Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for small primary lesions less than ...100 mm2. Individual studies on the topic are small and heterogeneous, and they have differed in their main findings; for this reason, systematically reviewing the available evidence seems important.
In this systematic review, we asked: (1) What patient-reported outcomes and pain scores have been observed after arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus? (2) What complications were reported? (3) What demographic and clinical factors were reported to be associated with better patient-reported outcome scores?
We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Embase, EmCare, PubMed, CINAHL, and Scopus (databases last searched June 23, 2021). A two-stage title/abstract and full-text screening process was performed independently by two reviewers. Randomized control trials, cohort studies, and observational studies published in English that evaluated the outcome of arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus were included. Case reports, review articles, commentaries, abstracts, and letters to the editor were excluded. A total of 12 articles (10 case series and two retrospective comparative studies) involving 446 patients were included. Of these, 111 patients with a mean age of 33 years (range 20 to 49) received arthroscopic bone marrow stimulation for a secondary osteochondral lesion of the talus. The Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the methodologic quality of included studies. The MINORS is a numerical score ranging from 0 to 16 for studies with no comparison group and 0 to 24 for comparative studies, with higher quality studies receiving higher scores. Of the 10 noncomparative case series, the highest score was 10 of 16, with a median (range) score of 7.5 (4 to 10), while the two comparative studies scored 22 of 24 and 19 of 24, respectively.
Studies varied widely in terms of patient-reported outcome measures such as the American Orthopaedic Foot and Ankle Society score (AOFAS), with inconsistent reporting across studies regarding whether or how much patients improved; there was variation in some effect sizes with regard to improvement seeming close to or below the minimum clinically important difference (MCID). Although no perioperative complications were reported in any included studies, 34% (26 of 77, in seven studies that reported on this endpoint) of patients who underwent a revision procedure. One study found a negative association between lesion size and AOFAS and VAS score. No other studies reported on factors associated with patient-reported outcome scores, and most studies were far too small to explore relationships of this sort.
We found that arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus yielded inconsistent and often small improvements in patient-reported outcomes, with approximately one in three patients undergoing a revision procedure. Reported outcomes likely represent a best-case scenario, inflated by low-level study designs and major sources of bias that are known to make treatment effects seem larger than they are. Therefore, the use of arthroscopic bone marrow stimulation in such patients cannot be recommended, unless we are able to refine selection criteria to effectively identify patients who show a substantial clinical benefit.
Level IV, therapeutic study.
Category:
Hindfoot; Sports; Trauma
Introduction/Purpose:
The incidence of Achilles tendon rupture in the United States is approximately 2.6 per 100,000 person years, with a significant increase in ...incidence over recent years reported. Should the acute rupture not be diagnosed promptly, as is the case in up to 20% of patients, the injury may be termed chronic. A number of operative treatment strategies for chronic Achilles ruptures have been described, including v-y tendinous flap, flexor hallucis longus tendon transfer, peroneus brevis graft and free gracilis transfer. Despite the extensive investigation of non-operative treatment in acute ruptures, there is a lack of similar research into chronic injuries. This article aims to address this gap in the literature, reporting treatment results of patients treated conservatively after being deemed unfit for operative intervention.
Methods:
A retrospective review of all patients receiving non-operative treatment for chronic Achilles ruptures, in the senior author's clinic between December 2014 and May 2019 was performed. A chronic injury was defined as occurring when there was a delay of at least 28 days between initial injury and start of treatment. Patients with a minimum final follow up of less than 6 months were excluded. All patients were managed according to the previously described Leicester Achilles Management Protocol (LAMP), an eight-week functional dynamic regime with use of a VACOped boot (OPED, Valley, Germany). Formal physiotherapy treatment was also provided following completion of the LAMP. Hospital records were searched for relevant data including patient age and sex, side of injury, time between injury and start of treatment and post-treatment Achilles tendon total rupture score (ATRS).
Results:
A total of 17 consecutive patients with a minimum follow up of 6 months were managed non-operatively during the stated time period. The cohort included eight males and nine females with a mean age of 63.4 14.3 years. The right side was injured in five cases, with the left side affected in 12. The mean time from initial injury to start of treatment was 43.9 days (range 30 - 102 days). The mean ATRS at 6 months post treatment was 53+-17.8. A total of 10 patients were also available for follow up at 12 months. The mean ATRS in these patients at 12 months was 73 +-15.2.
Conclusion:
The mean 12-month ATRS of 73 achieved is lower than figures of 89-92.5 reported in previous studies describing operative treatment. However, our results indicate that good outcomes may be achieved using a non-operative protocol in patients who decline or are unfit for surgery. Recent research reports that the mean age of Achilles rupture has increased by 0.721 years every five years, since 1953. It could therefore be likely that an increasing number of patients suffering chronic Achilles ruptures may be unfit for surgical treatment. It is important that further research into the non-operative treatment of these patients is conducted.
