Category Archives: Uncategorized

June 2016

9 (2), 2016


Modified Scarf osteotomy for treatment of hallux valgus
by Saad R. El Ashry, M. S. Sidhu, Abhay Tillu


Lisfranc-like injury involving lateral tarsometatarsal joints: a case report
by Mir Tariq Altaf, Muhammad Haseeb, Varun Narula, Aakash Pandita


Postoperative analgesic efficacy of dexamethasone sodium phosphate versus triamcinolone acetonide in bunionectomy: A prospective, single-blinded pilot randomized controlled trial
by Chris Olivia Ongzalima, Wei Lin Renee Lee, Anh Hoang, Ming Yi Wong, Reza Naraghi


Does shoe midsole temperature affect patellofemoral and Achilles tendon kinetics during running?
by Sinclair J, Atkins S, Shore H


Form determines function: Forgotten application to the human foot?
by Mick Wilkinson, PhD and Lee Saxby, BSc


Lateral and open medial subtalar dislocation: Report of two uncommon cases
by Ganesh Singh Dharmshaktu, Irfan Khan


Steroid intra-articular injections for foot and ankle conditions: How effective are they?
by Mohammed KM Ali, Suhayl Tafazal, CA Mbah, D Sunderamoorthy


Effects of energy boost and springblade footwear on knee and ankle loads in recreational runners
by Jonathan Sinclair


Longitudinal Arch Angle (LAA): Inter-rater reliability comparing Relaxed Calcaneal Stance with Toe Off
by Edward S. Glaser DPM, Stephen Goodman MS, David Fleming BS, Misty Shelby cPed, Raymond Lovato cPed, Eric Tidwell cPed


Longitudinal Arch Angle (LAA): Inter-rater reliability comparing Relaxed Calcaneal Stance with Toe Off

by Edward S. Glaser DPM1, Stephen Goodman MS2, David Fleming BS2*, Misty Shelby cPed2, Raymond Lovato cPed2, Eric Tidwell cPed2pdflrg

The Foot and Ankle Online Journal 9 (2): 9

Purpose:  The purpose of this study is to determine the inter-rater reliability of the LAA taken at the bottom of the foot’s postural range of motion RCSP(Relaxed Calcaneal Stance Posture) as compared with the LAA when the foot is in a toe off posture at forty degrees of heel elevation.
Design:   An investigation into a new technique for capturing Longitudinal Arch Angle in patients.
Samples:  Subjects submitted voluntarily from a heterogeneous sampling of factory workers in rural Tennessee.
Methods:  LAA captured in RCSP and toe off posture using the iOS LAAngle™ App
Main Outcome Measures:  We measured the LAA of 85 sets of feet with the iOS App to obtain the LAA in RCSP and Toe off conditions.
Results:  The IntraClass  Correlation Coefficient (2,1) was 0.7 for RCSP and Toe off.  This was across an age range of 17 to 68 years with 50 male and 35 female subjects.
Conclusions: The  iOS LAAngle™ App is an efficient and reliable method for calculating a patient’s LAA.
Key words: Longitudinal Arch Angle, Foot Posture, MASS Posture,  biomechanics

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0009

1 – Founder and CEO of  Sole Supports, Inc.
2 – Sole Supports, Inc.
* Corresponding author: dfleming@solesupports.com


The measurements of static foot positions and motions recommended by Root, Orien and Weed in the static biomechanical examination [1] have been brought into question by several authors. Van Gehluwe et al showed that the inter rater reliability of these measurements was poor [2]. Fifteen of the seventeen measurements demonstrated an inter rater reliability of 0.5 and the remaining two had 0.6 which was still insignificantly clinically.

Additionally McPoil et al studied the relationship of the static biomechanical examination values in relation to calcaneal eversion angles taken in gait as measured with a motion analysis system and found that the values measured in the static biomechanical examination proposed by Root et al did not correlate with dynamic foot function [3]. Measurements of Radiographs have also been used to evaluate the foot biomechanically but these images are taken with the foot in angle and base of gait with the foot in its relaxed calcaneal stance posture [4]. They therefore may give the clinician information on the extent of over pronation that is possible when the foot fully collapses but tell us nothing about the corrected posture.

They do have some value in determining pre-operative collapse as compared to post-operative correction but fail to give any information regarding the extent of correction that is either possible or ideal. We were unable to find a study that supports a test that gives the clinician any information as to how much postural correction is possible with a custom molded prescription foot orthotic.

Donatelli proposed a measurement of the angle between the medial malleolus, the navicular tubercle, and the medial aspect of the first MTP joint [5].  Jonson et al studied a similar angle in young healthy Navy subjects.  In this study, dots were made on the center of the medial malleolus, medial prominence of the navicular bone and medial head of the first metatarsal head.  The angle was measured manually with a goniometer with the patient in the relaxed calcaneal stance posture.  Again, the bottom of the postural range of motion of the foot, was tested giving the clinician no indication as to how much postural correction is possible.  They demonstrated a high inter and intra-rater reliability (0.81) and the test yielded almost identical results of both right and left feet.  Although, they stated their sampling was of relatively lean and physically fit young males with easy to identify boney prominences, subjects from a specific geographical region [6].

McPoil and Cornwell did further testing to determine the correlation of this angle between static stance and walking [7], and showed that the relaxed calcaneal stance posture LAA correlated 90% to the same angle measured at the lowest posture achieved during walking.  McPoil and Cornwell went on to compare this fully collapsed LAA between standing and running and found approximately an 85% correlation[8].  The LAA was further studied by Heidi Burn et al who concluded that the “LAA is been shown to be a good static measure for dynamic foot function and can reliably be implemented in a normal clinical environment to evaluate and assess the efficacy of the prescribed foot orthoses” [9]. Again, the LAA was only tested in its fully pronated or maximally collapsed posture.

We propose an exact protocol for measurement and introduce an iOS App to measure the LAA that may improve the accuracy of this test.  Additionally, the LAA is measured in two different postures.  The relaxed calcaneal stance posture LAA is compared to the LAA when measured at 40 degrees of rear foot elevation.  This angle was selected because it closely approximates MASS posture, as defined by Glaser et al as the Maximal Arch Supination Stabilization Posture which is the most elevated posture the foot can attain at midstance with the heel and forefoot in full contact with the supporting surface with the soft tissues evenly compressed.  Glaser proposes this posture as a corrective geometry for a calibrated leaf spring to apply an equal and opposite range of forces to those imposed by the body during the gait cycle.  Glaser has theorized that this shape leaf spring may assist the foot in resisting the repetitive downward forces of walking and aid the foot in achieving a more functional posture for propulsion and thereby alleviate many foot symptoms and possibly reverse some deformity of the foot as well as improve the passage of center of pressure through the foot during gait.

Higbie et al demonstrated that foot orthotics made in MASS posture initially transferred 44% more force to the first metatarsal head at toe off than any orthotic previously tested at Georgia State University and at 6 weeks the improvement over previous technologies measured 61% [10].  Cobb et al demonstrated a significant improvement in postural sway (movement of the body’s center of gravity from right to left) in patients with greater than 7 degrees of forefoot varus [11].  Piernowski and Trotter tested the inter and intra-rater reliability of the casting with Canadian cPeds.  They found intra-rater reliability to be significantly improved with MASS Posture casting technique [12].  Piernowski and Trotter also tested the Biomechanical Efficiency Quotient(BEQ) on patients wearing MASS posture orthotics and found significant improvements in BEQ using MASS Posture [13] which correlated to patient outcomes in a separate paper [14].  Garbalosa et al showed that foot orthoses that incorporate total contact and direct support of the medial longitudinal arch are clinically significant in their effect on the kinematics of the foot as well as their ability to reduce painful symptoms of the lower extremity [15].

Materials and Methods

Eighty-Five subjects were selected for the study.  Due to the non-invasive nature of the measurements taken no Human Subjects committee approval was deemed necessary but each patient did sign an informed consent form.  Subjects did not receive payment for their participation.   Patients with previous surgical correction were eliminated.  There was 85 subjects total, 50 were male and 35 female and ranged in age from 17 to 68 years with a mean age of 40.7 years.  Three certified pedorthists performed the testing.  A pilot study was performed to determine the protocol.  The testers and authors met to approve final protocol.  An App was written to capture the LAA in real time with automatic capture at the lowest posture of the foot:  Relaxed calcaneal stance posture and the posture the foot will attain at a 40 degree angle between the plane of the plantar aspect of the foot and the ground.  The following protocol for capturing the LAA was used in this experiment:

Figure 1

Figure 1  iOS scanning setup with green adhesive dots placed on key areas. Subjects foot placed in Relaxed Calcaneal Stance Position.

Figure 2

Figure 2  “Mask” mode of LAAngle™ App to set contrast.

  • Green adhesive dots were placed on the center of the medial malleolus and center of the navicular tuberosity off weight bearing.  
  • The patient places the foot on the ground in heel to toe fashion.
  • Dots on the medial aspect of the first metatarsal head and heel are placed parallel to the supporting surface (Figure 1).
  • The IOS camera is positioned approximately 45cm from the foot with the device parallel to the medial aspect of the foot (Figure 1).
  • “Mask” or adjust contrast until only the dots are visible (Figure 2).
  • Select Capture Mode or “Cap”.
  • The patient shifts to full weight bearing onto the foot being measured.
  • Hips and knees positioned in frontal plane with the distal tips of contralateral toes touching the supporting surface.
  • Examiner stabilized knee vertically.
  • Relaxed Calcaneal Stance LAA was recorded automatically by the LAAngle™ app.
  • Subject body weight shifted posteriorly onto opposite foot while lifting the foot into toe off.
  • Heel elevation of 40 degrees LAA was recorded automatically by the LAAngle™ app.
  • The procedure was repeated with the contralateral foot.

Each test was repeated independently and single blind with three different examiners.  Each examiner placed the dots independently and did all recording without knowledge of prior findings.  Examinations were performed consecutively on the same visit.

Data Analysis

Interexaminer reliability were documented for the research subjects by calculating the mean absolute difference and standard deviation between paired measurements for ratio data.  Intraclass correlation coefficient [ICC(2,1)] version of the ICC was used to enable abstraction to other examiners.  Standard deviations, ranges, and mean values for males and females were calculated for each of the variables measured.

Results

Descriptive statistics for the subjects appear in Table 1.  Table 2 lists inter examiner mean absolute differences for measurement variables.   Interexaminer reliability ICC(2,1) values for subject measurement variables are presented in Table 3.  Relaxed Calcaneal Stance Position and forty degree Heel Off reliabilities ICC(2,1) were calculated via the proposed protocol utilizing the LAAngle™ App.  Table 4 lists the mean, standard deviation, and range of all subjects left and right feet absolute values for the measurement variables.

Table 1

Table 1 Descriptive statistics for male and female subjects.

The subjects consisted of fifty (50) male and thirty-five (35) female with an average age of 40.59 years with a standard deviation of 13.06, and a range of 17 to 68 years.  Average height of the subjects was 173.59cm with a standard deviation of 10.48, and a range of 154.94cm to 200.66cm.  Average weight of the subjects was 883.47N with a standard deviation of 221.54, and a range of 467.06N to 1556.88N.

Table 2

Table 2 Interexaminer mean absolute difference for subject measurement variables (N=85).

Average absolute difference between the examiners across all subjects was 8.64° with a standard deviation of 4.35 for the relaxed calcaneal stance position of the left foot, for the right foot the difference was 8.05° with a standard deviation of 4.45.  The 40° Toe off position average absolute difference was 8.08⁰ with a standard deviation of 4.35 for the left foot, right foot had an average of 9.46° with a standard deviation of 4.95.

Table 3

Table 3 Interexaminer reliability ICC(2,1) for subject measurement variables (N=85).

The Inter rater reliability for the LAA test as collected with the iOS LAAngle™ App showed that the Intraclass correlation coefficient [ICC(2,1)] in measurements of the same subject between the three examiners was 0.70 using the described protocol across all feet and genders.  The right foot had an ICC(2,1) of 0.71 for RCSP and 0.66 for 40° Heel Off.  The left foot had an ICC(2,1) of 0.70 for RCSP and .74 for 40° Heel Off.

Table 4

Table 4 Mean values, standard deviations, and ranges for subject measurement variable means (N=85).

The Average measurement values across all subjects and all feet for RCSP was 144.97° with a standard deviation of 8.93, and a range of 127.03° to 168.07°.  The average measurement values across all subjects and all feet for 40° Toe Off was 166.07° with a standard deviation of 9.35, and a range of 139.26° to 184.66°.

Discussion

The subjects came from a diverse sampling of male and female with varying heights, weights, and ages.  The majority of the subjects were born and spend most of their time in Tennessee.  The relatively heterogeneous sample supports the generalizability of the results to other populations.   Additionally, the subjects were of varying body types.  Bony prominences, therefore, may have been palpated with more or less difficulty in this sample than in other samples or populations.

The authors present a clinical test to determine the amount of postural correction possible in each patient reliably and repeatedly by determining the LAA with the foot in RCSP and toe off postures.  This fast and simple examination tool can be used in a clinical setting to determine whether or not a patient will benefit from a prescribed custom foot orthotic.  It can also be used to determine the extent of correction possible.   This affords the practitioner the ability to present third parties with justification for the use of prescription foot orthoses as well as complete documentation.

