Foot & Ankle Orthopaedics最新文献

Background: Medial malleolar stress fractures (MMSFs) naturally appear to occur primarily in athletes participating in sports requiring prolonged running or repetitive jumping. Nonoperative and operative modalities have been described, yielding a wide range of outcomes and return to activity (RTA) rates.

Hypothesis/purpose: To systematically review the current literature to identify reports of MMSFs to better understand the current state of treatment, outcomes, and RTA rate.

Methods: Studies published in PubMed, Embase, and the Cochrane Library reporting on patients sustaining MMSF from inception to October 2024 were identified. Human subjects, articles published in English, and studies reporting treatment (operative vs nonoperative), outcomes, RTA rates, and the incidence of any complications, were included.

Results: Seventeen studies were identified, consisting of 68 patients, with 74% (n = 50/68) of patients being male. Weighted mean patient age was 26.1 (range, 9-73) years. Overuse injury mechanisms during sporting activities accounted for 94% (n = 64/68) of injuries, with soccer being the most commonly reported athletic activity (n = 18). Initial operative management was reported in 44% (n = 30/68) of patients at a weighted mean of 10.1 weeks from symptom onset, with an additional 14 patients undergoing operative treatment following a weighted mean 16.8-week trial of nonoperative management. Complications following treatment were reported in 4 (n = 4/30) patients treated initially with surgery and 2 (n = 2/38) patients initially treated nonoperatively. A total of 98% (n = 57/58) of patients reported successful return to preinjury activity levels at a weighted mean of 3.4 months.

Conclusion: Medial malleolar stress fractures are reported to occur primarily in younger, adult patients, commonly as a result of overuse, especially in individuals participating in soccer. Operative management was performed in 65% (n = 44/68) of overall cases with a low rate of complication and a high rate of successful RTA following nonoperative and operative management.

Background: Intrinsic foot muscle weakness has been implicated in a wide range of forefoot conditions and is typically measured by the paper grip test. The proposed "knuckle test" is intended to evaluate intrinsic foot muscle function, in which active flexion of toes makes the metatarsal heads ("knuckles") prominent in the forefoot. This study seeks to compare prevalence of negative knuckle test results and intrinsic muscle weakness in patients, primarily by association with a positive paper grip test result and secondarily with presence of toe deformities.

Methods: Ninety-eight patients, 55 with toe deformity and 43 without, were evaluated for ability to flex their toes to the extent of knuckle prominence (knuckle test) and grip paper on the ground with their toes (paper grip test). Variables were compared between those with positive and negative knuckle test results.

Results: A negative knuckle test result is significantly associated with the inability to grip a paper strip (P < .05).

Conclusion: Given that the paper grip test outcomes are a well-established sign of intrinsic muscle weakness, the significant association between knuckle and paper grip test outcomes substantiates the use of the knuckle test to detect intrinsic muscle weakness. The knuckle test is a potentially quick, simple, and cost-effective clinical maneuver to indicate intrinsic foot muscle weakness in a patient.

Level of evidence: Level III, diagnostic test development.

Background: Nitinol compression staples have been increasingly used in foot and ankle orthopaedic surgery because of simple implantation, reproducibility, and favorable biomechanical features. Compared with traditional implants (i.e., plates and screws), nitinol staple use in foot and ankle orthopaedics has not been extensively described. This systematic review aims to describe the current clinical outcomes of nitinol staple use in forefoot and midfoot surgery.

Methods: A search was conducted using PubMed, Web of Science, and Embase. All studies that included clinical outcomes of nitinol in foot surgery were evaluated for their demographics, outcome scores, or complication rates. Biomechanical studies and studies investigating nitinol nails in the hindfoot were excluded. Two reviewers screened titles, abstracts, and full texts.

Results: Of the 198 total articles from the search, 9 articles met the inclusion criteria. Of the 9 articles, 4 articles investigated outcomes of nitinol in the forefoot, 3 articles in the midfoot, 1 article in the forefoot and midfoot, and 1 article in the midfoot and hindfoot. This systematic review included articles that were retrospective in nature and thus subject to selection bias. The mean follow-up ranged from 6 to 35.9 months. The included studies demonstrated significantly improved postoperative visual analog scale pain score (P < .001), Ankle Osteoarthritis Scale scores (P < .001), and Foot and Ankle Ability Measure activities of daily living scores (P < .001). Of the 6 studies that report union for patients receiving purely nitinol staple constructs or nitinol staples in combination with another construct, the overall fusion rate was 94.6% and the overall complication rate was 11.25%.

Conclusion: This systematic review demonstrates that nitinol staples in foot surgery, whether alone or in combination with another construct, can achieve an acceptable fusion rate. However, currently we found highly limited clinical study data directly comparing nitinol staples to traditional implants. The current literature is heterogenous in its discussion of nitinol staple configurations and designs.

