[Lateral ankle ligament injuries]. / Laterale ankelligamentskader.

Lateral ankle ligament injuries occur in connection with inversion traumas and are one of the most common injuries, both in the general population and among athletes. A lateral ankle ligament injury weakens the stabilising structures in the ankle and disposes the ankle joint to prolonged instability. Acute lateral ankle ligament injuries with no suspicion of fracture can be treated and followed up conservatively in the primary health service. In this clinical review article, we emphasise the importance of adequate physical training before referral to an MRI and orthopaedic surgeon for further assessment. Patients with chronic instability who fail to respond to adequate conservative treatment should be referred for surgical assessment.

Outcome after nonoperative treatment of stable Lisfranc injuries. A prospective cohort study.

BACKGROUND: The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries. METHODS: 26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury. RESULTS: All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up. CONCLUSION: Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.

Unilateral, Volume-expanding Os Subcalcis: Patient History and Treatment: A Case Report.

Accessory bones of the foot are common, but the presence of accessory bones located at the plantar aspect of the calcaneus is rare. We present the case of a 72-year-old female that suffered with a volume expanding os subcalcis. Due to marked disability, the large os subcalcis was excised with a favorable outcome.

Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

BACKGROUND: Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries. METHODS: Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of the medial 3 TMT joints, whereas 24 patients were randomized to temporary bridge plate (BP) over the first TMT joint and primary arthrodesis of the second and third TMT joints. The main outcome parameter was the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale and the secondary outcome parameters were the 36-Item Short Form Health Survey (SF-36) and visual analog scale for pain (VAS pain). Computed tomography (CT) scans pre- and postoperatively were obtained. Radiographs were obtained at follow-ups. Pedobarographic examination was performed at the 2-year follow-up. Twenty-two of 24 patients in the PA and 23/24 in the BP group completed the 2-year follow-up. RESULTS: The mean AOFAS midfoot score 2 years postoperatively was 89 (SD 9) in the PA group and 85 (SD 15) in the BP group (P = .32). There were no significant differences between the groups with regard to SF-36 or VAS pain scores. The alignment of the first metatarsal was better in the BP group than in the PA group measured by the anteroposterior Meary angle (P = .04). The PA group had a reduced peak pressure under the fifth metatarsal (P = .047). In the BP group, 11/24 patients had radiologic signs of osteoarthritis in the first TMT joint. CONCLUSION: Both treatment groups had good outcome scores. The first metatarsal was better aligned in the BP group; however, there was a high incidence of radiographic osteoarthritis in this group. LEVEL OF EVIDENCE: Therapeutic level I, prospective randomized controlled study.

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot.

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.

Lisfranc injuries: Incidence, mechanisms of injury and predictors of instability.

BACKGROUND: In Lisfranc injuries the stability of the tarsometatarsal joints guides the treatment of the injury. Determining the stability, especially in the subtle Lisfranc injuries, can be challenging. The purpose of this study was to identify incidence, mechanisms of injury and predictors for instability in Lisfranc injuries. METHODS: Eighty-four Lisfranc injuries presenting at Oslo University Hospital between September 2014 and August 2015 were included. The diagnosis was based on radiologically verified injuries to the tarsometatarsal joints. Associations between radiographic findings and stability were examined. RESULTS: The incidence of Lisfranc injuries was 14/100,000 person-years, and only 31% were high-energy injuries. The incidence of unstable injuries was 6/100,000 person-years, and these were more common in women than men (P = 0.016). Intraarticular fractures in the two lateral tarsometatarsal joints increased the risk of instability (P = 0.007). The height of the second tarsometatarsal joint was less in the unstable injuries than in the stable injuries (P = 0.036). CONCLUSION: The incidence of Lisfranc injuries in the present study is higher than previously published. The most common mechanism of injury is low-energy trauma. Intraarticular fractures in the two lateral tarsometatarsal joints, female gender and shorter second tarsometatarsal joint height increase the risk of an unstable injury. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Open Reduction and Internal Fixation of Acute Lisfranc Fracture-Dislocation with Use of Dorsal Bridging Plates.

