Capsular Interposition Arthroplasty With Percutaneous Suture Anchoring: A Pragmatic and Novel Surgical Technique for Hallux Rigidus.

There is support for the use of capsular interposition arthroplasty (CIA) as an alternative to arthrodesis in the surgical treatment of hallux rigidus. In this technical report, the authors describe novel technical variations to the traditional capsular interposition arthroplasty that are anatomically rational, reproducible, and efficient. This technique was developed by the primary author and has been the preferred approach to CIA for over 10 years. The key technical differences of the procedure are metatarsal head preparation, the use of a proximally based capsular graft, and anchoring by utilizing a simple percutaneous anchoring technique. This approach maintains anatomic joint morphology, preserves vascular supply, and bone stock to facilitate future procedures if required.

Angioleiomyoma of the Plantar-Medial Arch: A Case Report.

An angioleiomyoma is a benign soft tissue tumour that arises from smooth muscle layer of blood vessels. The true aetiology of these masses is largely unknown and quite often may not be associated with pain. This paper illustrates the occurrence of an angioleiomyoma in the medial arch of the foot, a previously unreported location. Significant delay occurred in the patient being referred for specialist consultation, after attending numerous general practitioners for management. This highlighted the need for ongoing publication for case reports of this nature. The patient underwent excision with no recurrence of the lesion reported at 12 months. Often masses of this type may be left alone. However, when symptomatic simple excision will suffice where no other surrounding complication exists and where the mass is well encapsulated in the sub cutaneous area.

Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators.

BACKGROUND: There is increasing global interest and performance of minimally invasive foot surgery (MIS) however, limited evidence is available in relation to complications associated with MIS for digital deformity correction. The aim of this prospective audit is to report the surgical and medical complications following MIS for digital deformity against standardised clinical indicators. METHODS: A prospective clinical audit of 179 patients who underwent MIS to reduce simple and complex digital deformities was conducted between June 2011 and June 2013. All patients were followed up to a minimum of 12 months post operatively. Data was collected according to a modified version of the Australian Council of Healthcare standards (ACHS) clinical indicator program. The audit was conducted in accordance with the National Research Ethics Service (NRES) guidelines on clinical audit. RESULTS: The surgical complications included 1 superficial infection (0.53%) and 2 under-corrected digits (0.67%), which required revision surgery. Two patients who underwent isolated complex digital corrections had pain due to delayed union (0.7%), which resolved by 6 months post-op. No neurovascular compromise and no medical complications were encountered. The results compare favourably to rates reported in the literature for open reduction of digital deformity. CONCLUSION: This audit has illustrated that performing MIS to address simple and complex digital deformity results in low complication rates compared to published standards. MIS procedures were safely performed in a range of clinical settings, on varying degrees of digital deformity and on a wide range of ages and health profiles. Further studies investigating the effectiveness of these techniques are warranted and should evaluate long term patient reported outcome measures, as well as developing treatment algorithms to guide clinical decision making.

Plantar pressures and relative lesser metatarsal lengths in older people with and without forefoot pain.

Forefoot pain is a common problem in older people. We determined whether plantar pressures during gait and the relative lengths of the lesser metatarsals differ between older people with and without plantar forefoot pain. Dynamic plantar pressure assessment during walking was undertaken using the Tekscan MatScan® system in 118 community-dwelling older people (44 males and 74 females), mean age 74 (standard deviation=5.9) years, 43 (36%) of whom reported current or previous plantar forefoot pain. The relative lengths of metatarsals 1-5 were determined from weightbearing X-rays. Participants with current or previous plantar forefoot pain exhibited significantly (p=0.032) greater peak plantar pressure under metatarsal heads 3-5 (1.93 ± 0.41 kg/cm(2) vs. 1.74 ± 0.48 kg/cm(2) ). However, no differences were found in relative metatarsal lengths between the groups. These findings indicate that older people with forefoot pain generate higher peak plantar pressures under the lateral metatarsal heads when walking, but do not exhibit relatively longer lesser metatarsals. Other factors may be responsible for the observed pressure increase, such as reduced range of motion of the metatarsophalangeal joints and increased stiffness of plantar soft tissues.

Metatarsocuneiform joint resection arthroplasty for atraumatic osteoarthrosis: an alternative to arthrodesis.

