Osteoarthritis in England: Incidence Trends From National Health Service Hospital Episode Statistics.

OBJECTIVE: It is typical in epidemiological research of osteoarthritis (OA) to collect data for the hand, hip, and knee. However, little population-based data exist for this disease in the foot. Thus, we addressed patterns of OA for the foot compared with the hand, hip, and knee spanning 2000/2001 to 2017/2018 in England. METHODS: Secondary-care data from 3 143 928 patients with OA of the foot, hand, hip, and knee were derived from the National Health Service (NHS) Hospital Episode Statistics (HES) database. Distribution, population prevalence, and incidence of joint-specific OA were stratified by age and sex. RESULTS: OA incidence increased significantly at the foot [3.8% (95% confidence interval [CI] 3.0, 4.6)], hand [10.9% (10.1, 11.7)], hip [3.8% (2.9, 4.7)], and knee [2.9% (2.2, 3.6)] per year from 2000/2001 to 2017/2018. A higher proportion of women were diagnosed with OA, whereas greater incidence in men was estimated for the hand and hip. Foot OA presented comparable diagnosis numbers to the hand. More recently during 2012/2013 to 2017/2018, a significant rise in hip OA was estimated among younger adults, whereas knee OA decreased across all age groups. Incidence of OA in the foot and hand were particularly significant among the 75 or older age group, though bimodal age distributions were observed for both sites. CONCLUSION: The significant increase in secondary care records for OA in England underscores the importance of exploring possible causative factors and identifying groups most at risk. Further detailed data may be particularly important for the hip, which represents significant incidence among younger adults. Greater incidence of OA in the foot compared with the knee emphasizes the need for well-conducted epidemiological research in this area. Monitoring the performance of surgical outcomes at the population-level for this frequently affected yet understudied site could have substantial potential to reduce the socioeconomic burden it represents to the NHS.

Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle.

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution. All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments.

Achilles tendon repair: Achillon system vs. Krackow suture: an anatomic in vitro biomechanical study.

BACKGROUND: Limited open repairs of acutely ruptured Achilles tendon, using the Achillon device, are becoming a frequently used method of treatment. To date there are no biomechanical studies comparing the strength of the Achillon repair to the Krackow repair. This study provides a direct comparison of the strength of these two repair techniques. METHODS: Using 10 paired cadaveric Achilles tendon specimens; repairs were performed using a Krackow technique on one specimen and a repair with the Achillon Suture System on the contralateral specimen. All repairs were made with identical suture material. Specimens were tested for ultimate strength using a servo-hydraulic testing device. FINDINGS: The mean load to failure of the control group (Krackow suture) was 276N (standard deviation 87.0), and for the experimental group (Achillon suture) was 342N (standard deviation 92.8). Using a Wilcoxon test this result was found to be statically significant (P=0.03). INTERPRETATION: The current study has demonstrated that the Achillon repair is stronger in a cadaveric biomechanical study than the Krackow repair using identical sutures. This provides biomechanical evidence to support the continued use of the limited open repair as opposed to the traditional open repair.

Anterior iliac crest bone graft harvesting using the corticocancellous reamer system.

