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C OPYRIGHT Ó 2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Specialty Update
What’s New in Foot and Ankle Surgery
Sheldon S. Lin, MD, Omkar Baxi, MD, and Michael Yeranosian, MD
Investigation performed at the Department of Orthopaedic Surgery, Rutgers New Jersey School of Medicine, Newark, New Jersey

This article provides a summary of recent research pertaining
to orthopaedic foot and ankle surgery, from September 2016 to
September 2017. The included studies were published in The
Journal of Bone & Joint Surgery and Foot & Ankle International.
Achilles Tendon
In an era of cost-containment medicine, the use of ultraso-
nography as a diagnostic modality for Achilles tendon ruptures
will likely continue to expand. Griffin et al. compared a novel
dynamic ultrasound technique and conventional static ultra-
sonography among a group of patients with magnetic reso-
nance imaging (MRI)-confirmed Achilles tendon ruptures1. In
this Level-II study, a real-time Thompson test under ultra-
sound was performed, with Achilles rupture defined as a loss of
the quadrilateral shape of the tendon. The authors found that
the dynamic test had superior sensitivity, specificity, and
interobserver reliability and can be performed with minimal
training in ultrasonography.
The long-term implications of tendon elongation after
an acute Achilles tendon rupture are controversial. In a pro-
spective study, Heikkinen et al. followed 52 patients who
underwent surgical repair2. MRI evaluation and isokinetic
strength testing were performed for both legs at a minimum of
13 years postoperatively. The authors found that the Achilles
tendon was, on average, 6% longer and the calf musculature
was 11% to 13% smaller in the affected leg compared with the
unaffected leg. Additionally, plantar flexion strength was 12%
to 18% less on the affected side. The authors concluded that
increased tendon length is associated with persistent calf
atrophy and strength deficits at long-term follow-up.
Achilles tendon ruptures are devastating injuries for
professional athletes, often prematurely ending their careers.
Jack et al. sought to determine the return-to-sport rate fol-
Specialty Update has been developed in collaboration with the Board of
Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
lowing surgical repair for players in the National Football
League (NFL) as well as their postoperative career length and
performance as compared with matched controls and their
postoperative compared with preoperative performance3. Of
the 95 players included in the analysis in this retrospective
study, <75% returned to the NFL. Postoperative career length
was 1 season shorter than that of the matched controls, and
postoperative performance scores were significantly worse than
preoperative scores for running backs and linebackers.
Ankle Arthroscopy
Studies demonstrating the efficacy of arthroscopy in the
treatment of certain ankle pathologies have broadened the
indications for its use. In a recent Level-I study, Liszka and
Ga˛ dek investigated the efficacy of preemptive local anesthesia
in combination with general or spinal anesthesia in 80 patients
undergoing ankle arthroscopy4. The authors found that
patients receiving local anesthesia did not require any on-
demand pain medication and reported lower pain intensity up
to 24 hours post-arthroscopy. Patients in the spinal anesthesia-
only group had better pain control than did patients with
general anesthesia only. The results of this study indicate that
preemptive local anesthesia should be considered for ankle
arthroscopic procedures.
A tourniquet is routinely used during ankle arthroscopy
to improve visualization and decrease operative time. These
purported advantages have not been demonstrated in recent
studies on knee arthroscopy5-8. In a Level-I study, Dimnjaković
et al. examined whether or not this was also the case in ankle
arthroscopy9. Fifty patients were randomized to undergo ankle
arthroscopy with or without tourniquet inflation. The authors
found that operative time, visualization, and function scores
were similar between the 2 groups. Moreover, the non-
tourniquet group had significantly less pain in the early post-
operative period. These results call into question whether
routine tourniquet use during ankle arthroscopy is warranted.

Disclosure: One of the authors (S.S.L.) reports a stipend for this work from JBJS. On the Disclosure of Potential Conflicts of Interest forms, which are
provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in
the biomedical arena outside the submitted work and “yes” to indicate that the author had other relationships or activities that could be perceived to
influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/E696).

J Bone Joint Surg Am. 2018;100:892-8 d http://dx.doi.org/10.2106/JBJS.17.01672

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Diabetes and Charcot Neuroarthropathy
Charcot neuroarthropathy is associated with notable functional
impairment, as demonstrated by previous investigations uti-
lizing the validated yet cumbersome Short Form (SF)-36 and
the American Orthopaedic Foot & Ankle Society Diabetic Foot
Questionnaire (AOFAS-DFQ)10,11. In light of the growing dia-
betic population, the need for simpler outcome measures has
become apparent. The results of a prospective study by Kroin
et al. suggest that the Short Musculoskeletal Function Assess-
ment (SMFA) is a valid and easier-to-use tool for measuring
preoperative impairment and provides a benchmark for as-
sessing improvement following corrective surgery in the
Charcot neuroarthropathy population12.
Vacuum-assisted closures or negative pressure wound
therapy (NPWT) has become popular in treating recalcitrant
or slow-healing wounds. Although known to promote granu-
lation tissue formation, the mechanism of action of NPWT at
the molecular level only recently has been investigated. In a
Level-I study, Yang et al. randomized 40 patients with diabetic
foot ulcers to receive either NPWT or wet-to-dry (control)
dressing changes13. An analysis of the granulation tissue after
7 days showed higher levels of cellular fibronectin and trans-
forming growth factor-b1, key regulators of wound-healing, in
the NPWT group compared with the control group.
