Orthopaedic Knowledge Update 7
Koval, KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL. American Academy of Orthopaedic Surgeons. 2002 Ch. 46, pp. 547-564.
Judith F. Baumhauer, MD, Mark J. Geppert, MD, James D. Michelson, MD, Arthur K. Walling, MD
Chapter 46: Ankle and Foot: Trauma
Ankle and Pilon Fractures
Ankle Anatomy and Biomechanics
In a neutral position, approximately 90% of the load to the ankle is transmitted via the tibial plafond, with the remaining load borne through the lateral talofibular articulation. The talus in cross section forms a trapezoid, which is wider anteriorly than posteriorly. Consequently, during dorsiflexion of the talus, the increased talar width that is introduced into the ankle mortise forces the fibula to translate laterally and rotate externally. During weight bearing, plantar flexion is associated with internal rotation of the talus relative to the tibia. The deltoid ligament is responsible for this coupled rotation by acting as a checkrein on the talus.
The ankle is said to be stable when, under physiologic loading conditions, the talus moves in a normal pattern through the full range of motion. Injury to the ankle that results in a stable mechanical configuration therefore can be treated nonsurgically. In an unstable ankle, the joint surface contact area within the ankle is diminished, which predisposes the ankle to premature articular cartilage damage and degeneration.
The primary stabilizer of the ankle under physiologic loading conditions is the deltoid ligament, in conjunction with the deep and superficial components. If the deltoid is rendered incompetent either by direct rupture or medial malleolar fracture, the motion of the talus is markedly changed. During plantar flexion, the talus externally rotates from underneath the tibial plafond, the exact opposite of its normal pattern of movement. Stabilization of the fibula ameliorates this abnormal motion to some extent, but it is not corrected. Furthermore, in the absence of medial injury, fibular osteotomy or fracture does not result in abnormal motion of the ankle.
The Lauge-Hansen fracture classification system is based on the mechanism of injury and may guide closed reduction. The first word (supination, pronation) denotes the position of the foot at the time of injury, and the second phrase (for example, external rotation) denotes the direction of the deforming force. The most common injury pattern is supination-external rotation, which accounts for up to 85% of all ankle fractures.
The Weber/AO classification system is based on the level of the fibular fracture: type A, below the plafond; type B, at the plafond; and type C, absent the plafond. However, Weber B ankle fractures, the most common type, do not constituent a homogeneous group of fractures because patients with medial injury benefit from surgical intervention whereas patients with isolated lateral fractures do not.
The Lauge-Hansen and Weber classification systems have poor interobserver and intraobserver reproducibility. The limitations of these classifications is a result of the uncertain link between specific fracture patterns and associated soft-tissue injuries (deltoid ligament injury) and the inherent limitations of plain radiography of ankle fractures.
The instability pattern in ankle fractures is external rotation of the talus under the plafond, not simply lateral translation. Furthermore, studies using CT have shown that the distal fibular fragment is anatomic with respect to the talus, and the apparent distal fibular external rotation is actually proximal fibular internal rotation relative to the tibia (Fig. 1). Consequently, historic radiographic criteria based on "distal fibular displacement" result from radiographic limitations and may not be adequate criteria for surgical intervention.
The complete lack of standardization for radiographic magnification renders the absolute measurement of displacement distances unreliable. The most reliable criteria for instability is a lateral talar shift on the AP or mortise view, as defined by a medial clear space that is measurably larger than the superior clear space. Three views of the ankle (AP, mortise, and lateral) probably provide greater fracture detection sensitivity than two views (AP and lateral or mortise and lateral).
Treatment of Ankle Fractures
The majority of ankle fractures are stable, isolated, lateral malleolar injuries. In the absence of medial tenderness, isolated lateral malleolar fractures may be treated nonsurgically. Immobilization is primarily aimed at protecting the ankle from further injury and can consist of a short leg walking cast, a walking boot, or a high-top sneaker, all with similar satisfactory results. Surgical treatment of isolated lateral malleolar fractures carries a 1% to 3% chance of significant wound complications or infection and, on average, results in greater long-term swelling about the ankle.
Bimalleolar ankle fractures are most typically treated with open anatomic reduction and internal fixation. Although closed reduction can yield satisfactory results in up to 65% of cases, the procedure is generally reserved for patients with major associated medical problems that preclude surgical treatment. Bimalleolar fractures that are initially dislocated or significantly displaced should undergo a closed reduction and splinting at initial presentation to diminish swelling and associated soft-tissue damage. Although immediate surgical intervention prior to the onset of swelling has been advocated, it may be safer to allow the initial swelling to recede prior to surgical fixation. Surgical treatment consists of reduction and stabilization of both the medial and lateral malleoli.
For bimalleolar-equivalent fractures, in which the deltoid ligament is ruptured and the lateral malleolus is fractured, routine repair of the deltoid does not improve the clinical results and may lead to a worse long-term outcome. Medial exploration may be undertaken if the talus is not reduced anatomically underneath the plafond, in which case the deltoid ligament is extricated from between the talus and medial malleolus.
In the patient with lateral fracture and medial deltoid tenderness, any lateral talar shift signifies ankle instability and is treated accordingly. In the absence of a talar shift, individual clinical judgment dictates the treatment.
Postoperative treatment consists of initial splinting in neutral position followed by casting with progressive weight bearing and range of motion. Weight bearing may be started immediately in those patients in whom stable medial and lateral fixation has been achieved. Although there are theoretical advantages to instituting early range of motion in these patients, clinical studies have not demonstrated any major long-term benefit when compared with weight bearing in a cast or brace. After surgical treatment of a bimalleolar equivalent fracture, early range of motion should not be instituted because the long-term stability of the ankle depends on the deltoid healing at its resting length, which is with the ankle in neutral position.
Syndesmotic injuries constitute a special subgroup of fracture in which the fibular fracture is above the level of the tibial plafond and is associated with disruption of the syndesmotic ligament between the plafond and the level of fibula fracture. The contribution of the syndesmosis to ankle stability depends on the reestablishment of medial structural integrity. Provided that the fibula is anatomically reduced to the tibia, a syndesmotic screw may not be required for ankle stability as long as the deltoid is intact and the medial malleolus is either intact or surgically stabilized. In a bimalleolar-equivalent injury, where it is not possible to reestablish medial integrity, a syndesmotic screw may be placed whenever the fibular fracture is greater than 3.5 cm above the plafond. For bimalleolar-equivalent injuries with the fracture less than 3.5 cm above the plafond, as well as any syndesmotic injury in which medial integrity is restored, placement of a syndesmotic screw if the fibula is unstable to manual examination intraoperatively has been advocated. Because there are no standardized intraoperative tests for syndesmotic integrity that have been validated with follow-up clinical studies, this is an area of controversy.
When used, the syndesmotic screw is placed parallel to the tibial plafond at a distance roughly 1.5 cm proximal to the plafond. Care is taken to angle the screw 30° anteriorly from the fibula to the tibia to ensure full engagement in the tibia. The ankle is held in full dorsiflexion while the screw is placed, and lag screw technique avoided, to prevent overtightening of the syndesmosis and limitation of ankle dorsiflexion. Either 3.5-mm, 4.0-mm, or 4.5-mm screws are used that engage either three or four cortices.
