What’s New in Foot and Ankle Surgery
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 and Michael Yeranosian, MD, co-authors of the May 18, 2016 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies they cited.
Ankle Fractures and Syndesmotic Injuries
–A randomized study compared syndesmotic fixation versus no fixation in patients with supination-external rotation (SER) IV-type ankle fractures and positive intraoperative stress tests (persistent widening of the medial clear space). At four years of follow-up researchers found no clinical or radiological differences between the two groups.1
–A randomized single-blinded trial to help determine optimal methods for soft-tissue management after ankle trauma compared standard treatment using ice and elevation with the use of multilayer compression bandages. Researchers found that multilayer compression therapy resulted in faster resolution of edema than cryotherapy.
Total Ankle Arthroplasty
–A prospective cohort study found that patients undergoing total ankle arthroplasty (TAA) had higher preoperative expectation scores than did those undergoing ankle arthrodesis. TAA patients were also more likely than arthrodesis patients to report improved postoperative satisfaction scores. Postoperative expectation and satisfaction scores in both groups were closely linked to postoperative Ankle Osteoarthritis Scale (AOS) scores. The study emphasizes the importance of preoperative patient education.2
Orthobiologics
–A randomized controlled trial looking at union rates in ankle and hindfoot arthrodesis compared the use of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) plus an injectable osteoconductive beta-tricalcium phosphate (β-TCP) collagen matrix to standard autograft. Complete fusion of all involved joints at 24 weeks occurred in 84% of those treated with the growth factor-matrix combination and in 65% of those treated with autograft (p <0.001).3
Patient-Reported Outcomes Assessment
–The 10-center Orthopaedic Foot & Ankle Outcomes Research (OFAR) Network conducted a three-month trial of collecting preoperative and six-month postoperative patient outcome information using the Patient Reported Outcomes Measurement Information System (PROMIS). Of the 328 patients enrolled, 76% completed the preoperative instruments and 43% completed the six-month postoperative instruments. Despite substantial loss to follow-up, the OFAR Network process enabled easy data aggregation and analysis, suggesting its utility in facilitating multicenter trials.4
References
- Kortekangas THJ, Pakarinen HJ, Savola O, Niinimäki J, Lepojärvi S, Ohtonen P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2014 Oct;35(10):988-95. Epub 2014 Jun 24.
- Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
- Daniels TR, Younger ASE, Penner MJ, Wing KJ, Le ILD, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW. Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int. 2015 Jul;36(7):739-48.Epub 2015 Apr 6.
- Hunt KJ, Alexander I, Baumhauer J, Brodsky J, Chiodo C, Daniels T, Davis WH, Deland J, Ellis S, Hung M, Ishikawa SN, Latt LD, Phisitkul P, SooHoo NF, Yang A, Saltzman CL; OFAR (Orthopaedic Foot and Ankle Outcomes Research Network). The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle. Foot Ankle Int. 2014Sep;35(9):847-54.
What’s New in Foot and Ankle Surgery: Level I and II Studies
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. Here is a summary of selected findings from Level I and II studies cited in the May 20, 2015 Specialty Update on foot and ankle surgery:
Talar and Calcaneal Fractures
- A prospective randomized study comparing the sinus tarsi approach with the minimally invasive approach to the calcaneus found significantly fewer wound healing complications and shorter operative times with the minimally invasive longitudinal approach, but better outcomes were noted with the sinus tarsi approach for Sanders type-IV fractures.
- An RCT comparing outcomes of operative and nonoperative treatment for displaced intra-articular calcaneal fractures found no between-group differences at one year, but a trend toward better pain scores and function was noted in the operative group at eight to twelve years.
Ankle Instability
- A prospective randomized study of treatments for severe lateral ankle sprains compared a walking boot with restricted joint mobilization for three weeks with immediate application of a functional brace. No between-group differences in pain scores or development of mechanical instability were found, but the immediate functional-brace group had better function scores and shorter recoveries.
- A randomized trial comparing neuromuscular training, bracing, and a combination of the two for managing lateral ankle sprains concluded that bracing is the dominant secondary preventive intervention.
Total Ankle Arthroplasty
- A Level II study comparing total ankle arthroplasty (TAA) with ankle arthrodesis found that both procedures improved gait postoperatively, but TAA came closer to restoring a normal gait.
- A Level II study comparing fixed and mobile-bearing TAA devices found nearly equivalent improvements in pain and function.
- A Level I study looking at TAA outcomes in relation to preoperative coronal-plane malalignment found that results were similar for ankles with a preoperative coronal-plane varus deformity of ≥10° and those with <10° of varus deformity.
Ankle and Hindfoot Arthrodesis
- A pilot RCT comparing B2A-coated ceramic granules with autograft in foot and ankle arthrodesis found that the B2A approach produced a 100% fusion rate, compared with a 92% rate in the autograft group.
Achilles Tendon
- A Level II study found that weight-bearing cast immobilization provided outcomes that were similar to those of non-weight-bearing cast immobilization in non-operative management of acute Achilles tendon ruptures.
Peripheral Neuropathy
- In an RCT comparing standard-of-care orthoses with experimental pressure-based orthoses to prevent plantar foot ulcers, the experimental orthoses outperformed the standard ones.
- A Level I study investigating surgical-site infections after foot and/or ankle surgery found an increased risk of infection associated with concomitant peripheral neuropathy, even in patients without diabetes.
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