What’s New in Foot and Ankle Surgery

This article provides a summary of research pertaining to orthopaedic foot and ankle surgery, published from September 2018 to September 2019. The included studies were published in The Journal of Bone & Joint Surgery, The Bone & Joint Journal, Foot & Ankle International, Foot and Ankle Surgery, The BMJ, Clinical Orthopaedics and Related Research, the Journal of Pain Research, the Journal of Orthopaedic Trauma, the Journal of Orthopaedic and Sports Physical Therapy, BMC Musculoskeletal Disorders, and The American Journal of Sports Medicine. The Forefoot Hallux Rigidus Midterm outcomes of a synthetic cartilage, polyvinyl hydrogel implant for the first metatarsophalangeal joint in advanced hallux rigidus were prospectively assessed for 112 patients in a noninferiority, randomized clinical trial (RCT)1. Measures included a visual analog scale (VAS) for pain, the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale, the FAAM Sports subscale, active great toe dorsiflexion, and radiographs. Clinical and safety outcomes observed at 2 years were maintained at 5.8 years. A shorter operative time was demonstrated for synthetic cartilage implant compared with arthrodesis (35 and 58 minutes, respectively) in the treatment of advanced hallux rigidus2. The patients treated with the implant were permitted to bear weight at 1 week and recover with a soft dressing, whereas patients who had arthrodesis were immobilized in a cast or boot for ≥6 weeks. Hallux Valgus In a prospective cohort study, minimally invasive chevron-Akin (MICA) surgery (n = 50) and open scarf-Akin surgery (n = 48) demonstrated similar improvements with respect to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, VAS for pain, and radiographic outcomes at minimum 2-year follow-up3. Each group had 3 cases of moderate stiffness (range of motion [ROM], 30° to 74°). Extension increased by 10° in the MICA group. Reoperation was required for 13 (26%) of the patients in the MICA group and 4 (8%) in the scarf-Akin group, including 11 cases of hardware removal, 5 cases of secondary resection of the residual medial prominence, and 1 case of a postoperatively dislocated fracture with MICA that required reoperation. Among groups treated with Akin osteotomy fixation with staples (n = 43), screws (n = 47), or transosseous sutures (n = 48), AOFAS Ankle-Hindfoot scores improved similarly, with no cases of delayed union or nonunion4. Suture fixation was advantageous regarding cost and potential complications. Scarf osteotomy with fixation using 2 screws (n = 50), 1 screw (n = 55), or no screws (n = 64, including 20 with transosseous sutures) demonstrated similar degrees of correction, AOFAS Ankle-Hindfoot Scale scores, and rates of complications5. Sutherland and colleagues evaluated hallux valgus from a public-health perspective in a study of 95 patients who completed preoperative and postoperative patient-reported outcome measures (PROMs) and reported a significant difference in patient-reported health after surgery6. The cost per quality-adjusted life year was relatively inexpensive and changed on the basis of patient age and sex. Hallux valgus surgery was deemed cost-effective overall and offered significant health benefits to the patient. A prospective comparative study of 87 patients demonstrated that longer wait times for hallux valgus surgery were associated with smaller gains in the Foot and Ankle Outcome Score (FAOS) domains of pain and ADL, indicative of poorer postoperative outcomes7. Among 80 patients awaiting bunion surgery for a mean of 34.9 weeks, high pain levels and compromised foot function did not change significantly from the beginning to the end of the waiting period8. Midfoot Injuries and Lisfranc Fractures Over 5 years at a university hospital, 233 (75.9%) of 307 midfoot injuries were Lisfranc injuries, 56 (18.2%) were Chopart injuries, and the remainder were combined injuries9. The primary mechanism of injury was low-energy trauma. The amount of energy and mechanism of trauma were not associated with injury severity9, although in a previous report10, higher-energy trauma increased the risk of additional, adjacent foot fractures or distributed musculoskeletal injury. Transarticular screw utilization in open reduction and internal fixation (ORIF) of Lisfranc fractures is concerning for damage to articular cartilage. Jastifer et al. determined the mean articular surface area of joints comprising the Lisfranc complex using digital imaging software in a cadaveric study11. Nonarticular screw trajectories large enough to allow adequate screw fixation were simulated to be plantar-medial to dorsal-lateral and approximately perpendicular to the long axis of the foot. In a retrospective comparative study, 88 feet (189 joints) underwent arthrodesis for tarsometatarsal arthritis, with the use of screws alone (n = 105), bridge plating with all screws through the plate (n = 67), or combined bridge plating and an independent compressive lag screw (n = 17)12. The overall rate of nonunion was 11.4%. Significant risk factors for nonunion were the use of a plate only, nonanatomic alignment postoperatively, and smoking in the perioperative period. Seventy (79.5%) of the patients received bone graft (autograft or demineralized bone