Postoperatively, patients are in a cast and do not bear weight, followed by protected weight bearing. There is controversy regarding the necessity for syndesmotic screw removal prior to unprotected weight bearing. Removal before 3 months is not advised because of the risk of incomplete healing of the syndesmosis which may lead to recurrent syndesmotic widening. Weight bearing with the syndesmotic screw in place may cause fracture of the syndesmotic screw, but no major clinical consequences of such hardware failure have been reported. Initial enthusiasm for the use of biodegradable syndesmotic screws has faded because of abscess development in a sterile environment, which may require surgical débridement.
An absolute requirement for a syndesmotic screw, regardless of other considerations, is that there be persistent widening of the syndesmosis on intraoperative radiographs. The syndesmosis may be reduced using an external clamp and stabilized with screws.
Posterior malleolar fractures with more than 2 mm of displacement after fibular reduction and plating may be reduced and stabilized if they constitute more than 30% of the articular surface on a lateral radiograph, with a lag screw placed either anterior to posterior or the reverse.
Ankle fractures in patients with diabetes are associated with higher rates of complications than in nondiabetic patients. Surgical infection and would dehiscence rates are higher in diabetics than other patients. However, attempts to maintain a closed reduction in unstable fractures is associated with a high rate of skin breakdown and infection because of the high contact pressures between the skin and cast that are required to maintain the reduction. Unstable fractures, in which a reduction is difficult to achieve and maintain, may be treated surgically because this will afford greater control over the fracture and probably are associated with a lower overall complication rate. The postoperative regimen of progressive weight bearing should be markedly delayed until there is radiographic evidence of healing to minimize the risk of fixation failure and Charcot degeneration.
The treatment of pilon fractures presents a formidable challenge to the skills of the orthopaedic surgeon. The immediate goals of pilon fracture treatment are to avoid complications, restore overall limb alignment, and reconstruct the articular surface. The ability to achieve these objectives is a function of the severity of fracture and the associated soft-tissue injuries.
Radiographic classification of pilon fractures is based on comminution (Fig. 2). A type I fracture is nondisplaced; type II has intra-articular displacement but intact metaphyseal structure; and type III has comminution and displacement at both the metaphyseal and articular regions. The degree of soft-tissue damage tends to increase with the severity of fracture type, which correlates with the force and energy that produce injury. The fracture also can be categorized as either a rotational injury or axial load injury. The former mechanism occurs during low-energy activities such as skiing, and leads to spiral or oblique fractures of the tibia and fibula with much less damage to the articular cartilage. Axial load injuries, such as from motor vehicle accidents or a fall from a height, result in burst type fractures of the plafond and tend to have greater comminution as well as more damage to the articular cartilage. The rotational injuries have a much better prognosis.
Full assessment of these injuries is aided by CT to completely define the anatomy of the fractures (Fig. 3). Identification of anatomy is critical to planning the surgical approach because plain films are unable to provide sufficient information to guide placement of fixation devices.
The early successes in treating pilon fractures by extensive open reduction with internal fixation was directly related to the selection bias in those studies in which low-energy type I injuries were predominant. Attempts to extend the principles of anatomic reduction and rigid fixation, which entailed extensive soft-tissue dissection around the distal tibia, resulted in a major complication rate of up to 50% in patients who sustained higher energy types II and III injuries. The primary complications encountered were extensive wound dehiscence with soft-tissue loss, deep infection, nonunion, malunion, and ultimate below-knee amputation. In an attempt to head off these complications, the method of external fixation for primary stabilization accompanied by limited internal fixation for restoration of the articular surface was developed (Fig. 4). The external fixator can be uniplanar or multiplanar, can engage the tibia alone or cross the ankle and/or subtalar joints, and may or may not be reinforced by fibular plating for further stability. Small incisions (1 to 2 cm) are used to obtain articular reduction and limited interfragmentary screw fixation. Extensive dissection is avoided because an arthritic ankle with an intact soft-tissue envelope is preferable to an anatomically reduced ankle that has undergone multiple débridements for soft-tissue loss and infection.
Timing of the definitive surgery is dictated by the resolution of swelling and soft-tissue compromise around the fracture. External fixation can be applied immediately to limit additional soft-tissue damage and maintain limb length and alignment. The external fixator configuration need not be definitive, because it can be easily modified at the time of definitive surgery. There are as yet no definitive studies identifying which configuration of external fixation yields superior results.
Removal of the external fixator and the initiation of weight bearing are based on radiographic signs of healing. Weight bearing may be begun prior to the removal of external fixation if a particularly stable configuration, such as a multiplanar ring fixator, has been used. Consideration should be given to early bone grafting at 6 weeks after injury for high-energy injuries that do not demonstrate radiographic evidence of healing at the metaphyseal site. Soft-tissue defects should be expeditiously and aggressively handled by appropriate coverage techniques.
The development of arthritis in these patients is a direct consequence of the initial injury, and usually is not reflective of the surgical care rendered. Avoidance of major complications, however, is a testament to good surgical judgment and technique.
Calcaneal fractures account for approximately 2% of all fractures. The calcaneus is the most commonly fractured tarsal bone. The majority of these fractures occur in industrial settings among males age 40 to 45 years. Associated fractures of the extremity and spine are frequent. The economic impact of these fractures is profound. Although enthusiasm for surgical treatment of calcaneal fractures has increased over the past 2 decades, there are few randomized trials on the management of calcaneal fractures.
Fracture classification is important to describe fractures, guide treatment selection, and predict outcomes. Although numerous classifications were based on standard radiographic technique, these have been largely supplemented by CT classification systems. A CT classification system has been developed based on an evaluation of 120 surgically treated calcaneal fractures (Fig. 5). This classification, based on the number and location of articular fracture fragments, has effectively suggested treatment methods and predicted outcomes.
Displaced intra-articular fractures account for 60% to 75% of all calcaneal fractures. Treatment for these fractures falls into four categories: nonsurgical; closed reduction/manipulation with or without minimal fixation; open reduction and internal fixation; and primary arthrodesis.
Indications for nonsurgical treatment include fractures where the relationship between the three facets is disrupted less than 4 mm, there is no subluxation of the subtalar joint secondary to widening (the calcaneus is widened to the extent that the two surfaces are not congruent), and there is no subfibular impingement. Shortening of the calcaneus results in an altered relationship of the facets. Treatment consists of temporary immobilization followed by the use of compression hose, early range of motion, and no weight bearing for 12 weeks. Other indications for nonsurgical treatment include severe open fractures or patients with soft-tissue compromise, such as with massive fracture blisters and prolonged edema that prevent surgery, patients with life-threatening injuries that prevent timely surgical intervention, and patients with severe peripheral vascular disease.
Closed reduction and pinning is usually relegated to tongue-type fractures, usually referred to as the Essex-Lopresti technique. Although recent articles have confirmed satisfactory results in this particular fracture pattern, the question remains whether immobilization and lack of early motion may negate any improvement gained by reduction. Furthermore, the pins-in-plaster technique may be associated with a risk of calcaneal osteomyelitis.
Open reduction and internal fixation usually is delayed until edema has decreased and skin lines become apparent. Ideally, surgery should be performed within 3 weeks after injury because once fracture consolidation has occurred it is much more difficult to ascertain the fracture planes. Appropriate plain radiographs and CT scans can be obtained during this initial waiting period.
