series of 9 patients. Results: All patients presented with disease involving multiple joints. Clinical deformity was apparent in each case, and extensive joint destruction was seen on plain radiographs. In 6 patients, histopathological CPPD disease was confirmed on tissue biopsy of the affected joints. In the remaining 3 patients a clinical diagnosis was made on the basis of the classic appearance of pseudo-neuroarthropathy in the foot, with additional recognized features of CPPD. Operative management with deformity correction using joint arthrodesis produced satisfactory clinical and radiological results. Conclusions: In the absence of peripheral neuropathy and systemic disease, the pseudo-neuroarthropathy of CPPD should be considered when a progressively deforming and destructive arthritis is seen in the foot and ankle. Level of Evidence: Level IV, case series.

Clear cell sarcoma of the distal tibialis posterior tendon insertion: a case report.

An os naviculare or accessory navicular bone is present in 5% to 10% of the population. Most are asymptomatic but one can present with medial foot pain as a result of inflammation of the tibialis posterior tendon insertion or synchondrosis with swelling and pes planus.1,9 Clear cell sarcoma is a rare musculoskeletal tumor that is usually intimately associated with tendons and muscle aponeuroses. It classically presents as a slow growing soft tissue mass with young white females being most commonly affected.4,8,16 Although approximately 300 cases of clear cell sarcoma have been reported in the literature,7 few have concentrated on clinical findings. To our knowledge, this is the first case of an association between clear cell sarcoma and an accessory navicular.

Evaluation of the 1st metatarso-sesamoid joint using standing CT — The Stanmore classification

BACKGROUND Little is understood about the role that relative sesamoid displacement and chondral wear have on outcome after hallux valgus (HV) surgery. All existing methods to evaluate relative sesamoid displacement have limitations and furthermore, there have been no radiographic studies evaluating metatarso-sesamoid joint wear. Standing CT scan circumvents many of the existing problems in evaluation of relative sesamoid displacement, and also enables the first radiographic study assessing metatarso-sesamoid joint wear. METHODS Fifty feet (in 43 patients) with symptomatic HV (Group A) were compared with a control group of 50 feet (50 patients) (Group B). All images were standardised to enable reproducible measurements. The hallux valgus angle, Intermetatarsal angle, sesamoid rotation angle, sesamoid position and metatarso-sesamoid joint space were measured in all patients. RESULTS The intra and inter-observer reliability correlation showed that the standing CT assessment of sesamoid position (1.000), rotation (0.991) and metatarso-sesamoid joint space (0.960) were highly reproducible. There was a highly significant difference (p<0.0001) in sesamoid position, sesamoid rotation and metatarso-sesamoid joint space between Group A and Group B. CONCLUSIONS Standing CT has been shown to be a reproducible and accurate method of assessing the relative sesamoid displacement and metatarso-sesamoid joint space narrowing. The results have been used to propose a novel standing CT based classification of hallucal sesamoids, considering the degree of displacement and wear. This classification may ultimately facilitate research to provide new insight into the effect relative sesamoid displacement and chondral wear have on outcomes from hallux valgus surgery.

Gastrocnemius tightness: A population based observational study

BACKGROUND Gastrocnemius tightness is believed to be associated with multiple musculoskeletal pathologies such as back pain, plantar fasciitis and metatarsalgia. Although surgical treatment of gastrocnemius tightness is gaining popularity the objective definition of a gastrocnemius contracture has not been determined. The aim of our study was therefore to quantify gastrocnemius tightness in a normal population. METHODS Adult participants with no obvious foot and ankle pathology were recruited. Gastrocnemius tightness was quantified using a weightbearing lunge test. Maximal ankle-foot dorsiflexion was measured on participants with the knee in full extension and flexed to 20° using a digital inclinometer. The ankle-foot dorsiflexion index or ADI (difference in ankle dorsiflexion with the knee extended and flexed) was calculated. The ADI values were plotted on a histogram to identify the distribution of values and were compared according to participant demographics. RESULTS 800 limbs from 400 participants were examined. There was a wide distribution of absolute values of maximal ankle-foot dorsiflexion ranging from 8 to 52°. The ADI ranged from 0 to19° and approximated to a normal distribution. The mean ADI was 6.04±3.49° and was positively correlated with age (r=0.132, P<0.001) and negatively correlated with physical activity (r=-0.88, P=0.015). CONCLUSION(S) Our study is the first to quantify gastrocnemius tightness in a large healthy adult population with differences observed by age and physical activity. We have defined an easy and reproducible weightbearing test that can be used in both research and clinical settings. The majority of the population have some degree of gastrocnemius tightness and values of ADI greater than 13° (>2 SD of the mean), as measured by the lunge test, may be considered abnormal.

Measuring Functional Range of Motion in Patients with Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: Measurement of range of motion is an important outcome measure following ankle surgery. However, there is wide variation in its measurement: from clinical evaluation, to radiographic metrics, and gait analysis. The purpose of this study was to present and validate a simple, standardized technique for measurement of function total range of motion between the tibia and the floor using a digital goniometer. Methods: Institutional review board approval was obtained. Forty-five ankles from 33 participants were recruited into two groups. Group 1 (Healthy controls), comprised 20 ankles from 10 participants. None had any musculoskeletal or neurological pathology. Group 2 (Ankle osteoarthritis), comprised 25 ankles from 23 patients. Ankle pathology had been treated with ankle arthrodesis (n=5), total ankle replacement (n=6), and non-operative treatment (n=14). Measurement was performed by two testers according to a standardized protocol developed for the Pivotal Total Ankle Replacement Versus Arthrodesis (TARVA) RCT. Intra- and inter-rater reliability was calculated using intra-class correlation coefficients. Results: Group 1 (Healthy controls). The median difference for all measurements within an observer was 1.5 (IQR 0.7-2.5) degrees. The ICC for inter-rater total ankle range of motion was excellent 0.95 (0.91-0.97, 95% confidence interval, p < 0.001). The ICC for intra-rater total ankle range of motion was excellent 0.942 (0.859-0.977, 95% CI, p < 0.001). Group 2 (Ankle osteoarthritis). The median difference for all measurements within an observer was 0.6 (IQR 0.2 -1.3) degrees. The intra-class coefficient (ICC) for inter-rater total ankle range of motion was excellent 0.99 (0.97 -1.0), 95% CI, p < 0.001). The ICC for intra-rater total ankle range of motion was 0.99 (0.96 -1.0), 95% CI p < 0.001). Conclusion: This technique provides a reliable, standardized method for measurement of total functional range of motion between the tibia and the floor. The technique requires no specialist equipment or training, and provides a valid functional assessment for patients with and without ankle osteoarthritis and also following treatment even with an ankle arthrodesis.