The reasoning for utilizing custom foot orthoses is that the patient’s foot posture was collapsed to a measurable quantity, the LAA.  The correction of this same foot can be achieved to the anatomical limit as determined by the measurable quantity; the LAA at 40 degrees.  Based on the results of this study, it is further postulated that the clinician or patient can use this test as stated by Heidi Burn et al to “reliably be implemented in a normal clinical environment to evaluate and assess the efficacy of prescribed foot orthoses” [9].  Meaning; the iOS LAAngle™ App can be used as a test to evaluate and assess the efficacy of current and future foot orthoses for the patient.  The degree to which custom prescribed foot orthoses can correct posture can be determined utilizing the LAAngle™ App.

Conclusion

Foot posture can be measured using the LAA and is made easier, faster, and with reliability with the iOS LAAngle™ App.  Since postural collapse, whether attributed to single axis rotation or all axis movement, is responsible for the development of many foot ailments, injuries and deformities seen in clinical practice, it is advisable to take a baseline measurement of LAA in both RCSP and elevated postures and calculate the difference in these postures in a reliable repeatable fashion for most patients with biomechanical related diagnoses.  In this way the clinician can determine the extent to which postural collapse may contribute to the patients’ disease and the extent that postural collapse can be corrected with a custom foot orthotic or surgical procedure.

Additional research is needed to determine if the change in LAA can predict the formation of foot deformity and predict the occurrence of overuse injury, plantar fasciitis, and other symptomatic conditions of the foot, ankle, knee, hip and back as well as prevent injury.

Acknowledgements  

Thanks to the employees of Sole Supports, Inc. for being subjects of the study, Sole Supports, Inc. for funding the study.

References

  1. Root M. Biomechanical examination of the foot. J Am Podiatr Med Assoc 1973;63(1):28–29. doi:10.7547/87507315-63-1-28.
  2. Gheluwe BV, Kirby KA, Roosen P, Phillips RD. Reliability and accuracy of biomechanical measurements of the lower extremities. J Am Podiatr Med Assoc 2002;92(6):317–326. doi:10.7547/87507315-92-6-317.
  3. Mcpoil TG, Hunt GC. Evaluation and management of foot and ankle disorders: present problems and future directions. J Orthop Sports Phys Ther 1995;21(6):381–388. doi:10.2519/jospt.1995.21.6.381.
  4. Bryant A, Tinley P, Singer K. A comparison of radiographic measurements in normal, hallux valgus, and hallux limitus feet. J Foot Ankle Surg 2000;39(1):39–43. doi:10.1016/s1067-2516(00)80062-9.
  5. Donatelli R. The biomechanics of the foot and ankle. Philadelphia: F.A. Davis; 1996.
  6. Jonson LSR, Gross MT. Intraexaminer reliability, interexaminer reliability, and mean values for nine lower extremity skeletal measures in healthy naval midshipmen. J Orthop Sports Phys Ther 1997;25(4):253–263. doi:10.2519/jospt.1997.25.4.253.
  7. Mcpoil TG, Cornwall MW. Use of the longitudinal arch angle to predict dynamic foot posture in walking. J Am Podiatr Med Assoc 2005;95(2):114–120. doi:10.7547/0950114.
  8. Mcpoil TG, Cornwall MW. Prediction of dynamic foot posture during running using the longitudinal arch angle. J Am Podiatr Med Assoc 2007;97(2):102–107. doi:10.7547/0970102.
  9. Burn H, Branthwaite H, Chockalingam N, Chevalier TL, Naemi R. Do foot orthoses replicate the static longitudinal arch angle during midstance in walking? The Foot 2011;21(3):129–132. doi:10.1016/j.foot.2010.12.004.
  10. Hodgson B, Tis L, Cobb S, McCarthy S, Higbie E. The effect of two custom molded orthotics on plantar pressure. J Sport Rehabil. 2006;15(1):33–44.
  11. Cobb SC, Tis LL, Johnson JT. The effect of 6 weeks of custom-molded foot orthosis intervention on postural stability in participants with ≥7 degrees of forefoot varus. Clin J Sport Med 2006;16(4):316–322. doi:10.1097/00042752-200607000-00006
  12. Trotter LC, Pierrynowski MR. Ability of foot care professionals to cast feet using the nonweightbearing plaster and the gait-referenced foam casting techniques.  J Am Podiatr Med Assoc 2008;98(1):14–18. doi:10.7547/0980014.
  13. Trotter LC, Pierrynowski MR. Changes in gait economy between full-contact custom-made foot orthoses and prefabricated inserts in patients with musculoskeletal pain.  J Am Podiatr Med Assoc 2008;98(6):429–435. doi:10.7547/0980429.
  14. Trotter LC, Pierrynowski MR. Changes in gait economy between full-contact custom-made foot orthoses and prefabricated inserts in patients with musculoskeletal pain. J Am Podiatr Med Assoc 2008;98(6):429–435. doi:10.7547/0980429.
  15. Elliott B, Garbalosa J.  The effect of maximum arch subtalar stabilization on flexible flat feet during normal walking: a case report.   Poster session presented at: Annual Fall Conference.  1st Annual  Conference of the Connecticut Physical Therapy Association; 2013; New Haven, Connecticut.

Effects of energy boost and springblade footwear on knee and ankle loads in recreational runners

by Jonathan Sinclair1pdflrg

The Foot and Ankle Online Journal 9 (2): 8

The aim of the current investigation was to comparatively examine the effects of conventional, energy boost and spring footwear on the loads experienced by the patellofemoral joint and Achilles tendon during running. Ten male runners underwent 3D running analysis at 4.0 m/s. Patellofemoral joint and Achilles tendon loads were quantified using a musculoskeletal modelling approach and contrasted between footwear using one-way repeated measures ANOVA. The results showed that peak patellofemoral force and pressure were significantly greater in conventional (force = 31.72 N/kg & pressure = 10.05 MPa) footwear in relation to energy boost (27.80 N/kg & pressure = 9.02 MPa). In addition peak Achilles tendon force was shown to be significantly greater in conventional (54.98 N/kg) compared to springblade (49.92 N/kg) footwear. On the basis that peak patellofemoral and Achilles tendon forces were significantly greater when running in conventional footwear, the findings from the current investigation indicate that utilization of conventional running footwear may place runners at increased risk from knee and ankle pathologies in comparison to energy boost and springblade shoe conditions.

Key words: springblade footwear, knee loads, ankle loads, running

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0008

1 – Centre for Applied Sport and Exercise Sciences, School of Sport and Wellbeing, College of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK.
* Corresponding author: jksinclair@uclan.ac.uk


Recreational runners are renowned for their susceptibility to chronic injuries; as many as 80 % of all who participate in running activities will suffer from a chronic pathology over the course of one year [1]. The structures of the knee and ankle joints are the most common injury sites and have been shown to be associated with one-fifth of running-related injuries [1].

Given their high susceptibility to injuries, runners and clinicians/ researchers have investigated a number of different strategies which aim to attenuate the risk of injury. One such strategy is to select running footwear with appropriate mechanical characteristics; the properties of athletic footwear have been linked to the prevention of running injuries and improvement of performance and have thus been extensively investigated in biomechanical/ clinical literature.

In recent years the concept of energy return has been of interest to the footwear biomechanics community. The first footwear to incorporate the energy return principle into their design were the energy boost concept designed by Adidas. These footwear utilize an expanded thermoplastic polyurethane midsole designed to be more compliant and associated with reduced energy loss in comparison to traditional footwear midsoles. There has been only limited published research which has investigated the biomechanics of the energy boost footwear. Sinclair et al [2] examined the kinetics and kinematics of running in conventional and energy return footwear. Their findings showed that the energy boost shoes were associated with significantly increased tibial accelerations and peak eversion angles. Both Woborets et al [3] and Sinclair et al [4] showed that energy boost footwear were able to improve treadmill running economy in comparison to conventional running shoes. In addition Sinclair et al [5] demonstrated that the energy boost footwear improved running economy and reduced the bodies’ reliance on carbohydrate as a fuel source compared to minimalist footwear. In addition to the energy boost footwear a further footwear design the springblade has been introduced by Adidas which also aims to improve energy return through 16 curved blades designed to compress and release energy with each footstrike. There has yet to be any published research concerning the biomechanics of the springblade footwear, nor has there been any investigations examining knee and ankle loading in energy return footwear. Given the high incidence of knee and ankle pathologies in runners and the popularity of these new footwear models research of this nature would be of both practical and clinical significance.

Therefore, the aim of the current investigation was to comparatively examine the effects of conventional, energy boost and spring footwear on the loads experienced by the patellofemoral joint and Achilles tendon during running. Given the high incidence of knee and ankle pathologies in runners, a study of this nature may provide important clinical information to runners regarding the selection of appropriate footwear.

Methods

Participants

Ten male participants volunteered to take part in the current investigation. The mean ± SD characteristics of the participants were; age 23.59 ± 2.00 years, height 177.05 ± 4.58 cm and body mass 77.54 ± 5.47 kg. All were free from musculoskeletal pathology at the time of data collection and provided written informed consent. The procedure utilized for this investigation was approved by the University of Central Lancashire, ethical committee in accordance with the principles outlined in the Declaration of Helsinki.

Procedure

The runners completed five successful trials in which they ran through a 22 m walkway at an average velocity of 4.0 m/s in each running shoe condition. The participants struck an embedded piezoelectric force platform (Kistler Instruments) with their right foot [6]. The force platform was collected with a frequency of 1000 Hz. Running velocity was controlled using timing gates (SmartSpeed Ltd UK) and a maximum deviation of 5% from the pre-determined velocity was allowed. Kinematic information from the stance phase of the running cycle were obtained using an eight camera motion capture system (Qualisys Medical AB, Goteburg, Sweden) with a capture frequency of 250 Hz. The order in which participants performed in each footwear condition was counterbalanced. The stance phase was delineated as the duration over which > 20 N of vertical force was applied to the force platform.

Lower extremity segments were modelled in 6 degrees of freedom using the calibrated anatomical systems technique [7]. To define the segment co-ordinate axes of the foot, shank and thigh, retroreflective markers were placed bilaterally onto 1st metatarsal, 5th metatarsal, calcaneus, medial and lateral malleoli, medial and lateral epicondyles of the femur. To define the pelvis segment further markers were posited onto the anterior (ASIS) and posterior (PSIS) superior iliac spines. Carbon fiber tracking clusters were positioned onto the shank and thigh segments. The foot was tracked using the 1st metatarsal, 5th metatarsal and calcaneus markers and the pelvis using the ASIS and PSIS markers. The centers of the ankle and knee joints were delineated as the mid-point between the malleoli and femoral epicondyle markers [8,9], whereas the hip joint centre was obtained using the positions of the ASIS markers [10]. Static calibration trials were obtained allowing for the anatomical markers to be referenced in relation to the tracking markers/ clusters.

Footwear

The footwear used during this study consisted of conventional footwear (New Balance 1260 v2), energy boost (Adidas energy boost) and spring (Adidas springblade drive 2) footwear, (shoe size 8–10 in UK men’s sizes).

Processing

Dynamic trials were digitized using Qualisys Track Manager in order to identify anatomical and tracking markers then exported as C3D files to Visual 3D (C-Motion, Germantown, MD, USA). Ground reaction force and kinematic data were smoothed using cut-off frequencies of 25 and 12 Hz with a low-pass Butterworth 4th order zero lag filter. 3D kinematics of the knee and ankle were calculated using an XYZ cardan sequence of rotations (where X = sagittal plane; Y = coronal plane and Z = transverse plane). Kinematic curves were normalized to 100% of the stance phase then processed trials were averaged. Joint kinetics were computed using Newton-Euler inverse-dynamics. To quantify net joint moment anthropometric data, ground reaction forces and angular kinematics were used.

A previously utilized musculoskeletal model was used to determine patellofemoral contact force and pressure [11]. This method has been successfully utilized to resolve differences in patellofemoral contact force and pressure when wearing different footwear [12-14]. Patellofemoral joint contact force (N/kg) during running was then estimated as a function of knee flexion angle (Kfa) and knee extensor moment (ME) according to the biomechanical model described by Ho et al [15]. Firstly, the moment arm of the quadriceps muscle (mq) was calculated as a function of knee flexion angle using non-linear equation, which is based on cadaveric information presented by van Eijden et al [16]:

mq = 0.00008 Kfa3 – 0.013 Kfa2 + 0.28 Kfa + 0.046

Quadriceps force (QF) was then calculated using the below formula:

QF = ME / mq

PTF was estimated using the QF and a constant (K):

PTF = QF K

The constant was described in relation to the fa using a curve fitting technique based on the non-linear equation described by Eijden et al [16]:

K = (0.462 + 0.00147 Kfa2 – 0.0000384 fa2) / (1 – 0.0162 Kfa + 0.000155 Kfa 2 – 0.000000698 Kfa 3)

Patellofemoral pressure (MPa) was calculated as a function of the patellofemoral contact force divided by the patellofemoral contact area. The contact area was described in accordance with the Ho et al [15] recommendations by fitting a second-order polynomial curve to the data of Powers et al [17] who documented patellofemoral contact areas at varying levels of knee flexion.