OBJECTIVE: To evaluate the anterior iliac crest bone graft harvesting procedure using a corticocancellous acetabular reamer system. DESIGN: A total of 390 bone grafting procedures were reviewed using retrospective chart review. Two hundred twenty procedures were performed using the reamer system, and 170 were performed using traditional techniques (cortical strip, tricortical wedge, and cancellous trap door grafts). SETTING: The Hospital for Special Surgery, New York, New York. PARTICIPANTS: Operative cases involving an anterior iliac crest bone graft procedure between January 1, 1991 and February 28, 1998. MAIN OUTCOME MEASUREMENTS: Complications were organized by the categories major, intermediate, and minor. Statistical analysis included assessment of comorbidity to determine risk factors that may be associated with a propensity for complications. RESULTS: Of the 390 patients reviewed, 13.1 percent (51 of 390) developed a total of seventy-one complications. Of the seventy-one complications, forty were reamer-associated and thirty-one were traditional method-associated complications. As compared with the traditional group, major morbidity was lower in the reamer group (0.9 percent [2 of 220] as compared with 1.8 percent [3 of 170] [ p = 0.4]). Intermediate and minor morbidity were slightly higher in the reamer group than in the traditional group (5.9 percent [13 of 220] as compared with 5.3 percent [9 of 170] [ p = 0.7] and 9.5 percent [21 of 220] as compared with 7.1 percent [12 of 170] [ p = 0.4], respectively). Of the forty reamer-associated complications, 90 percent (36 of 40) resolved within ninety days (average 36.6 days). Of the thirty-one traditional method-associated complications, 74.2 percent (23 of 31) were resolved by 90 days (average 50.6 days). Using logistical regression analysis obesity (body mass index) ( p = 0.03) and smoking ( p = 0.03) were correlated with development of a complication. Furthermore, if a patient was obese and a smoker, the analysis predicted an 83 percent chance of developing a complication. CONCLUSIONS: The reamer technique was found to be safe and efficacious while producing a large amount of autogenous corticocancellous bone graft. Overall complication rates for the reamer and the traditional groups were comparable. The corticocancellous reamer system represents an effective option for bone graft harvesting.

The adult acquired flatfoot and spring ligament complex. Pathology and implications for treatment.

This article reviews the anatomy of the spring ligament complex, the extent of ligament involvement in addition to the spring ligament, and implications for clinical reconstruction.

Outcome following addition of peroneus brevis tendon transfer to treatment of acquired posterior tibial tendon insufficiency.

The flexor digitorum longus, the tendon most often used for transfer in posterior tibial tendon insufficiency, is one-half to one-third the size of the posterior tibial tendon. Occasionally it may be particularly small or may have been previously used for transfer. In these cases, the senior author has felt that the addition of a transfer of the Peroneus Brevis (PBr) tendon may be helpful in maintaining sufficient tendon and muscle mass to rebalance the foot. Thirteen patients who underwent this procedure were retrospectively identified and matched by age and length of follow-up to patients who underwent a more standard tendon transfer operation minus the addition of the PBr transfer. Pain and functional status were then assessed by the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale. Each patient was tested by an independent physical therapist to evaluate inversion and eversion strength. The mean duration of follow-up was 20.6 months (12 to 34 months). The average AOFAS score of the PBr group was 75.8 compared to 71.5 for the standard control group. There was no significant difference between the groups when inversion or eversion strengths were compared. Inversion strength and eversion strength was rated good or excellent (4 or 5) in 12 out of 13 of the PBr transfer group patients. No major complications were encountered in either group. Although it does not increase inversion strength, a PBr transfer can be used to augment a small FDL without causing significant eversion weakness. This can be useful when the FDL is particularly small or in revision surgery.

A closed-loop cadaveric foot and ankle loading model.

Investigations of human foot and ankle biomechanics rely chiefly on cadaver experiments. The application of proper force magnitudes to the cadaver foot and ankle is essential to obtain valid biomechanical data. Data for external ground reaction forces are readily available from human motion analysis. However, determining appropriate forces for extrinsic foot and ankle muscles is more problematic. A common approach is the estimation of forces from muscle physiological cross-sectional areas and electromyographic data. We have developed a novel approach for loading the Achilles and posterior tibialis tendons that does not prescribe predetermined muscle forces. For our loading model, these muscle forces are determined experimentally using independent plantarflexion and inversion angle feedback control. The independent (input) parameters -- calcaneus plantarflexion, calcaneus inversion, ground reaction forces, and peroneus forces -- are specified. The dependent (output) parameters -- Achilles force, posterior tibialis force, joint motion, and spring ligament strain -- are functions of the independent parameters and the kinematics of the foot and ankle. We have investigated the performance of our model for a single, clinically relevant event during the gait cycle. The instantaneous external forces and foot orientation determined from human subjects in a motion analysis laboratory were simulated in vitro using closed-loop feedback control. Compared to muscle force estimates based on physiological cross-sectional area data and EMG activity at 40% of the gait cycle, the posterior tibialis force and Achilles force required when using position feedback control were greater.