Level of evidence: Level IV, Systematic Review.

Background: Few studies assess rates of return to play and postinjury performance in National Hockey League (NHL) players who sustain Achilles tendon ruptures. Our objective was to determine the rate of return to play and performance impact among NHL players who undergo surgical repair of Achilles tendon tears.

Methods: NHL players who sustained an Achilles tendon rupture between 2001 and 2021 were identified using a publicly available injury database. Demographic and outcome data were collected for the 1-year period preceding and the 2-year period following surgery. Our primary outcome was expected wins above replacement per 60 minutes played. A position, draft year, and index season performance matched cohort was created. Pre- and postinjury outcomes were compared between cases and controls with a paired t test.

Results: We identified 15 cases (9 forwards, 5 defencemen, 1 goaltender). Fourteen of 15 (93%) players returned to play. Preinjury, postinjury year 1, and postinjury year 2 expected wins above replacement were 0.05, 0.05, 0.05 respectively (P > .05). There was no significant difference in performance between cases and controls at any time point.

Conclusion: Achilles tendon tears are associated with a high rate of return to play in the NHL and are not associated with a significant change in offensive, defensive, or overall performance-based metrics.

Level of evidence: Level III, case-control study.

Background: With higher incidences of ankle sprains and chronic ankle instability in women, it has been postulated that hormonal modulation and ligamentous laxity influences injury propensity. The purpose of this study is to investigate the impact of hormonal fluctuation on ankle stability and ligamentous laxity and their potential contribution to injury propensity in the female athlete.

Methods: In November 2023, a systematic review of the MEDLINE, Embase, and Cochrane Library databases was performed following PRISMA guidelines. Articles were included if they were published after the year 2000, evaluated outcomes related to the impact of hormones on ankle stability in healthy patients, and included menstrual tracking. The following search terms were used: "(sex or gender) AND (ankle stability)" and "(hormone) AND (ankle)."

Results: Thirteen articles were included, with 253 (76.4%) women at a weighted mean age of 21.9 ± 2.0 years (range, 20.0-25.9). Five studies evaluated postural sway and balance noting greater sway rates during ovulation compared with the follicular phase. Greater muscle tone (P < .001) was observed in the follicular phase than ovulation for the tibialis anterior, peroneus longus, and lateral gastrocnemius. Significantly higher ankle joint laxity was observed in ovulation (P = .016).

Conclusion: This review found that during ovulation, when estrogen peaks, subjects showed impaired balance with higher postural sway rates, greater ankle joint laxity, and decreased muscle and ligamentous tone and stiffness-an indicator of laxity. An underlying hormonally mediated etiology for the increased propensity to ankle instability in the female athlete is suggested. Syncing an athlete's workout type and intensity around menstrual cycle phase may be an advantageous strategy for injury prevention.

Background: Surgery is often needed for resistant plantar diabetic foot ulcers (DFUs) of the big toe. For noninfected ulcers, 2 types of surgery are available: the Keller and the hallux interphalangeal joint arthroplasty (HIPJ-A) procedures. Yet, no evidence synthesis on the outcomes of these procedures has been conducted; thus, this systematic review is an attempt to fill this gap.

Methods: Only studies reporting the results of Keller (or its variants) and HIPJ-A (or its variants) procedures for noncomplicated ulcers (Texas 1A/2A, or Wagner I/II) were included. Ulcers located beneath the metatarsal head were excluded. Ultimately, 11 studies were selected for inclusion and were analyzed. The primary outcome was defined as the ulcer healing frequency. The secondary outcomes were mean healing time, ulcer recurrence frequency, ulcer transfer frequency, postoperative infection rate, and revision surgery rate.

Results: The overall (combined techniques) weighted healing rate was 94% with a mean healing time of 3.1 ± 0.4 weeks. The ulcer recurrence frequency was 6%, the ulcer transfer frequency 4.5%, the postoperative infection rate 18%, and the revision surgery rate 3.8%. No significant differences were found between both techniques. When compared to standard of care, the odds ratio of ulcer healing frequency was 27.1 (95% CI 1.442-508.174, P = .01) in favor of the Keller arthroplasty with a faster healing time (P = .02).

Conclusion: Both surgical offloading procedures are highly effective in treating chronic noncomplicated DFU of the plantar aspect of the hallux along with low complication frequencies. There is a need to fine-tune the indication in relation to the location of the plantar wound with future comparative controlled research studies with far more patients than we could include in this meta-analysis.

Background: Randomized controlled trials (RCTs) are the gold standard for treatment efficacy, but foot and ankle RCTs are often small or inconsistent. The Fragility Index (FI) evaluates the stability of significant findings. This study assessed the fragility of RCT outcomes for Achilles tendon pathology (ATP) interventions.