Total contact orthoses are frequently used as conservative
measures to prevent diabetic ulcers or protect healed feet from
recurrent diabetic ulcers. Previous studies showed that total
contact orthoses redistributed foot pressures and diminished
peak plantar forces during level walking14-17. A Level-II study by
Nouman et al. investigated the pressure distribution patterns
under different walking conditions, with and without the use of
total contact orthoses18. The study demonstrated that diabetic
patients have the highest load in the toes and forefeet during
level walking and ramp walking. Moreover, total contact
orthoses decreased forefoot pressures and transferred pressure
to the midfoot in all walking conditions.
Forefoot
Morton neuromas are a frequent cause of forefoot pain and are
often first treated conservatively with local anesthetic or cor-
ticosteroid injections. In a Level-I study by Lizano-Dı́ez et al.,
41 patients were randomized to receive injections of a corti-
costeroid plus a local anesthetic or a local anesthetic alone19.
The groups did not differ significantly with regard to pain or
function at 3 and 6 months post-injection or in the rate of
eventual surgical excision. These findings are in accordance
with those of prior studies indicating that corticosteroids have
no added benefit for Morton neuroma.
Surgery for hallux rigidus remains a controversial topic.
While arthrodesis of the first metatarsophalangeal (MTP) joint
is the preferred treatment among most providers, concerns
over medial column lengthening and degenerative changes at
adjacent joints have led to continued interest in MTP arthro-
plasty. Stone et al. reported on the long-term (15-year) follow-
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
up of patients randomized to MTP joint arthrodesis or
arthroplasty in a trial originally conducted from 1998 to 200120.
In their cohort of 52 patients, those who underwent arthrodesis
had less pain, fewer revisions, and greater satisfaction than
those in the arthroplasty group, with equal function scores. On
the basis of these data, arthrodesis remains the treatment of
choice for severe hallux rigidus.
The trend toward minimally invasive surgery has pro-
gressed to hallux valgus treatment. Studies comparing percu-
taneous techniques and traditional open procedures have been
lacking until recently. A prospective, randomized study by Lee
et al. assigned 50 patients to undergo either percutaneous
chevron plus Akin osteotomies or open scarf plus Akin oste-
otomies21. At 6 months of follow-up, both groups demon-
strated good to excellent clinical and radiographic outcomes.
The percutaneously treated group, however, had significantly
less pain in the first 6 weeks following surgery.
Patients commonly ask when they can safely return to
driving following hallux valgus surgery. A Level-II study by
McDonald et al. may give practitioners some evidence-based
answers to this question22. The authors found that 85% of
patients who underwent right first metatarsal osteotomy were
safe to drive at 6 weeks on the basis of their brake reaction time,
and 100% were deemed safe by 8 weeks. Patients who were not
safe to drive by 6 weeks had greater pain scores and diminished
first MTP range of motion.
Outcomes
Accurately assessing outcomes following foot and ankle proce-
dures is of paramount importance. Patient-satisfaction surveys
provide valuable information to surgeons, but what these surveys
do not capture is the effect of patients’ expectations on their
ultimate satisfaction. Recognizing this, Cody et al. developed a
valid and reliable patient-derived survey to gauge preoperative
expectations and to help guide treatment23. The final survey
consisted of 23 items, with an overall score calculated on the basis
of the amount of improvement patients expected for each item.
In a subsequent study by Cody et al., their previously
developed survey was administered to 352 patients to examine
whether patients’ preoperative expectations were related to
their demographic and clinical characteristics24. The authors
found that expectation scores were not related to age and that
women expected to achieve complete improvement more fre-
quently than did men. In addition, patients with worse func-
tion, more depressive and anxiety symptoms, and higher pain
scores had higher expectations. These results can help surgeons
guide preoperative discussions with patients and help improve
their ultimate satisfaction postoperatively.
Currently, no widely accepted, gold standard patient-
reported outcome (PRO) tool exists in the foot and ankle lit-
erature. While numerous validated measures are available, they
are often time-intensive and place a heavy respondent burden
on patients. As part of a National Institutes of Health initiative
to address this problem, a series of computer adaptive tests
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(CATs) have recently been developed. A Level-II study by
Koltsov et al. sought to validate 3 of these CATs against the Foot
and Ankle Outcome Score (FAOS) among 240 patients with 6
common foot and ankle pathologies25. CAT scores were more
normally distributed than FAOS scores and the tests took much
less time to complete (<1 minute versus 6.5 minutes). The
authors concluded that the CATs performed as well as or better
than the FAOS in all aspects of psychometric validity and
carried a significantly reduced respondent burden.
Total Ankle Arthroplasty
Total ankle arthroplasty (TAA) is being performed with
increased frequency, and surgeons have multiple implants at
their disposal. A prospective study by Lefrancois et al. com-
pared clinical and functional outcomes of 4 prostheses: the
HINTEGRA implant (Integra LifeSciences), the Agility implant
(DePuy), the Mobility implant (DePuy), and the Scandinavian
Total Ankle Replacement (STAR; Small Bone Innovations)26. A
total of 451 patients with an average follow-up of 4.5 years were
included in the analysis. Patients with the Mobility implant had
less improvement in score on the Ankle Osteoarthritis Scale,
while the other 3 implants had comparable results. All 4
implants were considered to have acceptable outcomes.
The choice of ankle arthroplasty versus arthrodesis is
controversial in many cases. A Level-II study by Heckmann
et al. investigated the relationship between insurance status and
the likelihood of undergoing either procedure27. A total of
10,010 patients who underwent TAA and 18,094 patients who
underwent arthrodesis for tibiotalar osteoarthritis were iden-
tified. Patients with Medicare or private insurance were 3 times
more likely to undergo TAA than were patients with Medicaid.
The authors suggest further research in this area to ensure the
delivery of equitable care.