The goal of open reduction and internal fixation is to restore articular integrity and height and width of the calcaneus, and correct any tuberosity malalignment. A variety of surgical approaches have been described (medial, lateral, combined); however, most studies now favor the extensile right-angled lateral incision. A full-thickness flap is created by subperiosteal dissection of all tissues off the lateral wall of the calcaneus.
The sequence of reduction varies, but basically consists of (1) opening the fracture and elevating the posterior facet that has been impacted into the body; (2) reducing the calcaneocuboid joint; (3) restoring the calcaneal height by reduction of the medial fracture fragment to the sustentaculum; (4) reducing the posterior facet and restoring the crucial angle of Gissane; (5) provisional fixation and appropriate intraoperative imaging to assess reduction; and (6) restoration of the lateral wall and permanent fixation (Fig. 6). Postoperatively, patients are immobilized until there is complete healing of the surgical wound. Next, range of motion exercises are instituted and patients are instructed not to bear weight for 10 to 12 weeks, after which progressive weight bearing is allowed.
Although the use of subtalar arthrodesis for late sequelae of traumatic arthritis following calcaneal fractures is well established, the use of primary arthrodesis has been less readily accepted. Using the CT scan classification, it has been suggested that the results of open reduction and internal fixation in the highly comminuted type IV fractures remain quite poor, even in the hands of surgeons experienced in the treatment of calcaneal fractures. For this reason, it has been recommended that the shape of the calcaneus is restored first (that is, height, width, and as much articular congruity as possible); if the articular surface cannot be restored, or if alignment of the facets is not obtainable, then primary fusion should be done.
Much progress has occurred in the management of calcaneal fractures. Although anatomic reconstruction of calcaneal fractures is difficult to obtain, in two-part fractures an anatomic reduction is obtainable in more than 80% of patients. In three-part fractures, anatomic reduction is possible in approximately 60% of patients. These two subgroups account for approximately 90% of all calcaneal fractures, with 70% good to excellent clinical results obtainable with surgery. Smoking, diabetes, and open fractures are factors that increase the risk of wound complications and lead to poorer results. Cumulative risk factors further increase the likelihood of complications, and nonsurgical management should be considered.
The talus is composed of five weight-bearing articular surfaces. Articular cartilage covers 60% of these surfaces, and neither tendons nor muscles insert or originate from its surfaces. Vascular supply to the talus is limited to the nonarticular areas of the bone. Because the talus is the critical link between the subtalar, transverse tarsal, and ankle joints, injuries to the talus are serious. If the talus is damaged, the linked motions of the foot and ankle are compromised, resulting in severe disability. Fractures of the talus are classified depending on their primary location of involvement (head, neck, and body).
Fractures of the talar head are uncommon, but because they often involve the articulation between talus and navicular, treatment is necessary to avoid subsequent traumatic arthritis. Open reduction and internal fixation is indicated if there is articular step-off (more than 3 to 4 mm), talonavicular instability, and involvement of more than 50% of the articular surface.
Fractures of the talar neck are significant because of the frequency and severity of their associated complications, including malunion, nonunion, osteonecrosis, infection, and arthritis. The Hawkins classification guides treatment and addresses the increasing chance of osteonecrosis from type I to IV. Although type I fractures were considered nondisplaced, and thus could be treated nonsurgically, more recent attention has been directed toward open reduction and internal fixation to make certain that there is no subtle displacement or rotation, and to allow early range of motion by providing stable fixation. All type II through IV injuries require open reduction and internal fixation.
Surgical exposure of talar neck fractures is planned to maximize fracture and joint surface exposure, minimize soft-tissue stripping, and avoid vascular compromise. A medial approach is standard, and can be coupled with a medial malleolar osteotomy. An additional anterolateral approach is strongly recommended because it affords a better assessment of rotation and subtalar joint congruity. Occasionally, lateral malleolar osteotomy is also required. Debate exists regarding the placement of fixation from anterior to posterior or from posterior to anterior. Although posterior to anterior placement seems to offer an advantage in rigidity, an additional incision is required.
The incidence of osteonecrosis increases with the severity of injury. The appearance of Hawkins sign (radiolucent line just beneath the subchondral surface of the talar dome as seen on an anteroposterior radiograph of the ankle) at approximately 6 to 8 weeks is indicative of vascular sufficiency to the talar body. MRI can aid in determining fracture healing and vascular status. Osteonecrosis can be partial or complete, and does not always result in collapse. Prolonging non-weight bearing has not been shown to prevent collapse, and weight bearing is usually begun when fracture healing has occurred. The role of non-weight bearing or protected weight bearing to prevent further collapse is not known.
Talar body fractures encompass (1) osteochondral fractures; (2) shear, sagittal, or coronal fractures; (3) posterior process fractures; (4) lateral process fractures; and (5) crushed or compression fractures.
Osteochondral fractures are discussed elsewhere in this book. Shear, sagittal, or coronal fractures are often associated with ankle fractures. Open reduction and internal fixation is necessary for stability and early range of motion. Reductions must be anatomic, and the surgical exposure is dictated by location of the fracture.
Posterior process fractures are notable in that nonsurgical treatment fails in two thirds of these fractures. A posterior surgical approach is recommended. Open reduction and internal fixation or excision is based on the size of the fragment. These fractures are often missed or diagnosis is delayed.
Lateral process fractures are often misdiagnosed as a chronic sprain of the ankle. A high index of suspicion for this fracture is warranted. These fractures usually can be seen with conventional radiographs; additional imaging studies such as CT or MRI also can help identify these fractures. There has been increasing awareness of the lateral process fracture because of its association with snowboarding injuries. Treatment is dependent on fragment size and consists of either excision or open reduction and internal fixation.
Crush fractures are high-energy impact injuries and are usually associated with additional injury, often open, either to the talus, malleoli, or foot. The goal of treatment is to restore articular integrity and avoid infection or osteonecrosis. Primary arthrodesis or excision of involved joint surfaces or talectomy have not been shown to produce better results than restoration of bone stock.
A subtalar dislocation is defined as the simultaneous dislocation of the subtalar and talonavicular joints without associated dislocation of the calcaneocuboid or tibiotalar joints, and without talar neck fracture. Medial dislocations are four times as common as lateral dislocations. High-energy injuries and sports injuries account for most of these dislocations; these injuries are often open injuries.
Prompt reduction is essential to minimize skin necrosis and circulatory compromise. Closed reduction cannot be achieved in approximately 5% to 10% of medial dislocations and 15% to 20% of lateral dislocations. Blocks to closed reduction may include the extensor digitorum brevis (medial dislocation) and the posterior tibial tendon (lateral dislocation). After either closed or open reduction, the joint is usually stable. If an unstable reduction occurs, the presence of a large intra-articular fracture must be ruled out because reduction and fixation of the fragment often will stabilize the joint. A CT scan is recommended after reduction to identify unrecognized articular fragments. Fixation or excision of displaced fragments is recommended to avoid instability or arthritis. Disagreement regarding early range of motion centers around preventing stiffness, but avoiding recurrent dislocation or instability.