Patellofemoral pressure = patellofemoral contact force / contact area

Achilles tendon force (N/kg) was determined using a previously utilized musculoskeletal model. This model has been used previously to resolve differences in Achilles tendon force between footwear [14,18].  Achilles tendon force was quantified as the plantarflexion moment (MPF) divided by the estimated Achilles tendon moment arm (mat). The moment arm was quantified as a function of the ankle sagittal plane angle (ak) using the procedure described by Self and Paine [19]:

Achilles tendon force = MPF / mat

mat = -0.5910 + 0.08297 ak – 0.0002606 ak2

Average patellofemoral contact force and Achilles tendon load rate were quantified as the peak patellofemoral contact force / Achilles tendon force divided by the time over which the peak force occurred. Instantaneous patellofemoral/ Achilles tendon load rate were also determined as the peak increase in patellofemoral contact force/ Achilles tendon force between adjacent data points. In addition to this we also calculated the total patellofemoral contact force/ Achilles tendon force impulse (N/kg·s) during running by multiplying the patellofemoral contact force/ Achilles tendon force estimated during the stance phase by the stance time.

Analyses

Means and standard deviations were calculated for each outcome measure for all footwear conditions. Differences in Achilles tendon force and patellofemoral contact force parameters between footwear were examined using one-way repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v22.0 (SPSS Inc., Chicago, USA).

Results

Tables 1-2 and figure 1 present the knee and ankle loads during the stance phase of running, as a function of the different experimental footwear. The results indicate that footwear significantly influenced both knee and ankle kinetic parameters.

Fig1

Figure 1 Knee and ankle loads as a function of footwear; a. = Patellofemoral contact force, b. = Patellofemoral pressure, c. = Achilles tendon force (black = energy boost, grey = springblade, dash = conventional).

Conventional Energy return Spring
Mean SD Mean SD Mean SD
Peak patellofemoral contact force (N/kg) 31.72 6.37 27.80 5.70 30.17 4.73
Time to patellofemoral contact force (s) 0.09 0.01 0.08 0.01 0.08 0.01
Patellofemoral load rate (N/kg/s) 372.34 53.13 334.11 60.83 356.99 34.94
Patellofemoral instantaneous load rate (N/kg/s) 1470.35 561.44 1435.06 529.05 1532.02 372.51
patellofemoral contact force impulse (N/kg·s) 2.84 0.90 2.26 0.68 2.58 0.82
Patellofemoral pressure (MPa) 10.05 1.87 9.02 1.71 9.70 1.38

Table 1 Knee loads as a function of footwear.

Conventional Energy return Spring
Mean SD Mean SD Mean SD
Peak Achilles tendon force (N/kg) 54.98 7.73 52.40 8.50 49.92 7.21
Time to Achilles tendon force (s) 0.13 0.02 0.13 0.02 0.13 0.01
Achilles tendon load rate (N/kg/s) 449.21 110.49 436.33 138.79 381.65 88.49
Achilles tendon instantaneous load rate (N/kg/s) 1316.78 387.07 1114.70 342.44 1377.57 570.81
Achilles tendon force impulse (N/kg·s) 6.23 1.26 5.82 1.22 5.88 1.06

Table 2 Ankle loads as a function of footwear.

Knee loads

A main effect (P<0.05,2=0.32) was found for peak patellofemoral contact force. Post-hoc analyses indicated that peak patellofemoral contact force was significantly greater in conventional footwear compared to energy boost (Table 1; Figure 1a). A main effect (P<0.05,2=0.29) was similarly for peak patellofemoral pressure. Post-hoc analyses indicated that peak patellofemoral pressure was significantly greater in conventional footwear compared to energy boost (Table 1; Figure 1b). There was also a main effect for (P<0.05,2=0.33) patellofemoral load rate. Post-hoc analyses indicated that peak patellofemoral load rate was significantly greater in conventional footwear compared to energy boost (Table 1). A main effect (P<0.05,2=0.31) was shown for patellofemoral impulse. Post-hoc analyses indicated that patellofemoral impulse was significantly greater in conventional footwear compared to energy boost (Table 1).

Ankle loads

A main effect (P<0.05,2=0.30) was found for peak Achilles tendon force. Post-hoc analyses indicated that peak Achilles tendon force was significantly greater in conventional footwear compared to springblade (Table 2; Figure 1c).

Discussion

The aim of the current investigation was to comparatively examine the effects of conventional, energy boost and spring footwear on the loads experienced by the patellofemoral joint and Achilles tendon during running. To the authors knowledge this represents the first investigation to comparatively investigate knee and ankle loads when running in energy boost and spring footwear.

The first key finding from the current study is that patellofemoral contact force and contact pressure were shown to be significantly greater in the conventional footwear in relation to the energy boost condition. This finding is in agreement with the findings of Sinclair, [14] and Bonacci et al [12] who confirmed that different footwear can significantly influence patellofemoral loading magnitude. This observation may be important clinically with regards to the aetiology of patellofemoral disorders in runners. Patellofemoral pain syndrome is is considered to be caused by repeated high loads that are imposed too frequently to the patellofemoral joint itself [15]. Therefore the findings this study indicate that the energy boost footwear may be the most efficacious for runners who are susceptible to patellofemoral joint conditions.

A potential limitation of previous research investigating the effects of different running footwear on the forces experienced by the musculoskeletal system when running is that only the peak forces experienced per step have been reported. Therefore the potential effects that alterations in stance time/ stride frequency may have on the summative loads experienced by the body are not accounted for. The findings from the current investigation can be further contextualized by examining the patellofemoral impulse associated with each footwear. The findings for patellofemoral impulse mirror those in relation to peak patellofemoral force in that energy boost footwear significantly reduced impulse, giving further support to the earlier proposition that these footwear may be able reduce the likelihood of experiencing patellofemoral pain symptoms in runners.   

A further important finding from the current study is that Achilles tendon load was shown to be significantly larger in the conventional footwear in comparison to the springblade shoes. This observation similarly concurs with the findings of Sinclair, [14] who showed that different footwear significantly influenced Achilles tendon force. This observation may also be relevant clinically with regards to the aetiology of Achilles tendon pathologies in runners. The aetiology of Achilles tendinosis relates to repeated high loads applied too frequently to the tendon itself without sufficient rest [20]. Loads exceeding the tendons physiological threshold mediate collagen degradation which ultimately leads to injury [21]. Therefore the findings from the current investigation indicate that the springblade footwear may be most appropriate for runners who are susceptible to Achilles tendon pathologies.

In conclusion, although energy return footwear have been investigated extensively in biomechanics research, the current knowledge regarding the effects of energy boost and springblade footwear on patellofemoral contact and Achilles tendon forces is limited. The present investigation therefore adds to the current knowledge by providing a comprehensive evaluation of patellofemoral and Achilles tendon force parameters when running energy boost, springblade and conventional footwear. On the basis that patellofemoral and Achilles tendon force were significantly greater when running in conventional footwear, the findings from the current investigation indicate that utilization of conventional running footwear may place runners at increased risk from knee and ankle pathologies in comparison to energy boost and springblade shoe conditions.

References

  1. van Gent, R, Siem DD, van Middelkoop M, van Os TA, Bierma-Zeinstra SS, Koes, BB. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine 2007: 41: 469-480. (PubMed)
  2. Sinclair, J, Franks, C, Goodwin, JF, Naemi, R, Chockalingam, N. Influence of footwear designed to boost energy return on the kinetics and kinematics of running compared to conventional running shoes. Comparative Exercise Physiology 2014; 10: 199-206. (Link)
  3. Worobets, J, Wannop, JW, Tomaras, E, Stefanyshyn, D. Softer and more resilient running shoe cushioning properties enhance running economy. Footwear Science 2014; 6: 147-153. (Link)
  4. Sinclair, J, Mcgrath, R, Brook, O, Taylor, PJ, Dillon, S. Influence of footwear designed to boost energy return on running economy in comparison to a conventional running shoe. Journal of Sports Sciences, 2016; 34: 1094-1098. (PubMed)
  5. Sinclair, J., Shore, H., Dillon, S. (2016). The effect of minimalist, maximalist and energy return footwear of equal mass on running economy and substrate utilization. Comparative Exercise Physiology (In press).
  6. Sinclair J, Hobbs SJ, Taylor PJ, Currigan G, Greenhalgh A. The Influence of Different Force and Pressure Measuring Transducers on Lower Extremity Kinematics Measured During Running. Journal of Applied Biomechanics 2014 30: 166–172. (PubMed)
  7. Cappozzo A, Catani F, Leardini A, Benedeti MG, Della CU. Position and orientation in space of bones during movement: Anatomical frame definition and determination. Clinical Biomechanics 1995; 10: 171-178. (PubMed)
  8. Graydon, R, Fewtrell, D, Atkins, S, Sinclair, J. The test-retest reliability of different ankle joint center location techniques. Foot Ankle Online J. 2015; 8: 1-11. doi: 10.3827/faoj.2015.0801.0011
  9. Sinclair, J, Hebron, J, Taylor, PJ. The Test-retest Reliability of Knee Joint Center Location Techniques. Journal of Applied Biomechanics 2015; 31: 117-121. doi: 10.1123/jab.2013-0312
  10. Sinclair, J, Taylor, PJ, Currigan, G, Hobbs, SJ. The test-retest reliability of three different hip joint centre location techniques. Movement & Sport Sciences. 2014; 83: 31-39. doi: (Link)
  11. Ward SR, Powers CM. The influence of patella alta on patellofemoral joint stress during normal and fast walking. Clinical Biomechanics 2004; 19: 1040–1047. (PubMed)
  12. Bonacci J, Vicenzino B, Spratford W, Collins P. Take your shoes off to reduce patellofemoral joint stress during running. British Journal of Sports Medicine, (In press). (Link)
  13. Kulmala JP, Avela J, Pasanen K, Parkkari J. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers. Medicine & Science in Sports & Exercise 2013; 45: 2306-2313. (PubMed)
  14. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clinical Biomechanics 2014; 29: 395-399. (PubMed)
  15. Ho, KY, Blanchette MG, Powers CM. The influence of heel height on patellofemoral joint kinetics during walking. Gait & Posture 2012; 36: 271-275. (PubMed)
  16. van Eijden TM, Kouwenhoven E, Verburg J, Weijs WA. A mathematical model of the patellofemoral joint. Journal of Biomechanics 1986; 19: 219–229, 1986. (PubMed)
  17. Powers CM, Lilley JC, Lee TQ. The effects of axial and multiplane loading of the extensor mechanism on the patellofemoral joint. Clinical Biomechanics 1998; 13: 616–624. (PubMed)
  18. Sinclair, J, Taylor, PJ, Atkins, S. Influence of running shoes and cross-trainers on Achilles tendon forces during running compared with military boots. Journal of the Royal Army Medical Corps 2015; 161: 140-143. (PubMed)
  19. Self, BP, Paine, D. Ankle biomechanics during four landing techniques. Medicine & Science in Sports & Exercise 2001; 33: 1338–1344.
  20. Selvanetti, ACM, Puddu, G. Overuse tendon injuries: basic science and classification. Operative Techniques in Sports Medicine 1997; 5: 110–17. (Link)
  21. Kirkendall, DT, Garrett W.E. Function and biomechanics of tendons. Scandinavian. Journal of Medicine & Science in Sports 1997; 7: 62–66. (PubMed)

Steroid intra-articular injections for foot and ankle conditions: How effective are they?

by Mohammed KM Ali1*, Suhayl Tafazal1, CA Mbah1, D Sunderamoorthy1pdflrg

The Foot and Ankle Online Journal 9 (2): 7

Purpose: Intra–articular steroid injection is commonly given for the non-operative management of foot and ankle arthritis; however, there is little evidence in the literature about the effectiveness of these injections. The aim of our study was to assess the effectiveness of injections given for the treatment of foot and ankle arthritis.
Methods: We retrospectively reviewed the prospectively collected data of 64 foot and ankle injections done over a period of 12 months. 0.5% Chirocaine and 40 mg of Kenalog was used for the injection. A visual analogue score was used to determine the efficacy of the injection.
Results: The mean follow up was 12 months. 84% (54/64) patients had significant pain relief following the foot and ankle injection. 16% (10/64) went on to have further procedures at six months.  There were 6 patients with ankle arthritis in whom the injection effect did not last more than six months. Two had arthroscopic debridement, two had fusion and of the remaining two patients, one was not fit for surgery and the last one declined surgical intervention. Additionally at six months there were two patients with midfoot OA and two with hindfoot OA, who required further procedures. Patients with no remaining  symptoms were either discharged or given an open appointment.
Conclusions: Our study has shown that patients receiving an intra-articular steroid injection for forefoot conditions have positive outcomes following the injection for six months. Whereas 22% of patients having an intra-articular steroid injection for the ankle, hindfoot and midfoot arthritis have failed to maintain the symptom relief at six months and required further intervention.. This information is useful when obtaining an informed consent from the patient receiving an  intra-articular injection for foot and ankle conditions.

