Ankle fractures in diabetic patients.

Surgical complications are more common in patients with complicated diabetes (presence of inner organ failure, neuropathy).Of all patients undergoing ankle fracture fixation, approximately 13% are diabetic and 2% have complicated diabetes mellitus.Non-operative management of ankle fractures in patients with complicated diabetes results in an even higher rate of complications.Insufficient stability of ankle fractures (treated operatively, or non-operatively) can trigger Charcot neuroarthropathy, and result in bone loss, deformity, ulceration, and the need for amputation.Rigid fixation is recommended. Hindfoot arthrodesis (as primary procedure or after failed ankle fracture management) can salvage the limb in approximately 80% of patients.Early protected weight bearing can be allowed, provided rigid fixation without deformity has been achieved. Cite this article: EFORT Open Rev 2020;5:457-463. DOI: 10.1302/2058-5241.5.200025.

Morton's interdigital neuroma: instructional review.

The terminology 'Morton's neuroma' may represent a simplification of the clinical condition as the problem may not be a benign tumour of the nerve, but neuropathic foot pain associated with the interdigital nerve.Foot and ankle pathomechanics leading to metatarsalgia, clinical examination and differential diagnosis of the condition and imaging of the condition, for differential diagnosis, are discussed.Nonoperative management is recommended initially. Physiotherapy, injections (local anaesthetic, steroid, alcohol), cryotherapy, radiofrequency ablation and shockwave therapy are discussed.Operative treatment is indicated after nonoperative management has failed. Neuroma excision has been reported to have good to excellent results in 80% of patients, but gastrocnemius release and osteotomies should be considered so as to address concomitant problems.Key factors in the success of surgery are correct diagnosis with recognition of all elements of the problem and optimal surgical technique. Cite this article: EFORT Open Rev 2019;4:14-24. DOI: 10.1302/2058-5241.4.180025.

Midterm Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus.

BACKGROUND:: A prospective, randomized, noninferiority clinical trial of synthetic cartilage implant hemiarthroplasty for hallux rigidus demonstrated functional outcomes and safety equivalent to first metatarsophalangeal (MTP) joint arthrodesis at 24 months. We prospectively assessed safety and efficacy outcomes for synthetic cartilage implant hemiarthroplasty at a minimum of 5 years. METHODS:: Of 135 eligible patients from the original trial, 112 (83.0%) were enrolled (mean age, 58.2 ± 8.8 years; 87 females). Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), and FAAM Sports subscales were completed preoperatively and 2 and 5 years postoperatively. Great toe active dorsiflexion, weightbearing radiographs, secondary procedures, and safety parameters were also evaluated. RESULTS:: At 24 months, 14/152 (9.2%) patients had undergone implant removal and conversion to arthrodesis. In years 2 to 5, 9/119 (7.6%) patients underwent implant removal and conversion to arthrodesis. At mean 5.8 ± 0.7 (range, 4.4-8.0) years' follow-up, pain VAS, FAAM ADL, and FAAM Sports scores improved by 57.9 ± 18.6 points, 33.0 ± 17.6 points, and 47.9 ± 27.1 points, respectively, from baseline. Clinically significant changes in VAS pain, FAAM ADL, and FAAM Sports were reported by 103/106 (97.2%), 95/105 (90.5%), and 97/104 (93.3%) patients, respectively. Patient-reported outcomes at 24 months were maintained at 5.8 years in patients who were not revised. Active MTP joint peak dorsiflexion was maintained. Ninety-nine of 106 (93.4%) patients would have the procedure again. CONCLUSION:: Clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty observed at 2 years were maintained at 5.8 years. The implant remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus. LEVEL OF EVIDENCE:: Level IV, case series.

Stability in ankle fractures: Diagnosis and treatment.

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057.

Treatment of first metatarsophalangeal joint arthritis using hemiarthroplasty with a synthetic cartilage implant or arthrodesis: A comparison of operative and recovery time.

BACKGROUND: First metatarsophalangeal joint (MTPJ1) hemiarthroplasty using a novel synthetic cartilage implant was as effective and safe as MTPJ1 arthrodesis in a randomized clinical trial. We retrospectively evaluated operative time and recovery period for implant hemiarthroplasty (n=152) and MTPJ1 arthrodesis (n=50). METHODS: Perioperative data were assessed for operative and anaesthesia times. Recovery and return to function were prospectively assessed with the Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) subscales and SF-36 Physical Functioning (PF) subscore. RESULTS: Mean operative time for hemiarthroplasty was 35±12.3min and 58±21.5min for arthrodesis (p<0.001). Anaesthesia duration was 28min shorter with hemiarthroplasty (p<0.001). At weeks 2 and 6 postoperative, hemiarthroplasty patients demonstrated clinically and statistically significantly higher FAAM Sport, FAAM ADL, and SF-36 PF subscores versus arthrodesis patients. CONCLUSION: MTPJ1 hemiarthroplasty with a synthetic cartilage implant took less operative time and resulted in faster recovery than arthrodesis. LEVEL OF EVIDENCE: III, Retrospective case control study.