Transverse Tarsal (Chopart) Dislocations
The transverse tarsal (Chopart) articulation is made up of the talonavicular and calcaneocuboid joints. Isolated dislocations of these individual articulations are rare. Transverse tarsal injuries are classified into five categories based on the direction of force and subsequent displacement. Longitudinal injuries account for approximately 40%, and often are associated with tarsometatarsal (Lisfranc) injuries because of the similar mechanism of injury. Medial stress injuries are the second most common, and lateral stress injuries are associated with compression (nutcracker) fractures of the cuboid.
Treatment options include closed reduction, open reduction and internal fixation, primary arthrodesis, or a combination of open reduction and internal fixation and limited fusion. Because of variations in the injury patterns, treatment is tailored to the specific features of the injury. Likewise, prognosis is dependent on pattern, early diagnosis, stable reduction, and articular damage.
The midfoot region includes the navicular, three cuneiforms, cuboid, and tarsometatarsal articulations. Because of the highly constrained joint articulations and strong plantar ligamentous support, isolated injury to one bone in this region is rare. Midfoot fractures commonly affect joint congruity, not only of the contiguous joint but also of adjacent joints that rely on coupled motion for normal function. The joints of the midfoot do not provide a significant contribution to foot motion in any plane. Therefore, primary importance is given to the maintenance of height, width, and length of the fractured segments at the expense of contiguous joint motion (with the exception of the fourth and fifth metatarsocuboid joints) to allow for normal motion at the adjacent joints. As a result, the column theory has been discussed. The medial column of the foot consists of the medial aspect of the navicular, medial cuneiform, and first metatarsal. The middle column is made up of the middle and lateral aspect of the navicular, middle and lateral cuneiforms, and the second and third metatarsals. The cuboid and the fourth and fifth metatarsals comprise the lateral column. In comminuted segments of the midfoot or in crush injuries where articular congruity cannot be reestablished, bridging the injured column through the use of internal plating or external fixation and bone grafting may be necessary for stability and to establish appropriate column length relationships.
Injuries to the midfoot usually occur from a high-energy mechanism. A number of common fracture patterns have been described.
Navicular fractures have been classified as avulsion, tuberosity, and body type. The avulsion fractures are characterized by capsular injuries, which commonly involve small dorsal fragments. These fractures are treated with cast immobilization and full weight bearing for 4 to 6 weeks followed by an ankle rehabilitation protocol for strengthening and proprioception. Fragments involving more than 25% of the bone may require open reduction and internal fixation to avoid dorsal subluxation of the navicular fragment.
The navicular tuberosity is the main attachment site of the posterior tibialis tendon. The posterior tibial tendon sends plantar extensions to insert on many of the tarsal and metatarsal bones. Nondisplaced fractures of the tuberosity may be treated with cast immobilization, and the patient should not bear weight for 4 to 6 weeks. It has been found that the navicular undergoes significant vertical dorsal and medial displacement with weight bearing at the stance phase of gait. Fragments displaced more than 2 to 3 mm should be reduced and stabilized with screw fixation. An accessory navicular may mistakenly be diagnosed as an acute fracture. The absence of sharp fracture lines on radiographs and the lack of clinical findings of ecchymosis, tenderness, and swelling will rule out this diagnosis. Occasionally, the synchondrosis between the accessory navicular and the main body of the bone can be injured. When clinical findings suggest a fracture of this nature, a three-phase technetium bone scan can confirm the diagnosis with increased uptake on the delayed images. If a synchondrosis injury is nondisplaced, it can be treated in the same manner as an acute fracture, with immobilization, if nondisplaced, in a short leg cast and no weight bearing for 4 to 6 weeks. If pain persists after immobilization and the fragment is small, resection of the ossicle with tendon reattachment (if necessary) has been successful. With a large, triangular-shaped accessory navicular (cornate tubercle), surgical stabilization with resection of the interposing cartilage may be performed after immobilization has failed.
Three types of body fractures have been described to aid in pattern recognition and treatment options. Type I is a fracture in the horizontal plane that produces dorsal and plantar fragments without forefoot angulation (Fig. 7). Interfragmentary screw fixation provides adequate stabilization through an anteromedial approach. Half pins (2 to 3 mm) placed in the talus and cuneiform can be used for temporary external fixator distraction to allow for visualization of the reduction of any type of body fracture. Type II fractures consist of a fracture in the dorsolateral to plantarmedial plane that leads to medial displacement of the major fragment and forefoot (Fig. 8). This is the most common navicular body fracture pattern. Reduction can be difficult and may require stabilization of the medial fragment to the adjacent cuneiform to maintain medial column length. Violation of the talonavicular joint is avoided because this articulation contributes significantly to coupled motion of the hindfoot. Type III navicular fractures occur from an axial load mechanism resulting in central or lateral comminution in the sagittal plane with the forefoot laterally displaced (Fig. 9). Associated injuries to the cuboid and/or anterior calcaneus are not uncommon with this fracture pattern. External fixation or bridging internal fixation across the naviculocuneiform or calcaneocuboid joints with primary intraosseous bone grafting, or in severe cases, primary arthrodesis, may be necessary to maintain column length. Body fractures require casting without external fixation and no weight bearing for 6 to 8 weeks, followed by progressive weight bearing guided by radiographic healing.
Isolated injuries to the cuboid or cuneiforms rarely occur because of the constrained articulations and strong plantar ligaments. The nutcracker injury is a common fracture pattern involving the cuboid. The mechanism of injury is abduction of the forefoot; the cuboid is compressed as it is wedged between the fourth and fifth metatarsal bases and the anterior aspect of the calcaneus, resulting in shortening of the lateral column. The medial column injury is to the tarsometatarsal region, resulting in fractures or ligament disruptions (Lisfranc). Treatment includes the reestablishment of lateral column length with an external fixation or internal fixation and plate bridging of the cuboid with or without intraosseous bone grafting. Because of the disruption of all three columns with this injury, medial and middle column screw stabilization will also be needed.
Cuneiform fractures occur in conjunction with tarsometatarsal joint injuries. The tarsometatarsal joints may have pure ligamentous disruption or transcuneiform or transmetarsarsal equivalent injuries. When the tarsometatarsal or intertarsal joints appear disrupted on initial radiographs, surgical planning should address the reestablishment of joint congruity and fracture fragment alignment. When the joints appear reduced and stability is in question, simulated weight bearing or abduction stress radiographs may be helpful to determine whether internal fixation is necessary to maintain anatomic alignment. An often-missed fracture pattern with a tarsometatarsal disruption is further propagation of the injury between the medial and middle cuneiforms and exiting the medial cuneiform-navicular articulation. Failure to recognize this pattern leads to subluxation of the medial cuneiform medially and dorsally, resulting in a shortened medial column.
Nonsurgical treatment of tarsometatarsal injuries is reserved for patients with nondisplaced fracture-dislocations confirmed by CT scan or those who are medically unstable. Surgical treatment is indicated for patients with displacement of the articular surfaces of more than 1 mm. With an anatomic closed reduction, percutaneous fixation is an option in an anatomically reduced fracture; if displacement is present, open reduction is favored. Fixation consists of percutaneous screw fixation of the first, second, and potentially third tarsometatarsal joints and Kirschner wire fixation of the fourth and fifth metatarsocuboid joints is appropriate. With an inadequate closed reduction as evidenced by persistent disruption in radiographic lines (as outlined in Table 1) open reduction through one or two longitudinal incisions allows for anatomic restoration of the joint surfaces and stabilization with screws and Kirschner wires. An additional screw placed across the navicular-medial cuneiform joint may be necessary if this injury pattern is present. The postoperative protocol consists of a non-weight-bearing cast for 8 to 12 weeks, and then progressive weight bearing and rehabilitation for ankle strengthening and proprioception. Screw removal is delayed for 4 to 6 months. Permanent screw placement has also been suggested. Posttraumatic arthritis develops in up to 50% of Lisfranc fracture/dislocations. Stiff rocker bottom shoes and nonsteroidal anti-inflammatory drugs provide some pain relief. Arthrodesis of the affected posttraumatic joints assessed through a positive response to fluoroscopy-guided lidocaine joint injection aids in pain control. The fourth and fifth tarsometatarsal joints are treated with metatarsal base resections to maintain the mobile lateral rays of the foot.