The advent of newer implant designs and improved
surgical techniques for TAA has led to improved outcomes over
the years. This concept is reflected in recent studies examining
the complication rates of TAA and ankle arthrodesis. A data-
base study by Odum et al. compared in-hospital complication
rates between a statistically matched cohort of patients who
underwent either TAA or ankle arthrodesis28. A total of 3,148
patients were included in the analysis. The authors found that
patients undergoing arthrodesis had a 1.8-times higher risk of a
major perioperative complication than those undergoing TAA.
Another database study comparing complication rates
between TAA and arthrodesis was performed by Stavrakis and
SooHoo29. The authors identified 1,280 cases of TAA and 8,491
cases of arthrodesis. They found that patients managed with TAA
had lower rates of readmission and infection compared with the
arthrodesis group. With continued design improvements over
time, the number of TAA procedures will likely continue to rise.
Ankle and Syndesmotic Injuries
Ankle injuries are very common in soccer athletes. Numerous
injury-prevention programs have been developed to address
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
this issue, but their effectiveness is not completely known. A
Level-I meta-analysis by Grimm et al. sought to shed some light
on this topic30. Ten randomized controlled trials and a total of
4,121 athletes were included in the analysis. The authors
found a risk ratio of 0.60 with injury-prevention programs,
suggesting a decreased rate of injury. Furthermore, they high-
lighted the need for future studies to further evaluate the
effectiveness of specific exercises as well as the optimal age of
implementation among these athletes.
Syndesmotic injuries are a topic of continued debate.
Proper reduction and fixation requires knowing the precise
relationship between the distal aspects of the tibia and fibula in
the uninjured state and in different ankle positions. A 2013
study by Nault et al. established a validated measurement sys-
tem to define this relationship on the basis of axial images of
normal ankles31. A more recent investigation by Nault et al.
went a step further by being the first in vivo study that we are
aware of to demonstrate the impact of sagittal ankle position on
the uninjured distal tibiofibular articulation32. They found that
ankle dorsiflexion leads to increased external rotation and
translation of the fibula on MRI. Their results support the
practice of placing the ankle in neutral dorsiflexion for syn-
desmotic fixation.
The degree of stability of isolated lateral malleolar frac-
tures is the primary determinant between operative and non-
operative treatment. Two methods of assessing stability are the
use of gravity stress radiographs and weight-bearing radio-
graphs. A prospective study by Seidel et al. compared these 2
techniques in a series of patients with supination-external
rotation type lateral malleolar fractures33. Ninety patients had
no obvious initial talar displacement and were assessed with use
of both weight-bearing and gravity stress radiographs. Forty-
four of those patients were stable on weight-bearing views but
borderline unstable on gravity stress views (“gravity-border-
line”). The remaining 46 patients were stable on both views
(“gravity-stable”). There were no functional or radiographic
differences in outcome between the patients who were “gravity-
borderline” and “gravity-stable” at the 2-year follow-up. These
findings suggest that gravity stress radiographs may overrate
the need for operative treatment.
Ankle fractures are typically treated in the outpatient
setting, as rising costs of health care have driven the trend to
minimize hospitalization. The safety of this practice is largely
anecdotal and was therefore the subject of a recent investigation
by Qin et al.34. Excluding open fractures and emergency cases, a
total of 5,256 patients were included. The authors found that
outpatient procedures were associated with lower rates of
urinary tract infection, pneumonia, and venous thromboem-
bolism. Furthermore, no differences were demonstrated with
respect to surgical complications, reoperations, or read-
missions. These results support the current practice of defer-
ring admission for low-risk patients.
Posttraumatic osteoarthritis is commonly seen following
intra-articular ankle fracture (IAF). Chondrocyte apoptosis
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from the energy absorbed at the time of trauma and biome-
chanical derangements from articular incongruity are known
contributors to this phenomenon. The intra-articular inflam-
matory response has also been proposed as a causative factor
and was the topic of a study by Adams et al.35. The authors
analyzed synovial fluid aspirations at the time of surgery, which
ranged from 0 to 31 days following intra-articular ankle frac-
ture. These analytes included various interleukins, matrix
metalloproteinases, and byproducts of heme metabolism. The
results demonstrated acute temporal fluctuations resulting in
an overall catabolic environment by 10 days post-fracture.
Although much remains to be elucidated regarding the
molecular cascades leading to posttraumatic arthritis, these
findings raise the question of whether early joint-space evac-
uation to reduce the initial inflammatory burden should be
considered in certain cases.
Ankle Instability
Patients with chronic ankle instability have known impair-
ments in the neuromuscular recruitment patterns of the per-
oneus longus and brevis muscles. Although their different
insertions impart different functions during gait, these muscles
are typically grouped together during clinical evaluation and
rehabilitation. A study by Donnelly et al. aimed to determine
whether the peroneus longus and brevis could be isolated
during isometric muscle testing and whether strength and
electromyographic (EMG) differences existed between patients
with and without chronic ankle instability36. Testing was per-
formed in neutral and plantar-flexed positions. Although
patients with chronic ankle instability showed large deficits in
peak eversion strength compared with healthy controls, force
production and EMG activity of the peroneus longus and
brevis were similar in both positions and between both groups.
These findings suggest that the peroneus longus and brevis
muscles cannot be selectively activated and that EMG activity
did not translate to force production in patients with chronic
ankle instability as it did in healthy controls.
The diagnosis of chronic ankle instability is typically
made on the basis of clinical examination and stress radio-
graphs. Although MRI is often performed as part of the pre-
operative evaluation, its efficacy in diagnosing instability is not
clear. A retrospective cohort study by Jolman et al. compared
the diagnostic value of MRI to that of the use of stress radio-
graphs among 187 patients37. While MRI had high sensitivity
compared with stress radiographs in their series (83% versus
66%), its specificity was significantly worse (53% versus 97%).