Key words: steroid injections, arthritis, intra-articular injection, foot, ankle

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0007

1 – Trauma and Orthopaedics, Royal Derby Hospital, United Kingdom.
* Corresponding author: Mohammedkhider84@hotmail.com


Intra-articular injections into foot and ankle joints are used for therapeutic and diagnostic purposes. Injection of local anaesthetic may provide temporary relief of pain and suggests the joint as the source of symptoms; inclusion of a corticosteroid in the injection may diminish inflammation from various causes to alleviate pain [1]. Mitchell et al. reported selective intra-articular injections afford a direct method of confirming the site of hindfoot pain and may aid in surgical planning [2].

Osteoarthritis (OA) is the most common form of joint disease and a leading cause of disability in the elderly. The etiology is multi-factorial, with  a variety of risk factors such as aging, genetics, trauma, malalignment, and obesity, which interact to cause this disorder [3]. Foot and ankle arthritis can cause substantial pain and functional limitation and intra–articular corticosteroids are commonly used as a non-operative treatment for pain relief [4].

Intra-articular corticosteroids have previously been shown to offer good pain relief in patients with knee, hip or shoulder OA; however there is little evidence in the literature about the effectiveness of foot and ankle injections [5-8]. The aim of this study is to evaluate the efficacy of intra-articular corticosteroid injection in patients with Foot and ankle OA.

Materials and Methods

We performed a retrospective review of prospectively collected data of 64 patients who had foot and ankle injections between July 2013 to June 2014. The most common indication for injection was osteoarthritis of the joint involved. Each patient was evaluated clinically and radiologically by the Senior Author (DS) to determine the need for the intra-articular injection. We also recorded age, sex, diagnosis, symptoms duration and any relevant co-morbidities.
0.5% Chirocaine and 40 mg of Kenalog (Triamcinolone) was used for the injections. All the injections were performed by the Senior Author (Foot & Ankle Consultant) in the operative theatre using Image Intensifier guidance. Patients were then seen at 12 weeks and  six months. Based on their symptoms at six months, patients either had further procedures, discharged or given an open appointment. The primary efficacy outcomes were a reduction in global pain. A 0–10 Visual Analog Scale (VAS) was used for global pain measurement. VAS was recorded along the different visits (Figure 1).

fig1

Figure 1 Visual analogue score

Injection site Number of patient Joints involved
Ankle 28/64 (44%) Ankle joint (28)
Hindfoot 10/64 (16%) Talonavicular (7),

Calcaneocuboid (3)

Midfoot 10/64 (16%) Tarsometatarsal (10)
Forefoot 16/64 (28%) Metatarsophalangeal (11)

Interphalangeal joints (5)

 

Table 1 Demonstrating the number of patient in each group arranged by injection site location.

Results

Sixty four patients were studied: twenty four males and forty females. The average age was fifty four years (range 37 to 79 yrs). Mean follow up was 12 months. Patients had mean duration of symptoms of three years (range one to five years). Patients were put into four groups, according to the site of the injections (Table 1).

The initial VAS average was nine, with a range from six to 10. 84% (54/64) of patients had significant pain relief following the foot and ankle injection with a VAS below five that lasted more than six months. In 16% (10/64) of the patient’s symptoms remained and they went on to have further intervention (surgery/ arthroscopy) (Table 2).

Pre op pain score  average 9 (6-10)
Post op pain score  84% <5 average 3

 16% >5 average 8

Table 2 Overall pain score; pre and post injections.

Injection site

(No of pts)

VAS pre-inj

Mean (range)

VAS at 12 weeks Mean (range) Patients had more injections VAS at 6 months  Mean (range) Patients needed further Procedure
Ankle joint

28

8 (6-10) 5 (3-9) 5 patients 6 (4-10) 6 patients

5 had inj at 6 months+ 1 new)

Hind-foot

10

9 (8-10) 4 (0-8) 3 patients 6 (4-8) 2 patient

(both had inj at 6 months)

Mid –foot

10

9 (7-10) 3 (3-5) 1 patients 5 (3-10) 2 patients

(1 had inj at 6 months)

Fore-foot

16

9 (8-10) 3 (0-4) none 3 (0-5)

4 did not attend

None

Table 3 Pre and post injections VAS

At 12 weeks; the injections failed to provide pain relief in nine patients and they all were provided further injections. At six months; eight out of those nine patients continued to have symptoms after the second injections and required surgical interventions. Additionally  there were  two patients who had one injection initially and presented after six months with worsening symptoms (Table 3).

There were six patients with ankle arthritis in whom the injection effect did not last more than six months. Two had arthroscopic debridement, two had fusions (Figures 2 and 3), one was not fit for surgery and the last one declined it. Additionally t 6 months 2 patients with midfoot OA and two  with hindfoot OA, who required further intervention (Table 4).

Age sex Duration of symptoms

Months

Co-morbidities Investigation Diagnosis Pre inj

VAS

12 weeks post inj VAS 6 mo

VAS

More injections Further surgery?
48 F 18 RA MRI 2, 3rd TMTJ

Arthritis

10 06 10 No Fusion
49 F 24 None X rays Ankle OA 10 09 09 No Arthroscopic

Debridement

60 M 60 Pilon Fracture CT

X rays

Ankle OA

Post-traumatic

10 03 10 No Fusion
70 F 48 None CT 2, 3rd TMTJ

Arthritis

10 05 10 No Fusion
79 M 120 Cardiac problems X rays Ankle OA 08 10 10 No Not fit for surgery
39 M 36 Calcaneus fracture CT

X rays

Subtalar OA 09 09 09 No Fusion
54 F 30 None X rays Ankle OA 10 08 10 No Arthroscopic

Debridement

67 M 60 None X rays Talo-Nav, Calc-Cub OA 08 06 08 No Fusion
63 M 36 Hip OA X rays Ankle OA 08 08 08 No Declined surgery
72 M 36 None CT

X rays

Ankle OA 10 03 10 No Fusion

Table 4  Patients who required further intervention at six months post injection.

fig2

Figure 2 Second and third tarsometatarsal joint fusion.

Discussion

Cortisone was first used in the treatment of rheumatoid arthritis in the late 1940s [3] and in 1950; Thorn was the first to inject steroids into the knee of a patient with rheumatoid arthritis [4]. In the beginning, the results were somewhat disappointing, however, it later became clear that cortisone is dependent for its action on hydroxylation to hydrocortisone in the liver. Direct injection of hydrocortisone gave better results, but the effect was only transient. The development of less soluble esters provided steroids with longer half-lives and long term effectiveness [5]. The rate of systemic absorption of an intra-articular corticosteroid is related to the solubility of the compound, and it is understood that more insoluble corticosteroid compounds are better suited to intra-articular use as the local duration of action may be prolonged and effects due to systemic absorption are kept to a minimum [6]. Triamcinolone Acetonite (Kenalog) has an extended duration of effect which may be sustained over a period of several weeks and for reasons related to availability and cost, as well as pharmacokinetics, was the  steroid used in this clinical investigation.

fig3

Figure 3  Ankle OA intraoperatively during fusion procedure.

Intra-articular corticosteroids remain widely used for symptomatic treatment of peripheral joint osteoarthritis, although the duration of the effect can be highly variable depending on many factors,  such as type of  joint involved and the use of image guidance or not [7-11].

Kevin et al suggest experienced surgeons may be able to place intra-articular injections without fluoroscopy in a normal posterior subtalar joint with a 97% accuracy rate [1]. Fluoroscopy may not be necessary for injections used solely for therapeutic purposes. However, if the injection is intended for diagnostic purposes and surgical decision making for potential arthrodesis or if the joint is abnormal, they recommend fluoroscopy to ensure accurate placement without extension or extravasations into nearby structures that also might be potential sources of pain. Concerns for surrounding soft tissues may warrant use of fluoroscopy in cases of arthrosis and indwelling hardware [1]. Similarly Khoury et al. reported injections performed under fluoroscopic control allowed confirmation of the painful joint, which in turn led to successful patient outcomes after arthrodesis [12]. All our patients had the intra-articular steroid injection under fluoroscopy guidance as suggested in the literature to improve the accuracy of the injections.

Ward et al in a prospective one year follow up of intra-articular steroid injection of the foot and ankle has shown a statistically significant foot and ankle score improvement following corticosteroid injection up to and including six months post-injection. No independent clinical factors were identified that could predict a better post-injection response.

The magnitude of the response at two months was found to predict a sustained response at nine months and one year. Intra-articular corticosteroids improved symptom scores in patients with foot and ankle arthritis. The duration of this response was varied and patient factors affecting the response remain unclear. Response to the injection at two months can be used to predict the duration of beneficial effects up to at least one year [13].

In our study, there was a statistically significant improvement in foot and ankle scores above the starting point using the visual analogue score.  84% (54/64) of the patients had an appreciable pain relief up to six months post injection. Only 16% (10/84) of the patients needed further procedures at six months and in the majority of them. At 12 weeks; the injections failed to provide pain relief in nine patients and they all were provided further injections. At six months; eight out of those nine patients continued to have symptoms after the second injections and required surgical interventions. Similar to Ward et al findings our study has shown a similar result in a poor outcome at 12 weeks correlates well with the long term outcome resulting in further injection or surgical intervention.

Furthermore, our study has shown that patients having forefoot injections had a good outcome with none of them requiring surgical intervention at one year. Whereas the ankle, hindfoot and midfoot injections had a failure rate of 22% resulting in surgical intervention.  There is no evidence in the literature of the failure rate of the injections and the percentage of patients requiring surgical intervention for the injection failure. Our study is the first one to show that failure rate for the different regions of the foot and ankle over a one year period.

The above evidence would be a useful tool when it comes to obtaining  informed consent for patients having foot and ankle injections.
This study was limited by a number of weaknesses. Our sample size, although sufficient to identify statistically significant differences for some of the factors that we measured, was possibly too small for us to detect other statistically significant factors, should they have presented.

We assumed that the joints identified by the foot and ankle surgeon as the source of symptoms, in fact, were the cause of our patients’ foot pain. If this diagnosis was inaccurate, or if other unidentified joints or pathology were contributing to the participant’s symptoms, this would have biased our results toward the null.

Conclusion

Our study has shown that patients having intra-articular steroid injection for forefoot conditions have good outcome following the injection and they maintain it at six months. Whereas approximately 22% of patients receiving intra-articular steroid injection for arthritis of the ankle, hindfoot or  midfoot,  have failed to remain free of symptom sat six months and required further intervention. This information is useful when obtaining an informed consent from the patient receiving  an intra-articular injection for foot and ankle conditions, in order to provide them with realistic expectations for treatment.

References

  1. Kirk KL, Campbell JT, Guyton GP, Schon LC. Accuracy of posterior subtalar joint injection without fluoroscopy. Clin Orthop Relat Res. 2008;466(11):2856-60.
  2. Mitchell MJ, Bielecki D, Bergman AG, Kursunoglu-brahme S, Sartoris DJ, Resnick D. Localization of specific joint causing hindfoot pain: value of injecting local anesthetics into individual joints during arthrography. AJR Am J Roentgenol. 1995;164(6):1473-6.
  3. Hench PS, Slocumb CH. The effects of the adrenal cortical hormone 17-hydroxy-11-dehydrocorticosterone (Compound E) on the acute phase of rheumatic fever; preliminary report. Proc Staff Meet Mayo Clin. 1949;24(11):277-97.
  4. Hollander JL. Intra-articular hydrocortisone in arthritis and allied conditions; a summary of two years’ clinical experience. J Bone Joint Surg Am. 1953;35-A(4):983-90.
  5. Grillet B, Dequeker J. Intra-articular steroid injection. A risk-benefit assessment. Drug Saf. 1990;5(3):205-11.
  6. Derendorf H, Möllmann H, Grüner A, Haack D, Gyselby G. Pharmacokinetics and pharmacodynamics of glucocorticoid suspensions after intra-articular administration. Clin Pharmacol Ther. 1986;39(3):313-7.
  7. D’agostino MA, Ayral X, Baron G, Ravaud P, Breban M, Dougados M. Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind-, and mid-foot in chronic inflammatory diseases. Arthritis Rheum. 2005;53(2):284-92.
  8. Peterson CK, Buck F, Pfirrmann CW, Zanetti M, Hodler J. Fluoroscopically guided diagnostic and therapeutic injections into foot articulations: report of short-term patient responses and comparison of outcomes between various injection sites. AJR Am J Roentgenol. 2011;197(4):949-53.
  9. Friedman DM, Moore ME. The efficacy of intraarticular steroids in osteoarthritis: a double-blind study. J Rheumatol. 1980;7(6):850-6.
  10. Gaffney K, Ledingham J, Perry JD. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 1995;54:379-81.
  11. Dieppe P, Cushnaghan J, Jasani MK, McCrae F, Watt I. A two-year, placebo-controlled trial of non-steroidal anti-inflammatory therapy in osteoarthritis of the knee joint. Br J Rheumatol 1993;32(7):595-600.
  12. Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA. Intraarticular foot and ankle injections to identify source of pain before arthrodesis. AJR Am J Roentgenol. 1996;167:669–673.
  13. Ward ST, Williams PL, Purkayastha S. Intra-articular corticosteroid injections in the foot and ankle: a prospective 1-year follow-up investigation. J Foot Ankle Surg. 2008;47(2):138-44.
  14. Kumar N, Newman RJ. Complications of intra- and peri-articular steroid injections. Br J Gen Pract. 1999;49(443):465-6.