The forefoot consists of the metatarsals and phalanges. Fracture of the fifth metatarsal is the most common, and consists of tuberosity, metaphyseal-diaphyseal (Jones), and shaft fractures. These fractures often occur in conjunction with an inversion ankle injury and lateral ankle ligament sprain.
The fifth metatarsal base tuberosity fracture can be extra-articular or extend into the articular surface. Treatment may include a stiff-soled shoe or walking brace for comfort. Posttraumatic arthritis with this fracture is rare. Ankle rehabilitation exercises targeted at the prevention of recurrent ankle instability are implemented early and an ankle brace is used for sporting activities to avoid recurrent ankle injury.
The Jones fracture occurs at the metaphyseal/diaphyseal junction of the fifth metatarsal. This area is a watershed zone for blood flow and is particularly susceptible to delayed union or nonunion. The treatment is immobilization in a short leg cast or brace, and no weight bearing for 6 to 12 weeks until callus is seen on foot radiographs. Progressive protected weight bearing can then occur. In higher-level athletes, primary screw fixation with a 4.5-mm malleolar type screw may be undertaken. Spiral fractures of the fifth metatarsal shaft may be treated nonsurgically with weight bearing to tolerance in a stiff-soled shoe.
Metatarsal shaft fractures of the middle rays may occur with crush injuries or as a Lisfranc fracture variant. With crush injuries, additional energy is imparted to the adjacent soft tissues, which may lead to a compartment syndrome of the foot. Stiffness and neuritic pain may be the sequela of a crush injury long after the fractures have healed. Indications for surgical stabilization of metatarsal fractures include angulation of greater than 10° in the sagittal plane or displacement of more than 3 to 4 mm resulting in a prominent or unweighted metatarsal head. Attempts at open reduction of the metatarsal shafts, metatarsophalangeal joints, or phalangeal fractures leads to scarring and stiffness, adding surgical injury to the traumatic injury, and should be performed only to provide a plantigrade foot for weight bearing.
A patient history of any prodromal symptoms in the fifth metatarsal is helpful to identify a stress fracture. Clinical examination of foot and ankle alignment during weight bearing is critical to determine if there are any biomechanical issues, such as cavovarus foot malalignment, that can cause excessive forces on the fifth metatarsal. The patient's training schedule and technique should be reviewed because these, too, can lead to stress fractures. Radiographs may demonstrate sclerotic margins on the fracture fragments that are suggestive of a stress fracture. Screw fixation and potential bone grafting may be needed to facilitate healing. With a cavovarus foot malalignment, a lateral heel wedge orthosis may be helpful to alter the weight on the fifth ray and prevent recurrence of injury.
Phalangeal fractures rarely require surgical intervention or stabilization, with the great toe being the rare exception. Closed reduction when possible and occasionally open reduction and Kirschner wire or minifragmentary stabilization can maintain toe alignment and function. Some phalangeal fractures can be loosely buddy taped to adjacent toes for comfort or left alone in a shoe with a wide width or stiff sole. Because of swelling, normal shoe wear may be painful. Early weight bearing in patients with phalangeal fractures has been shown to improve outcome and healing times.
Sports Injuries of the Foot and Ankle
Ankle and Subtalar Sprains/Instability
Ankle sprains are the most common athletic injury and result primarily from an inversion stress during ankle plantar flexion. The anterior talofibular ligament (ATFL), the most commonly injured ankle ligament, is intimately associated with the joint capsule and is responsible for anterior drawer stability and inversion stability during plantar flexion of the ankle. The calcaneofibular ligament (CFL) is extracapsular and is the primary restraint to inversion instability during dorsiflexion.
The most important aspect of the initial orthopaedic management of the common ankle sprain is failure to recognize an associated injury. Determination of the mechanism of force can suggest a diagnosis. External rotation is associated with syndesmotic, peroneal tendon, and deltoid injuries. Inversion stress of the dorsiflexed ankle is associated with CFL injury. Point palpation tenderness and the inability to bear weight are findings that warrant radiographic evaluation. Commonly missed diagnoses include tendon subluxation (peroneal); tendon tears (posterior tibial, Achilles); fractures (anterior process of calcaneus, lateral process of talus, fifth metatarsal, Lisfranc, navicular, calcaneocuboid); and osteochondritis dissecans of the talus. A complete radiographic examination includes three views of the foot (AP, lateral to include the ankle, and oblique) and mortise and AP views of the ankle if clinically indicated.
An emergency room evaluation occasionally reports negative ankle radiographs, whereas the pathology might have been detected with foot radiographs (for example, oblique view of the foot revealing anterior process of a calcaneus fracture). Similarly, repeat weight bearing or stress radiographs may be required to detect subtle syndesmotic or Lisfranc injuries.
Classification as grade I, II, and III ankle sprains or the high (syndesmotic) versus low (lateral collateral ligaments) sprains is important prognostically regarding time to return to sport activity.
The familiar regimen of protection, rest, ice, compression, and elevation, early weight bearing, and range of motion (alphabet) exercises form the mainstay of early rehabilitation. Functional ankle braces are used for grade I and II injuries; severely symptomatic grade III sprains may benefit from cast immobilization or removable short leg walking braces that maintain a neutral ankle position and function as a removable cast for the first few weeks after surgery. Functional rehabilitation includes isometric and resistance exercises, and proprioceptive training. Return to sport is permitted when painless cutting, running, and the ability to jump on the affected leg 10 times without pain is experienced. Protective bracing for patients with grade II and III injuries for 6 months is helpful and has not been shown to interfere with athletic performance. Several recent studies indicate extremely limited indications for acute surgical stabilization of injuries to the lateral ankle ligament.
Approximately 15% to 30% of simple sprains will result in residual symptoms with peroneal weakness; inadequate rehabilitation is indicated as the primary cause. It is important to differentiate functional instability (pain causing an ankle to give way) from mechanical instability, with attenuated restraints allowing excess motion and subsequent pain. Mechanical laxity should be clinically detectable by the standard anterior drawer test, though the reliability and specific diagnostic criteria of mechanical instability are controversial. Stress radiography can be helpful though factors such as positioning, quantity of stress applied, pain, and guarding can lead to variable results, particularly in an acute or subacute setting. Lateral radiographic stress views revealing a forward translation of 3 mm more than the contralateral limb, or an absolute value of 10 mm forward translation generally has been accepted to indicate mechanical instability.