Deltoid ligament strain after correction of acquired flatfoot deformity by triple arthrodesis.

Deltoid insufficiency represents a difficult surgical challenge. We have witnessed patients who have developed a valgus tibiotalar deformity following a properly positioned triple arthrodesis. To investigate whether the triple arthrodesis itself, by creating a rigid triple joint complex below the ankle, leads to increased strain of the deltoid complex, a flatfoot model was created in 8 fresh-frozen below-knee amputation specimens. Each specimen was loaded in three gait cycle (GC) positions: Heel strike (0% GC), midstance (10% GC), and heel rise (40% GC). The three components of the ground reaction force (GRF) and the tendon forces consistent with those respective positions were applied. To simulate a posterior tibial tendon insufficient state the posterior tibial tendon was not loaded. Strain at the tibiocalcaneal fibers of the superficial deltoid ligament complex was determined at each of the three foot positions. A triple arthrodesis was performed and the deltoid strains were again recorded for each position. A significant increase in the strain of the deltoid ligament was observed for only the heel rise position (p=0.007) in our cadaver model following triple arthrodesis. The results favor medializing the calcaneus following arthrodesis to protect the deltoid complex.

The medial crosssover toe: a cadaveric dissection.

UNLABELLED: The development of a medial crossover second toe (second toe crossing over the first toe) is not a rare clinical condition. It often occurs in the setting of hallux valgus, although not exclusively so. The resulting displacement of the second toe can cause pain in shoes, with surgical correction being problematic. The pathologic anatomy of this condition has not been fully described. In an effort to better understand it, dissection of a cadaveric specimen with a full crossover toe is presented. The dissection revealed findings not previously documented. They include medial displacement of the flexor tendons and plantar plate along with deformity of the plate itself. These changes are in addition to contracture of the medial collateral ligaments and the previously described rupture of the lateral collateral ligaments. Both the plantar plate and the collateral ligaments, the two major static soft tissue stabilizers of the lesser MP joint, were found to be significantly involved. Pull on the flexor tendons only accentuated the malalignment of the toe. CLINICAL SIGNIFICANCE: The extensive soft tissue changes explain the difficulty in achieving a successful long term correction of a full medial crossover toe with a soft tissue procedure. With attenuation of the plantar plate and medial displacement of the flexor tendons, there is an imbalance of muscle forces across the MP joint. This muscle imbalance would not be corrected by release of the medial collateral ligament, dorsal capsular release or extensor tendon lengthening. Reconstruction of the collateral ligament is at risk for incomplete correction since it is unlikely to resolve deformity in the plate if already present.

Biomechanics of the ankle joint. A perspective on total ankle replacement.

The biomechanics of the ankle present a unique set of challenges for arthroplasty surgery. Its biomechanics are not simple. Although the ankle joint may seem like a hinge, it is not in a line perpendicular to the tibia. The axis of rotation does not stay constant during range of motion, despite a relative congruency of this joint. Allowing for rotational forces must be accomplished, while maintaining the stability of the joint and its components. Success of the arthroplasty depends on how successful designs can dissipate these rotational forces, while maintaining the stability of the joint. It is not yet clear from the biomechanical analysis of the normal ankle joint that this dissipation of forces has been accomplished successfully in modern implants, although early results in the semiconstrained designs are encouraging. Careful assessment of long-term follow-up will determine how close the present designs are to mimicking the unique requirements of the arthritic foot and ankle. Further work on the biomechanics of these replacements would be beneficial.

Medial arch strain after lateral column lengthening: an in vitro study.

Posterior tibial tendon dysfunction with concomitant progressive flatfoot deformity is associated with ligamentous failure along the medial arch. Lateral column lengthening is being used alone and in combination with other procedures with the expectation that it contributes to restoring and maintaining the arch. The primary objective of this study was to examine the effect of lateral column lengthening on medial arch strain. A secondary objective was to examine the effect of subtalar, talonavicular, double and triple fusions on medial arch strain. Whole cadaver feet were subjected to vertical loads while in a plantigrade position. Spring ligament length was monitored using liquid metal displacement gauges. Two outcomes were examined: the length of the ligament and the change in length of the ligament per unit of applied load. Ligament length was unchanged after lateral column lengthening. Ligament length was decreased after talonavicular, double and triple arthrodeses, consistent with the ligament being protected by these fusions. The change in length per unit of applied load after simulated lateral column lengthening was comparable to that for the intact foot, which is consistent with the ligament remaining functional during weightbearing and not being overloaded.

