Management of chronic Achilles ruptures: a scoping review.

PURPOSE: This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research. METHODS: A scoping review was performed according to the frameworks of Arksey and O'Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria. RESULTS: A total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%). CONCLUSION: Although beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient

Gastrocnemius Release in the Management of Chronic Plantar Fasciitis: A Systematic Review.

BACKGROUND: This systematic review aims to summarize the outcomes of gastrocnemius recession in the treatment of plantar fasciitis. METHODS: A systematic review was performed according to PRISMA guidelines using the PubMed, Embase, Emcare, Web of Science, Scopus, and CINAHL databases. A 2-stage title/abstract and full text screening process was performed independently by 2 reviewers. Randomized controlled trials, cohort, and case-control studies reporting the results of gastrocnemius recession in patients with plantar fasciitis were included. The MINORS and Joanna Briggs Institute Criteria were used to assess study quality and risk of bias. RESULTS: A total of 285 articles were identified, with 6 of these studies comprising 118 patients being ultimately included. Significant postoperative improvement in American Orthopaedic Foot & Ankle Society, visual analog scale, 36-Item Short Form Health Survey, Foot Forum Index, and Foot and Ankle Ability Measure scores were reported. Included studies also described an increase in ankle dorsiflexion range of motion and plantarflexion power. An overall pooled complication rate of 8.5% was seen, with persistent postoperative pain accounting for the most common reported complication. Gastrocnemius recession is associated with greater postoperative improvement than plantar fasciotomy and conservative stretching exercises. CONCLUSION: The current evidence demonstrates that gastrocnemius recession is effective in the management of plantar fasciitis, specifically in patients with gastrocnemius contracture who do not respond to conservative treatment. LEVEL OF EVIDENCE: Level III, Systematic review of level I-III studies

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review.

PURPOSE: This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy. METHODS: A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria. RESULTS: Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases. CONCLUSION: The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment. LEVEL OF EVIDENCE: Level IV

A comparison of two different high-volume image-guided injection procedures for patients with chronic noninsertional achilles tendinopathy: a pragmatic retrospective cohort study

© 2016 American College of Foot and Ankle Surgeons.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

Results of Single incision Hallux Valgus Surgery

Category: Bunion Introduction/Purpose: Soft tissue release is an integral part of Hallux Valgus surgery and is traditionally performed through an additional dorsal first web space incision. We performed a review of Hallux Valgus correction with Scarf +/- Akin osteotomy using single medial incision with lateral release performed through the same incision. Methods: The study included 202 feet operated by a single surgeon between July 2009 and July 2014. Average age of patients at the time of operation was 60 years +/- 14. Patient satisfaction survey was conducted at the time of study. Patients with minimum follow up of 12 months post surgery were included in this study. The average follow up at the time of study was 45+/- 18 months. Pre-operative and final post-operative radiographic data was collected for Hallux Valgus angle, Intermetatarsal angle, Distal Metatarsal Articular Angle and Medial Sesamoid Position. The average Mean radiological follow up duration was 6.7 months. Results: Mean Hallux Valgus Angle improved from 33.2 to 15.6 degrees, Intermetatarsal angle improved from 14.4 to 7.8 degrees, Distal Metatarsal Articular Angle improved from 17.6 to 9.8 and Medial Sesamoid Position improved from 3 to 1 [p < 0.05 for each variable]. Response rate was 78% (Very satisfied 69%, Satisfied 14%, Satisfied with reservation 11%, Dissatisfied 6%). There was no correlation of any preoperative or postoperative radiographic measure with satisfaction grade. Two patients had intraoperative fracture with no long term sequelae. No patient required revision procedure. Conclusion: Single medial incision surgery for Scarf +/- Akin Osteotomy for Hallux Valgus Correction is a simple, safe and effective technique with very high satisfaction. The results are comparable to, if not better that, traditional two-incision surgery thus questions requirement of a second dorsal first web space incision

Patient-related Risk Factors Associated with Poorer Outcomes Following Total Ankle Arthroplasty: A Scoping Review of 101552 Cases

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

Leicester Achilles Management Programme (LAMP)

