Foot & Ankle
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Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component.
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High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density.
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Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient.
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Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects.
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A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments.
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Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org
Nisantasi Ortopedi Merkezi, Hakkı Yeten Cad., Unimed Center, No:19, 34365 Fulya, Istanbul, Turkey
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Nisantasi Ortopedi Merkezi, Hakkı Yeten Cad., Unimed Center, No:19, 34365 Fulya, Istanbul, Turkey
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The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness.
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An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it.
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Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together.
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Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org
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An estimated 40% of the US population have foot problems.
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Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed ‘hallux rigidus’. First MTP osteoarthritis is the most common arthritic condition in the foot.
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Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.
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In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.
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In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.
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A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal head
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Multiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results.
Cite this article: EFORT Open Rev 2017;2:13–20. DOI: 10.1302/2058-5241.2.160031
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Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders.
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The most common foot and ankle tendoscopies are: Achilles; peroneal; and posterior tibial tendon.
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Tendoscopy may be used as an adjacent procedure to other techniques.
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Caution is recommended to avoid neurovascular injuries.
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Predominantly level IV and V studies are found in the literature, with no level I studies still available.
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There are many promising and evolving endoscopic techniques for tendinopathies around the foot and ankle, but studies of higher levels of evidence are needed to strongly recommend these procedures.
Cite this article: EFORT Open Rev 2016;1:440-447. DOI: 10.1302/2058-5241.160028
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Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature.
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The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities.
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There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions.
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We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed.
Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.
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Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.
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Eccentric stretching is the most effective treatment.
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Surgical treatment is reserved for recalcitrant cases.
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Minimally-invasive and tendinoscopic treatments are showing promising results.
Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.
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Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone.
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Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus.
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Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms.
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There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial.
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Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically.
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Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved.
Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.
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The incidence and severity of ankle fractures in elderly patients is increasing steadily. These injuries are challenging to treat and prone to complications.
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Individual fracture treatment is tailored depending on bone quality, skin conditions, comorbidities, and functional demand of the patient. This article provides a review of current techniques to obtain stable fixation despite poor bone quality. To avoid complications, it is imperative to consider and treat comorbidities such as diabetes and osteoporosis.
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In the absence of severe systemic comorbidities, the results after open reduction and internal fixation of malleolar fractures in patients above and below 60 years of age are nearly identical, while nonoperative treatment of unstable fractures leads to significantly inferior outcomes. Therefore, the general indications for surgery in elderly patients should not differ from those in younger patients.
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However, it is essential to detect severe conditions such as Charcot neuro-osteoarthropathy because these require a completely different treatment regime, and standard internal fixation will invariably fail in these patients.
Cite this article: Rammelt S. Management of ankle fractures in the elderly. EFORT Open Rev 2016;1:239-246. DOI: 10.1302/2058-5241.1.000023.
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The pathogenesis of hallux valgus deformity is multifactorial. Conservative treatment can alleviate pain but is unable to correct the deformity. Surgical treatment must be adapted to the type and severity of the deformity. Success of surgical treatment ranges from 80% to 95%, and complication rates range from 10% to 30%.
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Ankle osteoarthrosis most commonly occurs as a consequence of trauma. Ankle arthrodesis and total ankle replacement are the most common surgical treatments of end stage ankle osteoarthrosis. Both types of surgery result in similar clinical improvement at midterm; however, gait analysis has demonstrated the superiority of total ankle replacement over arthrodesis. More recently, conservative surgery (extraarticular alignment osteotomies) around the ankle has gained popularity in treating early- to mid-stage ankle osteoarthrosis.
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Adult acquired flatfoot deformity is a consequence of posterior tibial tendon dysfunction in 80% of cases. Classification is based upon the function of the tibialis posterior tendon, the reducibility of the deformity, and the condition of the ankle joint. Conservative treatment includes orthotics and eccentric muscle training. Functional surgery is indicated for treatment in the early stages. In case of fixed deformity, corrective and stabilising surgery is performed.
Cite this article: Crevoisier X, Assal M, Stanekova K. Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments. EFORT Open Rev 2016;1:58–64. DOI: 10.1302/2058-5241.1.000015.
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Ankle sprains fall into two main categories: acute ankle sprains and chronic ankle instability, which are among the most common recurrent injuries during occupational activities, athletic events, training and army service.
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Acute ankle sprain is usually managed conservatively and functional rehabilitation failure by conservative treatment leads to development of chronic ankle instability, which most often requires surgical intervention.
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Enhancing the in-depth knowledge of the ankle anatomy, biomechanics and pathology helps greatly in deciding the management options.
Cite this article: Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev 2016;1:34-44. DOI: 10.1302/2058-5241.1.000010.