Lisfranc injuries consist of a wide spectrum of injuries, ranging from subtle injuries to severe fracture-dislocations. Injuries with instability of the tarsometatarsal, intercuneiform, or naviculocuneiform joints should be treated with anatomic reduction and stable fixation. The best method of fixation is debated. Transarticular screw fixation has the disadvantage of damaging the tarsometatarsal joints. Bridging the tarsometatarsal joints with use of low-profile locking plates avoids the placement of screws through the joint and potentially reduces the risk of posttraumatic arthritis. Primary arthrodesis of the 3 medial tarsometatarsal joints is also an option in treating Lisfranc injuries and has been shown to lead to better outcomes compared with transarticular screw fixation in ligamentous Lisfranc injuries. In this article, we show the technique of open reduction and internal fixation of Lisfranc fracture-dislocation with use of dorsal bridging locking plates. The following steps are presented in the video: (1) incision technique with use of a dorsomedial incision and a dorsolateral incision, (2) open reduction and temporary fixation of the tarsometatarsal joints with use of Kirschner wires, (3) confirmation of anatomic reduction of the tarsometatarsal joints with direct visualization and fluoroscopy, (4) fixation of the medial 3 tarsometatarsal joints with dorsal bridging locking plates, (5) placement of a "homerun" screw from the medial cuneiform to the base of the second metatarsal, (6) fixation of the fourth and fifth tarsometatarsal joints with Kirschner wires, and (7) checking of reduction and fixation with use of fluoroscopy and performance of wound closure. Postoperatively, the foot is kept non-weight-bearing in a below-the-knee cast for 6 weeks, followed by 6 weeks of protected weight-bearing in a walker boot. Any Kirschner wires fixating the fourth and fifth tarsometatarsal joints are removed 6 weeks postoperatively. We prefer to remove the dorsal bridging plates 4 to 6 months postoperatively. Anatomic reduction and stable fixation is associated with better functional outcomes. Hardware failure and loss of reduction are potential complications that can lead to worse outcomes.

Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study.

BACKGROUND: The transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented. METHODS: 21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs. RESULTS: The median maximal concentric strength was equal,1300 vs 1336W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219J vs. 2398J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes. CONCLUSIONS: Patients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.

Tibial Nerve Palsy After Lateralizing Calcaneal Osteotomy.

Background: Lateralizing calcaneal osteotomy (LCO) is a common procedure used to correct hindfoot varus. Several complications have been described in the literature, but only a few articles describe tibial nerve palsy after this procedure. Our hypothesis was that tibial nerve palsy is a common complication after LCO. Methods: A retrospective study of patients undergoing LCO for hindfoot varus between 2007 and 2013 was performed. A total of 15 patients (18 feet) were included in the study. The patients were examined for tibial nerve deficit, and all the patients were examined with a computed tomography (CT) scan of both feet. Patients with a preexisting neurological disease were excluded. The primary outcome was tibial nerve palsy, and the secondary outcomes were reduction of the tarsal tunnel volume, the distance from subtalar joint to the osteotomy, and the lateral step at the osteotomy evaluated by CT scans. Results: Three of the 18 feet examined had tibial nerve palsy at a mean follow-up of 51 months. The mean reduction in tarsal tunnel volume when comparing the contralateral nonoperated foot to the foot operated with LCO was 2732 mm3 in the group without neurological deficit and 2152 mm3 in the group with neurological deficit (P = .60). Conclusion: 3 of 18 feet had tibial palsy as a complication to LCO. We were not able to show that a larger decrease in the tarsal tunnel volume, a more anterior calcaneal osteotomy, or a larger lateral shift of the osteotomy is associated with tibial nerve palsy. Levels of Evidence: Level IV: Retrospective case series.

Proximal Medial Gastrocnemius Recession and Stretching Versus Stretching as Treatment of Chronic Plantar Heel Pain.

BACKGROUND:: Plantar heel pain is a common disorder that can lead to substantial pain and disability. Gastrocnemius recession has been described as an operative treatment option, but there is a lack of prospective clinical and biomechanical outcome data. The aim of this study was to evaluate the clinical and biomechanical outcomes of gastrocnemius recession and stretching compared with a stretching exercise protocol for patients with plantar heel pain lasting more than 12 months. METHODS:: Forty patients with plantar heel pain lasting more than 1 year were randomized to a home stretching exercise program only or to surgery consisting of a proximal medial gastrocnemius recession in addition to stretching exercises. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary clinical outcomes were the Short Form-36 (SF-36) and visual analogue scale (VAS) pain scores. The biomechanical outcome parameters were ankle dorsiflexion, Achilles function evaluated by a test battery with 6 independent tests, and plantar pressure evaluated by pedobarography. All data were obtained at baseline and at 12-month follow-up. RESULTS:: The AOFAS score increased from 59.5 (42-76) to 88.0 (50-100; P < .001) for the operative group and from 52.5 (37-73) to 65.5 (31-88; P = .138) for the nonoperative group. The AOFAS, VAS pain, and SF-36 scores were significantly better in the operative compared with the nonoperative group at 12-month follow-up ( P < .05). Ankle dorsiflexion increased from 6 degrees (-3 to 15) to 10.5 degrees (0 to 23; P < .001). No between-group difference was observed for Achilles function at follow-up. The average forefoot plantar pressure for the operative group increased from 536 KPa (306-708) to 642 KPa (384-885) at follow-up ( P < .001). CONCLUSION:: Proximal medial gastrocnemius recession with a stretching program was a safe and efficient method of treating chronic plantar heel pain. LEVEL OF EVIDENCE:: Level 1, randomized clinical trial.