Category:
Ankle Arthritis
Introduction/Purpose:
Total ankle arthroplasty and ankle arthrodesis are both first line options for end stage arthritis. Both have good outcomes in terms of patient ...reported outcome measures, complications, and revision rate. Despite efforts to determine a superior option, results are inconsistent. It may be better to take a patient-specific approach in deciding which procedure to use based on risk factors such as BMI, age, and co-morbidities. This scoping review aims to identify and summarise all literature on total ankle arthroplasty and risk factors to guide a patient-specific decision making process, helping clinicians refine selection criteria and identify patients who are likely to respond well to the procedure.
Methods:
A scoping review was performed using the Preferred Reporting Items for Systematic Reviews an Meta-Analyses (PRISMA) guidelines. Computer based literature searching was performed in PubMed, Embase, Cochrane trials and ISI Web of science. Two reviewers independently performed title/abstract and full text screening according to pre-determined selection criteria. English-language original research studies reporting patient related factors associated with a poorer outcome following total ankle arthroplasty were included. Outcomes were defined as patient reported outcome measures (PROMs), peri-operative complications and failure.
Results:
A total of 94 studies reporting 101,552 cases of total ankle arthroplasty in 101,177 patients were included. The most common patient-related risk factor associated with poorer outcomes were younger age (21 studies), rheumatoid arthritis (17 studies) and diabetes (16 studies). Of the studies using multivariate regression specifically, the most frequently described risk factors were younger age (12 studies), rheumatoid arthritis (8 studies) and diabetes (8 studies).
Conclusion:
When controlling for cofounding factors, the most commonly reported risk factors are younger age, rheumatoid arthritis and co-morbidities such as diabetes and smoking. These patient-related risk factors reported may be used to facilitate the refinement of patient selection criteria for total ankle arthroplasty and inform patient expectations.
Category:
Midfoot/Forefoot
Introduction/Purpose:
The most common presentation of Morton's neuroma is that of a single neuroma in a single interdigital space. However, the occurrence of multiple ...neuromas in adjacent interdigital spaces of the same foot is not uncommon, with this scenario reported in 3-4% of all cases. Treatment of Morton's neuroma has been studied extensively, with most authors recommending surgical intervention only after failure of non-operative approaches such as steroid injection orthoses or shockwave therapy. Whilst systematic reviews on the management of Morton's neuroma have been performed previously, these focus on the treatment of a single neuroma in a single foot. This review aims to address this gap in the literature by systematically reviewing studies reporting treatment of multiple neuromas in adjacent intermetatarsal spaces of the same foot.
Methods:
A systematic review was performed according to PRISMA guidelines. A thorough computer-based search was performed by two reviewers independently in Pubmed, Embase, Cinahl, Emcare, Web of Science and Scopus databases using relevant terms such as 'interdigital', 'Morton's', 'intermetatarsal', 'neuroma', 'neuralgia', 'adjacent' and 'multiple'. Title/abstract and full text screening was performed independently by the same two reviewers, using a-priori selection criteria. All original research articles (randomised control trails, cohort studies and observational studies) reporting any management strategy for multiple adjacent Morton's neuromas in the same foot were included. Studies describing treatment of both single and multiple adjacent neuromas in the same article were included if results were clearly separated according to these distinct presentations. The methodological index for non-randomized studies (MINORS) was used to assess risk of bias and methodological quality of included studies.
Results:
A total of 253 unique articles were identified, with seven studies, including 383 patients included in the final review. Of these seven studies, four describe treatment of both single and multiple neuromas in the same article, whilst three include only patients with multiple adjacent neuromas in the same foot. Simultaneous excision using a single incision was the most common strategy, reported in three studies. Whilst two studies each reported use of simultaneous excision with two distinct incisions and delayed excision respectively. Of the four studies reporting treatment of both single and multiple neuromas, the pooled proportion of patients with the later presentation was 51/354 (14.4%). Only two studies, both describing simultaneous excision with a single incision, used scoring scales to assess treatment outcomes. These articles find significant increases in Manchester Oxford Foot questionnaire (MOXFQ), 12 item short form health survey (SF-12) and American Orthopaedic Foot & Ankle Society (AOFAS) scores.
Conclusion:
There is currently no evidence favouring use of a delayed excision or multiple incision approach in the treatment of multiple adjacent neuromas. However, there is a paucity of literature describing this presentation, with a number of studies failing to separate outcomes of single and multiple neuroma treatment. Given that the presentation of multiple adjacent neuromas may not be as rare as previously thought, it is important that further high-quality comparative research is performed to enable clinicians to draw firm, evidence-based conclusions to guide clinical practice. Future research should also investigate the role of alternative strategies such as non-operative treatment.