The reported operative treatment of primary osteoarthrosis of the metatarsocuneiform joint has focused primarily on methods of arthrodesis. Arthrodesis of the metatarsocuneiform joint can result in complications in the older or obese patient who is unable to tolerate non-weightbearing. Age and health status can also increase the rate of nonunion and venous thromboembolism, especially in the immobile patient. We present a technique not previously described. The procedure is presented as an alternative to arthrodesis and involves resection arthroplasty of the metatarsocuneiform joint.

Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial.

OBJECTIVE: To investigate the effectiveness of ultrasound guided corticosteroid injection in the treatment of plantar fasciitis. DESIGN: Randomised, investigator and participant blinded, placebo controlled trial. SETTING: University clinic in Melbourne, Australia. PARTICIPANTS: 82 people with a clinical and ultrasound diagnosis of plantar fasciitis unrelated to systemic inflammatory disease. INTERVENTIONS: Participants were randomly allocated to ultrasound guided injection of the plantar fascia with either 1 mL of 4 mg/mL dexamethasone sodium phosphate (experimental group) or 1 mL normal saline (placebo). Before injection the participants were given an ultrasound guided posterior tibial nerve block with 2% lidocaine (lignocaine). MAIN OUTCOME MEASURES: Primary outcomes were pain, as measured by the foot health status questionnaire (0-100 point scale), and plantar fascia thickness, measured by ultrasound at 4, 8, and 12 weeks. RESULTS: Reduction in pain at four weeks favoured the dexamethasone group by 10.9 points (95% confidence interval 1.4 to 20.4, P=0.03). Between group differences for pain scores at eight and 12 weeks were not statistically significant. Plantar fascia thickness measured at four weeks favoured the dexamethasone group by -0.35 mm (95% confidence interval -0.67 to -0.03, P=0.03). At eight and 12 weeks, between group differences for plantar fascia thickness also favoured dexamethasone, at -0.39 mm (-0.73 to -0.05, P=0.02) and -0.43 mm (-0.85 to -0.01, P=0.04), respectively. The number needed to treat with dexamethasone for one successful outcome for pain at four weeks was 2.93 (95% confidence interval 2.76 to 3.12). There were no reported adverse events associated with the intervention. CONCLUSION: A single ultrasound guided dexamethasone injection is a safe and effective short term treatment for plantar fasciitis. It provides greater pain relief than placebo at four weeks and reduces abnormal swelling of the plantar fascia for up to three months. However, clinicians offering this treatment should also note that significant pain relief did not continue beyond four weeks. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000239066.

Development and reliability of an intraoperative first metatarsophalangeal joint cartilage evaluation tool for use in hallux valgus surgery.

The objective of this study was to examine the reliability of an intraoperative evaluation tool for assessing cartilage degeneration of the first metatarsophalangeal joint in hallux valgus surgery. During hallux valgus reconstruction, 2 examiners documented the location, depth, and surface area of cartilage lesions affecting the first MTPJ in 20 females aged 17 to 69 (mean 50.9 ± 13.5) years. Depth of cartilage lesions was assessed using the 5-level International Cartilage Repair Society (ICRS) scale and a 3-level scale (normal, partial thickness, full thickness). Interexaminer reliability of lesion location and depth was assessed using absolute percentage agreement and kappa (κ) statistics, and interexaminer reliability of lesion surface area was assessed using intraclass correlation coefficients (ICCs) and 95% limits of agreement (LOAs). For lesion location, percentage agreement ranged from 90% to 100% and κ values ranged from 0.78 to 1.00, reflecting substantial to excellent levels of agreement. For lesion depth using the ICRS and 3-level scale, percentage agreement ranged from 33% to 100% and weighted κ values ranged from 0 to 1.00, reflecting poor to excellent levels of agreement. For lesion surface area, the ICC was 0.98 (95% confidence interval = 0.97 to 0.99) and 95% LOA was 0.74 to 1.41, indicating excellent reliability. The results of this study demonstrate a generally high degree of reliability between examiners for the intraoperative use of the first metatarsophalangeal joint cartilage evaluation tool, and the tool may have some value in predicting surgical outcomes associated with hallux valgus.

Interventions for treating osteoarthritis of the big toe joint.