Clinical determination of abnormal tibiotalar (inversion) instability is correlated with injury to the CFL. The CFL is a restraint to abnormal motion of both the tibiotalar and subtalar joints, and a combination of ankle/subtalar instability may exist in the unstable ankle. Abnormal tibiotalar tilt has been variably defined as 3° to 15° more than the contralateral limb, or an absolute value of 9°, limiting radiographic exposure to the symptomatic ankle. Subtalar instability is even more difficult to diagnose and its documentation more controversial than ankle instability because the recommended 40° Broden stress view demonstrated wide variability in a study of asymptomatic, uninjured patients. Loss of parallelism of the posterior facet or more than 3 mm of translation of the talus on the calcaneus on the lateral view has been defined by some authors to indicate subtalar instability. Coexistent subtalar and tibiotalar instability has been demonstrated via stress fluoroscopy in 75% of subjects with a lateral ankle sprain.
In the mechanically unstable ankle for which peroneal strengthening and proprioceptive rehabilitation fail, anatomic repair can be done using the technique originally described by Broström. The initial description emphasized repair of the ATFL in all cases, with 30% requiring repair of the CFL. The modified technique emphasizes shortening of both the ATFL and the CFL in addition to reefing of the lateral extensor retinaculum, probably accounting for the improved results noted in recent studies. The primary advantage of this technique is the preservation of dynamic stabilizers (peroneals) with the maintenance of anatomic ligament stabilizers. Variations on this technique include advancing the ligaments through drill holes and bony troughs, the use of suture anchors and resorbable sutures, or vest-over-pants suturing of the ligaments. Absolute or relative contraindications to the Broström technique include a fixed heel varus, connective tissue disorders (Ehlers-Danlos), failed prior surgery, and severely attenuated tissue (> 10 years of tibiotalar instability).
The need for revision Broström procedures with potential augmentation of a checkrein (peroneus brevis) tendon can be more difficult when a previous anterior curvilinear exposure is used as advocated in most descriptions of the Broström procedure. Inspection of the peroneal tendons and their use for a subsequent (rare) revision technique favor a longitudinal exposure during the index procedure.
Failed ankle reconstructions generally require the addition of tendon graft (half of the peroneus brevis). Numerous techniques and modifications exist, including the Evans, Watson-Jones, and Chrisman-Snook procedures. Biomechanically, the split tendon grafts are stiffer and have less strain to failure than ligaments so that nonanatomic (nonisometric) reconstructions can result in ankle stiffness or tendon graft failure. Newer augmented reconstructions emphasize drill hole placement and tendon passage in more anatomically correct positions. Excellent results have been reported with a new technique using bone anchors and passage of the tendon outside the fibula.
Reports comparing Broström anatomic reconstructions with various checkrein procedures reveal equivalent functional results but fewer complications with the anatomic reconstructions. Currently, indications and recommendations for surgical management of a clinically unstable ankle include (1) failed complete peroneal strengthening and proprioceptive training; (2) preferred anatomic reconstruction with some variation of a Broström technique if adequate tissue exists; (3) calcaneal osteotomy for excessive heel varus; (4) augmentation with a slip of peroneus brevis tendon if there is severe attenuation of tissue or ligamentous laxity, obesity, high demand, or failed prior anatomic reconstruction.
Subtalar instability is most often treated with the Chrisman-Snook procedure. Other reports indicate satisfactory results with the Broström alone, or reconstruction of the interosseous ligament. Though no consensus exists, it appears that the simple Evans procedure is not as effective because the reconstructed ligament is oriented parallel to and does not cross the subtalar joint.
Injury to the ankle syndesmosis is usually associated with a combined external rotation and dorsiflexion stress. Severe injuries with associated fibular fractures and deltoid injury will be detected on radiographs, but there should be a high index of suspicion for syndesmotic injury when severe pain is associated with "normal" radiographs. If there is pain with external rotation of the ankle or when squeezing the calf several centimeters proximal to the syndesmosis, stress radiographs are warranted if the initial studies are normal. Closed treatment of syndesmotic injury without fracture is reserved for stable sprains; unstable injuries demonstrated by radiographs or stress views may be fixed with 4.5-mm cortical screws. The use of bioabsorbable fixation, weight-bearing restrictions, and the necessity of implant removal are controversial options.
Prolonged recovery time after syndesmotic injury is common and the term "high ankle sprain" can be useful in communication to trainers and coaches who quickly learn that this injury is more serious than the common ankle sprain. Protection in a functional brace and avoidance of weight bearing and functional rehabilitation until the ankle is pain-free are important to avoid prolonged recovery time.
Chronic pain after syndesmotic injury may indicate subtle instability, heterotopic ossification, or a softtissue impingement described in the recent arthroscopic literature. Bone scans, repeat radiographs, stress radiographs, CT scans, and selective injection can help determine a treatable cause for chronic symptoms.
Sprains of the midfoot can occur as isolated injuries but are usually associated with tarsal or tarsometatarsal (Lisfranc) fractures. Clinical examination includes provocative side-to-side midfoot compression and dorsoplantar stress of the first and second tarsometatarsal joints. Marked pain may indicate the need for weight-bearing radiographs to evaluate the alignment of the metatarsals with the respective cuneiforms and cuboid on the oblique view. Diastasis of the first or second tarsometatarsal joints of more than 2 mm should be reduced and fixed. Non-weight-bearing films might not demonstrate the instability, but excessive pain may prohibit weight-bearing radiographs from being taken. A bone scan may document a major injury to the midfoot when weight-bearing radiographs are negative. Protected weight bearing and rapidity of rehabilitation are dependent on clinical response and therefore are controversial. Medial midfoot sprains take much longer to heal than lateral sprains, and return to sports can require up to several months.
Sprains of the first metatarsophalangeal joint (turf toe) have achieved considerable attention because of the use of artificial turf on the playing surface and the involvement of well-known athletes. The mechanism of injury is an excessive dorsiflexion force frequently seen with push-off in flexible shoes while playing football. Valgus and hyperflexion injuries also have been described. Severity of injury may vary, but acute surgical treatment is rarely indicated. Radiography is necessary to rule out fractures. Treatment generally includes rest and avoidance of excessive dorsiflexion.
A thin steel prefabricated insole or a custom orthosis or orthotic insole with Morton's extension can be used for treatment. For clinically unstable or recalcitrant painful toes that require surgical treatment as a result of failed nonsurgical treatment, MRI could be used to more accurately determine the site of anatomic injury. A 50% incidence of chronic problems, including hallux valgus, hallux rigidus, and chronic pain, has been noted in the literature, reflecting the potential severity and disability resulting from this injury.
Tendon Injuries in Athletes
Sports participation by older athletes has been associated with the increased incidence of tendon injury, including inflammation (tendinitis), degeneration (tendinosis), subluxation, and rupture. The peritenon of the Achilles tendon is frequently inflamed as an overuse injury in aging runners. Peritendinitis is commonly associated with intratendon degeneration in the hypovascular zone approximately 5 cm proximal to the calcaneal insertion. Chronic thickening usually indicates intratendon rupture.
Orthotic support of mechanical abnormalities (such as cavus feet), avoidance of training errors, and stretching exercises may diminish the frequency of this condition. Treatment includes rest, nonsteroidal anti-inflammatory drugs (NSAIDs), orthotic insoles, stretching exercises, and a gradual return to activity. Recalcitrant cases can respond to longitudinal débridement of the tendon evaluated preoperatively with MRI to identify regions of intratendinous degeneration.
