Foot最新文献

BACKGROUND

Calcaneal fractures remain a big challenge in orthopaedic surgery and lead to long lasting disabilities. Cadaveric research plays an important role in determining optimal fracture treatment. This scoping review aims to provide insight into cadaveric research that has been conducted on calcaneal fractures, including biomechanics, fixation, approaches and radiographic studies.

METHODOLOGY

A search strategy was created and implemented as per PRISMA guidance. 3 databases, Medline, Embase and Scopus, were used when conducting this review.

Results

484 individual studies were retrieved across the 3 databases, of which 186 duplicates were excluded. Study abstracts were individually reviewed, of which 208 studies were excluded in accordance with study criteria. 90 papers were sought for retrieval, of which 83 full text papers were successfully retrieved. Of the full papers retrieved, 22 did not meet our inclusion criteria, and 19 papers related only to talus fractures. In the end, 43 cadaveric studies pertaining to this scoping review were included and reviewed.

Discussion

Studies were grouped into biomechanical, anatomical, fixation and radiographic studies for review.

Conclusion

Evaluation of current cadaveric studies pertaining to calcaneal fractures has allowed greater insight into the myriad challenges in the management of these injuries. Effects of intra-articular fractures on calcaneal biomechanics assist in establishing surgical goals. Whilst fixation studies showing good stability of nail fixations could encourage further development in minimally invasive techniques. Avoiding pitfalls seen in the extensile lateral approach. Recommendations of areas for further research include use of external fixators, fixation in non-Sanders Type 2 fractures, and comparison of intraoperative CT/3D fluoroscopy with o conventional fluoroscopy.

Background

Talar neck fractures are rare but potentially devastating injuries, with early reduction and rigid fixation essential to facilitate union and prevent avascular necrosis. Even small degrees of malunion will alter load transmission and subtalar joint kinematics. Changes in fixation techniques have led to dual plating strategies. While locked plating has perceived advantages in porotic bone and comminution, its biomechanical benefits in talar neck fractures have not been shown.

Aim

To compare the strength of locking vs. non-locking plate fixation in comminuted talar neck fractures.

Method

Seven pairs of cadaveric tali were randomised to locking or non-locking plate fixation. A standardised model of talar neck fracture with medial comminution was created, and fixation performed. The fixed specimens were mounted onto a motorised testing device, and an axial load applied.

Results

Peak load to failure, deformation at failure, work done to achieve failure, and stiffness of the constructs were measured. No statistically significant difference was found between locking and non-locking constructs for all parameters.

Conclusions

Both constructs provide similar strength to failure in talar neck fracture fixations. Mean peak load to failure did not exceed the theoretical maximum forces generated of 1.1 kN when weight-bearing. We would advocate caution with early mobilisation in both fixations.

Introduction

Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation.

Material and methods

A retrospective cohort study was performed on PM ankle fracture patients aged 18–55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs.

Results

Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis.

Conclusion

After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis.

Level of evidence

Level III – Retrospective cohort study

Background

Two biomechanical mechanisms for the development of Achilles tendinopathy in runners have been proposed: A whipping mechanism characterized by prolonged and excessive rearfoot eversion, and a tearing mechanism characterized by high eccentric plantar flexor forces. The purpose of this pilot study was to determine if runners with and without a history of Achilles tendinopathy exhibited gait biomechanics consistent with either of these mechanisms.

Methods

Seven male runners with previous or current Achilles tendinopathy and seven healthy male control runners were evaluated by three-dimensional gait analysis. Peak rearfoot eversion angle, rearfoot eversion excursion, duration of rearfoot eversion, and peak rearfoot inversion angle were compared between groups to evaluate the whipping mechanism of injury. Peak dorsiflexion angle, peak dorsiflexion velocity, and peak ankle power absorption were compared between groups to evaluate the tearing mechanism. Additionally, rearfoot eversion angle and sagittal plane ankle power waveforms were compared between groups using statistical parametric mapping.

Findings

There were no differences in any rearfoot eversion, inversion, or dorsiflexion variables or waveforms during running in the Achilles tendinopathy group compared to controls.