Lateral and open medial subtalar dislocation: Report of two uncommon cases

by Ganesh Singh Dharmshaktu1* , Irfan Khan2pdflrg

The Foot and Ankle Online Journal 9 (2): 6

Subtalar or peritalar dislocation is a rare injury and limited to a small number of reported cases. The proper and early diagnosis and judicious management is paramount to good functional outcome. The documentation of other associated injuries and respective management is also crucial. We present two cases describing each of the two variants i.e. medial and lateral subtalar dislocation. These cases add value to existing literature by strengthening the knowledge about early identification and appropriate management of such uncommon pattern of injuries.

Key words: subtalar joint, dislocation, medial subtalar dislocation, lateral subtalar dislocation, closed reduction.

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0006

1* – Assistant Professor , Department of Orthopaedics, Government Medical College, Haldwani , Uttarakhand. drganeshortho@gmail.com
2 – Senior Residnt , Department of Orthopaedics, Government Medical College, Haldwani , Uttarakhand.


Subtalar dislocation, also referred as peritalar dislocation, is an uncommon injury pattern and may or may not involve associated talar fracture. The incidence has been reported to be 0.9% (42 cases in a series of 4215 dislocations) in one series [1]. Another series reported its incidence of 15% of all talar injuries[2]. Initially regarded as a traumatic event in young adults, recent observations reveal sizeable number of patients beyond forty years of age [3]. The injury usually presents with deformed anatomy, and medial dislocation is more common[4]. Lateral dislocation are associated with higher energy injuries and carry a worse prognosis of the two. Motor vehicle accidents, fall from height, and sports injury are common mechanisms of these injuries. Apart from the primary dislocation, the frequent presence of open injuries requires careful soft tissue handling and asepsis in the treatment [5]. Two cases of both types of dislocation including one with small a open wound is presented here with appropriate management and good outcomes.

Case Reports

Case 1  

A 26-year-old male patient presented to us with history of road traffic accident two hours prior to presentation, after getting hit by a moving car while cycling, and his right foot got stuck under the bike after falling to the ground. The exact mechanism and position of the foot at the time of impact could not be recalled by the patient and he noticed a deformity and inability to bear weight since the injury. The deformity involved the foot to be appearing lateral. There was mild swelling at presentation and active toe movement along with an intact distal neurovascular status. A small 2cm open wound at lateral aspect of the ankle was present that was apparently uncontaminated (Figure 1). Prompt radiological evaluation was ordered to reveal a medial subtalar dislocation without noticeable fracture (Figure 2). Urgent reduction under anesthesia was planned.

The talus appeared to remain at normal location while the structures below it were displaced medially along with talonavicular dislocation. A through copious lavage was done through the wound. The reduction was done by traction and initially accentuating the deformity and reducing by digital pressure over the talus and giving lateral force to the foot for a smooth reduction. The reduction was confirmed on image intensifier for restoration of normal foot anatomy in biplanar views before applying a plaster protection splint (Figure 3). The limb was elevated and pain medications were given as active toe movements were encouraged throughout treatment.

fig1

Figure 1 Clinical picture of case with medial dislocation and small lateral wound.

fig2

Figure 2 The radiograph of medial subtalar dislocation of right foot in both planes.

fig3

Figure 3 Post-reduction radiograph showing good reduction stabilized with plaster slab.

Case 2

A 53-year-old male patient hit and twisted his right foot after fall from a height of six feet into hard ground five hours prior to presentation. The weight of the body was concentrated on ankle and foot region at ground strike. His foot was everted as he fell followed by body weight over the area leading to deformity and pain. There was painful restriction of ankle movement and unable to ambulate. He was taken to a local clinic where a cardboard make-do splint was provided before consultation. There was no open wound or distal neurovascular deficit present. His radiograph showed a lateral subtalar dislocation with a small bony fragment between the navicular and talus in lateral view, suggestive of probable osteochondral fracture of talus (Figure 4). He was posted for urgent reduction under anaesthesia following informed consent. Slight traction and accentuation of deformity by eversion followed by inward foot pressure with counter-pressure at navicular bone resulted in successful reduction.

The reduction was assessed under image intensifier followed by plaster back-slab (Figure 5). The further management and the results were similar to the first case and uncomplicated recovery and follow up period was noted. The patient was lost to follow up after ten months.

fig4

Figure 4 The radiograph of lateral subtalar dislocation of right foot in both planes, and a small osteochondral fragment from navicular is also noted.

fig5

Figure 5 Post-reduction radiograph showing good reduction stabilized with plaster slab.

Results

The follow up period was uneventful and there were no recurrence noted. The patients gradually started protected weight bearing after rest of four weeks for optimal soft tissue healing and reduction of swelling. Supervised physiotherapy was instrumental in regain of function and ambulation. The follow up of fourteen weeks was unremarkable and patients were pursuing activities of daily living.

Discussion

The characteristic deformities following subtalar dislocation resemble an ‘acquired clubfoot’ and ‘acquired flatfoot’ in cases of medial and lateral dislocation respectively [6]. Other regional or remote injuries including small osteochondral fractures need to be searched and treated accordingly as they involve a large portion of cases[3-5,7]. Skin tenting should be relieved by prompt reduction to avoid complication. Open wounds should be thoroughly lavaged and debrided before closure [8]. Reduction is preferably done with complete muscle relaxation and often accentuation of deformity by either inversion or eversion maneuver for medial and lateral dislocations respectively. This reduction maneuver is well described in the literature and was followed by us to an uneventful outcome [9]. The reduction usually is achieved in closed manner but adjacent tissue and other structures might impede reduction at times and require open reduction. Shortest possible immobilization has been advocated followed by physical therapy to regain subtalar and midtarsal mobility. Conservative management has been an excellent modality with good results in previous studies[4,10]. Both of our cases had a successful result of uneventful closed reduction and satisfactory functional outcome.

References

  1. Leitner B. The mechanism of total dislocation of the talus. J Bone Joint Surg. 1955; Jan 37A:89-95. (PubMed)
  2. Pennal GF. Fractures of the talus. Clin Orthop. 1963;30:53-63. (PubMed)
  3. Bibbo C, Anderson RB, Davis WH. Injury characteristics and the clinical outcome of  subtalar dislocations: A clinical and radiographic analysis of 25 cases. Foot Ankle Int. 2003; 24:158-163. (PubMed)
  4. DeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg. 1982;64A:433-437. (PubMed)
  5. Merchan EC. Subtalar dislocations: Long-term follow-up of 39 cases. Injury. 1992;23:97-100. (Link)
  6. Straus DC. Subtalar dislocation of the foot. Am J Surg. 1935;30:427-434.
  7. Christensen SB, Lorentzen JE, Krogsoe O, et al. Subtalar dislocation. Acta Orthop Scand. 1977;48:707-711. (Link)
  8. Edmunds I, Elliott D, Nade S. Open subtalar dislocation.Aust NZ J Surg. 1991 Sep;61:681-686. (PubMed)
  9. Sanders DW. Fractures and dislocations of the talus. In: Court-Brown CM, Heckman JD, McQueen MM, et all, editors. Rockwood and Green’s Fractures in adults. 8th ed. Philadelphia. Wolters Kluwer Health; 2015.
  10. de Palma L, Santucci A, Marinelli M, et al. Clinical outcome of closed isolated subtalar dislocations. Arch Orthop Trauma Surg. 2008;128(6): 593598. (Link)

Form determines function: Forgotten application to the human foot?

by Mick Wilkinson, PhD1* and Lee Saxby, BSc1pdflrg

The Foot and Ankle Online Journal 9 (2): 5

There has been and continues to be much debate about the merits and detriments of barefoot and minimal-shoe running. Research on causes of running-related injury is also characterised by equivocal findings. A factor common to both issues is the structure and function of the foot. Comparatively, this has received little attention. This perspective piece argues that foot function and in particular, how foot structure determines function, has largely been overlooked, despite basic principles of physics dictating both the link between structure and function and the importance of function for stability in locomotion. We recommend that foot shape and function be considered in the interpretation of existing findings and be incorporated into future investigations interested in running mechanics, injury mechanisms and the effects of footwear on both.

Key words: human foot, mechanics, barefoot, locomotion

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0005

1 – Sport, Exercise and Rehabilitation, Northumbria University, UK.
* Correspondence – Mic.wilkinson@northumbria.ac.uk


As stated by evolutionary biologist EO Wilson, “everything in biology is subject to the laws of physics and chemistry and has arisen through evolution by natural selection” [1]. Applying this logic to the study of human locomotion, and in particular the structure and role of the foot, can bring clarity to the interpretation of many past and recent studies on barefoot-versus-shod-and minimal-shoe locomotion, and the associated benefits and risks. Using laws and undisputed theories as filters through which to interpret study outcomes can provide a context to equivocal findings and also suggest fruitful lines of future inquiry.

The ‘purpose’ of the foot

Assigning a purpose to a biological structure is often criticised as teleological. However, as Nobel Laureate Albert Szent-Gyorgyi [2] wrote “teleology resembles an attractive lady of doubtful repute whose company we cherish but in whose company we do not like to be seen”. Purpose provides the context without which many observations in nature make no sense. A teleological view is therefore adopted in this piece.
In an upright biped, the purpose of the foot is to support and control the direction of the body weight as it falls forwards during the stance phase of locomotion [3-5]. With this and fundamental physics in mind, a reverse-engineering approach suggests a larger base of support, that is widest at the front, would serve both purposes.

It is not surprising therefore, that comparisons of habitually-unshod with habitually-shod populations consistently show wider (particularly at the front) feet in unshod populations, in agreement with that predicted by fundamental principles [6-10]. Studies on habitually-barefoot populations also demonstrate the benefits of a wide base of support in the form of more uniform distribution of pressure through the entire plantar surface during walking [9], and reduced peak pressure and pressure-time integral under the forefoot in running [11].

Structure determines function

There has been recent attention on the role of intrinsic foot musculature [12] and how barefoot / minimal footwear use might influence their strength and function [13]. However, it must be remembered that these muscles simply respond to the forces acting on them [3,12]. In the foot, the magnitude and direction of these forces will be partly determined by the shape of the foot, and in particular by the position of the hallux [14,15]. It has been suggested that the thickness, length and position of the hallux represents evolutionary adaptation to terrestrial-bipedal locomotion [14,16-19]. The effect of foot shape on control of the path of body weight through the foot has long been established and is explained by simple physics [14]. This questions a research focus on the strength and /or training of intrinsic-foot musculature without consideration of foot shape, as it is unlikely that strength of muscles in a structurally-compromised foot could overcome gravity and the ground-reaction force as effectively as a structurally-sound foot.

A logical prediction from an engineering view of an ideal foot is that a wider foot would offer a more stable base over which to pass the body weight, and a larger surface area over which to distribute pressure. Here, the hallux is of special importance [15]. Morton [14] demonstrated that the hallux position, secondary to a correctly aligned first metatarsal, directed body weight in the sagittal plane through the axis of leverage between the first and second metatarsal heads.

He also demonstrated that a valgus position of the hallux resulted in excessive pronation, as the hallux was not mechanically positioned to control and direct the path of the body weight in the sagittal plane. This resulted in transfer of motion into the transverse and frontal planes. Chou et al [15] reported impaired single-leg balance and directional control of weight shifting when hallux use was constrained by a purpose-made splint. A recent study also highlighted that separation of the hallux from the second toe characterised the feet of a habitually-unshod Indian population [10] and differentiated them from a habitually-shod- Chinese population. A relationship between Morton’s toe and peak pressure under the first metatarsal head in walking has also been demonstrated, providing support for the assertion that static-foot structure is an important determinant of foot function, specifically, the ability to direct body weight in the sagittal plane in locomotion [20]. More recently, Mei et al [11] demonstrated the importance of an abducted-hallux position in habitually-barefoot participants while running, showing the hallux to share and therefore reduce forefoot loading, possibly due to a wider surface area of support .

Given the mechanical effects of static foot shape, it is worthy of consideration as a mechanism underlying overuse injury in tissues and joints further up the kinetic chain. If force is not appropriately directed in the sagittal plane at the foot, it follows from basic physics that compensations and additional muscular work will have to ensue to counteract unwanted transverse-and frontal-plane motion. The knee joint in particular might be at risk, given its small capacity for non-sagittal-plane movement. Given that walking and running are derived capabilities in humans, and that humans are adapted to perform both activities with minimal energy expenditure [21], it is logical to suggest that a sagittal-plane joint, such as the knee, is best supported with a wide foot that controls and directs the body weight, such that motion at the knee is in the plane for which the joint has evolved.

The effects of footwear on foot structure and function

The plasticity of foot structure was well known and exploited by the Chinese in the ancient cultural practice of footbinding [6,22]. The timescale of structural alterations appears to be rapid, particularly in the young, where bones have yet to fully ossify. Hoffman [6] observed hallux deformation in a habitually-barefoot teenager required to wear shoes for just six weeks. In an adult-case-study patient, Knowles [23] showed reversal of hallux valgus after two years wearing anatomically-shaped shoes (i.e. tip of shoe medial to the medial border of the hallux). Other observational research [7] reported a highly-significant relationship between years of shoe wear and hallux-valgus angle in shoe-wearing communities, with hallux-valgus angle increasing in a linear fashion with years of shoe wear. The observed adaptation of foot structure to shoe wear is in accord with Wolfe’s law, as is the reversal of deformity observed by Knowles [23].

