Keeping Up With the Latest in Foot and Ankle SurgeryIn an effort to help orthopedic surgeons keep up with the latest research, the authors of this specialty update present a summary of evidence related to foot and ankle surgery. More than a dozen of the most common problems are presented including ankle fractures, calcaneal (heel bone) fractures, chronic ankle instability, ankle joint replacement, ankle fusion, diabetes-related problems, tendon problems, bunions, impingement problems, foot deformities, and amputations.
By reviewing all studies published in the last year on foot and ankle surgeries and summarizing presentations made at orthopedic meetings, the information presented hits the high points of what's new. Surgeons reading this summary can then decide if they need to delve deeper into the literature for themselves.
When it comes to trauma resulting in ankle fractures, MRIs and arthroscopy now make it possible to see that the joint surface is often damaged with more severe ankle fractures. Surgeons must be on the look out for lesions of the articular surface of the joint. Sometimes the force is enough to break off bits of cartilage and bone leaving them inside the joint as a loose body. The surgeon must look for, find, and remove these fragments.
Severe ankle fractures may require open reduction and internal fixation (ORIF). An open incision is made; the fracture site is realigned; and metal plates, pins, and/or screws are used to stabilize (hold) everything together. This type of fixation works well with few complications. Problems occur most often in patients with diabetes and poor circulation. Surgeons are advised to keep a close eye on these patients during the post-operative period to prevent infections and the need for amputation.
And a final note on ankle fractures in particular. Surgeons often debate the need to cast or immobilize the ankle after surgery versus having the patient move the ankle early in order to keep joint mobile. So far, it looks like early motion is better but has some risks. Early motion helps prevent blood clots but seems to increase the risk of wound infection. The surgeon should strive for early mobility but make the decision based on each patient's individual characteristics and risk factors.
As for calcaneal (heel bone) fractures, there's enough evidence now to show that these patients end up with painful arthritis and foot deformities. Can these be prevented? Are they the result of the type of treatment (surgery vs. nonoperative care) provided in the first place? All evidence points to a better end-result when open reduction and internal fixation (ORIF) is later followed by fusion of the joint.
Efforts are being made to place screws percutaneously (through the skin without an open incision) for the fixation of calcaneal fractures. Using titanium screws instead of metal plates seems to work well and reduces the risk of wound infection.
Severe ankle pain following repeated ankle sprains or caused by traumatic arthritis that develops years after ankle injuries may require an arthrodesis (ankle fusion) or even a total ankle arthroplasty (ankle joint replacement). Ankle instability (the ankle gives way often while standing or walking) despite all efforts at rehabilitation is an indication that fusion or joint replacement might be the next step.
Patients are often encouraged to have an ankle fusion first with later conversion to joint replacement. Fusion stabilizes the ankle but has a poor track record. The lack of ankle motion limits activities and transfers load to the midfoot and hindfoot joints. Increased motion at these adjacent joints helps compensate for the loss of ankle motion but can create degenerative damage and arthritis.
Improved surgical techniques and joint replacement implants at least makes the conversion from fusion to joint replacement a possibility now. The authors discuss computer-assisted surgery and specific placement of screws in patterns that have been proven ideal for ankle fusion.
That brings us to a different type of problem: diabetes and charcot foot deformities (named after the physician who first described it). Because too much sugar in the system destroys nerve tissue, people with diabetes often end up with loss of sensation, reduced joint integrity, and collapse of the midfoot. The severe flat foot looks like the curved bottom of a rocking chair and is referred to as a rocker bottom foot deformity or charcot joint. Surgery to stabilize, reconstruct, or sometimes fuse the joint may be needed. The authors also review tecniques for surgical correction.
A different group of problems treated by orthopedic specialists involve the tendons. Surgery to repair tendon ruptures affecting the Achilles and anterior tibialis tendons is discussed. There's a new Achillon suture system available now to repair ruptured Achilles using a minimally invasive (very small incision) technique. Some surgeons have tried reinforcing the tendon repair with additional tissue from the calf muscle but there's no evidence that this improves the results or prevents a second rupture later.
The latest in treatment of tendinopathy (any tendon disease such as tendinitis or tendinosis) is also presented. When standard conservative (nonoperative) care of tendon problems doesn't help, extracorporeal shock wave therapy seems to have a healing effect on tenocytes (tendon cells). Surgeons will want to keep an eye out for reported results of future studies in this area.
Researchers investigating treatment for hallux valgus (bunions) is focused on finding the best surgical technique and a way to measure the results reliably. Different types of osteotomies (surgery using a piece of bone to reshape the toe angle) are discussed with criticisms and results reported from various studies. One new tool available to assist surgeons when performing an osteotomy on the big toe is the Opening Wedge Low Profile Plate and Screw
System. Angle correction is improved using a spacer of this type.
These are just the highlights of the many topics and updates provided in this review article. The article is filled with summaries of individual studies and meta-analyses for the dozen or more conditions covered. The use of endoscopy and fluoroscopy has changed what surgeons now know about ankle and foot injuries from the inside out. As a result, surgical techniques have changed and overall results (motion and function) have improved as well.
With these advanced imaging tools, surgeons are slowly eliminating the need for open incisions. The shift to minimally invasive procedures has also reduced post-operative complications and problems. There are fewer wound infections and a better chance of full recovery without second (revision) surgeries or the need for amputation. Joint-sparing surgeries are also changing the prognosis for foot deformities from paralysis or trauma.
Randall C. Marx, MD, and Mark S. Mizel, MD. What's New in Foot and Ankle Surgery. In Journal of Bone and Joint Surgery. February 2010. Vol. 92-A. No. 2. Pp. 512-523.
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