Category:
Other
Introduction/Purpose:
Optimising clinical practice requires emphasis on patient-orientated care and therefore patient reported outcome measures (PROMs) play a key role in shaping ...evidence-based clinical guidelines. As such, it is crucial that we use appropriate, valid and reliable PROMs to quantify outcomes in orthopaedic research. A previous systematic review evaluating evidence published between 2002-2011 identified 139 different PROMs used in the foot and ankle literature and found the most common PROM was The American Orthopaedic Foot and Ankle Society (AOFAS) score. However, in 2011, AOFAS issued a position statement outlining the lack of reliability and validity of the AOFAS score, describing it as a ‘less than ideal’ measure. This systematic review aims to provide an updated analysis of the PROMS used in the foot and ankle literature.
Methods:
This systematic review was performed according to PRIMSA guidelines. An electronic title/abstract screen of every article published between January 2012- December 2022 in Foot and ankle international, Clinical Orthopaedics and Related Research, Knee Surgery Sports Traumatology and Arthroscopy, The Bone and Joint Journal and The American Journal of Sports Medicine was performed by two reviewers. Articles with a foot and ankle focus were selected for full text screening and papers reporting at least one PROM were included in the final review. The following data was extracted from each article: journal of publication, month/year of publication, pathology/intervention described, PROMS reported and use of the minimally clinically important difference (MCID) to evaluate post intervention changes in PROMs. The number of studies using each individual PROM was calculated and a subgroup analysis was performed to investigate variation in PROM selection according to year of publication, journal of publication and the condition being investigated.
Results:
A total of 3,174 foot and ankle articles were identified, of which 1,168 (36.8%) articles reporting at least one PROM were included. The most common PROM was the AOFAS score, reported in 50.3% of studies, followed by visual analogue scale (VAS) pain score (44.4%) and 36-item short form survey (SF-36) (15.3%). Use of the AOFAS score declined across the review period. Between 2012-2016 AOFAS was the most common PROM, whilst VAS pain was most common in four of the last six years. Although some variation in PROMs according to clinical pathology exists, AOFAS score is featured in the top 3 most common PROMs for every analysed condition. Only 8/1,168 (0.7%) articles reported the number of patients achieving a minimally clinically important difference (MCID) post-intervention.
Conclusion:
Whilst use of the AOFAS score declined over the review period, it remains the most common PROM overall across all included journals and many conditions. There exists a lack of consensus regarding the most suitable alternative PROMs, with multiple validated instruments including FAOS, FAAM and FFI used inconsistently with relatively low frequency. There is a heavy reliance on statistical significance to evaluate and compare post-intervention PROM changes. However, it is important to quantify PROMs according to the patient perspective. Reporting the proportion of patients achieving MCID will allow clinicians to interpret PROMs and develop management guidelines in a patient-focused manner.
Fusion of the first metatarsophalangeal joint (MTPJ) is the reference standard surgery for significant hallux rigidus. A number of different techniques for first MTPJ fusion have been reported. We ...describe our technique of first MTPJ fusion using cup and cone reamers for joint surface preparation and 2 crossed cannulated screws for fixation. To the best of our knowledge, this is the single largest series using this technique. The present study reports on a single-surgeon, consecutive series of 166 consecutive cases in 147 patients who had undergone first MTPJ fusion. The demographic data and comorbidities of the patients were collected from the digital medical records, and the radiographs were evaluated by 2 of us (S.Q., M.A.) independently to document fusion status. Radiologic nonunion was seen in 11 of 166 cases (6.6%). The mean duration of follow up was 60 ± 29.5 (minimum 26, maximum 183) days. However, only 4 of the 11 cases (36%) of nonunion were clinically symptomatic and underwent revision using a bone graft and locking plate. A statistically significant difference was found in union rates among males and females (p = .01). Other factors, such as diabetes (p = .2), inflammatory arthritis (p = .5), steroids (p = .6), smoking (p = .5), hallux valgus deformity (p = .5), and concomitant forefoot surgery, did not have a statistically significant (p = .3) effect on union in our study. The union rate of first MTPJ fusion with our technique was comparable to that of others, with the advantage of being simple and less expensive compared with the use of a plate.
Category:
Other
Introduction/Purpose:
Ganglion cysts are a well documented phenomena occurring in a variety of joints. They are described as a tumour like lesion filled with mucopolysaccharides. The ...majority occur in the hand and wrist (88%) with a small yet significant minority occurring in the foot and ankle (11%). Currently, there is a lack of high-quality literature regarding the management of ganglia in the foot and ankle region. Therefore this scoping review aims to systematically map and summarise current evidence regarding the management of ganglia of the foot and ankle, whilst identifying areas for further research.