The effect of footwear on foot structure and function will largely depend on the nature of the footwear. The oldest record of footwear dates back some 10000 years [24] with the footwear being a type of sandal. Open sandals have been and continue to be commonly used by hunter-gatherer populations [25]. Such footwear is unlikely to interfere with foot function and shape, but rather simply offers some protection for the plantar surface. In contrast, the highly cushioned, narrow, stiff-soled and toe-sprung footwear characteristic of the modern-running shoe is likely to compromise foot structure and function. Indeed, altered gait patterns, increased maximum impact force, reduced arch deformation and toe flexion have been reported in children running in conventional-running shoes compared to barefoot [26, 27]. Moreover, a comparison of shod and barefoot populations suggested that habitual-western-footwear use leads to stiffer feet with impaired function [28]. There is a dearth of longitudinal studies examining the effects of long-term shoe wear on foot function. A controlled-longitudinal study of the effect of footwear on foot structure and function would be valuable, but is certainly not without methodological challenges. In the absence of such data, the ‘if-you-don’t-use-it-you-lose-it’ principle would suggest that reduced use of the arch and toes would lead to impaired function over time.

The relationship between loss of function and change in foot shape would be of particular interest, but again, previous observational data and simple mechanical principles suggest such a relationship. From an evolutionary perspective, footwear makes sense, particularly given the range of environments in which humans thrive. However, the mechanics and evolution of the foot dictate that such footwear should be anatomically shaped to allow natural-hallux position and function, and also flat and flexible enough to allow unimpeded movement of the foot and toes during locomotion. Such characteristics have been previously recommended [22].

Summary and recommendations

Fundamental physical and mechanical laws and evolutionary biology provide a context to understand structure and function of the human foot, and how both might be compromised by inappropriate footwear. The characteristics that a foot ought to possess to perform load bearing, cushioning and stability roles are observed in the feet of habitually-barefoot populations. Likewise, deformed structure and impaired function have been observed with habitual shoe wear. Future studies on factors related to both performance and injury, and acute-and chronic biomechanical investigations of barefoot-versus-shod running, should attempt to examine data in light of measures of foot structure. Furthermore, care should be exercised in footwear choice, particularly in children, where the effects of conventional footwear on locomotive patterns and foot function have been demonstrated. Interpreting research in light of physical laws and from an evolutionary perspective, might add clarity to a field of investigation that is characterized by equivocal findings.

References

  1. Wilson, E.O. Consilience: The unity of knowledge. New York: Vintage Books; 1998.
  2. Szent-Gyorgyi, A. The Living State, with observations on cancer. New York: Academic Press; 1972.
  3. Mann, R. and V.T. Inman, Phasic Activity of Intrinsic Muscles of the Foot. J Bone Joint Surg. 1964; 46: 469-481. [PubMed]
  4. Reeser, L.A., R.L. Susman, and J.T. Stern, Electromyographic Studies of the Human Foot: Experimental Approaches to Hominid Evolution. Foot Ankle. 1983; 3: 391-407. [PubMed]
  5. Rolian, C., et al., Walking, running and the evolution of short toes in humans. J Exp Biol. 2009; 212: 713-721. [Link]
  6. Hoffman, P., Conclusions drawn for a comparative study of the feet of barefooted and shoe-wearing peoples. J Bone Joint Surg. 1905; 3: 105-136. [Link]
  7. Shine, I.B., Incidence of hallux valgus in a partially shoe-wearing community. Br Med J. 1965; 1: 1648-1650. [PubMed]
  8. Morioka, M., T. Miura, and K. Kimura, Morphological and functional changes of feet and toes of Japanese forestry workers. J Hum Ergol. 1974; 3: 87-94. [PubMed]
  9. D’Aout, K., et al., The effects of habitual footwear use: foot shape and function in ntaive barefoot walkers. Footwear Sci. 2009; 1: 81-94. [Link]
  10. Shu, Y., et al., Foot morphological difference between habitually shod and unshod runners. PLoS ONE. 2015; 10: e0131385. [Link]
  11. Mei, Q., et al., A comparative biomechanical analysis of habitually unshod and shod runners based on foot morphological difference. Hum Mov Sci. 2015; 42: 38-53. [PubMed]
  12. Kelly, L.A., et al., Intrinsic foot muscles have the capacity to control deformation of the longitudinal arch. J R Soc Interface. 2014; 11: 20131188. [Link]
  13. Miller, E.E., et al., The effect of minimal shoes on arch structure and intrinsic muscle strength. J Sport Health Sci. 2014; 3: 74-85. [Link]
  14. Morton, D.J. The Human Foot: its evolution, physiology and functional disorders. New York: Columbia University Press; 1935.
  15. Chou, S., et al., The role of the great toe in balance performance. J Orthop Res. 2009; 27: 549-554. [PubMed]
  16. Weidenreich, F., Evolution of the human foot. Am J Phys Anthropol. 1923; 6: 1-10. [Link]
  17. Elftman, H. and J. Manter, Chimpanzee and human feet in bipedal walking. Am J Phys Anthropol. 1935; 20: 69-79. [Link]
  18. Mann, R.A. and J.L. Hagy, Function of toes in walking, jogging and running. Clin Orthop Relat Res. 1979; 142: 24-29. [PubMed]
  19. Hughes, J., P. Clark, and L. Klenerman, The importance of toes in walking. J Bone Joint Surg. 1990; 72: 245-251. [Link]
  20. Cavanagh, P.R., et al., The relationship of static foot structure to dynamic foot function. J Biomech. 1997; 30: 243-250. [PubMed]
  21. Bramble, D. and D. Lieberman, Endurance running and the evolution of Homo. Nature  2004; 432: 345-352. [PubMed]
  22. Stewart, S.F., Footgear – Its history, uses and abuses. Clin Orthop Relat Res. 1972; 88: 119-130. [PubMed]
  23. Knowles, F.W., Effects of shoes on foot form: An anatomical experiment. Med J Aust. 1953; 1: 579-581. [PubMed]
  24. Pinhasi, R., et al., First direct evidence of chalcolithic footwear from near eastern highlands. PLoS ONE. 2010; 5: e10984. [Link]
  25. Lieberman, D.E., Strike type variation among Tarahumara Indians in minimal sandals versus conventional running shoes. J Sport Health Sci. 2014; 3: 86-94. [Link]
  26. Wegener, C., et al., Effects of children’s shoes on gait: a systematic review and meta analysis. J Foot Ankle Surg. 2011; 4: 1-13. [PubMed]
  27. Hollander, K., et al., Effects of footwear on treadmill running biomechanics in preadolescent children. Gait Posture. 2014; 40: 381-385. [PubMed]
  28. Kadambande, S., et al., Comparative anthropometric analysis of shod and unshod feet. Foot. 2006; 16: 188-191. [Link]

Does shoe midsole temperature affect patellofemoral and Achilles tendon kinetics during running?

by Sinclair J1*, Atkins S2,  Shore H1pdflrg

The Foot and Ankle Online Journal 9 (2): 4

The aim of the current investigation was to examine the effects cooled footwear on patellofemoral and Achilles tendon kinetics during running. Ten participants completed running trials at 4.0 m/s in two identical footwear one of which was cooled for 30 min. Lower extremity kinematics were obtained using an eight camera motion capture system and force data was obtained using a force platform. Differences between cooled and normal footwear temperatures were examined using paired samples t-tests. The results showed that peak Achilles tendon load was significantly larger in the cooled footwear (5.86 ± 1.06 B.W) in comparison to non-cooled (4.89 ± 1.04 B.W). In addition Achilles tendon loading rate was also significantly larger in the cooled footwear (48.95 ± 10.17 B.W/s) in comparison to non-cooled (42.49 ± 10.40 B.W/s). This study indicates that running in cooled footwear may place runners at increased risk from the biomechanical parameters linked to the aetiology of Achilles tendinopathy.

Key words: footwear, ankle, knee, temperature

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0004

1 – Centre for Applied Sport and Exercise Sciences, School of Sport Tourism and Outdoors, University of Central Lancashire,
2 – School of Psychology, University of Central Lancashire.
3 – School of Health Sciences, University of Salford.
* Correspondence – jksinclair@uclan.ac.uk


Runners are known to be extremely susceptible to chronic lower extremity pathologies; 19.4-79.3 % of all runners’ will suffer from a chronic pathology over the course of one year [1]. The knee and ankle joint are the most commonly injures musculoskeletal structures and are associated with up to one-fifth of all running injuries [1]. The running shoe represents the main interface between the runners and the surface during running [2], and has thus been strongly advocated as a mechanism by which the injury rate can be mediated. One of the most important aspects of the running shoe is the mechanical dampening properties of the midsole [3]. The majority of running shoes utilize a copolymer called Ethylene-vinyl acetate as it is both durable and flexible even at low densities [3]. Ethylene-vinyl acetate like most polymers exhibits viscoelastic properties [4], and thus its mechanical properties are temperature dependant [5].

The effects of different midsole temperatures have been examined previously. Kinoshita & Bates [6] investigated the influence of different environmental temperatures on the shock absorbing characteristics of running shoe midsoles using mechanical testing. Their findings showed that with increasing temperature, peak acceleration and energy absorption decreased, and the total peak deformation of the midsole increased. Sinclair et al., [7] examined the effects of cooled footwear on the kinetics and kinematics of running in comparison to identical footwear maintained at room temperature. Their findings showed that the cooled footwear were associated with significantly increased vertical loading rate and also peak angle of eversion/ tibial internal rotation.

There has yet to be any published information concerning the effects of footwear midsole temperature on the loads experienced by the frequently injured knee and ankle joints. Therefore the aim of the current investigation was to examine the effects cooled footwear on patellofemoral and Achilles tendon kinetics during running in comparison to footwear at normal temperature.

Methods

Participants

Ten female runners took part in this study. All were injury free and provided written informed consent. The mean characteristics of the participants were: Age = 21.55 ± 2.58 years, Height = 1.67 ± 0.07 m, Mass = 61.29 ± 5.01 kg. The procedure utilized for this investigation was approved by the University of Central Lancashire, ethical committee.

Procedure

Two identical trainers (Nike Free run 5.0+; sizes 4-7 UK) were used one of which was artificially chilled (cooled) and one was maintained at room temperature (normal). The temperature of the experimental footwear was reduced by placing them inside a freezer which maintained a constant temperature of -25°C for 30 mins [7].

Kinematic data were obtained via an camera optoelectric motion capture system (Qualisys Medical AB, Goteburg, Sweden) using a capture frequency of 250 Hz. Participants completed five trials running at 4.0 m/s in both cooled and normal footwear conditions. A maximum deviation of 5 % from the predetermined velocity was allowed. The participants struck a force platform (Kistler Instruments, Model 9281CA) sampling at 1000Hz with their right (dominant) foot. Locomotion velocity was measured using timing gates (SmartSpeed Ltd UK). The stance phase of running was defined as the duration over which > 20 N vertical force was applied to the force platform [8].

To model the thigh, shank and foot segments calibrated anatomical systems technique was utilized [9]. To define the segment coordinate axes of the right; foot, shank and thigh, retroreflective markers were placed unilaterally onto 1st metatarsal, 5th metatarsal, calcaneus, medial and lateral malleoli, medial and lateral epicondyles of the femur. The centres of the ankle and knee joints were delineated as the midpoint between the malleoli and femoral epicondyle markers. The hip joint centre was taken as a point one-quarter of the distance from the ipsilateral to the contralateral greater trochanter [10]. The centres of the knee and ankle joints were taken as the midpoint between the malleoli and femoral epicondyle markers [11, 12]. Carbon fibre tracking clusters were utilized to track the shank and thigh segments, whereas the foot was tracked using the 1st metatarsal, 5th metatarsal and calcaneus markers. Static calibration trials were obtained allowing for the anatomical markers to be referenced in relation to the tracking markers/ clusters.

Data processing

Ground reaction force and kinematic data were filtered at 50 and 15 Hz respectively using a low-pass Butterworth 4th order filter using Visual 3-D (C-Motion, Rockville, MD, USA). Kinematic measures from the knee and ankle joints which were extracted for statistical analysis were 1) angle at footstrike, 2) peak angle and 3) relative range of motion (representing the angular displacement from footstrike to peak angle. Joint moments were calculated using Newton-Euler inverse-dynamics, which allowed net knee and ankle joint moments (Nm) to be calculated. The net joint moments were normalized by dividing by body mass (Nm/kg).

Patellofemoral kinetics were examined through extraction of peak knee extensor moment (KEM), patellofemoral contact force (PTCF) and patellofemoral contact pressure (PTS). PTCF was normalized by dividing the net PTCF by body weight (B.W).

PTCF during running was estimated using knee flexion angle (kfa) and KEM through the biomechanical model of Ho et al., [13]. This model has been utilized previously to resolve differences in PTCF and PTS in different footwear [14-16].