Insertional Achilles calcific tendinosis is commonly associated with retrocalcaneal bursitis or Haglund's deformity, although they are distinct entities. Usual nonsurgical measures include iontophoresis, heel lifts, and cushioned heel counters. Surgical treatment includes removal of the Haglund's deformity and débridement of the calcific spur. A lateral, combined medial-lateral, or a central splitting exposure has been advised.
Rupture of the Achilles tendon is usually associated with a sudden push-off movement during sporting activity in the middle-aged athlete, but may be accompanied by antecedent symptoms. Physical examination should confirm the diagnosis without the need for ancillary tests, but lateral radiographs should be obtained to exclude an avulsion of the posterosuperior calcaneal tuberosity.
Treatment options for Achilles tendon rupture are surgical or nonsurgical. Poor results of prolonged casting in plantar flexion can be attributed to immobilization and delayed weight bearing. Nonsurgical treatment with a functional brace has produced good results. Ultrasonography can be used to monitor continued apposition of Achilles tendon ends if nonsurgical management is elected. Current postoperative rehabilitation protocols emphasize early protected range of motion and weight bearing and are probably responsible for the improved results in recent surgical studies. Athletic individuals are usually advised to undergo surgical reconstruction for improved performance, quicker return to sport activity, less atrophy, better range of motion, and fewer complaints.
There are various techniques for the surgical repair of Achilles tendon rupture, but the most important factor to consider is reproduction of the dynamic resting length of the tendon so that range of motion and push-off strength are restored. Percutaneous methods are controversial because they cannot accurately appose the tendon ends to establish an anatomic resting length, and there is a reported incidence of sural nerve injury.
Delaying surgery for 7 to 10 days and applying a plaster splint may help reduce swelling and allow some organization of the "mop-ends" of torn tendon that can facilitate a restoration of the anatomic length of the repair. Immediate surgical repair is also acceptable. The plantaris tendon may be weaved through the Achilles tendon or fanned out for use as a fascial covering to prevent skin adhesions. Bulky, retained suture material may contribute to wound complications, and some surgeons prefer smaller (No. 2), absorbable sutures. Either absorbable or nonabsorbable suture technique is justified.
Much of the favorable results of surgical treatment can be attributed to more aggressive rehabilitation emphasizing early range of motion, weight bearing, and conditioning.
Attritional tears of the peroneus longus and brevis tendons have been reported, but athletic injury to the tendons primarily consists of tendinitis and subluxation. Tendinitis usually responds to nonsurgical measures such as use of lateral heel wedges, peroneal strengthening, and protection with a stirrup brace. Traumatic peroneal tendon subluxation is usually associated with a forceful reflex contraction of the peroneals when the ankle is dorsiflexed and inverted. Skiing, basketball, soccer, and skating are most commonly associated with this injury.
The anatomic restraint to peroneal subluxation is the superior peroneal retinaculum. Traumatic injury involves an avulsion of this structure that may result in a rim of bone evident on plain radiographs. Nonsurgical treatment includes cast immobilization, but acute surgical stabilization of an avulsed cortical rim is another option. Symptomatic chronic peroneal tendon subluxation may be treated by reefing the superior peroneal retinaculum, fibular groove deepening, creation of soft-tissue slings, or bony block reconstruction. The simplicity and efficiency of groove deepening procedures contribute to the increasing popularity of this technique.
Chronic tendinitis or recurrent subluxation may result in attritional peroneus longus or brevis tears that are diagnosed primarily by localized physical findings in the retrofibular groove. Tears in either tendon can be found at surgery despite reports of a normal MRI study. Persistent symptoms warrant surgical intervention with resection of small longitudinal tears, and tubularization of multiple tears with an absorbable suture. Tenodesis to the adjacent tendon may be necessary if severe tendon degeneration or rupture is present.
Flexor Hallucis Longus Tendon
The flexor hallucis longus (FHL) tendon is principally injured in dancers as a result of repetitive push-off of the forefoot, particularly during en pointe and demipointe positions. Because the tendon is constricted at the fibroosseous tunnel at the medial aspect of the calcaneus under the sustentaculum tali, this condition can be confused with either posterior tibial tendinitis or Achilles tendinitis. Diagnosis is determined clinically. With the ankle in dorsiflexion, the FHL muscle belly may be constricted by the sheath, resulting in limited dorsiflexion of the hallux (functional hallux rigidus). Increased dorsiflexion of the hallux and lessened pain are experienced during ankle plantar flexion. Treatment is with medial surgical release for refractory cases.
Impingement Syndromes in the Athlete
The tibiotalar joint is a frequent site of anterior impingement for dancers, basketball players, runners, catchers, and aging "weekend warriors" with a history of recurrent ankle sprains. Osteophytes on the anterior tibial lip are classified as type I; talar osteophyte as type II; and type III is a combination of talar and tibial osteophytes. Diagnosis is confirmed with limited dorsiflexion, pain with forced dorsiflexion, and radiographic imaging of spur formation. Heel lifts, NSAIDs, and avoidance of excessive dorsiflexion constitute nonsurgical treatment. Surgical treatment involves either arthroscopic or open débridement. Inadequate débridement is the primary cause of failed surgical treatment.
Anterolateral soft-tissue impingement of the ankle is commonly seen as a result of repetitive ankle injury. A hyalinized connective tissue lesion in the anterolateral gutter has been referred to as the meniscoid lesion. Three primary sites of origin of soft-tissue impingement of the anterolateral gutter are the superior portion of the anteroinferior tibiofibular ligament (AITF); distal AITF including a separate slip (Basset's ligament); and the ATFL. A high success rate has been reported for arthroscopic treatment of anterolateral impingement of the ankle.
Posterior impingement syndrome involves impaction of the os trigonum and/or posterior capsular structures between the tibia and calcaneus. This condition is most commonly seen in ballet dancers (nutcracker effect), but also is seen in kickers and soccer players. The potential association of FHL tendinitis with posterior impingement syndrome may alter surgical treatment. Surgical resection of the os trigonum can be performed by the medial or lateral approach whereas release of the FHL tendon can only be performed from the medial approach. An os trigonum can be excised via subtalar arthroscopy or an open medial or lateral approach.
Ankle and Pilon Fractures
Barrett JA, Baron JA, Karagas MR, Beach ML: Fracture risk in the U.S. Medicare population. J Clin Epidemiol 1999;52:243-249.
Using Medicare data of people between 65 and 90 years old in the United States, this study demonstrated that ankle fractures were the fourth most common fracture in this population. Between the ages of 65 and 90 years, the actuarial risk for ankle fracture was 3.9% for white women, 1.3% for white men, 2.4% for African-American women, and 0.9% for African-American men.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.
Surgical treatment of 21 ankle fractures in diabetic patients resulted in a 43% complication rate compared with a 15% complication rate in a control group of nondiabetic patients (P < 0.05). The complications in diabetic patients were more severe, including seven infections, three fixation failures, and two below-knee amputations.
Flynn JM, Rodriguez-del Rio F, Piza PA: Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000;21:311-319.
In a comparative study of ankle fracture treatment complications in 25 diabetic and 73 nondiabetic patients, the rate of infection after surgery was two times higher in the diabetic patients (21% vs. 9%), but the risk of infection in diabetic patients was even higher with nonsurgical treatment. Overall, the major risk factor for infection in diabetic patients was closed reduction and immobilization, both when compared with nondiabetic patients treated surgically or nonsurgically, and to diabetic patients treated surgically.
Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A: Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 2000;82:345-351.
In 288 surgically treated ankle fractures, initial arthroscopy was used to determine the existence of cartilage injury. Although most ankles demonstrated some cartilage damage (70% of tali, 40% to 45% of plafonds/malleoli), less than 10% had injury extending beyond 50% of the cartilage thickness, and none had full-thickness losses.
Jensen SL, Andresen BK, Mencke S, Nielsen PT: Epidemiology of ankle fractures: A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand 1998;69:48-50.
In a 1-year prospective study in Denmark, the incidence of ankle fracture was 107 per 105 person-years. At age 40 years or younger, men were twice as likely to have a fracture as women, but the fracture incidence in women equaled or exceeded that of men after age 45 years.
Kennedy JG, Johnson SM, Collins AL, et al: An evaluation of the Weber classification of ankle fractures. Injury 1998;29:577-580.
In a retrospective study of 96 patients with a minimum of 3 years follow-up, the Weber classification system for ankle fractures was not prognostic for the ultimate clinical results. The most significant predictors of a poor outcome were severe initial displacement, inadequate reduction, and more than one fractured malleolus.
Flemister AS Jr, Infante AF, Sanders RW, Walling AK: Subtalar arthrodesis for complications of intra-articular calcaneal fractures. Foot Ankle Int 2000;21:392.
A comparison between patients with calcaneal malunion, failed open reduction and internal fixation, and primary fusion in 86 subtalar fusions is presented.
Folk JW, Starr AJ, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma 1999;13:369-372.
Smoking, diabetes, and open fractures all increase the risk of wound complications after surgical treatment of calcaneal fractures. Risk factors are cumulative.
Metzger MJ, Levin JS, Clancy JT: Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg 1999;38:154-162.
An extensive literature review on talar neck fractures and rates of avascular necrosis is presented.
Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
This article presents a current concepts review of calcaneal fractures.
Thermann H, Krettek C, Hufner T, Schratt HE, Albrecht K, Tscherne H: Management of calcaneal fractures in adults: Conservative versus operative treatment. Clin Orthop 1998;353:107-124.
The best surgical results occur with anatomic reconstruction and function-directed postoperative management.
Tornetta P III: The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma 1998;12:469-473.
The Essex-Lopresti spike reduction is a useful method for the treatment of tongue-type Sanders IIC fractures of the calcaneus. Results are superior to those in previous series of intra-articular fractures treated with open reduction and internal fixation.
Tucker DJ, Feder JM, Boylan JP: Fractures of the lateral process of the talus: Two case reports and a comprehensive literature review. Foot Ankle Int 1998;19:641-646.
To achieve the best possible result, early diagnosis and treatment are emphasized.
Midfoot and Forefoot Trauma
Berlet G, Anderson R, Davis WH: Tendon arthroplasty for basal 4th and 5th metatarsal arthritis. 67th Annual Meeting Proceedings. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 489.
Coss HS, Manos RE, Buoncristiani A, Mills WJ: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int 1998;19:537-541.
This article presents a study of Lisfranc joint stability with abduction stress and simulated weight-bearing radiographs in cadavers before and after Lisfranc ligament sectioning compared with healthy volunteer controls.
Dhillon MS, Nagi ON: Total dislocations of the navicular: Are they ever isolated injuries? J Bone Joint Surg Br 1999;81:881-885.
This article presents a study of six cases of navicular dislocation without fracture but with complex ligamentous disruption. Instability of the medial and lateral columns of the foot were found, with a navicular dislocation necessitating stabilization of both columns.
Sports Injuries of the Foot and Ankle
Angermann P, Hovgaard D: Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot Ankle Int 1999;20:304-306.
Two thirds of athletes were improved or cured with long-term follow-up after nonsurgical treatment of chronic Achilles tendinopathy.
Dixon DJ, Monroe MT, Gabel SJ, Manoli A II: Excrescent lesion: A diagnosis of lateral talar exostosis in chronically symptomatic sprained ankles. Foot Ankle Int 1999;20:331-336.
The authors describe an anterolateral exostosis at the insertion of the ATFL in stable ankles with chronic pain. Diagnosis was confirmed with CT scan. Surgical excision resulted in laxity of the ATFL, which required a Brostöm reconstruction.
Frey C, Feder KS, DiGiovanni C: Arthroscopic evaluation of the subtalar joint: Does sinus tarsi syndrome exist? Foot Ankle Int 1999;20:185-191.
The authors' preoperative diagnosis of sinus tarsi syndrome was changed in all cases; 10 of 14 patients had interosseous ligament tears. Arthroscopy led to a more accurate diagnosis, and good to excellent results were reported in 94% of cases.
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC: Persistent disability associated with ankle sprains: A prospective examination of an athletic population. Foot Ankle Int 1998;19:653-660.
Early return to sports following ankle sprains is common, but approximately 40% of patients have dysfunction at 6 months. Syndesmosis sprains are more common than previously appreciated and this is the factor most predictive of residual symptoms.
Girard P, Anderson RB, Davis WH, Isear JA, Kiebzak GM: Clinical evaluation of the modified Broström-Evans procedure to restore ankle stability. Foot Ankle Int 1999;20:246-252.
Simple augmentation of the Broström repair with a portion of the peroneus brevis tendon is advised in overweight, hyperflexible patients or those involved in strenuous or athletic activity. Postoperatively, the average American Orthopaedic Foot and Ankle Association hindfoot score was 98 points, with no complications reported.
Hertel J, Denegar CR, Monroe MM, Stokes WL: Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc 1999;31:1501-1508.
This article discusses the coexistence of subtalar and tibiotalar instability following lateral ankle sprains. A good discussion of the evaluation of subtalar instability is provided.
Lahm A, Erggelet C, Reichelt A: Ankle joint arthroscopy for meniscoid lesions in athletes. Arthroscopy 1998;14:572-575.
The meniscoid lesion may be underdiagnosed, but is effectively treated with early arthroscopic resection.
Mortensen HM, Skov O, Jensen PE: Early motion of the ankle after operative treatment of a rupture of the Achilles tendon: A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am 1999;81:983-990.
Early restricted motion shortens the time for rehabilitation and was not associated with tendon elongation or an increased incidence of complications.
Povacz P, Unger SF, Miller WK, Tockner R, Resch H: A randomized, prospective study of operative and non-operative treatment of injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg Am 1998;80:345-351.
Nonsurgical treatment of ankle sprains yielded results similar to surgical repair, and is associated with a shorter period of recovery. Therefore, nonsurgical treatment was advised for all patients, including athletes.
Sammarco GJ, Idusuyi OB: Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Foot Ankle Int 1999;20:97-103.
Bone anchors are used for a simpler, more anatomic reconstruction with a split peroneus brevis tendon. Results were 94% good to excellent, with 97% mechanical stability.
Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA: The prevention of ankle sprains in sports: A systematic review of the literature. Am J Sports Med 1999;27:753-760.
The most common risk factor for ankle sprains in sports is a history of prior sprains. Braces do not interfere with athletic performance, and a moderate or severe sprain may be braced for at least 6 months for athletic participation.
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