Evidence in Foot and Ankle Surgery

Evidence in Foot and Ankle SurgeryDr Hitesh GopalanExpert Advisor, www.orthoevidence.comEditor, Orthopaedic Principleswww.orthopaedicprinciples.com

Advanced Clinical Evidence

Evidence in Foot and AnkleFoot and Ankle International(AOFAS)Foot and Ankle Surgery(British and European Society)JBJS- AmJBJS- British

Level 1 and level 2: 10%

Ankle Sprains

Grade 3 Ankle sprain:SurgeryVs No-Surgery

Pihlajamki et al.. JBJS A-201051 Finnish men

Grade 3 acute lateral ligament injuries

Intervention: Surgical repair followed by plaster cast for 6 weeks

Comparison: Functional rehab with aircast ankle brace

Level 1 RCT

14 years follow up

ResultsAll patients in both groups recovered to preinjury activity levelsRisk of reinjury: 1 out 15 in surgical group, 7/18 in non surgical groupOsteoarthritis: 4/15 in surgical group and 0/18 in non surgical group

Questions whether surgical treatment is necessary for grade 3 lateral ligament injuriesACE Score: 6/10

Plyometric training in Ankle SprainsIsmail MM 2010Population: 22 athletes with grade 1-2 inversion injuryIntervention: Plyometric trainingComparison: Resistive TrainingLevel 2 Randomised TrialTime: baseline and 6 weeks

Plyometric TrainingPeak torque of ankle evertors and invertors were sameOverall functional performance better in plyometric group

Plyometric training is good for acute injuries and may prove to be superior to resistance training in ankle injuries

ACE SCORE: 6/10

Sterility in Foot and Ankle Surgery

Preoperative foot bath

Ng AB , 2009Population: 44 patients, elective foot and ankle surgeryIntervention: Chlorhexidine+ I2 with foot bathComparison: I2 without foot bathOutcome: Bacterial culture taken prior, intra-op and post-op

Preoperative swabs: 100 % colonisationIntraop swab: 16 % colonisation in foot bath, 96% in comparisonPost op swab: no significant difference

Preoperative foot bath reduced intraoperative bacterial load

ACE SCORE: 6.5/10

Iodine Vs ChlorhexidineCheng K 2009 50 patients Forefoot preparationIntervention: Iodine +/- isopropyl alcoholComparison: Chlorhexidine +/- isopropyl alcoholOutcome: Swabs after applying solutionEqual resultsScrubbing does not prove to be advantageous

ACE Score: 7.5/10

Toes: Cover or notGoucher NR et al..2007Population: 40 patients ankle and foot surgeryIntervention: Surgery with toes coveredComparison: Not coveredOutcome: Cultures+ve cultures for 2 patients in both groups, but no signs of postoperative infectionNo difference when toes covered/uncovered

ACE Score: 6/10

Tendoachilles Rupture

Acute Tendoachilles tearsJiang et al..Int Orthop 2012

Analysis of 10 RCTs that compare surgical Vs Nonsurgical interventionCritical Appraisal: Modified Jaddad ScaleSoftware: RevMan 5.1 software894 patients

Surgical Vs NonsurgicalRe rupture: 4.3 Vs 9.71Complications: 26.6 Vs 7.91Early return to work in the operated group

Functional outcome could not be assessed

ACE: 10/10

Achilles Tendon Repair: Augment or not?Pajala A , 2009 60 patients Intervention: Augmented Repair with gasctrocnemius fascia flapComparison: Non augmented repairOutcome: Clinical measurements, Lepilahti score, isokinetic calf muscle performance testsFollow up: 12 monthsNo Significant differences

Achilles Tendinosis

Skin Derived FibroblastsObaid H et al..2012 32 patientsSkin derived fibroblasts suspended in autologous plasma: InterventionCompared with local anaesthesia aloneOutcomes: VISA and VAS scoresMean Visa scores improved from 34 to 75 in 6 month periodMaybe indicated in refractory cases

