Amid ongoing uncertainty regarding the optimum management of Achilles tendon ruptures, recent controlled trials seem to have moved the pendulum back toward nonsurgical treatment. Still, there are many people walking around on surgically repaired Achilles tendons, and in the September 20, 2017 issue of The Journal, Heikkinen et al. report on the 13+-year outcomes of operative repair followed by early functional postoperative management in 52 patients.
All orthopaedic surgeons who have treated patients with this tendon injury have noted the postoperative calf atrophy. Using carefully analyzed MRI studies, these authors found that the mean volumes of the soleus, medial gastrocnemius, and lateral gastrocnemius muscles were 13%, 13%, and 11% lower, respectively, in the affected legs than in the uninjured legs. The mean 6% elongation of the repaired tendon that Heikkinen et al. also found at this long-term follow-up makes sense, because we are repairing tendinous tissue whose inherent collagen bundle structure has been “overstretched” prior to total failure. It also makes sense that surgeons are often hesitant to shorten the ends of the tendon aggressively for fear of placing too great a tensile strain on the suture repair.
What is most impressive to me is the degree of calf-muscle atrophy revealed in these results. Whether the findings from future trials tilt us further toward nonoperative or back toward operative care, we need to solve the muscle atrophy issue. The solution will most likely come from even more aggressive rehabilitation. To date, many of us have erred on the side of not pushing these patients too far during rehab, out of concern for failure of repair or reinjury.
With solid surgical and nonsurgical treatments for fractures, we have solved many issues to achieve optimum bone healing with good anatomic and strength outcomes. However, we have not really begun to make gains on limiting muscle, ligament, and tendon atrophy in lower extremity injuries. This should be high on the agenda for the trauma research community during the next 2 to 3 decades.
Marc Swiontkowski, MD
Among the many variables discussed when patients and surgeons make a decision between ankle arthrodesis (fusion) and total ankle replacement (TAA) for end-stage ankle arthritis, in-hospital complication rate is an often-overlooked point of comparison, partly due to a dearth of good data.
In the September 6, 2017 edition of The Journal of Bone & Joint Surgery, Odum et al. report findings from a matched cohort study that compared these two ankle procedures in terms of minor and major perioperative complications. To make more of an apples-to-apples comparison, the authors statistically matched 1,574 patients who underwent a TAA with an equal number of those who underwent fusion.
A major in-hospital complication (such as a pulmonary embolism or mechanical hardware problem) occurred in 8.5% of fusion patients and in 5.3% of TAA patients. After adjusting for case mix, Odum et al. found that ankle arthrodesis was 1.8 times more likely than TAA to be followed by a major complication. Regarding minor in-hospital complications (such as venous thrombosis or hematoma/seroma), the authors found a 29% lower risk of complications among arthrodesis patients compared to TAA patients, although that difference was not statistically significant (p = 0.14). Regardless of surgical procedure, patient age ≤67 years and the presence of multiple comorbidities were independently associated with a higher risk of a major complication.
A possible explanation for the lower in-hospital major-complication rate in TAA patients, say the authors, is that “TAA is more likely to be performed in younger, healthier patients with better bone quality and smaller deformities.”
Ankle sprain is a common musculoskeletal injury throughout the world, affecting tens of thousands of patients daily. What treatments for lateral inversion ankle injury are most effective? When is a wait-and-see approach more beneficial than a training program, and functional interventions more appropriate than surgical treatment? What surgical interventions yield better outcomes for function and instability compared with conservative treatment, particularly when the calcaneofibular ligament is disrupted, and does one postoperative regimen produce better results than another?
On Tuesday, September 19, 2017 at 5:00 PM EDT, these intriguing and clinically applicable questions will be addressed during a complimentary* LIVE webinar, hosted jointly by The Journal of Bone & Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT).
JBJS co-authors Mark E. Easley, MD, and Manuel J. Pellegrini, MD, will discuss findings from a systematic quantification of the stabilizing effects of subtalar joint soft-tissue constraints in a novel cadaveric model.
JOSPT co-author John M. van Ochten, MD, will share the results of a systematic review of randomized controlled and controlled clinical trials on the effectiveness of treatments for ankle sprains.
