Foot & Ankle

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Matthieu Lalevee Department of Orthopedic Surgery, Rouen University Hospital, Rouen, France
CETAPS UR3832, Research Center for Sports and Athletic Activities Transformations, University of Rouen Normandy, Mont-Saint-Aignan, France

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Mo Saffarini ReSurg SA, Nyon, Switzerland

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Floris van Rooij ReSurg SA, Nyon, Switzerland

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Luca Nover ReSurg SA, Nyon, Switzerland

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Alexis Nogier Clinique Trénel, Sainte, Colombe, France

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Philippe Beaudet Clinique Trénel, Sainte, Colombe, France

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Purpose

  • Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to synthesize and critically appraise the literature on the long-term outcomes of shaft osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess the long-term HV recurrence rates of studies with a minimum follow-up of 5 years.

Methods

  • This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of shaft osteotomies of the M1 for non-inflammatory and non-degenerative HV having a minimum follow-up of 5 years were included. We found five eligible studies comprising six datasets, all assessed Scarf osteotomies with a mean follow-up that ranged from 8 to 14 years.

Results

  • The HV recurrence rate was 40%, considering the threshold of >15° hallux valgus angle (HVA), 30% having >20°, and 2% having >25°.

Conclusion

  • At a minimum follow-up of 8 years following shaft osteotomies of M1, the HVA was 15.9°, the intermetatarsal angle (IMA) was 7.7°, and the DMAA was 8.3°. Furthermore, the recurrence rates considering the various thresholds of HVA were: 40% having >15°, 20% having >20°, and 2% having >25°.

Level of Evidence

  • Meta-analysis, Level IV

Open access
Alessandro Sangiorgio Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

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Martina Sirone Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

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Federico Maria Adravanti Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Enrique Adrian Testa Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Martin Riegger Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Giuseppe Filardo Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Purpose

  • The association between fluoroquinolone intake and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) is widely documented. However, it is not clear whether different molecules have the same effect on these complications. The purpose of this study was to document Achilles tendon complications for the most prescribed fluoroquinolones molecules.

Methods

  • A literature search was performed on Pubmed, Cochrane, Embase, and Web of Science databases up to April 2023. Inclusion criteria: studies of any level of evidence, written in English, documenting the prevalence of AT/ATR after fluoroquinolone consumption and stratifying the results for each type of molecule. The Downs and Black’s ‘Checklist for Measuring Quality’ was used to evaluate the risk of bias.

Results

  • Twelve studies investigating 439,299 patients were included (59.7% women, 40.3% men, mean age: 53.0 ± 15.6 years). The expected risk of AT/ATR was 0.17% (95% CI: 0.15–0.19, standard error (s.e.): 0.24) for levofloxacin, 0.17% (95% CI: 0.16–0.19, s.e.: 0.20) for ciprofloxacin, 1.40% (95% CI: 0.88–2.03, s.e.: 2.51) for ofloxacin, and 0.31% (95% CI: 0.23–0.40, s.e.: 0.77) for the other molecules. The comparison between groups documented a significantly higher AT/ATR rate in the ofloxacin group (P < 0.0001 for each comparison). Levofloxacin and ciprofloxacin showed the same risk (P = n.s.). The included studies showed an overall good quality.

Conclusion

  • Ofloxacin demonstrated a significantly higher rate of AT/ATR complications in the adult population, while levofloxacin and ciprofloxacin showed a safer profile compared to all the other molecules. More data are needed to identify other patient and treatment-related factors influencing the risk of musculoskeletal complications.

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Jan Bartoníček Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice, Prague, Czech Republic

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Stefan Rammelt University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse, Dresden, Germany

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Michal Tuček Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice, Prague, Czech Republic

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  • Bosworth fracture (BF) is a special type of locked ankle fracture-dislocation, characterized by displacement of a fragment of the fractured fibula from the fibular notch behind the posterior surface of the distal tibia.

  • BF is a complex injury affecting multiple structures of the ankle joint, which is still frequently misjudged even today, potentially leading to severe complications.

  • CT examination, including 3D reconstructions, should be the diagnostic standard in BF, as it provides a complete picture of the fracture pathoanatomy, most prominently the morphology of the frequently associated posterior malleolar fracture.

  • BF requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction. Non-operative treatment of BF almost always fails. The standard treatment procedure is early open reduction internal fixation.

  • Due to the relative severity and paucity of the injury, BF seems to be particularly prone to soft tissue complications, including compartment syndrome.

  • The results of operative treatment are mixed. Many studies report persistent pain even after a short time interval, with limitations of the range of motion or even stiffness of the ankle joint, and development of degenerative changes. Larger studies with long-term results are still missing.

