Foot & Ankle

Surgical time and outcome after Achilles tendon rupture

Corticosteroid injection and plantar fasciitis

Mental health and outcomes in foot surgery

The effects that patient comorbidities, particularly mental health and psychological welfare, have on outcome measures are complex and yet to be entirely unpicked. It is heartening, therefore, to see ongoing research into the area. This paper from Singapore evaluates preoperative mental health status as a predictor of outcome and postoperative function in a cohort of 67 patients who underwent scarf osteotomy for hallux valgus.³ The authors undertook a year of follow-up for this cohort of patients, and the 36-Item Short-Form Health Survey (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) scores were collated. Traditional radiological measurements were also collected, including hallux valgus angle (HVA) and intermetatarsal angle (IMA). Mental health and wellbeing was assessed using the SF-36 Mental Component Score. Over the period of the study, all eight components of the SF-36 improved postoperatively at a minimum of one year’s follow-up. The preoperative mental component scores were not seen to correlate to change in AOFAS scores, although the preoperative mental health domain did relate to a poorer AOFAS score postoperatively. This relationship is, of course, associative rather than causative. It is important to appreciate that this observation may mean that a recalcitrant painful foot may affect your mental health – or, conversely, that those with mental health problems may perceive their painful foot to be worse despite an objectively similar outcome (as suggested by the authors’ reported IMA and HVA).

Total ankle arthroplasty: what are the risks?

Total ankle arthroplasty is one of those rapidly evolving areas in orthopaedic surgery where, year on year, the indications, expectations, and outcomes shift slightly – usually one way then another! Over the past decade, however, there has been a big change in the expected outcomes and indications for total ankle arthroplasty. The authors of this study from Wigan (UK) report their own series of 278 consecutive ankle arthroplasties, with an emphasis on what information should be given surrounding expected outcomes as part of the consent process.⁴ The authors supplement their own complication profile with a review of the literature. In this series, there were a number of complications reported that warranted discussion at the consent phase, with wound-healing problems in nine ankles (3.2%) and infection in 26 ankles (superficial 7.2% and deep in 2.2%). In terms of on-table complications, the malleoli fracture rate was nearly 11% (27 medial (9.7%) and four lateral (1.4%)). The longer-term outcomes looked a little rosier, however, with aseptic loosening and osteolysis seen in 16 ankles (5.8%). Clinically medial gutter pain and thromboembolism were postoperative problems in 31 ankles (11.1%) and two ankles (0.7%), respectively. These reported complication rates serve to remind us that total ankle arthroplasty is far from a benign operation. The authors argue that their results, while sombering, are comparable to the previously reported complications of total ankle arthroplasty in the literature. Clearly, the consent process should reflect the actuality of the complication profile.

Local antibiotic delivery in the diabetic foot

The management of the diabetic foot infection follows the principle of osteomyelitis surgery. Like all other bone infection surgery, a tissue diagnosis is followed by local debridement, soft-tissue management, and local and systemic antibiotics. However, although they are widely used, the evidence for local antibiotics is not entirely clear surrounding efficacy, method of delivery, or dosage. This systematic review from Nottingham (UK) highlights the current evidence surrounding this widely practised approach.⁵ Overall, the quality of evidence was poor, and in many areas was sparse or non-existent. The authors were only able to find a single trial reporting the outcomes of a gentamicin-impregnated collagen sponge. This suggested an improved rate of healing (8% vs 25%, not statistically significant) but no differences in length of stay or rate of subsequent amputation. In their systematic review, the authors identified 485 patients who were treated using local antibiotic delivery devices. The rates of wound healing, reoperation, and mortality were comparable to those that have been previously reported for the routine management of these infections. There is currently a lack of good-quality evidence to support the use of local antibiotic delivery devices in diabetic forefoot infections. While clearly still a matter for the treating surgeon, it will become increasingly difficult to continue to justify the ongoing use of such devices without the development of an evidence base. Given that diabetic forefoot infections are a relatively common presentation, it is surprising that the evidence base is at best tenuous for what is considered by many to be a key component in their treatment.

Treatment of chronic plantar heel pain

Chronic heel pain is a recalcitrant foot and ankle diagnosis, for which the mainstay of treatment is physiotherapy-led stretching, usually in the form of eccentric loading and strengthening. Like many enthesopathies, the causes of insertional Achilles tendonitis are unclear. This paper from Grålum (Norway) evaluates the role for gastrocnemius recession and stretching versus stretching alone in chronic plantar heel pain.⁶ This is a small randomized trial that, although reported as a standalone trial, in reality represents a large pilot study. The authors identified 40 patients with plantar heel pain that had been present for longer than a year, and randomized them to either a home stretching programme or to surgery consisting of a proximal medial gastrocnemius recession in addition to stretching exercises. Outcomes were assessed at a year using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score at 12 months. Secondary outcomes were assessed using the 36-Item Short-Form Health Survey (SF-36) and visual analogue scale (VAS) for pain, alongside some objective pedobarometric readings. In terms of the primary outcome for this study, the authors reported a significant increase in the AOFAS score from 59.5 to 88.0 in the operative group, and from 52.5 to 65.5 in the nonoperative group. In terms of secondary outcomes, there were significant differences in the AOFAS, VAS for pain, and SF-36 scores favouring the operative group. While this study is small and likely underpowered, it does raise the question: should these patients with intractable heel pain be offered surgical release? A larger trial with more robust methodology is clearly needed here. However, the authors have done enough to highlight the potential benefit and to inform a suitably powered study.