Ankle OA

Hyaluronic Acid in ankle OADeGroot H et al.. 65 patientsIntervention: noncross linked LMW HAComparison: Normal salineOutcome: AOFAS scores, AOS, VASFollow up: 12 weeksNo significant differencesHA not recommended for treating ankle OA

ACE: 8/10

Motion Distraction in ankle OASaltzman CL et al..201236 patients with ankle OA after anterior osteophyte removalIntervention: Distraction rods with hinges allowing joint motionComparison: Distraction rods without hingesOutcomes: AOS, PCS, SF-36Significant improvement in the joint motion groupACE: 7.5/10

Rh-PDGF for hindfoot fusionDi Giovanni 2011 20 patients requiring hindfoot fusionIntervention: rh-PDGF(Augment TM, Biomet)Compared with autologous bone graftOutcomes: Clinical and radiological parameters, AOFAS, FFI, SF-12, VAS77% union rate in the Augment synthetic groupSample size: smallNeeds large trialsACE: 6.5/10

Plantar Fasciitis

Shock waveWang CJ 2006 149 patientsIntervention: 1500 impulses of shock wave at 16kVComparison: NSAIDs, physical therapyOutcomes: 100 point scoring system, VAS

Follow up: 5- 6 years

Shock wave group: 69% excellent results, 13% good, 6.2 fair, 11% poor

Control: 0 excellent, 55% good, 36% fair, 9% poorNo systemic or local complications due to device

Shock wave is safe and effective in the long run

Autologous BloodLee TG, 2001 64 patientsIntervention: CorticosteroidComparison: Autologous BloodOutcomes: VAS, tenderness thresholdSignificant decrease in pain levels, but no differenceAutologous blood is a good alternative

Lisfranc injuriesLy TV 2006 41 patientsPrimary medial partial arthrodesis Vs primary ORIFAOFAS scores: 88 in arthrodesis group and 68.6 in ORIF groupPersistent pain in 5 patients in the ORIF group due to arthrosisPrimary arthrodesis was superior in ligamentous LisFranc injuries

Calcaneal Fractures

MetaanalysisNan Jiang 2012891 patientsSource: Published RCTs from pubmed, CochraneData Extraction: All RCTs involving displaced intraarticular fractures which compared surgical Vs nonoperative methods Revman 5.1 software

Surgical groupLess loss of calcaneal heightMore comfortable wearing shoesMore patients were able to return to preinjury level75/119 patients experienced residual pain77/338 developed complications

Non Surgical GroupSignificantly smaller Bohlers angleMore loss of calcaneal heightLess comfortable wearing shoes85/121 had residual pain53/328 developed complications

Calcaneal Intra-articular fracturesSurgical treatment may lead to better anatomical and functional outcome

Risk of complications

Anaesthesia

Intrarticular Lidocaine BlockBrian White, 200842 patients with ankle fracture dislocationsIntra-articular lidocaine block Vs SedationOutcomes: VASComparable pain scores, one failed reduction in sedation group Longer time to stabilisation in the sedation groupIntra-articular lidocaine should be offered to patients who are at risk for sedation

ACE score: 6/10

PRP for OCD TalusMei Dan- O 2012 32 patients with symptomatic OCD talusPRP: 3 injections over 4 week periodComparison: HA 3 injections over 2 week periodFollow up: 28 weeksOutcome: AHFS score, VAS, subjective function and disability

OCD Talus-PRPSignificant improvement in AHFS and VAS scores in the PRP group

PRP is safe and efficacious

RA forefoot

PLDLA for MTP joint SurgeryTiihonen R 2010 36 patients with refractory RAPLDLA MTP joint interposition arthroplastyCompared with conventional head resectionOutcomes: Functional assessment, VAS, AOFAS, gait ability and radiological assessmentFollow up: 3months and 12 monthsNo difference in scores

Hallux Valgus

Scarf Vs ChevronDeenik R 2007108 patientsScarf Vs ChevronOutcomes: AOFAS, hallux valgus scale, HV angle, IM angleFollow up: 27 months post surgery

Scarf Vs ChevronNo difference in outcomes

Complications were different:

Scarf: Type 1 CRPS -1 patient

Chevron: partial osteonecrosis of metatarsal head

Thank You