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Matías Sepulveda Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile
AO Foundation, LEGEC Expert Group, Davos, Switzerland

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Gabriel Orellana Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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Francisco Sanchez Clínica Puerto Varas, Puerto Varas, Chile
Clínica Puerto Montt, Puerto Montt, Chile

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Estefania Birrer Universidad Austral de Chile, Valdivia, Chile
Hospital Base de Valdivia, Valdivia, Chile

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  • Brachymetatarsia involves a reduction in length of one or more metatarsals.

  • The affected metatarsal is shortened by 5 mm or more, altering the normal metatarsal parabola.

  • In addition to being an aesthetic deformity, it can present with pain due to transfer metatarsalgia.

  • A possible association with genetic disorders needs to be investigated during clinical evaluation.

  • Surgical treatment may involve a one-stage lengthening procedure or progressive distraction, each having its advantages and limitations.

Open access
Gema Chamorro-Moriana Department of Physiotherapy, Research Group “Area of Physiotherapy CTS-305”, University of Seville, Seville, Spain

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Veronica Perez-Cabezas Department of Nursing and Physiotherapy, Research Group MOVEIT (eMpOwering health by physical actiVity, Exercise and nutrition) CTS-1038, University of Cadiz, Cadiz, Spain

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Marisa Benitez-Lugo Department of Physiotherapy, Research Group “Area of Physiotherapy CTS-305”, University of Seville, Seville, Spain

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Purpose

  • The aim of the study was to analyze the effects of functional or biomechanical bandages, whether elastic or inelastic, in Chronic Ankle Instability (CAI).

Methods

  • This review used PubMed, WoS, SCOPUS, and CINAHL following PRISMA and registering in Prospero. Main PICOS: (1) CAI; (2) intervention, functional/biomechanical bandages; (3) comparison, taping effect versus placebo/no taping, or another functional taping; (4) outcomes, improvement of CAI functionality (dynamic/static balance, ankle kinematic, perception, agility and motor control, endurance and strength; (5) experimental and preexperimental studies. The meta-analyses considered mean and s.d. of the results per variable; effect size (ES) of each study and for each type of intervention. Homogeneity (Q), heterogeneity (H 2 and I 2), and 95% CI were calculated.

Results

  • In total, 28 studies were selected. Significant differences were found for dynamic balance (66.66%) and static balance (87.5%), ankle kinematics (75.00%), perceptions (88.88%), plantar flexor strength (100%), muscle activity (66.6%), endurance (100%), functional performance (100%), and gait (66.6%). The main results of meta-analyses (eight studies) are as follows – h/M ratio soleus, ES: 0.080, 95% CI: −5.219–5.379; h/M ratio peroneus, ES: 0.070, 95% CI: −6.151–6.291; posteromedial KT, ES: 0.042 95% CI: −0.514–0.598; posteromedial—overall, ES: −0.006 95% CI: −1.071–0.819; mSEBT-KT, ES: 0.057 95% CI: −0.281–0.395; mSEBT—overall, ES: −0.035 95% CI: −0.190–0.590.

Conclusions

  • All biomechanical or functional bandages, whether elastic or inelastic, applied in CAI were favorable, highlighting patient perception, dynamic and static balance, kinematics and agility and motor control, for its effectiveness and evidence. Thus, bandages increase ankle functionality. The meta-analyses found no statistical significance. Clinically, soleus muscle activity, h-reflex/M-responses using fibular reposition with rigid tape, and dynamic balance with combined kinesiotaping during the modified star excursion balance test and with the posteromedial direction found improvements.

Level of evidence

  • Level of evidence according to Scottish Intercollegiate Guidelines Network: 1+. Level of evidence according to the Oxford Centre for Evidence-Based Medicine 2011: 1.

Open access
E Carlos Rodríguez-Merchán Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain
Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain

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Carlos A Encinas-Ullán Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain

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Juan S Ruiz-Pérez Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain

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Primitivo Gómez-Cardero Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain

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  • The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%.

  • To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique.

  • The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months.

  • The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%).

  • There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation.

  • Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications.

  • In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Open access
Fabian Tobias Spindler Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany

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Wolfgang Böcker Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany

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Hans Polzer Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany

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Sebastian Felix Baumbach Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany

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Objective

  • To this day, diagnostic standards and uniform definition for acute, isolated syndesmotic injuries are missing. The aim of the current study was to conduct a systematic review of the classification systems and diagnostics currently applied and to propose a best evidence diagnostic approach.