Methods: This systematic review queried PubMed up to May 14, 2024, for RCTs on ATP interventions. RCTs with significant binary outcomes were included. Two reviewers assessed eligibility, extracted data, calculated FIs, and evaluated risk of bias. Frequency-weighted means were used for narrative synthesis.

Results: Eleven RCTs with 4506 patients (mean cohort size: 409.64 ± 160.54) and a mean age of 36.97 ± 13.51 years (n = 4356; 96.67%) were included, covering 24 binary outcomes. The median FI across all outcomes was 3 (interquartile range 1-4; mean 3.92), indicating that changing the outcome of just a few patients could shift a study's results from statistically significant to nonsignificant. Trials having an FI ≤3 comprised 58.33%. Three outcomes (12.5%) had an FI of zero after recalculating P values using the two-sided Fisher exact test. Half of the outcomes were robust. No RCT reported FIs or adjusted significance for multiple testing. Most studies (81.82%) performed 2 or more statistical tests, with an average of 30.81 ± 41.28 P values reported per study. The overall risk of bias was low in 1 study (9.09%) and moderate in 7 (63.64%). Most studies had low risk of bias in randomization (72.73%) and missing outcome data (90.91%).

Conclusion: The FI assesses the fragility of statistically significant binary results, revealing that many ATP RCTs have fragile outcomes due to small sample sizes. A median FI of 3 means that changing the outcome of 3 patients could shift a study's results from statistically significant to nonsignificant.

Background: Morton neuroma (MN) is a common pathology with many reported subjective features and physical examination tests. The objective of this systematic review was to examine the diagnostic accuracy of subjective features and physical examination tests for MN.

Methods: CINAHL, CENTRAL, EMBASE, MEDLINE, PubMed, Opengrey, PEDro, PsycINFO, Scopus and Trials register were searched in January 2021. Two reviewers independently screened studies for inclusion using the following criteria: (1) prospective or retrospective cohort studies, (2) participants aged ≥18 years with suspected MN, (3) primary data allowing construction of 2 × 2 diagnostic table or reported sensitivity and specificity figures, (4) diagnosis of MN using magnetic resonance imaging, ultrasonography, surgery, positive response to steroid and/or anesthetic injection, and (5) in English or translatable. Quality of included studies was assessed using the Quality Assessment for Diagnostic Accuracy Studies version-2 (QUADAS-2) tool.

Results: The search yielded 1170 results, of which 9 were included in this systematic review. Narrative synthesis revealed that subjective clicking reported by a patient was highly specific (0.96) and had a high positive likelihood ratio (13.14). The modified webspace tenderness test (thumb index finger squeeze test) was highly sensitive (0.96) with a low negative likelihood ratio (0.04). The commonly reported feeling of "walking on a pebble" and "burning pain" had sensitivities of 43% to 53% and 54% to 57% and associated specificities of 52% and 48%, respectively.Only 1 study had low risk of bias. The review was limited by the number of studies that included few or no patients without MN, and the impact this had on the ability to calculate diagnostic accuracy.

Conclusion: There is strong evidence that clicking reported by a patient rules in MN and that the modified webspace tenderness test rules out MN when negative.

Background: Medial malleolus fractures (MMFs) are common across the world. Currently, there is a lack of consensus on the number of screws used in fixation of MMF. Our aim was to compare the radiographic outcomes of MMF with patients between fractures that have either undergone single-screw (SS) or dual-screw (DS) fixation.

Methods: This retrospective study assessed patients who had undergone fixation of their MMF from 2012 to 2022. Analysis of their perioperative radiographs was performed to determine the initial type of injury and then radiographic outcomes of nonunion and malunion.

Results: A total of 653 patients suffering bimalleolar fractures were identified across a 10-year period. There were 271 patients (41.50%) in the SS group and 382 in the DS group (58.50%). There was no difference found in the nonunion rate of SS (19.19% [52 of 271]) compared with DS (18.85% [72 of 382]) (P = .931). A statistically significant difference between malunion rates was found between the SS group (11.07% [30 of 271]) compared with the DS group (3.93% [15 of 382]) (P < .001).On multiregression analysis, factors that gained significance for development of nonunion was nonfixation of syndesmosis (P = .039), ankle dislocation on arrival (P < .001), and nonrestoration of fibular length (P < .001). Other factors that showed significance for failure to achieve medial anatomical reduction was nonfixation of syndesmosis (P < .001).

Conclusion: Use of an SS rather than DS showed a significant increase in nonanatomical reduction but did not increase nonunion or reoperation rate. Syndesmosis fixation was associated with higher rates of MMF nonunion and malunion; as such, surgeons should have a low index of suspicion of injury and fixation.

Level of evidence: Level III, retrospective case series.