Moderated by Dr. Alexej Barg, a leading authority on the foot and ankle and traumatic injuries to the lower extremity, the webinar will include additional insights from expert commentators J. Chris Coetzee, MD, and Phillip A. Gribble, PhD, ATC, FNATA. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.
Seats are limited, so Register Now.
* This webinar is complimentary for those who attend the event live and will continue to be available at no charge for 24 hours following its conclusion.
Recurrence rates after surgical treatment for hallux valgus (bunion) range from 4% to 25%. Findings from a study by Park and Lee in the July 19, 2017 edition of The Journal of Bone & Joint Surgery suggest that non-weight-bearing radiographs taken immediately after surgery can provide a good estimate of the risk of recurrence.
The study analyzed proximal chevron osteotomies performed on 117 feet. At an average follow-up of two years, the hallux valgus recurrence rate was 17%. (Recurrence was defined as a hallux valgus angle [HVA] of ≥20°.)
Bunions were 28 times more likely to recur when the postoperative HVA was ≥8° than when the HVA was <8°. The HVA continued to widen over time in patients with recurrent bunions, but stabilized at six months in those without recurrence. An immediate postoperative sesamoid position of grade 4 or greater was also significantly associated with recurrence.
If future studies confirm their results, the authors believe that such data could be used “to suggest intraoperative guidelines for satisfactory correction of radiographic parameters,” and thus help surgeons minimize the risk of hallux valgus recurrence. Commentator Jakup Midjord, MD concurs, noting that non-weight-bearing radiographs can be “closely related to intraoperative radiographs, so we can modify correction as needed in the operating room.”
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
One of the most challenging diagnoses for general orthopedic surgeons as well as fracture specialists is a fracture of the talar neck. The infrequency of displaced talar fractures means that orthopaedic residents receive relatively little training in this area. A pivotal JBJS article in 1978 focused attention on these vexatious injuries. “Fractures of the Neck of the Talus” by Canale and Kelly provides clinically useful information and does two things that are very difficult to do today:
- Follows patients for a long time (an average of nearly 13 years)
- Obtains direct evidence of outcomes by physical exam, one-on-one measurement, and long-term imaging.
This remarkable duration of follow-up, so important in determining the impact of treatment in musculoskeletal injury, is very difficult today as a result of overly enthusiastic privacy protections and a costly regulatory infrastructure.
This classic JBJS article capitalizes on other classics, such as those by Blair (1943) on talar body salvage and studies by Halliburton (1958) and Mulfinger (1970) on the anatomy of talar blood supply. While Mulfinger showed the vascular supply of the talus,1 that study did not link that information to clinical care. The study by Canale and Kelly provides insight into how our care for patients with these uncommon fractures affects outcomes. In addition, the relatively primitive state of art at the time for the operative treatment of talar fractures led to fear of infection, and limited understanding of the basics of fracture healing and underdeveloped implants for fixation steered many surgeons away from rigid fixation in favor of closed reduction and cast immobilization.
The authors identified 107 fractures treated over a 33-year period; they examined and obtained radiographs on 71 of those fractures in 70 patients at an average follow-up of almost 13 years. (Fourteen of the patients were followed for more than 20 years, and 5 were followed for more than 30 years.) The preferred treatment protocol was closed reduction and casting. A reduction with less than 5 mm of displacement and 5° of misalignment was considered adequate. Open reduction with internal fixation was performed when these criteria were not met.
To assess outcomes, the authors directly measured ankle and subtalar motion, assessed whether a limp was present, and asked patients to rate their pain. Long before “patient-reported outcome measures” was a recognized term, these authors recorded them. Only 59% of patients in this series achieved good or excellent outcomes. The authors identified the high morbidity of these injuries, including avascular necrosis in more than half and 25 who needed later surgical intervention. The authors also recommended against talectomy as a salvage procedure.
While hampered by relatively low-resolution imaging and outcome measures that don’t meet current standards of reproducibility, Canale and Kelly provided a great deal of information that focused attention on the importance of quality of reduction. In addition, the paper created an enduring fracture classification that paralleled complication rates and potential outcomes.
Bruce Sangeorzan, MD
JBJS Deputy Editor
- Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970 Feb;52(1):160-7
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sheldon Lin, MD, co-author of the April 19, 2017 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies cited in the article.