BACKGROUND: Osteoarthritis affecting of the big toe joint of the foot (hallux limitus or rigidus) is a common and painful condition. Although several treatments have been proposed, few have been adequately evaluated. OBJECTIVES: To identify controlled trials evaluating interventions for osteoarthritis of the big toe joint and to determine the optimum intervention(s). SEARCH STRATEGY: Literature searches were conducted across the following electronic databases: CENTRAL; MEDLINE; EMBASE; CINAHL; and PEDro (to 14th January 2010). No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised trials, or controlled clinical trials that assessed treatment outcomes for osteoarthritis of the big toe joint. Participants of any age or gender with osteoarthritis of the big toe joint (defined either radiographically or clinically) were included. DATA COLLECTION AND ANALYSIS: Two authors examined the list of titles and abstracts identified by the literature searches. One content area expert and one methodologist independently applied the pre-determined inclusion and exclusion criteria to the full text of identified trials. To minimise error and reduce potential bias, data were extracted independently by two content experts. MAIN RESULTS: Only one trial satisfactorily fulfilled the inclusion criteria and was included in this review. This trial evaluated the effectiveness of two physical therapy programs in 20 individuals with osteoarthritis of the big toe joint. Assessment outcomes included pain levels, big toe joint range of motion and plantar flexion strength of the hallux. Mean differences at four weeks follow up were 3.80 points (95% CI 2.74 to 4.86) for self reported pain, 28.30 degrees (95% CI 21.37 to 35.23) for big toe joint range of motion, and 2.80 kg (95% CI 2.13 to 3.47) for muscle strength. Although differences in outcomes between treatment and control groups were reported, the risk of bias was high. The trial failed to employ appropriate randomisation or adequate allocation concealment, used a relatively small sample and incorporated a short follow up (four weeks). No adverse reactions were reported. AUTHORS' CONCLUSIONS: The reviewed trial presented a high risk of bias, which limited conclusions that could be drawn from the presented data. The inclusion of only one trial indicates the need for more robust randomised controlled trials to determine the efficacy of interventions for this condition.

Ultrasound guided injection of dexamethasone versus placebo for treatment of plantar fasciitis: protocol for a randomised controlled trial.

BACKGROUND: Plantar fasciitis is the most commonly reported cause of chronic pain beneath the heel. Management of this condition commonly involves the use of corticosteroid injection in cases where less invasive treatments have failed. However, despite widespread use, only two randomised trials have tested the effect of this treatment in comparison to placebo. These trials currently offer the best available evidence by which to guide clinical practice, though both were limited by methodological issues such as insufficient statistical power. Therefore, the aim of this randomised trial is to compare the effect of ultrasound-guided corticosteroid injection versus placebo for treatment of plantar fasciitis. METHODS: The trial will be conducted at the La Trobe University Podiatry Clinic and will recruit 80 community-dwelling participants. Diagnostic ultrasound will be used to diagnose plantar fasciitis and participants will be required to meet a range of selection criteria. Participants will be randomly allocated to one of two treatment arms: (i) ultrasound-guided injection of the plantar fascia with 1 mL of 4 mg/mL dexamethasone sodium phosphate (experimental group), or (ii) ultrasound-guided injection of the plantar fascia with 1 mL normal saline (control group). Blinding will be applied to participants and the investigator performing procedures, measuring outcomes and analysing data. Primary outcomes will be pain measured by the Foot Health Status Questionnaire and plantar fascia thickness measured by ultrasound at 4, 8 and 12 weeks. All data analyses will be conducted on an intention-to-treat basis. CONCLUSION: This will be a randomised trial investigating the effect of dexamethasone injection on pre-specified treatment outcomes in people with plantar fasciitis. Within the parameters of this protocol, the trial findings will be used to make evidence-based recommendations regarding the use of corticosteroid injection for treatment of this condition. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry. ACTRN12610000239066.

Postoperative infection rates in foot and ankle surgery: a clinical audit of Australian podiatric surgeons, January to December 2007.

BACKGROUND: Surgical site infections are one of the most common post-operative complications encountered by foot and ankle surgeons. The incidence reported in the literature varies between 0.5 and 6.5%. The results of a 12-month Australia-wide clinical audit analysing the rates of postoperative infections in association with podiatric surgery are presented. METHODS: De-identified patient data was collected from nine podiatric surgeons Australia-wide. Infections were identified according to Australian Council on Health Care Standards (ACHS) definitions and data was entered no earlier than thirty days post procedure. RESULTS: A total of 1339 patient admissions and 2387 surgical procedures were reported using the International Classification of Diseases (ICD-10) and Medicare Benefit Schedule (MBS) coding systems. The overall infection rate was 3.1% and the rate of infection resulting in hospital re-admission was 0.25%. CONCLUSIONS: The benchmark results presented in this paper suggest that infection rates associated with podiatric surgery are well within accepted industry standards as stated in recent literature.

Recent developments in podiatric prescribing in the UK and Australia.