Overall accuracy was 71% for MRI and 74% for stress radio-
graphs. The authors concluded that, while MRI was a useful
screening tool for concomitant ankle pathology, it should not
be used on its own for the diagnosis of chronic ankle instability.
The modified Broström procedure is commonly used in
the treatment of chronic ankle instability. Although it is typi-
cally performed as an open procedure, all-inside arthroscopic
techniques have also been developed. A randomized controlled
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
trial by Yeo et al. was the first Level-I study that we are aware of
in which these 2 types of procedures were compared38. Fifty
ankles were assigned to the open and all-inside arthroscopic
groups. Two dropped out of the open group, leaving a total of
48 patients (25 all-inside and 23 open). Measured outcomes
included functional and pain scores as well as anterior talar
translation and talar-tilt angle on radiographs. After a mini-
mum of 12 months of follow-up, the authors found no dif-
ference in clinical or radiographic outcomes between the 2
groups. Given these similar outcomes, as well as the rise of
arthroscopy in the fields of knee and shoulder surgery, it is
likely that arthroscopic treatment of chronic ankle instability
will continue to increase.
Orthobiologics
Orthobiologics continue to be an area of active research in foot
and ankle surgery. A study by Dekker et al. examined the use
of a cellular allogeneic bone graft for arthrodesis and revision
nonunion procedures in a patient population at high risk for
nonunion39. This allograft contained cortical cancellous bone
chips, demineralized bone matrix, and viable multipotent adult
progenitor cells capable of producing osteogenic and angio-
genic signals. Thirty-six patients with a mean-follow-up of
13 months were included in the analysis. The overall union rate
was 83%, and univariate analysis demonstrated that the use of
the allograft helped mitigate the presence of risk factors known
to cause nonunion. Additional benefit lies in avoidance of
morbidity associated with autograft harvesting.
Studies on platelet-rich plasma (PRP) have shown that it
may have some benefit in the treatment of hip and knee oste-
oarthritis40,41 and osteochondral lesions of the talus42. PRP
efficacy in ankle osteoarthritis, however, has only recently been
investigated. In a study by Fukawa et al.43, 20 patients received 3
intra-articular injections of PRP at 2-week intervals. Patients
were assessed 4, 12, and 24 weeks following the final injection.
No serious adverse effects were observed, and significant
reductions in pain and disability were noted at each time point.
Maximal pain reduction was at the 12-week mark, with a
reduced effect noted at 24 weeks. Although this study only
provides Level-IV evidence, it highlights the potential efficacy
of PRP and warrants future high-quality studies.
Ahmad and Maltenfort described another novel appli-
cation of orthobiologics for the treatment of osteochondral
lesions of the talus44. They reported on the use of allograft
cartilage extracellular matrix (ECM) at the site of microfracture
in a group of 30 patients in whom nonoperative management
had failed. Patients were followed for an average of 20 months
and demonstrated an increase in the Foot and Ankle Ability
Measure (FAAM) score, from 51.4 (of 100) preoperatively to
89.3 at the time of final follow-up. Additionally, visual analog
scale pain scores decreased from 8.1 (of 10) to 1.7. These initial
findings are promising, although additional studies are needed
to further specify the role of allograft cartilage ECM in the
treatment of osteochondral lesions of the talus.
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Pes Planovalgus
In an attempt to better understand the 3-dimensional nature of
adult-acquired flatfoot deformity, computed tomography (CT)
scans increasingly have been used. Conventional CT scans
provide non-weight-bearing images of the patient’s foot, which
may not reveal the true severity of the condition. A diagnostic
study by de Cesar Netto et al. tested this hypothesis by com-
paring weight-bearing and non-weight-bearing CT images for
20 patients with flexible flatfoot deformity45. They found that
measurements analogous to traditional radiographic parame-
ters of pes planovalgus could be obtained using high-resolution
cone-beam CT, with weight-bearing images more accurately
characterizing the severity of osseous derangement.
Calcaneal lengthening has been successfully used to treat
planovalgus feet, but outcomes have been less favorable in
children with cerebral palsy. To better understand the risk
factors for undercorrection of deformity in this population,
Luo et al. reviewed a case series of 20 children who had
undergone the procedure46. They found that talonavicular
lateral subluxation of >24° on the anteroposterior view and a
calcaneal pitch angle of <25° on the lateral view were inde-
pendent predictors of a deformity that cannot be restored to
normal alignment with calcaneal lengthening.
Plantar Fasciitis
Musculoskeletal foot disorders are frequently seen in overweight
and obese patients. It has been postulated that mechanical changes
in the plantar fascia and heel pad in this population may play a
causative role in the pathogenesis of these disorders. Tasx et al.
investigated plantar fascia and heel-pad stiffness and thickness
among overweight individuals with use of ultrasound and com-
pared the measurements with those of normal-weight controls47.
They found that increasing body mass index (BMI) was associated
with decreased plantar fascia stiffness, increased plantar fascia
thickness, and increased heel-pad stiffness and thickness.
In a randomized controlled trial, Ahmad et al. investi-
gated the efficacy of botulinum toxin in the treatment of
plantar fasciitis48. Twenty-five patients were randomized to
receive an injection of botulinum toxin or saline solution in the
affected foot. The botulinum toxin group had improved
References
1. Griffin MJ, Olson K, Heckmann N, Charlton TP. Realtime Achilles
ultrasound Thompson (RAUT) test for the evaluation and diagnosis of acute
Achilles tendon ruptures. Foot Ankle Int. 2017 Jan;38(1):36-40. Epub 2016
Oct 1.