Validation of a New Device for Measuring Isolated Gastrocnemius Contracture and Evaluation of the Reliability of the Silfverskiöld Test.

BACKGROUND: Important aspects on the diagnostics of isolated gastrocnemius contractures (IGCs) have been poorly described. This study was designed to validate a new ankle range of motion (ROM) measuring device for diagnosing an IGC. In addition, we wanted to investigate the reliability of the clinical Silfverskiöld test. METHODS: Twelve health care personnel (24 feet) were examined by 4 testers on 3 different occasions for the reliability testing of the new ankle ROM measuring device. The same participants were examined using the Silfverskiöld test to examine the reliability of the clinical test. Eleven patients (15 feet) with IGC were examined before gastrocnemius recession, immediately after surgery, and 3 months after surgery to examine the validity and responsiveness of the ankle ROM device. RESULTS: An intraclass correlation coefficient (ICC) >0.85 was found for both inter- and intrarater reliability for the new ankle ROM device. The device confirmed an IGC in 13 of 15 feet before surgery and 3 of 13 feet at 3-month follow-up. At baseline, the measured ankle dorsiflexion was median 3 degrees with the knee in extension, which increased to 10 degrees ( P < .001) immediately after surgery and 12 degrees ( P = .003) at 3-month follow-up. ICC values of 0.230 to 0.791 were observed for the inter- and intrarater reliability testing of the clinical Silfverskiöld test. CONCLUSION: The new ankle ROM measuring device was reliable and responsive for detecting IGC. The Silfverskiöld test had poor inter- and intrarater reliability. Level of evidence Level II, prospective cohort study.

Endoscopic Transfer of Flexor Hallucis Longus Tendon for Chronic Achilles Tendon Rupture: Technical Aspects and Short-Time Experiences.

BACKGROUND: Chronic Achilles tendon ruptures can lead to reduced power of plantar flexion in the ankle with impaired gait ability. The open 1- or 2-incision technique for flexor hallucis longus transfer has proven good functional outcome but has the disadvantage of relatively extensive surgery performed at a vulnerable location. To reduce the risk of soft tissue problems, the flexor hallucis longus transfer can be performed endoscopically. MATERIAL AND METHOD: An endoscopic technique for flexor hallucis longus transfer is presented together with the experiences from the first six patients operated with this method. RESULTS: No wound healing problems or infections. Five of 6 patients managed single leg heel raise on the affected side 12 months after surgery. CONCLUSION: The functional results are promising. The soft tissue dissection is minor, and no patients had postoperative wound healing problems or infection. Endoscopic flexor hallucis longus transfer may be an operative procedure that can be considered also in patients with potential wound healing problems. LEVELS OF EVIDENCE: Level IV: Technical note/case series without controls.

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot.

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.

Clinical and Functional Outcomes of Gastrocnemius Recession for Chronic Achilles Tendinopathy.

BACKGROUND: Although gastrocnemius recession has been proposed and used in the treatment of chronic noninsertional Achilles tendinopathy, only weak evidence exists to support this operative indication. The purpose of our study was to assess the clinical and functional outcomes of patients treated with gastrocnemius recession at 2 institutions for this problem. METHODS: Thirty-four patients were identified through our medical records and asked to participate in this study. Thirty patients (35 legs) responded to the invitation. Sixteen patients were eligible for clinical follow-up, and 14 patients responded by letter or telephone interview. Two patients did not want to participate, and 2 patients could not be reached. Data were collected by a satisfaction questionnaire, the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, a visual analog scale (VAS) for pain, a functional test battery, and a clinical examination. RESULTS: A subgroup with preoperative data (n = 8) showed an increase in the mean VISA-A score from 39.5 to 91.9. The mean overall VISA-A score (n = 30) was 91.4 at follow-up. The mean VAS for pain score when walking decreased from 7.5 before surgery to 0.8 after surgery. Twenty-eight of 30 patients reported that they were satisfied with their results after surgery. Functional testing showed no difference in gastrocnemius-soleus function between the operated and nonoperated leg (n = 10). CONCLUSION: The findings support the promising results from other studies regarding gastrocnemius recession as an effective and safe way of treating chronic Achilles tendinopathy. The patients recovered both in terms of pain and function. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Surgically treated talar fractures. A retrospective study of 50 patients.