Interpretation

Rearfoot strike runners with Achilles tendinopathy do not exhibit running biomechanics consistent with either the whipping or tearing mechanisms of injury.

Introduction

There is an absence in the application of standardised epidemiological principles when calculating and reporting on lower extremity amputation (LEA) rates [1]. The rates of minor LEAs in the diabetic population range from 1.2–362.9 per 100,000 and in the population without diabetes 0.9–109.4 per 100,000. The reported rates of major lower limb amputations vary from 5.6–600 per 100,000 in the diabetic population and 3.6–58.7 per 100,000 in the total population [1]. The variation in methodology does not facilitate comparison across populations and time. All studies published using the population from England, UK, describing minor amputations were systematically reviewed and rates and methodologies compared.

Method

A systematic search was carried out using (PRISMA) guidelines [2] to reveal primary data of minor lower extremity amputation rates in England between 1988–2018. This was carried out using electronic databases, grey literature and reference list searching. The search yielded eleven studies that were eligible for review.

Results

Significant variation in the reporting of minor lower extremity amputation rates across regional and gender groups in England was found. Rates in the diabetic and non-diabetic population varied from 1.2 to 362.9 per 100,000 and 0.9 to 109.4 per 100,000 respectively. This was predominately a result of poorly describing numerator and denominator populations and defining minor amputations differently. As a result, there was an inability to confidently establish regional, gender and time trends.

Conclusion

The inconsistent nature of reporting minor amputations makes drawing conclusions on temporal and population change difficult. Future studies should describe and present basic numerator and denominator population characteristics e.g. number, age and sex and use the standard definition of minor amputation as one that is at or below the ankle.

Introduction

First Ray Instability (FRI) and especially hypermobility leads to the collapse of the medial longitudinal arch's structural framework, which reduces the foot's ability to become a rigid lever for propulsion, resulting in progressive foot deformities. Early detection of FRI with prompt intervention helps prevent degenerative foot deformities. Various manual, device-based and radiographic diagnostic tests for FRI quantification have been described in the literature. We aim to conduct an up-to-date, comprehensive, systematic review of the literature reporting on diagnostic tests to evaluate FRI.

Methodology

Electronic databases (Medline, Embase and PubMed) and bibliography lists were searched until May 2021 for studies evaluating diagnostic tests for FRI. MeSH terms were used to conduct the literature search. The authors screened all produced abstracts. Selected articles were further assessed in full based on inclusion and exclusion criteria. The relevant studies were qualitatively assessed and grouped into tables based on tests.

Results

18,176 studies were identified. Thirty-two full-text articles were included for assessment. Ten articles were excluded based on evaluation criteria. 18 studies were included for qualitative assessment: two studies describing manual diagnostic tests, three evaluating device-driven tests, six image-guided studies and seven comparison studies assessing a new test versus an established one.

Conclusion

Gold standard tests in defining FRI need to be improved. Manual tests exhibit significant subjective variability. Radiographic tests, while accurate, are complex and cumbersome to perform and, therefore, are not widely applied. Dorsal rulers have demonstrated mixed results and shown variability when compared to instruments. The focus has been on assessing FRI in hallux valgus (HV). More studies are needed to investigate FRI in the absence of HV.

Introduction

Health specialists suggest a conservative approach comprising non-pharmacological interventions as the initial course of action for individuals with repetitive ankle sprain due to ankle instability. This systematic review aimed to assess the effectiveness of biomechanical devices (Foot Orthoses, Ankle Orthoses, and Taping) on gait and muscle activity in individuals with ankle instability.

Methods

A systematic search was performed on electronic databases, including PubMed, EMBASE, Clinical Trials.gov, Web of Science, and Scopus. The PEDro scoring system was used to evaluate the quality of the included studies. We extracted data from population, intervention, and outcome measures.

Results

In the initial search, we found 247 articles. After following the steps of the PRISMA flowchart, only 22 reports met the inclusion criteria of this study. The results show that biomechanical device therapy may increase swing time, stance time, and step. Additionally, studies suggest that these devices can reduce plantar flexion, inversion, and motion variability during gait. Biomechanical devices have the potential to optimize the subtalar valgus moment, push-off, and braking forces exerted during walking, as well as enhance the activity of specific muscles including the peroneus longus, peroneus brevis, tibialis anterior, gluteus medius, lateral gastrocnemius, rectus femoris, and soleus.