Recent and substantial changes in access to restricted medicines by podiatrists in Australia are clearly consistent with healthcare policies aimed at reshaping the healthcare workforce. At the same time, prescribing and access to medicines by allied health professionals, including podiatrists, has been the focus of a recent scoping project by the UK Department of Health. In this commentary we explore the possible implications of these changes.

Is there a role for podiatric surgeons in public hospitals? An audit of surgery to the great toe joint in Victoria, 1999-2003.

This project aimed to describe and compare the frequencies of procedures performed by podiatric surgeons and orthopaedic surgeons for elective surgery to the great toe joint, an area of identified clinical need. The objective was to determine whether podiatric surgeons in the Australian context possess a surgical skill set which can be utilised in the public health sector. The Medicare Benefits Schedule (Medicare Australia) was reviewed to identify all codes relating to great toe joint surgery and frequency data were obtained for the period July 1999 to June 2003. A separate audit of the activity of Victorian podiatric surgeons was conducted. During the 4 years in Victoria, the number of procedures performed on this joint by 152 orthopaedic surgeons was 5882. Two podiatric surgeons in Victoria performed 1260 operations on this joint over this period (17.6% of great toe joint surgery on average each year in the private sector). Utilising orthopaedic workforce figures and on a per-surgeon basis, during this period the podiatric surgeons performed this type of surgery between 2 and 16 times more often than the orthopaedic surgeons, and consideration should be given to using these skills in the public sector to address the growing demand.

Hallux valgus and hallux rigidus: a comparison of impact on health-related quality of life in patients presenting to foot surgeons in Australia.

BACKGROUND: Hallux valgus and hallux rigidus are common foot conditions that lead to a deterioration in health status. Patients with significant pain or deformity from these conditions frequently resort to surgery. In this project, the foot health status of patients with hallux valgus and hallux rigidus presenting to foot surgeons in Australia was compared. METHODS: Foot health status was measured in 120 participants using the Foot Health Status Questionnaire (FHSQ), a validated 0 - 100 point health status instrument. All participants had presented for surgical advice regarding hallux valgus/rigidus. The mean age of participants was 48.0 years (SD +/- 14.3, range 19 - 79). RESULTS: In the sample, 68% of participants were diagnosed with hallux valgus and 32% with hallux rigidus. Participants with hallux rigidus had greater levels of pain and functional limitation compared with hallux valgus. The mean difference for pain was 13.8 points (95% CI 4.6 to 22.9) and the mean difference for function was 15.0 points (95% CI 5.3 to 24.7). Both conditions result in similarly negative levels of impact on shoe fit and overall foot health. CONCLUSION: This study found measurable differences in foot health status between hallux valgus and hallux rigidus in participants presenting for surgical consultation. While both appear to have a negative impact on health status, hallux rigidus has a more significant impact.

Foot and ankle surgery in Australia: a descriptive analysis of the Medicare Benefits Schedule database, 1997-2006.

BACKGROUND: Foot and ankle problems are highly prevalent in the general community and a substantial proportion of people seek surgical treatment to alleviate foot pain and deformity. However, the epidemiology of foot and ankle surgery has not been examined in detail. Therefore, the aim of this study was to examine patterns and costs of private sector foot surgery provision in Australia. METHODS: Data pertaining to all foot and ankle surgical procedures for the calendar years 1997-2006 were extracted from the Australian Medicare Benefits Schedule (MBS) database and were cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number and type of procedures performed and to assess for temporal trends over the ten year assessment period. The total cost to Medicare of subsiding surgeons' fees in 2006 was also determined. RESULTS: During the 1997-2006 period, 996,477 surgical procedures were performed on the foot and ankle by private surgeons in Australia. Approximately equal numbers of procedures were performed on males (52%) and females (48%). However, males were more likely to undergo toenail, ankle, clubfoot, tarsal coalition and congenital vertical talus surgery, whereas females were more likely to undergo lesser toe, first metatarsophalangeal joint (MPJ), neuroma, heel, rearfoot and lesser MPJ surgery. The total number of procedures was stable over the assessment period, however there was a relative increase in the number of procedures performed on people aged over 55 years. The total contribution of Medicare to subsiding surgeons' fees for procedures performed in 2006 was $14 M. CONCLUSION: Foot and ankle surgery accounts for a considerable degree of healthcare expenditure in Australia, and the number of procedures in those aged over 55 years is increasing. Given the ageing demographics of the Australian population, the future public health and economic impact of foot morbidity is likely to be substantial. Strategies need to be implemented to ensure that the surgical labour force is adequate to address this increasing demand.