Posterior calcaneal osteotomy with wedge: cadaver testing of a new procedure for insufficiency of the posterior tibial tendon.

Insufficiency of the posterior tibial tendon is challenging to treat. When the deformity is flexible, treatment options have included tendon transfer, often combined with a medial slide calcaneal osteotomy and/or a lengthening of the lateral column. Posterior calcaneal osteotomy has been shown to give correction, although not full correction. Lengthening of the lateral column also has been shown to give correction and has been used in the more severe flexible deformities, but it involves either fusion of the calcaneocuboid joint or risk of arthritis at this joint. An osteotomy combining the calcaneal medial slide with a lengthening of the lateral column at the same osteotomy site has been tested in the laboratory. This combined osteotomy provides a lengthening of the lateral column, but it is positioned away from the calcaneocuboid joint. In this study, the osteotomy was compared with a medial slide calcaneal osteotomy and an Evans lengthening of the lateral column, using a cadaver flatfoot model. Radiographic measurements were made to evaluate correction of the planovalgus deformity after each of these procedures. There was statistically significant improved correction with the new osteotomy compared with that in a standard medial slide, and correction was comparable to that in the lengthening of the lateral column. This combined osteotomy may be a reasonable alternative when more correction is desired than can be obtained from a medial slide alone and when the surgeon wishes to avoid an osteotomy near the calcaneocuboid joint.

Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis.

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

Medial arch strain after medial displacement calcaneal osteotomy: an in vitro study.

Posterior tibial tendon dysfunction with concomitant progressive flatfoot deformity is associated with ligamentous failure along the medial arch. Medial displacement calcaneal osteotomy is being used alone and in combination with other procedures, with the expectation that it contributes to maintaining the arch. The objective of this study was to examine the effect of osteotomy on reducing medial arch strain. Whole cadaver feet were subjected to vertical loads while plantigrade. Spring ligament length was monitored using liquid metal displacement gauges. Two outcomes were examined: the length of the ligament under one-half body weight and the change in length of the ligament per unit of applied load. The medial displacement calcaneal osteotomy allowed elongation of the ligament with weightbearing, but at a shorter ligament length. This afforded the spring ligament protection from the levels of force experienced in the intact and lateral column-lengthened conditions.

Magnetic resonance imaging of the Lisfranc ligament of the foot.

Early recognition of subtle Lisfranc injuries is important, because deformity and disability may develop after initially unremarkable radiographs. The authors studied 23 patients (mean age, 25.4 years) with a history of midfoot trauma with both radiographs and magnetic resonance imaging (MRI). When compared with the uninjured side, diastasis on radiographs ranged from 0 to 2 mm. The MRI revealed 2 intact ligaments, 3 complete tears, and 18 partial tears. All patients with complete tears had at least 2 mm more displacement between the second metatarsal and medial cuneiform, compared with the unaffected side. Because of the presence of complete or near complete rupture, seven patients underwent surgery, and the degree of rupture was confirmed. MRI of five cadaver specimens was also performed, disclosing discrete dorsal and plantar components. MRI was found to be useful in identifying Lisfranc ligament tears. If there is clear diastasis on weightbearing radiographs, MRI is not indicated. Whereas radiographic findings may be equivocal, however, MRI may accurately disclose the degree of ligament disruption.

Ganglion cysts of the lower extremity: an analysis of 54 cases and review of the literature.