Methods

  • Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials, and Embase were searched from inception to June 5, 2022, for studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. First, all classifications used in the eligible studies were identified and illustrated according to the individual syndesmotic structures injured. Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intra-operatively), was analyzed, including the applied cutoff criteria.

Results

  • Ten out of 4190 studies, comprising 317 acute ligamentous syndesmotic injuries, met the inclusion criteria. Seven studies facilitated one of the three different classification systems (Calder, West Point, or Sikka classification). Eight studies based their indication for surgery on a combination of clinical and radiographic examinations and two on radiographs only. The most applied clinical tests were the external rotation stress test and squeeze test. The most common radiologic diagnostics were plain radiographs and MRI. Intraoperatively, instability was verified most commonly using arthroscopy.

Conclusion

  • Current classifications and diagnostics for syndesmotic injuries are heterogeneous, often cannot be attributed to the ligaments injured. An evidence-based diagnostic algorithm based on noninvasive diagnostics and an anatomy-based classification for acute syndesmotic instability is presented.

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Valentina Viglione Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Angelo Boffa Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Davide Previtali Department of Surgery, EOC, Service of Orthopaedics and Traumatology, Lugano, Switzerland

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Francesca Vannini Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Cesare Faldini Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

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Giuseppe Filardo Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Department of Surgery, EOC, Service of Orthopaedics and Traumatology, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Purpose

  • The study of the placebo effect is key to elucidate the ‘real effect’ of conservative interventions for plantar fasciitis. The aim of this meta-analysis was to quantify the impact of placebo in the different conservative treatments of plantar fasciitis.

Methods

  • A systematic literature review was performed on double-blind placebo-controlled trials (RCTs) according to PRISMA guidelines on PubMed, Embase, and Web of Science. The meta-analysis primary outcome was the 0–10 pain variation after placebo treatments analyzed at 1 week, 1, 3, 6, and 12 months. The risk of bias was assessed using the RoB 2.0 tool, while the overall quality of evidence was graded according to the GRADE guidelines.

Results

  • The placebo effect for conservative treatments was studied in 42 double-blind RCTs on 1724 patients. The meta-analysis of VAS pain showed a statistically significant improvement after placebo administration of 2.13/10 points (P < 0.001), being highest at 12 months with 2.79/10 points (P < 0.001). The improvement of the placebo groups was higher in the extracorporeal shock wave therapy studies compared to the injection studies (2.59 vs 1.78; P = 0.05). Eight studies had a low risk of bias, 23 studies had ‘some concerns,’ and 4 studies had a high risk of bias. The GRADE evaluation showed an overall high quality of evidence.

Conclusion

  • This systematic review and meta-analysis demonstrated that the placebo effect represents an important component of all conservative approaches to treat plantar fasciitis. This effect is statistically and clinically significant, increases over time, and depends on the type of conservative treatment applied to address plantar fasciitis.

Open access
Hagen Fritzsche University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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Anne Weidlich University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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Klaus-Dieter Schaser University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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Elisabeth Mehnert University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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Doreen Winkler University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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Stefan Rammelt University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse, Dresden, Germany

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  • Musculoskeletal tumours of foot or ankle make up about 4–5% of all musculoskeletal tumours. Fortunately, about 80% of them are benign. However, due to the rarity and low prevalence of each single tumour entity, diagnosis is often difficult and delayed.

  • Ultrasonography is an important diagnostic tool to safely recognize ganglion cysts as a frequently encountered ‘bump’ in the foot.

  • In suspicious lesions, malignancy must be excluded histologically in a tumour center by biopsy after imaging procedures using x-ray, computed tomography (CT) and magnetic resonance imaging (MRI).

  • Most of the benign tumours do not require any further surgical therapy. Resection should be performed in the case of locally aggressive tumour growth or local symptoms of discomfort. In contrast to malignant tumours, the primary purpose in the resection is the least possible loss of function.

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Michael J Raschke Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany

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Sabine Ochman Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany

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Alexander Milstrey Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany

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  • The relevance of geriatric ankle fractures is continuously increasing.

  • Treatment of these patients remains challenging and requires adapted diagnostic and therapeutic strategies, as compliance to partial weight bearing is difficult to maintain compared to younger patients.

  • In addition, in the elderly even low impact injuries may lead to severe soft tissue trauma, influencing timing and operative strategies.

  • Recently, the direct posterolateral approach and plate fixation techniques, angular stable implants as well as intramedullary nailing of the distal fibula have been found to improve stategical concepts.

  • This article aims to provide a comprehensive overview of the diagnostic and recent aspects with respect to how this difficult entity of injuries should be approached.

Open access