Arthroscopic versus open ankle arthrodesis.

BACKGROUND: It is thought that arthroscopic ankle fusion offers improved outcomes over open fusion in terms of functional outcomes, time to fusion, length of stay and fewer complications. However, there are doubts about whether correction of established severe deformity can be achieved using the arthroscopic approach. METHODS: A retrospective review of medical records and radiographs at our hospital identified consecutive tibio-talar ankle fusions between April 2009 and March 2014 with minimum 1 year follow up. Records were scrutinised for type of arthrodesis, demographics, length of stay (LOS), time to fusion (TTF), pre- and postoperative deformity, complications and unplanned procedures. Significant factors in the complication group were then compared, using multivariate binary logistic backward stepwise regression to see if any factors were predictive. RESULTS: There were 29 open and 50 arthroscopic ankle fusions (2 converted to open). Mean LOS was 1.93 versus 2.52 days (p=0.590). TTF was shorter after arthroscopic fusion 196d versus 146d (p=0.083). Severe deformity (>10°) was correctable to within 5° of neutral in the majority of cases (97% versus 96%, p=0.903). Union occurred in 83% versus 98% (p=0.0134). The open arthrodesis group had 9 (31%) complications (1 death-PE, 1 SPN injury, 5 non-unions, 1 delayed union and 1 wound infection) and 6 (25%) screw removals. The arthroscopic arthrodesis group had 4 (8%) complications (1 non-union, 1 reactivation of osteomyelitis and subsequent BKA, 1 wound infection, 1 delayed union) with 11 (24%) screw removals. After multi-variant regression analysis of all ankle fusions, low BMI was shown to be associated with complications (p=0.064). CONCLUSIONS: Open arthrodesis was associated with a higher rate of complications and a lower rate of fusion. However, there was no significant difference in terms of LOS and ability to correct deformity compared to arthroscopic arthrodesis. Overall, low BMI was also associated with more complications.

Correlation of Hallux Rigidus Grade With Motion, VAS Pain, Intraoperative Cartilage Loss, and Treatment Success for First MTP Joint Arthrodesis and Synthetic Cartilage Implant.

BACKGROUND: Grading systems are used to assess severity of any condition and as an aid in guiding treatment. This study examined the relationship of baseline motion, pain, and observed intraoperative cartilage loss with hallux rigidus grade. METHODS: A prospective, randomized study examining outcomes of arthrodesis compared to synthetic cartilage implant was performed. Patients underwent preoperative clinical examination, radiographic assessment, hallux rigidus grade assignment, and intraoperative assessment of cartilage loss. Visual analog scale (VAS) score for pain was obtained preoperatively and at 24 months. Correlation was made between active peak dorsiflexion, VAS pain, cartilage loss, and hallux rigidus grade. Fisher's exact test was used to assess grade impact on clinical success ( P < .05). RESULTS: In 202 patients, 59 (29%), 110 (55%), and 33 (16%) were classified as Coughlin grades 2, 3, and 4, respectively. There was no correlation between grade and active peak dorsiflexion (-0.069, P = .327) or VAS pain (-0.078, P = .271). Rank correlations between grade and cartilage loss were significant, but correlations were small. When stratified by grade, composite success rates between the 2 treatments were nearly identical. CONCLUSIONS: Irrespective of the grade, positive outcomes were demonstrated for both fusion and synthetic cartilage implant. Clinical symptoms and signs should be used to guide treatment, rather than a grade consisting of radiographic, symptoms, and range of motion factors. LEVEL OF EVIDENCE: Level II, randomized clinical trial.

Association Between Patient Factors and Outcome of Synthetic Cartilage Implant Hemiarthroplasty vs First Metatarsophalangeal Joint Arthrodesis in Advanced Hallux Rigidus.