This article reviews 54 consecutive patients with lower extremity ganglion cysts that were surgically removed and histologically confirmed at the Hospital for Special Surgery from 1981 to 1993. Lower extremity ganglia were more common among women. Patients' ages ranged from 13 to 80 years, with the fifth and sixth decades being the most common. Size of the cysts ranged from 3 cm to 10 cm (average: 2.9 cm). Thirty-six (67%) patients had ganglion cysts of the foot and ankle, and 18 (33%) patients had ganglion cysts of the knee area. Four (7%) patients had intraosseous ganglia located in the proximal tibia, patella, and the first metatarsal head. Follow-up data of 40 (74%) patients at an average of 5.9 years (range: 1 to 12.5 years) were obtained. Satisfaction was reported by 83% of patients. Recurrence was seen in 10% of patients, and a report of no or mild pain was given by 86% of the group. Patients who underwent revision ganglion excision had inferior results. Only 25% reported satisfaction and 50% reported no or mild pain. Patients who underwent curettage of an intraosseous ganglion appeared to have superior results. All patients reported satisfaction and no or mild pain. The performance of a concomitant surgical procedure, the anatomic region of the ganglion, or type of postoperative immobilization did not appear to affect the outcome.

Achilles tendon insertion: an in vitro anatomic study.

Seventeen adult fresh-frozen below-knee amputation cadaver specimens were studied. Calcific Achilles tendinitis was present in three specimens. After exposing the Achilles tendon insertion on the calcaneus, the insertion was outlined with waterproof paint. The specimens were photographed on a special plexiglass apparatus to highlight important findings. For the purpose of showing the length of insertion on lateral radiographs, lead beads were placed on the most superior and most inferior aspects of the insertion. All specimens showed that the tendon terminated at the medial and lateral bone borders of the calcaneus without significant extension around the medial or lateral wall. All specimens revealed a greater distance of insertion on the medial calcaneus than on the lateral side. In the specimens that had calcific Achilles tendinitis, the posterior bone surface of the spurs was devoid of tendinous insertion, instead, the insertion occurred between the spur and the posterior wall of the calcaneus. All spurs were located laterally at the most inferior border of the tendon insertion.

Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot.

Bilateral weightbearing anteroposterior and lateral radiographs were analyzed in 43 patients with a clinical diagnosis of posterior tibial tendon insufficiency by two independent observers. The radiographs of each patient's asymptomatic foot was considered to serve as the control for the preexistance of pes planus. The radiographs were assessed for the severity of flatfoot deformity, the degree of talonavicular coverage, the talometatarsal angle, the calcaneometatarsal angle, the cuneiform to ground height and the cuneiform to fifth metatarsal height. Interobserver correlations were assessed. Results indicated that there was a high interobserver correlation for the values measured, making these angles reproducible among observers. Strong correlations were found in the degree of severity of flatfoot deformity between the asymptomatic and symptomatic feet as well as the values used to assess pes planus (i.e., similar radiographic measurements on the opposite side). The data suggest that patients with posterior tibial tendon insufficiency often have a preexisting flatfoot. This substantiates our belief that a preexisting flexible flatfoot, although far from the determining factor, is one of several etiological factors in the development of posterior tibial tendon insufficiency.

Chronic ankle pain caused by osteoid osteoma of the neck of the talus.

Five patients with osteoid osteomas of the talar neck were treated at the Hospital for Special Surgery between 1981 and 1992. The course of care leading to definitive diagnosis and treatment was reviewed. All five of the patients had night pain relieved by aspirin or nonsteroidal anti-inflammatory drugs. One of the five reported associated trauma. The average time from onset of symptoms to correct diagnosis was 2.5 years. Juxta-articular osteoid osteoma can cause a small spur that resembles a traction spur on the neck of the talus. Anterior ankle impingement was the most common misdiagnosis. Initial treatments included arthroscopic spur debridement or synovectomy, casting for fracture, and repeated nerve blocks for reflex sympathetic dystrophy. The five patients were cured by en bloc excision of the lesion. In the diagnosis of osteoid osteoma, a history of relief of pain with aspirin is important. Plain radiographs and a bone scan are useful. Fine cut computed tomography scanning or magnetic resonance imaging are the best studies for making a definitive diagnosis. Localization by computed tomography guided needle placement or intraoperative radionuclide scanning are recommended to find the lesion for excision. Intraoperative radiographs of the excised lesion should be used to confirm complete removal.