–Recommendations for venous thromboembolism (VTE) prophylaxis in isolated foot and ankle fractures are conflicting. In a prospective study, Zheng et al.1 determined the incidence of VTE in 814 patients who received either low-molecular-weight heparin or placebo for 2 weeks postoperatively. The overall incidence of deep vein thrombosis was 0.98% in the heparin group and 2.01% in the placebo group, with no significant difference between the two. The risk factors were high body mass index (BMI) and advanced age. The authors concluded that routine chemical prophylaxis was not necessary in cases of isolated foot and ankle fractures.
Age and Total Ankle Arthroplasty
–Concerns regarding implant survivorship in younger patients have prompted investigations into the effect of age on total ankle arthroplasty outcomes. Demetracopoulos et al.2 prospectively compared patient-reported outcomes and revision rates in patients who were 70 years of age. At the 3.5-year follow-up, patients who were 70 years of age, although no differences were observed in pain, need for reoperation, or revision rates between groups.
Hallux Rigidus/Hallux Valgus
–Joint-preserving arthroplasties for hallux rigidus have been proposed as an alternative to first metatarsophalangeal joint arthrodesis. However, they have shown high rates of failure with associated bone loss, rendering salvage arthrodesis a more complicated procedure with worse outcomes. A Level-I study by Baumhauer et al.3 investigated the use of a synthetic cartilage implant that requires less bone resection than a traditional arthroplasty. Patients were randomized to implant and arthrodesis groups. At the 2-year follow-up, pain level, functional scores, and rates of revision surgical procedures were statistically equivalent in both groups. Secondary arthrodesis was required in <10% of the implant group and was considered to be a straightforward procedure because of preservation of bone stock.
–Hallux valgus surgical procedures are commonly performed under spinal, epidural, or regional anesthesia. Although peripheral nerve blocks have become increasingly popular with the advent of ultrasound, the associated learning curve has limited more widespread use. A Level-I study by Karaarslan et al.4 compared the efficacy of ultrasound-guided popliteal sciatic nerve blocks with spinal anesthesia in patients undergoing hallux valgus correction. The popliteal block group demonstrated decreased pain scores at every time point up to 12 hours postoperatively, longer time to first analgesic requirement, and increased patient satisfaction scores compared with the spinal anesthesia group. The popliteal block group also did not experience the adverse effects of hypotension, bradycardia, and urinary retention occasionally seen with spinal anesthesia.
–Orthobiologics continue to generate considerable interest within the orthopaedic community. Platelet-rich plasma and hyaluronic acid have been investigated as adjuncts to promote healing. In a Level-I study, Görmeli et al.5 randomized patients to receive platelet-rich plasma, hyaluronic acid, or saline solution injections following arthroscopic debridement and microfracture of talar osteochondral lesions. At the intermediate-term follow-up, the platelet-rich plasma and hyaluronic acid groups exhibited a significant increase in AOFAS scores and decrease in pain scores compared with the control group, with the platelet-rich plasma group showing the greatest improvement.
- Zheng X, Li DY, Wangyang Y, Zhang XC, Guo KJ, Zhao FC, Pang Y, Chen YX. Effect of chemical thromboprophylaxis on the rate of venous thromboembolism after treatment of foot and ankle fractures. Foot Ankle Int. 2016 Nov;37(11):1218-24.
- Demetracopoulos CA, Adams SB Jr, Queen RM, DeOrio JK, Nunley JA 2nd, Easley ME. Effect of age on outcomes in total ankle arthroplasty. Foot Ankle Int. 2015 Aug;36(8):871-80.
- Baumhauer JF, Singh D, Glazebrook M, Blundell C, De Vries G, Le ILD Nielsen D, Pedersen ME, Sakellariou A, Solan M, Wansbrough G, Younger AS, Daniels T; for and on behalf of the CARTIVA Motion Study Group. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot Ankle Int. 2016 May;37(5):457-69.
- Karaarslan S, Tekg¨ul ZT, S¸ ims¸ek E, Turan M, Karaman Y, Kaya A, Gönüllü M. Comparison between ultrasonography-guided popliteal sciatic nerve block and spinal anesthesia for hallux valgus repair. Foot Ankle Int. 2016 Jan;37(1):85-9. Epub 2015 Aug 20.