The effective moment arm of the quadriceps muscle group (QM) was calculated as a function of kfa using a nonlinear equation, based on information presented by van Eijden et al., [17]:

QM = 0.00008 kfa 3 – 0.013 kfa 2 + 0.28 kfa + 0.046

The force (N) of the quadriceps (QF) was calculated using the below formula:

QF = KEM / QM

Net PTCF (N) was estimated using the QF and a constant (C):

PTCF = QF * C

The C was described in relation to kfa using a curve fitting technique based on the nonlinear equation described by van Eijden et al., [17]:

C = (0.462 + 0.00147 * kfa 2 – 0.0000384 * kfa 2) / (1 – 0.0162 * kfa + 0.000155 * kfa 2 – 0.000000698 * kfa 3)

PTS (MPa) was calculated using the net PTCF divided by the patellofemoral contact area. The contact area was described using the Ho et al., [13] recommendations by fitting a 2nd order polynomial curve to the data of Powers et al., [18] showing patellofemoral contact areas at varying levels of kfa.

PTS = PTCF / contact area

Achilles tendon force (ATF) (B.W) was determined by dividing the plantarflexion moment (MPF) by the estimated Achilles tendon moment arm (mat). The moment arm was quantified as a function of the ankle sagittal plane angle (ak) using the procedure described by Self and Paine [19]:

ATF = MPF / mat
mat = -0.5910 + 0.08297 ak – 0.0002606 ak2

Statistical Analysis

Descriptive statistics (means and standard deviations) were obtained for each footwear temperature. Differences in patellofemoral and Achilles tendon load parameters between cooled and normal footwear conditions were examined using paired samples t-tests, with statistical significance was accepted at the P≤0.05 level [20]. In addition minimum clinically important differences (MCID) were calculated as being 2.3 * the pooled standard error. All statistical tests were conducted using SPSS v22.0 (SPSS Inc, Chicago, USA).

Results

Table 1 and figures 1-2 present the patellofemoral and Achilles tendon parameters observed as a function of footwear temperature.

Fig1

Figure 1 Knee joint kinetics and kinematics as a function of cooled footwear (a. = knee sagittal angle, b. = knee sagittal moment, c. = PTCF, d. = PTS) (black = cooled and grey = non-cooled).

Non-cooled Cooled MCID  
  Mean SD Mean SD  
Knee moment (Nm/kg) 2.72 0.51 2.70 0.46 0.32  
PTF (B.W) 3.59 0.77 3.63 0.69 0.48  
PTF load rate (B.W/s) 50.33 9.18 49.44 8.72 5.94  
Time to PTF (ms) 72.11 11.26 74.89 8.84 6.67  
PTS (Mpa) 9.34 1.91 9.35 1.71 1.20  
Ankle moment (Nm/kg) 2.33 0.49 2.80 0.49 0.33 *
ATL (B.W) 4.89 1.04 5.86 1.06 0.70 *
Time to ATL (ms) 118.78 11.60 121.17 10.86 7.46
ATL load rate (B.W/s) 42.49 10.40 48.95 10.17 6.05 *

Table 1 Patellofemoral and Achilles tendon load parameters as a function of footwear temperature.

Notes : * = significant difference

Fig2

Figure 2 Ankle joint kinetics and kinematics as a function of cooled footwear (a. = ankle sagittal angle, b. = ankle sagittal moment, c. = ATF) (black = cooled and grey = non-cooled).

Joint kinematics

No significant (P>0.05) differences in knee joint kinematics were observed. The ankle joint was shown to be significantly (t (11) = 3.62, P<0.05) more dorsiflexed at footstrike in the non-cooled footwear. In addition peak dorsiflexion was significantly (t (11) = 3.77, P<0.05) larger in the non-cooled footwear.

Patellofemoral loads

No significant (P>0.05) differences in patellofemoral loads were shown (Table 1; Figure 1).

Achilles tendon loads

Peak plantarflexion moment was significantly larger (t (11) = 3.25, P<0.05) in the cooled footwear (Table 1; Figure 2b). In addition Achilles tendon load was significantly (t (11) = 3.56, P<0.05) greater in the cooled footwear (Table 1; Figure 2c). Finally the results also confirm that Achilles tendon load rate was significantly larger (t (11) = 2.99, P<0.05) in the cooled footwear (Table 1).

Discussion

The aim of the current investigation was to investigate the effects of different footwear temperatures on the loads experienced by the patellofemoral joint and Achilles tendon. This represents the first investigation to explore the effects of footwear temperature on the specific loads experienced by the musculoskeletal structures during running. The current investigation may provide important investigation to runners regarding the effects of footwear temperature

The first key observation from the current work is that patellofemoral loads were not significantly influenced by alterations in shoe midsole temperature. Patellofemoral pain syndrome is the most common chronic pathology associated with running and is considered to be caused by excessive patellofemoral loading [13].  Therefore importantly it appears based on the findings from the current work that footwear temperature does not appear to affect runner’s susceptibility to patellofemoral disorders.   

However the findings from this investigation did show that Achilles tendon load parameters were shown to be significantly larger in the cooled footwear condition in comparison to the footwear maintained at normal temperature. This observation is in agreement with those of Kulmala et al., [15] and Sinclair, [16] who demonstrated that different midsole characteristics can influence the loads experienced by the Achilles tendon. The increases in Achilles tendon loads may have specific clinical relevance regarding the aetiology of Achilles tendon injuries as the differences exceed the magnitude denoted by the MCID. When loads of high magnitudes are applied to the tendon too frequently in sports such as running, this can lead ultimately to degradation of the tendon itself [21]. Based on these observations it appears that running in cooled footwear places runners at increased risk from Achilles tendinopathy.

It is proposed that this finding is due to the reduced midsole temperature of the cooled footwear. Sinclair et al., [7] found that cooled footwear midsoles offer reduced deformation and shock attenuating properties when compared to those at room temperature. The kinematic observations showed that the ankle position was significantly more plantarflexed in the cooled footwear throughout the stance phase when compared to the non-cooled condition.

This observation has been shown previously as an adjustment that most runners make in response to a increases in footwear or surface stiffness. Increases in ankle plantarflexion are associated with a shortening of the Achilles tendon moment arm, which leads to an increase in the load borne by the tendon itself [19].

A potential limitation of this study is that knee and ankle joint loading was estimated using a musculoskeletal modelling approach. This approach was necessary as direct measures of internal forces require invasive techniques. Nonetheless, the use of net extensor and plantarflexor moments as inputs into the calculation of patellofemoral and Achilles tendon kinetics means that antagonist forces acting in the opposing direction of the joint itself are not accounted for which may ultimately lead to an underestimation of joint loading.

In conclusion, whilst previous investigations have considered the effects of shoe midsole temperature on biomechanical parameters the effect of changing the temperature of the midsole on knee and ankle loading has not been considered. The current investigation addresses this by providing a comparison of patellofemoral and Achilles tendon kinetics when running in cooled and normal temperature footwear. Importantly the current study shows that Achilles tendon loading parameters were significantly greater when running in cooled footwear. First and foremost this study provides further insight into the biomechanical effects of reducing footwear temperature. Furthermore, the current work indicates that running in cooler footwear places runners at greater risk from chronic Achilles tendon pathologies.

References

  1. van Gent, B.R., Siem, D.D., van Middelkoop, M., van Os, T.A., Bierma-Zeinstra, S.S., & Koes, B.B. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. B J of Sport Med 2007 41; 469-480.
  2. Shorten, M.A. (2000). Running shoe design: protection and performance pp 159-169 in Marathon Medicine (Ed. D. Tunstall Pedoe) London, Royal Society of Medicine.
  3. Brückner, K., Odenwald, S., Schwanitz, S., Heidenfelder, J., & Milani, T. Polyurethane-foam midsoles in running shoes-impact energy and damping. Proc Eng 2010 2; 2789-2793.
  4. Knauss, W.G., Emri, I., & Lu, H. (2008). Mechanics of polymers: viscoelasticity (pp. 49-96). Springer US.
  5. Dib, M.Y., Smith, J., Bernhardt, K.A., Kaufman, K.R., & Miles, K.A. Effect of environmental temperature on shock absorption properties of running shoes. Clin J of Sport Med 2005 15; 172-176.
  6. Kinoshita, H., & Bates, BT. The effect of environmental temperature on the properties of running shoes. J App Biomech 1996 12; 25-268.
  7. Sinclair, J., Naemi, R, Chockalingam, N., Taylor, P.J., & Shore, H.F. The effects of shoe temperature on the kinetics and kinematics of running, Footwear Sci 2015 7; 173-180.
  8. Sinclair, J., Edmundson, C.J., Brooks, D., & Hobbs, S.J. Evaluation of kinematic methods of identifying gait events during running. Int J Sports Sci & Eng 2011 5; 188–192.
  9. Cappozzo, A., Catani, F., Leardini, A., Benedeti, M.G., & Della, C.U. Position and orientation in space of bones during movement: Anatomical frame definition and determination. Clin Biomech 1995 10; 171-178.
  10. Sinclair, J., Taylor, P.J., Currigan, G., & Hobbs, S.J. The test-retest reliability of three different hip joint centre location techniques. Mov Sport Sci 2014; 83, 31-39.
  11. Sinclair, J., Hebron, J., & Taylor, P.J. The Test-retest Reliability of Knee Joint Center Location Techniques. J App Biomech 2015 31; 117-121.
  12. Graydon, R., Fewtrell, D., Atkins, S., & Sinclair, J. The test-retest reliability of different ankle joint center location techniques. The Foot and Ankle Online journal, 8, 1-11.
  13. Ho, K.Y., Blanchette, M.G., & Powers, C.M. The influence of heel height on patellofemoral joint kinetics during walking. Gait Posture 2012 36; 271-275.
  14. Bonacci, J., Vicenzino, B., Spratford, W., & Collins, P. (2013). Take your shoes off to reduce patellofemoral joint stress during running. Br J Sports Med. Epub ahead of print: doi:10.1136/bjsports-2013-092160.
  15. Kulmala, J.P., Avela, J., Pasanen, K., & Parkkari, J. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers. Med Sci Sports Exerc 2013 45; 2306-2313.
  16. Sinclair, J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech 2014 29; 395-9.
  17. van Eijden, T.M., Kouwenhoven, E., Verburg, J., & Weijs, W.A. A mathematical model of the patellofemoral joint. J Biomech 1986 19; 219–229.
  18. Powers, C.M., Lilley, J.C., & Lee, T.Q. The effects of axial and multiplane loading of the extensor mechanism on the patellofemoral joint. Clin Biomech 1998 13; 616–624.
  19. Self, B.P., & Paine, D. Ankle biomechanics during four landing techniques. Med Sci Sports Exerc 2001; 33, 1338–1344.
  20. Sinclair, J., Taylor, P. J., & Hobbs, S.J. Alpha level adjustments for multiple dependent variable analyses and their applicability–a review. Int J Sport Sci Eng 2013; 7, 17-20.
  21. Magnusson, S.P., Langberg, H., & Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol 2010; 6: 262–268.

Postoperative analgesic efficacy of dexamethasone sodium phosphate versus triamcinolone acetonide in bunionectomy: A prospective, single-blinded pilot randomized controlled trial

by Chris Olivia Ongzalima1, Wei Lin Renee Lee1, Anh Hoang1, Ming Yi Wong1, Reza Naraghi1*pdflrg

The Foot and Ankle Online Journal 9 (2): 3

Background: Corticosteroids are often administered via injection preoperatively to reduce post-operative inflammation and pain. Despite their wide anecdotal application in clinical practice, there are no current guidelines pertaining to appropriate corticosteroid selection. This study aims to investigate and compare the efficacy of dexamethasone sodium phosphate (DSP) and triamcinolone acetonide (TA) in postoperative pain management following hallux valgus surgery.
Methods: A randomized, prospective, single-blind study comparing preoperative DSP versus TA injections was conducted on 20 participants who were undergoing elective hallux valgus surgery. Postoperative pain scores (pain intensity and pain interference with daily activities) were assessed with Brief Pain Inventory Short Form (BPI-sf) questionnaire at the time of first postoperative oral analgesic consumption or 14 days after surgery if no analgesics were required. Differences in clinically significant pain scores were also assessed with prospectively defined response criteria.
Results: The difference in mean for pain intensity and pain interference were found to be significantly lower for TA group as compared to DSP group (p = 0.006 and p = 0.001) respectively. Significant difference was also observed in the proportion of participants who reported absence of postoperative pain scores between DSP and TA groups (p = 0.025 and p= 0.006) respectively. However, there were no significant differences between time to postoperative analgesia consumption and proportion of participants requiring oral analgesia (p>0.05).
Conclusions: This study provides preliminary evidence suggesting that TA is associated with lower pain scores compared to DSP. Further research is required to establish the effects of TA and DSP in managing postoperative pain following hallux valgus surgery.

Key words: Hallux valgus; Bunionectomy; Corticosteroid; Triamcinolone Acetonide; Dexamethasone Sodium Phosphate; Podiatry; Post-operative; Pain; Analgesics

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0003

1 – School of Podiatric Medicine, Faculty of Medicine, Dentistry and Health Sciences,
The University of Western Australia, Perth, WA, Australia
* Corresponding author: Reza Naraghi  reza.naraghi@uwa.edu.au


Over the decades, pain continues to remain as one of the main postoperative adverse outcomes that cause distress to patients [1-5]. While great advances in the use of medications for postoperative pain control has been made, numerous studies have indicated continued undertreatment of pain [1-5].