Methods:
This scoping review follows the methodology outlined by Arksey and O'Malley, Levac, the Joanna Briggs Institute and PRISMA framework.. A detailed search strategy was used to identify relevant articles using free text terms such as 'foot' 'ankle' 'ganglion' 'ganglia' 'ganglionic cyst'. This was carried out in four electronic databases; PubMed, EMBASE, CINAHL and Ovid MEDLINE. A stage two-stage independent screening process based and title and/or abstract then full-text was carried our by two reviewers. The a-priori selection criteria included all primary research (observational studies and randomised control trials) whilst excluding (case reports, letters to editors, editorials, commentaries and review articles). Studies that did not separate the treatment of foot and ankle tumours from ganglia were excluded. The MINORS criteria were used to assess methodological quality of included studies.
Results:
In total, 2286 unique articles were initially identified, from which 11 met the criteria for inclusion. A variety of conservative and surgical treatment strategies were reported. The use of surgical excision was reported in all 11 studies, ten of which via an open surgical approach, with only one study using an endoscopic approach. The use of conservative treatments, involving aspiration and/or steroid injection, were reported in only 5 studies. As for the recurrence rate, 7 studies reported a rate of 5.7% - 65.7%, with an overall pooled recurrence rate of 30.6%. Pooled recurrence rates showed that surgical excisions were associated with a lower recurrence rate than conservative treatments. Complications other than occurrence were described in 6 studies. Only 3 studies performed an analysis of outcomes based on the location or site of origin of ganglia.
Conclusion:
The current literature regarding the treatment of foot and ankle ganglia is of a low-quality, as the articles included in this scoping review are level III or IV cohort or case series design. The literature alludes to the idea that a surgical approach provides greater efficacy than a conservative approach. There is also limited evidence to suggest that factors such as the origin or location of ganglia may affect treatment outcomes. Alternative approaches utilised in the treatment of wrist ganglia are yet to be investigated. Further research is required before more definitive conclusions into any such associations may be drawn.
Abstract The aim of the present study was to assess the diagnostic accuracy of 7 clinical tests for Morton's neuroma (MN) compared with ultrasonography (US). Forty patients (54 feet) were diagnosed ...with MN using predetermined clinical criteria. These patients were subsequently referred for US, which was performed by a single, experienced musculoskeletal radiologist. The clinical test results were compared against the US findings. MN was confirmed on US at the site of clinical diagnosis in 53 feet (98%). The operational characteristics of the clinical tests performed were as follows: thumb index finger squeeze (96% sensitivity, 96% accuracy), Mulder's click (61% sensitivity, 62% accuracy), foot squeeze (41% sensitivity, 41% accuracy), plantar percussion (37% sensitivity, 36% accuracy), dorsal percussion (33% sensitivity, 26% accuracy), and light touch and pin prick (26% sensitivity, 25% accuracy). No correlation was found between the size of MN on US and the positive clinical tests, except for Mulder's click. The size of MN was significantly larger in patients with a positive Mulder's click (10.9 versus 8.5 mm, p = .016). The clinical assessment was comparable to US in diagnosing MN. The thumb index finger squeeze test was the most sensitive screening test for the clinical diagnosis of MN.
Abstract We undertook a comparison evaluation of outcomes after 2 different high-volume image-guided injection (HVIGI) procedures performed under direct ultrasound guidance in patients with chronic ...noninsertional Achilles tendinopathy. In group A, the HVIGI involved high-volume (10 mL of 1% lidocaine combined with 40 mL of saline) and no dry needling. In group B, the HVIGI involved a smaller volume (10 mL of 1% lidocaine combined with 20 mL of saline) and dry needling of the Achilles tendon. A total of 34 patients were identified from the clinical records, with a mean overall age of 50.6 (range 26 to 83) years and an overall mean follow-up duration of 277 (range 49 to 596) days. The change between the preinjection and postinjection Victorian Institute of Sports Assessment–Achilles scores of 33.4 ± 22.5 points in group A and 6.94 ± 22.2 points in group B, was statistically significant ( p = .002). In group A, 3 patients (16.7%) required surgical treatment compared with 6 patients (37.5%) in group B requiring surgical treatment ( p = .180). Our results indicated that a higher volume without dry needling compared with a lower volume with dry needling resulted in greater improvement in noninsertional Achilles tendinopathy. However, confounding factors mean it is not possible to categorically state that this difference was solely due to different injection techniques.
Highlights • Single surgeon series of 192 consecutive patients. • Well established inclusion and exclusion criteria. • All radiological measures showed statistically significant improvement in each ...parameter. • Validated patient satisfaction survey with very good results with a 71% response rate. • No correlation of any radiological measure to patient satisfaction. • No significant complication and none of the cases required revision.
PDF