- Görmeli G, Karakaplan M, Görmeli CA, Sarıkaya B, Elmalı N, Ersoy Y. Clinical effects of platelet-rich plasma and hyaluronic acid as an additional therapy for talar osteochondral lesions treated with microfracture surgery: a prospective randomized clinical trial. Foot Ankle Int. 2015 Aug;36(8):891-900.
We have entered an era where total ankle arthroplasty (TAA) is accepted as a rational approach for patients with degenerative arthritis of the ankle. TAA results have been shown to be an improvement over arthrodesis in some recent comparative trials.
That was not always the case, however. In the 1980s, the orthopaedic community attacked ankle joint replacement with gusto, and numerous prosthetic designs were introduced with great enthusiasm based on short-term cohort studies. Unfortunately, the concept of TAA was all but buried as disappointing longer-term results with those older prosthetic designs appeared in the scientific literature. It took a full decade for new designs to appear and be subjected to longer-term follow-up studies before surgeons could gain ready access to more reliable instrumentation and prostheses. The producers of these implants behaved responsibly in this regard, facilitated by an FDA approval process that had increased in rigor.
In the December 21, 2016 issue of The Journal, Hofmann et al. publish their medium-term results with one prosthetic design that was FDA-approved in 2006. Implant survival among 81 consecutive TAAs was 97.5% at a mean follow-up of 5.2 years. There were only 4 cases of aseptic loosening and no deep infections in the cohort. Total range of motion increased from 35.5° preoperatively to 39.9° postoperatively.
The fact that a high percentage (44%) of ankles underwent a concomitant procedure at the time of TAA attests to the need for careful preoperative planning for alignment of the ankle joint and the need for thorough assessment of the hindfoot. The fact that a substantial percentage (21%) of ankles underwent another procedure after the TAA attests to the need for thoughtful benefit-risk conversations with patients prior to TAA.
I think the TAA concept and procedure are here to stay, but we still have much work to do in fine-tuning prosthetic designs and instrumentation and enhancing surgeon education for more reliable outcomes.
Marc Swiontkowski, MD
In the December 7, 2016 issue of JBJS, Krause et al. analyze data from a 2013 industry-sponsored RCT to investigate correlations between nonunions of hindfoot/ankle fusions indicated by early postoperative computed tomography (CT) and subsequent functional outcomes. Whether nonunion was assessed by independent readings of those CT scans at 24 weeks or by surgeon composite assessments at 52 weeks, patients with failed healing had lower AOFAS, SF-12, and Foot Function Index scores than those who showed osseous union.
This study suggests that a CT should be obtained from patients who are at least 6 months out from a surgical fusion and are not progressing in terms of activity-related pain and function. Depending on the specific CT findings, a repeat attempt at bone grafting, with the possible addition of bone-graft substitute and/or possible modification of internal fixation, may be warranted to forestall later clinical problems.
Krause et al. imply that trusting plain radiographs that show no indication of fusion failure is not acceptable when patient pain and function do not improve in a timely fashion. Conversely, they conclude that their findings do not support “the concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well),” because nonunions identified early by CT eventually resulted in worse clinical outcomes. The authors also noted that obesity, smoking, and not working increased the risk of nonunion, corroborating findings from earlier studies.
While advanced imaging such as CT is not necessary in foot/ankle fusion patients who are improving in terms of function, pain, and swelling , this study stresses the importance of achieving union following these fusion procedures.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent JAMA study, the following two commentaries come from Chad Krueger, MD, and Shahriar Rahman, MS.
“Hmmm…. Maybe I’m operating on too many ankle fractures.” That was my first thought as I read the abstract of the recent Willett et al. study in JAMA. They conducted a well-designed, randomized controlled trial that compared operative and nonoperative treatment of unstable ankle fractures, using the Olerud-Molander Ankle Score at 6 months postoperatively as the primary outcome measure.
On the surface, it appeared as though patients who were treated nonoperatively with close contact casting did just as well as those who underwent operative intervention. This seemed to be not only the case with the primary outcome measure, but also with secondary outcomes such as quality of life, pain, and patient satisfaction. “Do less” appeared to be the main message of the abstract. However, I became more skeptical after critically reading the entire article.
First off, the study was designed to determine differences between treatment groups, not to prove that they were equivalent. Finding no difference is not the same as showing equivalence, and the article did the former, not the latter.