2. Heikkinen J, Lantto I, Piilonen J, Flinkkilä T, Ohtonen P, Siira P, Laine V, Niinimäki
J, Pajala A, Leppilahti J. Tendon length, calf muscle atrophy, and strength deficit after
acute Achilles tendon rupture: long-term follow-up of patients in a previous study. J
Bone Joint Surg Am. 2017 Sep 20;99(18):1509-15.
3. Jack RA 2nd, Sochacki KR, Gardner SS, McCulloch PC, Lintner DM, Cosculluela
PE, Varner KE, Harris JD. Performance and return to sport after Achilles tendon repair
in National Football League players. Foot Ankle Int. 2017 Oct;38(10):1092-9. Epub
2017 Jul 25.
4. Liszka H, Gadek A. Preemptive local anesthesia in ankle arthroscopy. Foot Ankle
Int. 2016 Dec;37(12):1326-32. Epub 2016 Sep 12.
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
function and pain scores compared with the placebo group at 6
and 12 months post-injection as well as a lower rate of surgical
treatment for recalcitrant symptoms (0% versus 12%). It is
thought that the analgesic effect of botulinum toxin in plantar
fasciitis is attributable to paralysis of the adjacent flexor dig-
itorum brevis muscle as well as a local anti-inflammatory effect
on the plantar fascia.
Upcoming Educational Events
Several courses and events related to foot and ankle surgery are
sponsored and/or cosponsored by the American Academy of
Orthopaedic Surgeons (AAOS) and the American Orthopaedic
Foot & Ankle Society (AOFAS). These include the AOFAS
Annual Meeting, July 11 to 14, 2018, in Boston, Massachusetts,
and the AOFAS Advanced Foot Course, October 18 to 20, 2018,
in Scottsdale, Arizona.
Evidence-Based Orthopaedics
The editorial staff of The Journal reviewed a large number of
recently published studies related to the musculoskeletal system
that received a higher Level of Evidence grade. In addition to
articles cited already in the Update, 12 other articles with a higher
Level of Evidence grade were identified that were relevant to foot
and ankle surgery. A list of those titles is appended to this review
after the standard bibliography. We have provided a brief com-
mentary about each of the articles to help guide your further
reading, in an evidence-based fashion, in this subspecialty area.
Sheldon S. Lin, MD1
Omkar Baxi, MD1
Michael Yeranosian, MD1
1Department
of Orthopaedics, Rutgers New Jersey School of Medicine,
Newark, New Jersey
E-mail address for S.S. Lin: linss@njms.rutgers.edu
ORCID iD for S.S. Lin: 0000-0002-6639-428X
5. Johnson DS, Stewart H, Hirst P, Harper NJ. Is tourniquet use necessary for knee
arthroscopy? Arthroscopy. 2000 Sep;16(6):648-51.
6. Kirkley A, Rampersaud R, Griffin S, Amendola A, Litchfield R, Fowler P. Tourniquet
versus no tourniquet use in routine knee arthroscopy: a prospective, double-blind,
randomized clinical trial. Arthroscopy. 2000 Mar;16(2):121-6.
7. Smith TO, Hing CB. A meta-analysis of tourniquet assisted arthroscopic knee
surgery. Knee. 2009 Oct;16(5):317-21. Epub 2009 Feb 23.
8. Tsarouhas A, Hantes ME, Tsougias G, Dailiana Z, Malizos KN. Tourniquet use
does not affect rehabilitation, return to activities, and muscle damage after
arthroscopic meniscectomy: a prospective randomized clinical study. Arthroscopy.
2012 Dec;28(12):1812-8. Epub 2012 Oct 22.
9. Dimnjaković D, Hrabač P, Bojanić I. Value of tourniquet use in anterior ankle
arthroscopy: a randomized controlled trial. Foot Ankle Int. 2017 Jul;38(7):716-22.
Epub 2017 Apr 11.
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10. Dhawan V, Spratt KF, Pinzur MS, Baumhauer J, Rudicel S, Saltzman CL. Reliability
of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal
consistency, and measurable difference. Foot Ankle Int. 2005 Sep;26(9):717-31.
11. Raspovic KM, Wukich DK. Self-reported quality of life in patients with diabetes: a
comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int.
2014 Mar;35(3):195-200. Epub 2013 Dec 18.
12. Kroin E, Schiff A, Pinzur MS, Davis ES, Chaharbakhshi E, DiSilvio FA Jr.
Functional impairment of patients undergoing surgical correction for Charcot foot
arthropathy. Foot Ankle Int. 2017 Jul;38(7):705-9. Epub 2017 Apr 11.
13. Yang SL, Zhu LY, Han R, Sun LL, Dou JT. Effect of negative pressure wound
therapy on cellular fibronectin and transforming growth factor-b1 expression in
diabetic foot wounds. Foot Ankle Int. 2017 Aug;38(8):893-900. Epub 2017 Apr 29.
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redistribution: a finite element analysis. Clin Biomech (Bristol, Avon). 2003 Jul;18
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15. Fernandez ML, Lozano RM, Diaz MI, Jurado MA, Hernandez DM, Montesinos JV.
How effective is orthotic treatment in patients with recurrent diabetic foot ulcers? J
Am Podiatr Med Assoc. 2013 Jul-Aug;103(4):281-90.
16. Hamatani M, Mori T, Oe M, Noguchi H, Takehara K, Amemiya A, Ohashi Y, Ueki
K, Kadowaki T, Sanada H. Factors associated with callus in patients with diabetes,
focused on plantar shear stress during gait. J Diabetes Sci Technol. 2016 Nov 1;10
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17. Kato H, Takada T, Kawamura T, Hotta N, Torii S. The reduction and redistribution
of plantar pressures using foot orthoses in diabetic patients. Diabetes Res Clin
Pract. 1996 Mar;31(1-3):115-8.