Category: Trauma Introduction/Purpose: Conservative treatment of acute AT ruptures with functional rehabilitation has demonstrated superior results to surgery with equal reported re-rupture rates without the added complications of surgical treatment. The variation in patient selection for functional rehabilitation as well as the duration and type of rehabilitation regime utilised adds to the confusion of this clinically proven method of treatment. Since 2011, all patients presenting to our department with an acute AT rupture have been treated with a standardised functional rehabilitation regime in a Vacoped boot for 8 weeks with immediate weight bearing (the LAMP regime). The aim of this paper is to present ATRS scores and objective measures at 12 months follow up of patients treated with the LAMP regime. Methods: A prospective study of all AT ruptures treated conservatively with the LAMP regime between February 2011 and September 2015 was performed. The LAMP regime consists of the use of a Vacoped boot locked in 30° plantar flexion for the 1st 4 weeks. The boot is then dynamised allowing movement between 15-30° over the following 2 weeks, and finally completely dynamised allowing movement from 0-30° over the final 2 weeks. After a total of 8 weeks treatment, the boot is removed. During treatment, patients are allowed to remove the boot once a day to enable them to shower without putting any weight on the affected leg. Patients who had 12 months follow up data of ATRS scores were included. Subsequent evolution of the service has resulted in objective measures including the calf girth, heel raise height and heel raise repetitions being recorded. Complications of treatment were noted. Results: 442 patients were treated conservatively with the LAMP functional rehabilitation regime. Ultrasound imaging was only performed in 10% of cases where clinical assessment was equivocal. The incidence of a venous thromboembolic event was 5.9% with a re-rupture rate of 2%. 200 patients had 12 months ATRS scores available and 46 patients had ATRS scores as well as objective measures of calf girth, heel raise height and repetitions at 12 months. The average ATRS score was 75.3 at an average follow up of 25 months post injury. Men had significantly better outcomes compared to women. There were statistically significant differences in the muscle girth and heel raise height when compared with the uninjured side but these did not correlate with the ATRS score. Conclusion: This is the largest series of acute AT ruptures treated conservatively with the use of a standardised functional rehabilitation regime demonstrates satisfactory patient reported outcome measures at 12 months follow up. Objective measures demonstrate inferior results when compared to the uninjured side but this does not correlate with the ATRS scor

Randomised Controlled Trial of Ankle Block Versus Metatarsal Block for First Ray Surgery

Category: Bunion Introduction/Purpose: First ray arthrodesis or osteotomy is a day surgery procedure performed commonly under general anaesthetic. One of the aims with such procedures is to ensure our patients are discharged on the day of surgery and are relatively pain free on discharge. This is often achieved by the use of local anaesthetic blockades, either as an ankle block or as a metatarsal block. There are studies published on the effectiveness of ankle block for first ray surgery but there is a dearth of studies on metatarsal block. Therefore the aim of this study is to compare the effectiveness of ankle block versus metatarsal block in conjunction to general anaesthetic for first ray surgery. Methods: Both local trust board approval and National Research Ethics Committee approval were granted for the study. Statistical analysis to ensure an adequately powered study was performed. Fifty patients undergoing arthrodesis or osteotomy of the first ray were recruited into this study and randomly allocated to the cohort to receive either a metatarsal block or an ankle block. All patients had general anaesthesia. Those patients randomized to ankle block had this performed after induction of general anaesthesia using ultrasonography. Those patients randomized to metatarsal block had this performed at the end of the operative procedure. Patients scored their pain level using a visual analogue scale (0-10) at 2, 6 and 24 hours. A physiotherapist, who was blinded to their treatment arm, assessed patients at hourly intervals from two hours. Patients were contacted by telephone by a research nurse, who was also blinded to their treatment arm, over 24 hours from discharge. Results: Forty-eight patients completed the study: 25 in the ankle block treatment arm and 23 in the metatarsal block arm. The majority of the patients were female (44 patients) with an average age of 53 years (range 31-76 years). Analysis of pain scores showed that there was no statistically significant difference between the two groups at any of the measured time periods. Analysis of their analgesic requirement in the first 24 hours after surgery again revealed no striking difference between the two cohorts. Similarly analysis of the time taken to safely mobilise revealed that there was no difference between the two groups. However analysis of the time taken to perform the anaesthesia highlighted a mean addition of eleven minutes when an ultrasound guided ankle block was performed. Conclusion: This prospective randomised blinded study demonstrates that metatarsal blocks are just as effective in giving post- operative analgesia as ultrasound guided ankle blocks in patients undergoing first ray surgery under general anaesthetic