There are also a few things about the study that may limit the wide applicability of the findings and provide some solace to surgeons like me who feel that fixing unstable ankle fractures provides superior outcomes. First, only initial radiographs were used to determine who had unstable ankle fractures. Stress radiographs were an exclusion criterion, so for the many ankle fractures that require such imaging to determine instability, the results from Willett et al. may not apply.
Second, the study was designed to compare these treatments in older adults. The mean ages of operative and nonoperative groups were 69.8 and 71.4 years old, respectively, and almost 75% of both groups were female. While bone density was not measured in either group, it is likely that many patients included in this study had osteoporotic disease, which introduces another potential variable when interpreting the findings.
Furthermore, nearly 20 percent of all patients who initially were treated with casting developed some type of complication that required conversion to surgical fixation. This finding, plus the fact that all casts were applied by surgeons in the operating room with patients under general or spinal anesthesia, suggests that treating unstable ankle fractures with surgical fixation in a single visit would perhaps provide the most definitive treatment.
So, I will probably continue to offer patients with unstable ankle fractures surgical fixation. I have never tried the close contact casting that was described in the article, and I suspect, despite the authors’ claim of evidence to the contrary, that there is a significant learning curve associated with that technique. If about one out of every five patients I perform casting on as definitive treatment ends up needing additional procedures, I am not sure I have done the patient justice. While this study provides interesting evidence and may apply to a small subset of my older patients, I think it has limited applicability in other patients who present with unstable ankle fractures.
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.
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The Willett et al. study in JAMA indicates that some patients older than 60 years with unstable ankle fractures can be treated by modified casting alone, without the need for operative stabilization and fixation. The study protocol allowed conversion to surgery among patients randomized to casting if reduction was not possible during the initial procedure or was lost within the first 3 weeks.
One hundred surgeons applied close contact casting at 24 major trauma centers and general hospitals in the UK. After 6 months, the mean Olerud-Molander Ankle Score was 66.0 in the surgery group vs 64.5 in the casting group—no significant difference in the primary outcome.
Secondary outcomes showed that the rate of radiographic malunion was 15% in the casting group compared with 3% in the surgery group. Conversion from casting to operative treatment was high: of the 311 patients randomized to casting, 70 (23%) were ultimately treated by internal fixation, including 18 never treated with close contact casting and 52 who lost reduction and required conversion to internal fixation. Rates of infection and wound complications were 10% in the surgical group versus 1% in the casting group. Additional operating room procedures were required in 6% of the surgery group and 1% of the casting group. Casting required less operating room time compared with surgery.
The overall similarity in clinical outcomes in this study challenges the importance of restoring exact ankle-joint congruence in older adults and suggests that function and pain are not as closely related to malunion as many clinicians believe. Neither method yielded an entirely satisfactory outcome in older adults. In older patients with lower demand, shorter life expectancy, lesser bone and tissue quality, and diminished capacity for healing, the rates of delayed or infected wound healing and loss of implant fixation are greater.
Casting may be an imperfect alternative to surgery particularly in developing countries. One must remember, however, that plaster technique is an art. Achieving the successful outcomes with close contact casting as described by Willett et al. is likely to pose a learning curve. Further studies are needed to identify which specific patients are most and least likely to benefit from casting.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh.
Despite the remarkable success of modern treatments for congenital clubfoot, including the Ponseti method, some kids still end up with a rigid residual deformity after walking age. In the October 19. 2016 edition of JBJS, Dragoni et al. investigated the Ponseti treatment in 44 patients (68 feet; mean age of 4.8 years) who had been previously treated with various surgical and conservative protocols but whose outcomes were fair or poor, according to International Clubfoot Study Group scores.
The authors performed Ponseti manipulation and cast application with the patients under conscious sedation. Depending on the clinical situation, some patients also received percutaneous heel-cord surgery or percutaneous fasciotomy, and all those over 3 years old (88% of the feet) received tibialis anterior tendon transfer (TATT).
At a mean follow-up of just under 5 years, 84% of the feet had achieved excellent or good results. No feet showed a lack of plantar flexion or were not plantigrade. Despite the mobility problems that a series of long leg Ponseti casts posed for kids of walking age, the authors reported that “families enthusiastically agreed to continue the Ponseti treatment as soon as they looked at the improved shape of their child’s foot after removal of the first plaster cast.”