BACKGROUND: We evaluated data from a clinical trial of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis to determine the association between patient factors and clinical outcomes. METHODS: Patients ≥18 years with hallux rigidus grade 2, 3, or 4 were treated with synthetic cartilage implant MTPJ1 hemiarthroplasty or arthrodesis. Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) sports and activities of daily living (ADL) scores, and Short Form-36 Physical Function (SF-36 PF) subscore were obtained preoperatively, and at 2, 6, 12, 24, 52, and 104 weeks postoperatively. Final outcome data, great toe active dorsiflexion motion, secondary procedures, radiographs, and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. The composite primary endpoint criteria for clinical success included VAS pain reduction ≥30%, maintenance/improvement in function, no radiographic complications, and no secondary surgical intervention at 24 months. Predictor variables included hallux rigidus grade; gender; age; body mass index (BMI); symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, range of motion (ROM), and pain. Two-sided Fisher exact test was used ( P < .05). RESULTS: Patient demographics and baseline outcome measures were similar. Success rates between implant MTPJ1 hemiarthroplasty and arthrodesis were similar ( P > .05) when stratified by hallux rigidus grade, gender, age, BMI, symptom duration, prior MTPJ1 surgery status, and preoperative VAS pain, hallux valgus, and ROM. CONCLUSION: Synthetic cartilage implant hemiarthroplasty was appropriate for patients with grade 2, 3, or 4 hallux rigidus. Its results in those with associated mild hallux valgus (≤20 degrees) or substantial preoperative stiffness were equivalent to MTPJ1 fusion, irrespective of gender, age, BMI, hallux rigidus grade, preoperative pain or symptom duration. LEVEL OF EVIDENCE: Level II, randomized clinical trial.

Syndesmosis Stabilisation: Screws Versus Flexible Fixation.

Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.

Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus.

BACKGROUND: Although a variety of great toe implants have been tried in an attempt to maintain toe motion, the majority have failed with loosening, malalignment/dislocation, implant fragmentation and bone loss. In these cases, salvage to arthrodesis is more complicated and results in shortening of the ray or requires structural bone graft to reestablish length. This prospective study compared the efficacy and safety of this small (8/10 mm) hydrogel implant to the gold standard of a great toe arthrodesis for advanced-stage hallux rigidus. METHODS: In this prospective, randomized non-inferiority study, patients from 12 centers in Canada and the United Kingdom were randomized (2:1) to a synthetic cartilage implant or first metatarsophalangeal (MTP) joint arthrodesis. VAS pain scale, validated outcome measures (Foot and Ankle Ability Measure [FAAM] sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment, and safety parameters were evaluated. Analysis was performed using intent-to-treat (ITT) and modified ITT (mITT) methodology. The primary endpoint for the study consisted of a single composite endpoint using the 3 primary study outcomes (pain, function, and safety). The individual subject's outcome was considered a success if all of the following criteria were met: (1) improvement (decrease) from baseline in VAS pain of ≥30% at 12 months; (2) maintenance of function from baseline in FAAM sports subscore at 12 months; and (3) absence of major safety events at 2 years. The proportion of successes in each group was determined and 1-sided 95% confidence interval for the difference between treatment groups was calculated. Noninferiority of the implant to arthrodesis was considered statistically significant if the 1-sided 95% lower confidence interval was greater than the equivalence limit (<15%). A total of 236 patients were initially enrolled; 17 patients withdrew prior to randomization, 17 patients withdrew after randomization, and 22 were nonrandomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups. RESULTS: VAS pain scores decreased significantly in both the implant and arthrodesis groups from baseline at 12 and 24 months. Similarly, the FAAM sports and activity of daily living subscores improved significantly at 12 and 24 months in both groups. First MTP active dorsiflexion motion improvement was 6.2 degrees (27.3%) after implant placement and was maintained at 24 months. Subsequent secondary surgeries occurred in 17 (11.2%) implant patients (17 procedures) and 6 (12.0%) arthrodesis patients (7 procedures). Fourteen (9.2%) implants were removed and converted to arthrodesis, and 6 (12.0%) arthrodesis patients (7 procedures [14%]) had isolated screws or plate and screw removal. There were no cases of implant fragmentation, wear, or bone loss. When analyzing the ITT and mITT population for the primary composite outcome of VAS pain, function (FAAM sports), and safety, there was statistical equivalence between the implant and arthrodesis groups. CONCLUSION: A prospective, randomized (2:1), controlled, noninferiority clinical trial was performed to compare the safety and efficacy of a small synthetic cartilage bone implant to first MTP arthrodesis in patients with advanced-stage hallux rigidus. This study showed equivalent pain relief and functional outcomes. The synthetic implant was an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion. The percentage of secondary surgical procedures was similar between groups. Less than 10% of the implant group required revision to arthrodesis at 2 years. LEVEL OF EVIDENCE: Level I, prospective randomized study.

The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures.