18. Nouman M, Leelasamran W, Chatpun S. Effectiveness of total contact orthosis
for plantar pressure redistribution in neuropathic diabetic patients during different
walking activities. Foot Ankle Int. 2017 Aug;38(8):901-8. Epub 2017 Apr 29.
19. Lizano-Dı́ez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena
G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid injection for
the treatment of Morton’s neuroma: a prospective, double-blinded, randomized,
placebo-controlled trial. Foot Ankle Int. 2017 Sep;38(9):944-51. Epub 2017 Jun 15.
20. Stone OD, Ray R, Thomson CE, Gibson JNA. Long-term follow-up of arthrodesis
vs total joint arthroplasty for hallux rigidus. Foot Ankle Int. 2017 Apr;38(4):375-80.
Epub 2016 Dec 20.
21. Lee M, Walsh J, Smith MM, Ling J, Wines A, Lam P. Hallux valgus correction
comparing percutaneous chevron/Akin (PECA) and open scarf/Akin osteotomies.
Foot Ankle Int. 2017 Aug;38(8):838-46. Epub 2017 May 5.
22. McDonald E, Shakked R, Daniel J, Pedowitz DI, Winters BS, Reb C, Lynch MK,
Raikin SM. Driving after hallux valgus surgery. Foot Ankle Int. 2017 Sep;38(9):982-
6. Epub 2017 Jun 13.
23. Cody EA, Mancuso CA, MacMahon A, Marinescu A, Burket JC, Drakos MC,
Roberts MM, Ellis SJ. Development of an expectations survey for patients
undergoing foot and ankle surgery. Foot Ankle Int. 2016 Dec;37(12):1277-84. Epub
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24. Cody EA, Mancuso CA, Burket JC, Marinescu A, MacMahon A, Ellis SJ, HSS
Orthopaedic Foot and Ankle Surgery Group. Patient factors associated with higher
expectations from foot and ankle surgery. Foot Ankle Int. 2017 May;38(5):472-8.
Epub 2017 Feb 14.
25. Koltsov JCB, Greenfield ST, Soukup D, Do HT, Ellis SJ. Validation of patient-
reported outcomes measurement information system computerized adaptive tests
against the foot and ankle outcome score for 6 common foot and ankle pathologies.
Foot Ankle Int. 2017 Aug;38(8):870-8. Epub 2017 Jun 10.
26. Lefrancois T, Younger A, Wing K, Penner MJ, Dryden P, Wong H, Daniels T,
Glazebrook M. A prospective study of four total ankle arthroplasty implants by non-
designer investigators. J Bone Joint Surg Am. 2017 Feb 15;99(4):342-8.
27. Heckmann N, Bradley A, Sivasundaram L, Alluri RK, Tan EW. Effect of insurance
on rates of total ankle arthroplasty versus arthrodesis for tibiotalar osteoarthritis.
Foot Ankle Int. 2017 Feb;38(2):133-9. Epub 2016 Oct 22.
28. Odum SM, Van Doren BA, Anderson RB, Davis WH. In-hospital complications
following ankle arthrodesis versus ankle arthroplasty: a matched cohort study. J
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Evidence-Based Articles Related to Foot and Ankle
Surgery
Ahmad J, Jones K. Randomized, prospective comparison of bioabsorbable and
steel screw fixation of Lisfranc injuries. J Orthop Trauma. 2016 Dec;30(12):676-81.
Over a 5-year period, 40 patients were enrolled in a prospective ran-
domized trial comparing bioabsorbable screws with steel screws in open
reduction and internal fixation of Lisfranc injuries. Both groups had similar
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
29. Stavrakis AI, SooHoo NF. Trends in complication rates following ankle
arthrodesis and total ankle replacement. J Bone Joint Surg Am. 2016 Sep 7;98
(17):1453-8.
30. Grimm NL, Jacobs JC Jr, Kim J, Amendola A, Shea KG. Ankle injury prevention
programs for soccer athletes are protective: a level-I meta-analysis. J Bone Joint Surg
Am. 2016 Sep 7;98(17):1436-43.
31. Nault ML, Hébert-Davies J, Laflamme GY, Leduc S. CT scan assessment of the
syndesmosis: a new reproducible method. J Orthop Trauma. 2013 Nov;27(11):638-41.
32. Nault ML, Marien M, Hébert-Davies J, Laflamme GY, Pelsser V, Rouleau DM,
Gosselin-Papadopoulos N, Leduc S. MRI quantification of the impact of ankle
position on syndesmosis anatomy. Foot Ankle Int. 2017 Feb;38(2):215-9. Epub
2016 Oct 13.
33. Seidel A, Krause F, Weber M. Weightbearing vs gravity stress radiographs for
stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle
Int. 2017 Jul;38(7):736-44. Epub 2017 May 16.
34. Qin C, Dekker RG, Blough JT, Kadakia AR. Safety and outcomes of inpatient
compared with outpatient surgical procedures for ankle fractures. J Bone Joint Surg
Am. 2016 Oct 19;98(20):1699-705.
35. Adams SB, Reilly RM, Huebner JL, Kraus VB, Nettles DL. Time-dependent
effects on synovial fluid composition during the acute phase of human intra-articular
ankle fracture. Foot Ankle Int. 2017 Oct;38(10):1055-63. Epub 2017 Sep 11.
36. Donnelly L, Donovan L, Hart JM, Hertel J. Eversion strength and surface
electromyography measures with and without chronic ankle instability measured in 2
positions. Foot Ankle Int. 2017 Jul;38(7):769-78. Epub 2017 Apr 9.
37. Jolman S, Robbins J, Lewis L, Wilkes M, Ryan P. Comparison of magnetic
resonance imaging and stress radiographs in the evaluation of chronic lateral ankle
instability. Foot Ankle Int. 2017 Apr;38(4):397-404. Epub 2017 Jan 6.