Conclusion

Biomechanical devices affect gait (spatiotemporal, kinetic, and kinematic variables) and lower limb muscle activity (root mean square, reaction time, amplitude, reflex, and wave) in subjects with ankle instability.

Objectives

A common orthopedic issue for patients with spastic cerebral palsy (CP) is hindfoot varus deformity. One method of treatment is the split posterior tibialis tendon transfer (SPOTT). There is limited literature on the effect of SPOTT on foot progression angle (FPA) in children with CP who have equinovarus deformities. The objective of our study was to evaluate the change in FPA after SPOTT to determine if this procedure can improve FPA.

Research Question

This study aims to determine what axial changes are generated from a split posterior tibial tendon transfer in children with CP.

Methods

We performed a retrospective analysis of all ambulatory children with a diagnosis of CP who underwent SPOTT at our institution. Patients with bony rotational procedures were excluded. Descriptive statistics including mean and standard deviation (SD) were used to characterize continuous variables. Paired t-tests were used to evaluate outcomes, in which a target outcome was defined as a post-operative FPA between 0–10° of external rotation.

Results

44 limbs were included. Demographics were as follows: 26/13 female/male; mean age[SD] (years): 9.8[3.5]; 30 hemiplegic, 9 diplegic, and 1 triplegic. Of the 44 limbs, 18 limbs had a target outcome, 4 had no change, and 22 had a non-target outcome. Of the 22 with an outcome outside of the target, 4 limbs trended away from a target outcome. The overall change in FPA measured was − 10.9 ± 14.7° (p < 0.0001) Age at time of surgery, CP involvement, pre-operative FPA, and GMFCS level were not predictors of outcome (p > 0.05).

Conclusions

SPOTT produced a change of 10.9° external rotation in FPA post-operatively and its effects should be considered when planning a SEMLS.

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

Background

Running, a popular recreational activity, often leads to the experience of pain and discomfort among participants impacting performance and participation longevity. The ZOLES trial evaluates customised 3D-printed insoles for reducing pain in frequent parkrunners aged 35 and over. An innovative process of foot-scanning and responses to questions relating to size, pain, discomfort, and previous medical conditions are combined leading to the production of personalised 3D-printed orthotics.

Methods

The ZOLES trial is a pragmatic, outcome assessor blinded, randomised, controlled, superiority trial involving 200 recreational runners, randomised to receive either customised 3D-printed insoles (ZOLES) or to a "do-as-usual" control group. The study follows a robust protocol, ensuring adherence to established guidelines for clinical trials, and is based at St Mary's University, Twickenham, London. The primary outcome is change in running-related pain over a 10-week period, assessed using an 11-point Numeric Rating Scale. Secondary outcomes include overall pain and discomfort, running-related comfort, 5k-completion time, time-loss due to injuries, running exposure, and adherence to the intervention. A balanced-block randomisation process is stratified by sex and parkrun location, and an intention-to-treat analyses will be employed on all outcomes in the primary trial report. The trial includes a 52-week post-market surveillance to assess long-term effects of the customised insoles.

Discussion

The ZOLES trial aims to provide insights into real-world applicability and effectiveness of customised 3D-printed insoles in reducing running-related pain and enhancing overall running experience. Despite the limitation of a subjective primary outcome measure without participant blinding, the methodological rigor, including external outcome assessment and data handling, we anticipate results that are academically credible and applicable in real-world settings The results of this trial may have important implications for runners, clinicians, and the sports footwear industry, as evidence for the use of individualised insoles to improve running experience and prevention of pain may become evident.

Trial registration

The trial was pre-registered at ClinicalTrials.gov with the trial identifier NCT06034210 on September 4, 2023, and publicly posted on September 13, 2023 (https://clinicaltrials.gov/study/NCT06034210).

Protocol version

Version 1, September 27, 2023.