BACKGROUND: Distinguishing stable supination-external rotation (SER) 2 from unstable SER 4 ankle fractures, using standard radiographs, is controversial. Examination under anaesthesia (EUA), gravity-stress (GS) and weight-bearing (WB) radiographs can aid surgical decision-making. We evaluated the effect of three methods of fracture stability assessment. METHODS: Radiographs and case-notes of 312 consecutive patients with SER 2/4 fractures were reviewed. We recorded ankle stability assessment (plain film (PF) and EUA vs. GS vs. WB radiographs), management (conservative vs. operative), unplanned surgery and complications. RESULTS: Forty five percent assessed with GS underwent surgery (6% for PF/EUA, 4% for WB; P=0.0001). Amongst GS patients, 11% underwent additional surgery (0.1% PF/EUA, 0% WB; P=0.0001). Complications occurred in 2% of the WB group (8% for PF/EUA, 22% for GS; P=0.007). CONCLUSION: This study associates GS assessment with higher rates of surgery and complications. Subsequent studies may determine the longer term effect stability assessments have on post-traumatic arthritis.

Taking out the tarsal coalition was easy: but now the foot is even flatter. What now?

Patients with a preexisting hindfoot deformity, who undergo resection (with or without soft tissue interposition) of a tarsal coalition, may present with recurrent pain and worsening planovalgus deformity. This is due to the secondary effect of soft tissue contractures (lateral ligaments, peroneal tendons, calf muscles) "pulling" the foot into more valgus. Physiotherapy and insoles may help some patients. Depending on the flexibility of the hindfoot and the presence or otherwise of joint degeneration, joint-preserving corrective procedures or corrective joint fusions may be needed. Gastrocnemius, Achilles, and/or peroneal tendon releases may be required, to avoid equinus or further recurrence.

Proximal closing wedge lesser metatarsal osteotomy for metatarsophalangeal joint transverse plane realignment. Surgical technique and outcome.

BACKGROUND: We describe the surgical technique and outcome of a proximal closing wedge osteotomy of the lesser metatarsals, to treat medial or lateral subluxation of the MTP joints, with toe deviation, when dorsiflexion (MTPJ dorsal subluxation) deformity is not present. METHODS: The principle of surgical correction, is the shift of the metatarsal head in the direction of the deformity, to allow restoration of congruity of the metatarsophalangeal joint. The osteotomies were performed at the proximal metaphyseal level. At the same time, soft tissue release, consisting of division of the inter-metatarsal ligament on the other side of the deformity, allows adequate displacement. RESULTS: Four patients, followed for 12 months, were asymptomatic and very satisfied with the outcome, while clinical and radiographic alignment was maintained. CONCLUSIONS: The described surgical technique can be performed in selected patients with transverse plane deformities of the lesser metatarsals.

Supination-external rotation ankle fractures: stability a key issue.

UNLABELLED: Stability is a key issue in treating supination-external rotation ankle fractures, but we do not know how it affects functional outcome and subsequent development of radiographic osteoarthritis. With a systematic literature review, we identified 11 clinical studies (Level IV evidence) published in peer-reviewed journals reporting on at least 10 ankles. Followup was at least 1 year. Two authors independently scored the quality of the studies using the modified Coleman Methodology Score; the mean score was 58 of 100, with substantial agreement between the two examiners. Four studies used a general health assessment questionnaire. Several literature limitations (debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers and limited followup in some studies) do not allow definitive conclusions. Of 213 stable fractures treated nonoperatively, 2.8% of ankles had radiographic osteoarthritis develop (18 years' mean followup) and 84% were free of symptoms. The incidence of radiographic osteoarthritis in 420 unstable fractures treated operatively was 20.9% at 5.5 years versus 65.5% at 6.8 years in 137 ankles treated nonoperatively. The complication rate in 355 operatively treated fractures was 10.4%. A medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level negatively influenced general health outcome, physical function, and pain. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Investigation of incidence of superficial peroneal nerve injury following ankle fracture.

The aim of this study was to investigate the incidence of superficial peroneal nerve (SPN) injury following ankle fracture and to establish whether this differed between those treated by open reduction and internal fixation (ORIF) and those treated nonoperatively in a cast. Two hundred eighty patients who had been treated for an ankle fracture either surgically (ORIF group) or nonoperatively (cast group) were identified. Patients were invited for review, assessed using the AOFAS scoring system, and examined for any evidence of SPN injury. The surgical approach was documented and all fractures were classified according to the Weber classification. A total of 120 patients returned for review; 56 patients from the ORIF group and 64 patients from the cast group. The mean time from injury to review was 2 years (range, 12-36 months). Overall, 18 patients (15%) had a symptomatic SPN injury and these patients had a significantly lower AOFAS score. In the cast group, 9% of patients had painful symptoms from an SPN injury, compared to 21% of patients in the ORIF group (p < .05). No evidence of SPN injury was found in those who had a posterolateral approach to the ankle. Surgeons should be aware that the SPN is at risk during lateral approach to the fibula and that injury to this nerve can frequently be identified as a cause of chronic ankle pain.