38. Yeo ED, Lee KT, Sung IH, Lee SG, Lee YK. Comparison of all-inside arthroscopic
and open techniques for the modified Broström procedure for ankle instability. Foot
Ankle Int. 2016 Oct;37(10):1037-45. Epub 2016 Sep 13.
39. Dekker TJ, White P, Adams SB. Efficacy of a cellular bone allograft for foot and
ankle arthrodesis and revision nonunion procedures. Foot Ankle Int. 2017 Mar;38
(3):277-82. Epub 2016 Oct 24.
40. Battaglia M, Guaraldi F, Vannini F, Rossi G, Timoncini A, Buda R, Giannini S.
Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus
hyaluronic acid for hip osteoarthritis. Orthopedics. 2013 Dec;36(12):e1501-8.
41. Kanchanatawan W, Arirachakaran A, Chaijenkij K, Prasathaporn N, Boonard M,
Piyapittayanun P, Kongtharvonskul J. Short-term outcomes of platelet-rich plasma
injection for treatment of osteoarthritis of the knee. Knee Surg Sports Traumatol
Arthrosc. 2016 May;24(5):1665-77. Epub 2015 Sep 19.
42. Görmeli G, Karakaplan M, Görmeli CA, Sarıkaya B, Elmalı N, Ersoy Y. Clinical
effects of platelet-rich plasma and hyaluronic acid as an additional therapy for talar
osteochondral lesions treated with microfracture surgery: a prospective randomized
clinical trial. Foot Ankle Int. 2015 Aug;36(8):891-900. Epub 2015 Mar 30.
43. Fukawa T, Yamaguchi S, Akatsu Y, Yamamoto Y, Akagi R, Sasho T. Safety and
efficacy of intra-articular injection of platelet-rich plasma in patients with ankle
osteoarthritis. Foot Ankle Int. 2017 Jun;38(6):596-604. Epub 2017 Apr 11.
44. Ahmad J, Maltenfort M. Arthroscopic treatment of osteochondral lesions of the
talus with allograft cartilage matrix. Foot Ankle Int. 2017 Aug;38(8):855-62. Epub
2017 May 26.
45. de Cesar Netto C, Schon LC, Thawait GK, da Fonseca LF, Chinanuvathana A,
Zbijewski WB, Siewerdsen JH, Demehri S. Flexible adult acquired flatfoot deformity:
comparison between weight-bearing and non-weight-bearing measurements using
cone-beam computed tomography. J Bone Joint Surg Am. 2017 Sep 20;99(18):e98.
46. Luo CA, Kao HK, Lee WC, Yang WE, Chang CH. Limits of calcaneal lengthening
for treating planovalgus foot deformity in children with cerebral palsy. Foot Ankle Int.
2017 Aug;38(8):863-9. Epub 2017 May 5.
47. Taş S, Bek N, Ruhi Onur M, Korkusuz F. Effects of body mass index on
mechanical properties of the plantar fascia and heel pad in asymptomatic
participants. Foot Ankle Int. 2017 Jul;38(7):779-84. Epub 2017 May 23.
48. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum
toxin. Foot Ankle Int. 2017 Jan;38(1):1-7. Epub 2016 Oct 1.
outcomes, with a reliable decrease in pain and improvement in foot function as
measured by the FAAM. Bioabsorbable screws have theoretically fewer hard-
ware complications and obviate the need for removal of hardware.
Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of high-
volume injection, platelet-rich plasma, and sham treatment in chronic
midportion Achilles tendinopathy: a randomized double-blinded
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What’s New in Foot and Ankle Surgery
prospective study. Am J Sports Med. 2017 Jul;45(9):2034-43. Epub 2017
May 22.
Fifty-seven patients with chronic Achilles tendinopathy randomly
received high-volume injection (HVI) with local anesthetic and corticosteroid,
PRP, or placebo. Achilles tendon function scores were higher for the HVI group
compared with the PRP group at 12 weeks. Pain was improved in the HVI
group compared with the PRP group at 6 weeks and in both groups over
placebo at all time points. Both HVI and PRP treatment showed improvements
in Achilles symptoms compared with eccentric training alone, but HVI may
have better short-term outcomes than PRP.
Brison RJ, Day AG, Pelland L, Pickett W, Johnson AP, Aiken A, Pichora DR,
Brouwer B. Effect of early supervised physiotherapy on recovery from acute
ankle sprain: randomised controlled trial. BMJ. 2016 Nov 16;355:i5650.
The authors of this randomized trial assessed 229 patients with an acute
grade-1 or 2 ankle sprain treated with supervised physical therapy compared
with 214 patients treated with self-directed conservative care and graduated
weight-bearing. Excellent recovery was achieved in 43% of the therapy patients
and 37% of the standard care patients. This 6% absolute difference did not meet
the predetermined 15% change defined as the clinically significant difference.
On the basis of this study, there was no significant benefit to a defined physical
therapy protocol for grade-1 or 2 ankle sprains.
Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall
JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus
non-weightbearing and immobilization after open reduction and internal fix-
ation of unstable ankle fractures: a randomized controlled trial. J Orthop
Trauma. 2016 Jul;30(7):345-52.
In a multicenter, randomized controlled trial, 110 patients with surgically
treated unstable ankle fractures without syndesmotic or posterior malleolar repair
were randomized to either an early (2 weeks postoperative) weight-bearing pro-
tocol or a standard protocol with immobilization and non-weight-bearing for
6 weeks. There was no difference in the time to return to work, but patients with
early weight-bearing had better SF-36 scores. Some surgically treated unstable
ankle fractures without syndesmotic or posterior malleolar injury may be suitable
to beginning early weight-bearing at 2 weeks.