BACKGROUND: Talar fractures are associated with a high incidence of avascular necrosis (AVN), osteoarthritis (OA) and malunion. The aim of this study was to evaluate the complications, the functional outcome, and the need for secondary surgery following surgically treated talar fractures. METHODS: Fifty patients with 52 talar fractures were included in the study. The health related quality of life was evaluated using visual analogue scale (VAS). The ankle function was scored using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. OA and AVN were evaluated on plain radiographs and computerized tomography (CT) scans. RESULTS: VAS score was 69±18 (mean±SD) and AOFAS ankle-hindfoot score was 73±17 (mean±SD). OA was seen in 98% and AVN in 65% of the talar bones. Secondary surgery had been performed in 38% of the feet. CONCLUSION: Long-term complications were commonly seen after talar fractures and had a significant impact on daily life activities and quality of life. The need for secondary surgery was high. Prolonged follow-up is necessary to detect long-term complications, and the patients should be offered a low threshold for recontact.

A pilot study testing the feasibility of skin temperature monitoring to reduce recurrent foot ulcers in patients with diabetes--a randomized controlled trial.

BACKGROUND: Although monitoring foot skin temperatures has been associated with diabetic foot ulcer recurrence, no studies have been carried out to test the feasibility among European Caucasians. Moreover, the educational and/or motivational models that promote cognitive or psychosocial processes in these studies are lacking. Thus, we conducted a pilot randomized controlled trial to test the feasibility of monitoring foot skin temperatures in combination with theory-based counselling to standard foot care to reduce diabetic foot ulcer recurrence. METHODS: In a single-blinded nurse-led 1-year controlled trial, conducted at a hospital setting in Norway, 41 patients with diabetic neuropathy and previous foot ulcer were randomized to the intervention (n = 21) or control groups (n = 20). All participants were instructed in foot care and recording observations daily. Additionally, the intervention group was taught how to monitor and record skin temperature at baseline, and received counselling every third month supporting them to use the new treatment. Subjects observing temperature differences > 2.0 °C between corresponding sites on the left and right foot on two consecutive days were asked to contact the study nurse and reduce physical activity. Fisher exact test was used to evaluate the effect of the intervention on the proportion of subjects with a foot ulcer. Kaplan-Meier survival analysis was performed to compare the two groups in regard to the time to development of a foot ulcer. RESULTS: In the intervention group, 67 % (n = 14/21) monitored and recorded skin temperatures ≥ 80 % of the time while 70 % (n = 14/20) of the controls recorded foot inspections. Foot ulcer incidence was 39 % (7/21) vs. 50 % (10/20) in the intervention and control groups, respectively (ns). CONCLUSIONS: This feasibility study showed that the addition of counselling to promote self-monitoring of skin temperature to standard care to prevent recurrence of foot ulcer is feasible in patients with diabetes in Norway. Home skin temperature monitoring was performed as frequently by the intervention group as usual foot observations in the controls despite the extra effort required. We did not detect a difference in foot ulcer recurrence between groups, but our study may inform future full scale studies. TRIAL REGISTRATION: Clinicaltrials.gov NCT01269502.

Results after gastrocnemius recession in 73 patients.

BACKGROUND: Very few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession. PURPOSE: To survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions. MATERIAL AND METHODS: 93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result. RESULTS: 45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p=0.015) after surgery for patients with plantar fasciitis (n=18) and from 5.6 to 2.3 (p<0.01) for patients with metatarsalgia (n=28). CONCLUSION: Patients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.

Posterior tibial tendon transfer improves function for foot drop after knee dislocation.

BACKGROUND: Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop. QUESTIONS/PURPOSES: We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer. METHODS: Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution's database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM. RESULTS: Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001). CONCLUSIONS: Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.