matrix), which significantly decreased the rate of nonunion (odds ratio [OR], 0.2; p = 0.006). The study included patients with diabetes and Charcot neuroarthropathy, in whom surgeons had a strong preference for using plates; these factors did not significantly affect nonunion. The Ankle and Hindfoot Total Ankle Replacement Total ankle replacement (TAR) continues to be refined to improve longevity and patient outcomes. Among 200 Scandinavian Total Ankle Replacement (STAR; Stryker) implants, survivorship was 90%, 83%, and 76% at 5, 10, and 15.8 years of follow-up, respectively, using revision surgery as the primary end point13. Among 153 INFINITY (Wright Medical Technology) TARs, the incidence of revision was 10% at 13 months14. Common reasons for revision were deep infection (3.8%) and tibial-component loosening (3.8%). The patient population was heterogeneous; 79% required additional procedures at the time of TAR or had preexisting arthrodeses. In a consecutive series of 278 TARs, the overall incidence of postoperative complications was 41.7%, including amputation, deep infections, superficial infections, wound-healing delays, venous thromboembolism (VTE), fractures, osteolysis, aseptic loosening, subsidence, malpositioning, polyethylene fracture, edge-loading, soft-tissue injuries, pain, and stiffness15. The clinical outcome was affected in only 7.6% of the cases, as most complications were minor. In a prospective comparative series of TARs with use of the HINTEGRA (Newdeal/Integra LifeSciences) implant, patients ≤55 years (n = 38) and patients >55 years old (n = 85) had similar rates of complications (39.5% and 41.2%, respectively), overall survivorship (97% and 87.8%, respectively), and clinical outcomes, including AOFAS Ankle-Hindfoot scores and Short Form (SF)-36 physical component summary and mental component summary scores, and a VAS for pain at a mean of 78 months of follow-up16. Saito et al. performed a retrospective comparative study of patient-specific instrumentation (PSI) (n = 75) and standard referencing guides (n = 24)17. The groups were statistically similar regarding coronal and sagittal alignment of the tibial component; the talar component was not assessed. The PSI group had significantly shorter operative and fluoroscopy durations. Poor prediction of implant size was demonstrated for PSI (correct prediction of tibial component size in 73% of the cases and of talar component size in 51% of the cases). In 3 cases, PSI was abandoned in favor of standard referencing guides because of inaccuracy. Schipper et al. compared wear attributes of fixed-bearing ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (HXLPE)18. After 5 million cycles, HXLPE showed significantly less wear and significantly smaller and rounder particles compared with UHMWPE. In a separate study, HXLPE was strong enough to withstand the demands placed on the TAR bearing surface19. In a retrospective database cohort study of TAR (n = 2,993) and tibiotalar arthrodesis (n = 2,667), the 30-day readmission rate was significantly higher following arthrodesis (4.4%) compared with TAR (1.4%)20. Independent risk factors for having a readmission within 30 days included iron-deficiency anemia, coagulopathy, renal failure, nonprivate insurance, and tibiotalar arthrodesis. Shofer et al. prospectively evaluated levels patients who underwent TAR or ankle arthrodesis and and months increased in following the by and levels did not to The patients who underwent ankle arthrodesis were a mean of and had a a mean of the patients who underwent et al. evaluated patients with a fracture after was determined as of the implant or loosening or and was fractures were and required revision TAR or arthrodesis in fractures of the medial tibial and that were deemed were for treatment with deemed revision or arthrodesis. of the fracture was associated with with surgery required because of nonunion or in of the In the Foot and Ankle of the on Musculoskeletal on the and treatment of following TAR as in a of Foot & Ankle In these within TAR was In patients with infection the ankle the of to the was and for were by the Foot and Ankle Ankle Fractures studies evaluated fixation for ankle et al. assessed the use of an for fractures in patients months of follow-up, all fractures had reduction was and maintained with no infections, and the mean FAAM was patients required hardware A retrospective study of use for ankle fractures showed that the of reduction was in of the fractures, in 5 and in 2 with the fractures to a plate required of which required because of (n = deep infection (n = secondary (n = and Charcot (n = Among ankle fractures with an et al. 20 cases with in to and in 13 as a of et al. of the Orthopaedic on for ankle fracture with a overall rate included reduction or open not screws the patient is and only risk factors A of 3 and 5 retrospective studies = that outcomes and complications were similar for fixation and screw fixation for injuries, with a time to in the the the is from retrospective studies and only 1 that time to the cost of health be of fixation screws had no on ankle in was on and following implant removal, and 3 months ankle of motion not be the for implant reduction is for clinical outcomes. 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