Georgiannos D, Bisbinas I. Endoscopic versus open excision of os trigonum
for the treatment of posterior ankle impingement syndrome in an athletic
population: a randomized controlled study with 5-year follow-up. Am J Sports
Med. 2017 May;45(6):1388-94. Epub 2017 Jan 23.
Over 3 years, 52 athletes were randomized to either endoscopic or open
resection of a symptomatic os trigonum. While both groups had reliable pain
relief, the endoscopic group had better AOFAS function scores and shorter
return to training and previous sports level. Endoscopic resection of an os
trigonum should be considered for athletes seeking earlier return to play.
Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J.
A prospective randomized trial comparing surgical and nonsurgical treatments
of acute Achilles tendon ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14.
Epub 2016 Jun 15.
Over 4 years, 60 patients with an acute Achilles tendon rupture were
randomized to either surgical end-to-end repair or nonsurgical treatment. At
the 18-month follow-up, both groups had similar outcomes on the Leppilahti
Achilles performance test. Surgical patients had more plantar flexion strength
and a better health-related quality-of-life score, indicating that surgical treat-
ment of acute Achilles tendon ruptures may be beneficial.
Lauri C, Tamminga M, Glaudemans AWJM, Juárez Orozco LE, Erba PA,
Jutte PC, Lipsky BA, IJzerman MJ, Signore A, Slart RHJA. Detection of
osteomyelitis in the diabetic foot by imaging techniques: a systematic review
and meta-analysis comparing MRI, white blood cell scintigraphy, and FDG-
PET. Diabetes Care. 2017 Aug;40(8):1111-20.
W H AT ’ S N E W IN FOOT AND A N K L E S U R G E RY
The authors of this meta-analysis reviewed 29 studies regarding advanced
imaging and found an overall sensitivity and specificity of 89% and 92% for FDG-
PET (fluorodeoxyglucose positron emission tomography), 92% and 75% for in-
dium WBC (white blood cell) scan, 91% and 92% for technetium WBC scan, and
93% and 75% for MRI. With similar sensitivities between all examinations, the
FDG-PET and technetium WBC scan offered the best specificities and should be
considered for advanced imaging of suspected diabetic osteomyelitis.
Lynen N, De Vroey T, Spiegel I, Van Ongeval F, Hendrickx NJ, Stassijns G.
Comparison of peritendinous hyaluronan injections versus extracorporeal
shock wave therapy in the treatment of painful Achilles’ tendinopathy: a ran-
domized clinical efficacy and safety study. Arch Phys Med Rehabil. 2017 Jan;98
(1):64-71. Epub 2016 Sep 14.
Sixty-two patients with Achilles tendinopathy were randomized to receive
either 2 weekly hyaluronic injections or 3 weekly treatments with extracorporeal
shockwave therapy. Patients who received the injections had significantly greater
pain improvement at 4 weeks, 3 months, and 6 months post-intervention, with
corresponding improvements in Achilles function scores.
Willett K, Keene DJ, Mistry D, Nam J, Tutton E, Handley R, Morgan L,
Roberts E, Briggs A, Lall R, Chesser TJ, Pallister I, Lamb SE; Ankle Injury
Management (AIM) Trial Collaborators. Close contact casting vs surgery for
initial treatment of unstable ankle fractures in older adults: a randomized
clinical trial. JAMA. 2016 Oct 11;316(14):1455-63.
Over a 3-year period, 620 patients across 24 hospitals with unstable
ankle fractures were randomized to either casting or operative fixation. At
6 months, both groups had similar outcomes for pain, ankle function, ankle
motion, quality of life, and patient satisfaction. The operative group had a
higher level of infection or wound complications and repeat operative proce-
dures. Malunion and nonunion were more common in the group managed
with casting. Despite higher malunion, nonunion, and failure-of-treatment
rates in the casting group, the authors concluded that casting was a cost-
effective therapy for unstable ankle fractures in patients >60 years of age.
White TO, Bugler KE, Appleton P, Will E, McQueen MM, Court-Brown CM.
A prospective randomised controlled trial of the fibular nail versus standard
open reduction and internal fixation for fixation of ankle fractures in elderly
patients. Bone Joint J. 2016 Sep;98-B(9):1248-52.
In this randomized trial, 50 patients who underwent fibular nailing
were compared with 50 patients who underwent standard open reduction and
internal fixation of the fibula for unstable ankle fractures. At 1 year, ankle
function scores were similar between the groups, but significantly fewer wound
complications were noted in the nail cohort.
Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. A systematic review of
suture-button versus syndesmotic screw in the treatment of distal tibiofibular
syndesmosis injury. BMC Musculoskelet Disord. 2017 Jul 4;18(1):286.
The authors performed a meta-analysis of 10 studies with 390 patients
in whom either suture-button fixation or screw fixation was used in the
treatment of distal tibiofibular syndesmotic injury. Both groups had similar
outcomes with respect to the AOFAS score at an average of 17 months. How-
ever, the rate of complications including hardware failure and reoperation was
lower in the suture-button group, indicating that suture-button repair may be
more efficacious for patient function and satisfaction.
Zhang YJ, Zhang C, Wang Q, Lin XJ. Augmented versus nonaugmented repair
of acute Achilles tendon rupture: a systematic review and meta-analysis. Am J
Sports Med. 2017 Apr 1:363546517702872. [Epub ahead of print].
This meta-analysis reviewed 4 randomized controlled trials with 83
patients who underwent augmented Achilles repair and 86 patients who
underwent nonaugmented repair. No differences between augmented and
nonaugmented repair were noted with respect to patient-satisfaction scores,
rerupture rates, infection rates, or complications.