A 2003 national survey conducted by Apfelbaum et al. [6] showed evidence of this ineffectiveness in pain management, where approximately 80% of patients who experienced acute pain immediately after surgery.

Of these, 86% described their pain as being moderate to severe in intensity [6]. A recent study conducted by Gan et al. [7] revealed similar findings, illustrating the lack of progress in postsurgical pain management.

Current attempts to reduce post-operative pain include the use of several agents, categorized as opioids and nonopioid analgesics [1,3,4] Amongst these, opioid analgesics are used as the conventional first-line approach to postoperative pain management [2,3]. Its use, however, has been associated with serious adverse effects such as respiratory depression, constipation, sedation and postoperative nausea and vomiting [1,8]. As such, multimodal analgesic regimens that use non-opioid analgesics to facilitate lower dosing of opioids are gradually replacing plain opioid analgesics in postoperative pain management [8]. However, serious systemic side effects associated with multimodal analgesic regimens can still occur. Hence, there is still a need for further reductions in opioid intake.

Corticosteroids are a group of hormones that elicit analgesic effects through phospholipase A2 inhibition [9]. They prevent formation of arachidonic acid and subsequent inflammatory mediators that are responsible for causing inflammation, edema and pain [9]. Its analgesic properties have been well demonstrated in the context of oropharyngeal and maxillofacial surgeries [9-11]. Their value as a therapeutic approach to postoperative pain relief for podiatric surgery is however, not well explored.
The few studies that have reported corticosteroid use in podiatric surgeries have identified dexamethasone sodium phosphate (DSP) to be a frequently administered postoperative analgesic agent [12-15]. DSP, a synthetic and soluble adrenocortical steroid, is a rapid short-acting preparation of dexamethasone that has been profoundly used in conjunction with local anaesthetics to minimize acute pain and inflammation after foot and ankle surgeries [12-15]. A study by Curda [14] demonstrated the effectiveness of DSP-bupivacaine combination over bupivacaine alone in reducing postoperative pain at 24 hours (p < 0.0001) and 4 to 7 days after surgery (p = 0.0004).

Bryant et al. [15] illustrated the opioid sparing effects of DSP by demonstrating a marked reduction in narcotics and oral analgesics intake following DSP injections, as compared to its control. Miller and Wertheimer [13], however, did not find any improvements in postoperative pain outcomes 48 – 72 hours after the use of DSP.

It is to note that the clinical trials described previously were published before year 2000. There is no recent literature which investigates the efficacy of DSP as postoperative analgesia following hallux valgus surgery. Therefore, its effectiveness in reducing pain after podiatric surgery remains debatable. A longer acting corticosteroid which provides extended and uninterrupted pain relief can greatly improve postoperative pain management. Optimal pain relief will in turn minimize patient discomfort, decrease the need for postoperative oral analgesic, facilitate early mobilization and optimize functional recovery [4].

Triamcinolone acetonide (TA), normally formulated as a crystalised suspension, is a relatively insoluble, intermediate acting adrenocortical steroid with a long duration of action [16]. Synergistic use of TA alongside mixture of bupivacaine and epinephrine has demonstrated longer pain relief, better joint mobility and significant opioid sparing effect following knee surgeries compared to the mixture itself [16-20]. The use of TA in podiatric surgery, although popular, has not been investigated.
With the above in mind, further research is required to support the use of corticosteroids in podiatric surgery and determine the most appropriate corticosteroid to alleviate postoperative pain. The aim of this research was therefore to assess and compare the postoperative analgesic efficacy of DSP and TA in participants undergoing hallux valgus surgery. The null hypothesis was that TA would exhibit the same analgesic efficacy as DSP in hallux valgus surgery.

Methods

Ethics

This study was approved by the Human Research Ethics Committee, University of Western Australia, Australia (File Reference: RA/4/1/6631).

Study design and participants

This participant-blinded randomized controlled trial compared the efficacy of DSP with TA in alleviating postoperative pain in participants undergoing hallux valgus surgery, over 14 days. As this pilot study was exploratory in nature and undertaken for feasibility, no sample size calculations were performed. We estimated that 20 participants with similar demographics would represent an adequate sample to inform future trial design and generate appropriate study hypotheses.

Recruitment

From May to December 2014, 20 healthy participants (2 males, 18 females) fulfilling the enrolment criteria and providing informed consent were recruited at the University of Western Australia Podiatric Surgery Clinic. Participants were eligible for the study if they were above 18 years old and undergoing surgical correction of hallux valgus facilitated through the University of Western Australia Podiatric Surgery Clinic. Participants were excluded from the study if they had, 1) cognitive impairment, 2) intellectual disability, 3) physical disability or mental illness, 4) allergy or hypersensitivity to any corticosteroids, 5) systemic viral and fungal infections, 6) allergy or hypersensitivity to paracetamol or codeine, 7) diabetes mellitus, 8) chronic renal failure, 9) inflammatory arthritis and any other forms of immunodeficiency, and 10) taking medications that could interact with DSP or TA at the time of study.

Randomization and blinding

Participants were randomly allocated to receive either DSP (4mg/mL) or TA (10mg/mL). Randomization allocation was prepared using simple randomization coin tossing method prior to participant recruitment. The podiatric surgeon administering the corticosteroids was blinded to the intervention allocation until the day of hallux valgus surgery. Corticosteroid allocation was revealed to the podiatric surgeon by a study investigator prior to the surgery.

The study design was only single-blind due to the difference in solubility of the two corticosteroids, which caused an inevitable color difference that could be detected by the podiatric surgeon during injection. All participants remained blinded to the intervention group assignment.

Corticosteroids

The DSP injection used was DBLTM dexamethasone sodium phosphate (Hospira Inc., Australia), a sterile solution containing 4 mg dexamethasone phosphate, 8 mg creatinine, 10 mg sodium citrate, and water for injections quantity sufficient to 1 ml. The TA used was Kenacort ® -A 10 (Aspen Pharmacare, Australia), a sterile solution containing 10 mg triamcinolone acetonide, 6.6 mg sodium chloride, 15 mg benzyl alcohol, 6.4 mg carmellose sodium, 0.4 mg polysorbate 80, and water for injections quantity sufficient to 1 ml. pH was adjusted using sodium hydroxide and hydrochloride acid for both solutions.

Protocol

The corticosteroid injection was administered to the participants pre-operatively, in combination with 5mL of 0.75% Naropeine. The amount injected was divided equally and infiltrated on the dorsal, medial, plantar and lateral aspects of the first metatarsal, in a Mayo block fashion proximal to the surgical site. The dose injected was based upon previous experiences of the podiatric surgeon and falls within the recommended dose ranges for soft tissue corticosteroid injections. The hallux valgus surgery was then performed following the standard University of Western Australia protocol for Austin bunionectomy.
After the procedure, dressings for the surgical site were applied uniformly by the same surgeon to eliminate the risk of increased postoperative pain secondary to a tighter bandage on one participant than on the other. Participants were also advised to minimize weight-bearing activities to promote healing. All participants were given postoperative oral analgesic medication, which contained the active ingredients paracetamol and codeine, as part of the University of Western Australia Podiatric Surgery Clinic’s standard postoperative care procedure. Participants were encouraged to take the oral analgesic medication when pain was perceived as intolerable. Intolerable pain was defined as pain scores greater than 3/10 on a numerical rating scale (range 0-10).

Table1

Table 1 Primary and secondary outcomes of study.

Outcome measures

The primary outcomes of this study were pain intensity, pain interference with daily activities and presence of clinically significant pain. These postoperative pain scores were assessed using the Brief Pain Inventory-Short Form (BPI-SF) questionnaire. The BPI-SF is a validated, 15-item questionnaire that rates pain over the last 24 hours and the degree to which it interferes with activities on a 0 to 10 scale [21]. In this study, pain severity was measured as worst pain in the last 24 hours (i.e. item 3 of the BPI-SF) and the pain interference score as the mean score of all seven BPI-SF items (i.e item 9A-G) assessing interference of pain with activities of daily living. All measurements were done based on recommendations by Cleeland [22]. For the purpose of pain intensity analyses, the presence of clinically significant pain was defined as a score of 4 or more on BPI-SF item 3, and for the pain interference analyses, as a mean score of 4 or more on the BPI-SF pain interference scale.

Secondary outcomes of this study include time taken to postoperative oral analgesic consumption and proportion of participants requiring postoperative oral analgesia. All secondary outcomes were recorded with a patient logbook and analyzed prospectively as per analysis plan. Primary and secondary outcomes were outlined in Table 1.
Participants were instructed to complete a baseline questionnaire covering demographic information prior to the hallux valgus surgery. The self-administered BPI-SF questionnaire was completed at the time to first postoperative oral analgesic consumption or 14 days after surgery if no postoperative oral analgesics were required. Participants were also instructed to record the date of the first oral analgesic consumed after surgery on logbook. All outcome measures were obtained 14 days after the hallux valgus surgery.

Statistical analysis

All statistical analyses were performed using International Business Machines Statistical Package for the Social Sciences Statistics software version 22.0 (SPSS Inc., Chicago, Illinois).

Demographic and outcome variables were described by using means and standard error of means for continuous variables and percentages for categorical variables by treatment group. The data were explored for normality using the Shapiro-Wilk test prior to inferential analysis.

Two-sample t tests were used to compare between-group differences for age, worst pain level and mean pain interference. Mann-Whitney U test was used to compare time to postoperative oral analgesic consumption. Lastly, Pearson’s chi-squared tests or Fisher’s exact test were used to compare gender, sides, the absence or presence of clinically significant pain and pain interference with daily activities, and proportion of participants who consumed postoperative analgesic medication within each treatment group.

The significance for all tests was set at p-value < 0.05.

Results

Demographics

Between May and December 2014, a total of 20 participants were recruited and randomly assigned to two groups: 10 participants received DSP (Group D) and the remaining 10 received TA (Group T). There were 1 male and 9 female participants in each group, with an average age of 48.2 ± 5.1years in group D and 62.1 ± 4.1 years in Group T. Age difference between group D and T was statistically significant (p = 0.048). There were no significant differences in other baseline demographics between the two treatment groups (P > 0.05) (Table 2).

Table2

Table 2 Clinical demographic details of the study groups.

Table3

Table 3 Mean (SEM) postoperative BPI-SF questionnaire score.

Table4

Table 4 Pain severity and interference with daily activities (absent vs present).

Table5

Table 5 Time (day) to postoperative analgesic medication.

Table6

Table 6 Proportion of participants who consumed postoperative analgesic medication within each treatment group.

Mean pain severity and pain interference

Participants in Group T reported significantly lesser pain level and pain interference level as compared to Group D (p = 0.006 and p = 0.001 respectively) (Table 3). In addition, the mean scores for worst pain and pain interference level observed in Group T were lower than 3, in contrast to Group D, which reported mean values of 4 and above.

Absence and presence of clinically significant pain and interference with daily activities

Greater proportions of participants in Group T reported absence of clinically significant postoperative pain and pain interference compared to Group D (p = 0.025 and p = 0.006 respectively) (Table 4).

Time to postoperative analgesic medication consumption

There were no significant differences between Group T and Group D in the number of days before consumption of analgesia (p = 0.240) (Table 5).

Proportion of participants who consumed postoperative analgesic medication within each treatment group

There were no significant differences between Group T and Group D in the proportion of participants who consumed postoperative analgesics within each treatment group (p=0.136) (Table 6).

Discussion

To our knowledge, the current study represents the first investigation aimed at exploring and comparing the postoperative analgesic efficacy of DSP and TA in hallux valgus surgery. The proposed clinical benefits of TA derived from its insoluble nature was allowing prolonged uptake of TA from its injection site [16-20,23]. As a result, TA remains in tissues for an extended period to provide sustained anti-inflammatory action [16,20,23]. Duration of action of TA is therefore longer than the soluble DSP, lasting up to 2-3 weeks, as compared to only 36-72 hours with soluble DSP. [16,19,20,23,24]
In this pilot study, TA was found to favorably affect measures of postoperative pain symptoms (patient-reported pain severity and mean pain interference with daily activities) in hallux valgus surgery compared to DSP. Notably, more than half of participants in TA group considered the pain severity and interference with daily activities to be not clinically significant. This observation is in contrast with the effects of DSP, where more than half of the participants reported clinically significant pain and pain interference with daily activities (Table 4). These results suggest that postoperative oral analgesic medication may not be required when using TA in hallux valgus surgery. On the other hand, its use may be required when using DSP.

Although the effect of TA has not been investigated in previous podiatric literatures, there are evidences that TA can substantially decrease pain scores, postoperative oral analgesic intake, and improve range of motion post-operatively following knee surgeries. Wang et al. [16] found that TA could provide significant pain relief 6 to 24 hours post-operatively (p<0.05 to p<0.01) as compared to placebo. In addition, none of the patients from TA group required rescue analgesia as compared to 53% of patients from the placebo group (p <0.001). Pang et al. [19] found significant reductions in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and better range of motion of knee (p = 0.023 at three months) post-operatively in patients receiving TA, compared to a control group without TA. Kwon et al. [17] reported lower pain intensity in TA group immediately (p= 0.021) and for up to 7 days post operatively (p>0.05) following knee arthroplasty. This finding was accompanied with earlier functional recovery (p=0.013) as compared to the control group. Therefore, our findings support the hypothesis that a longer acting corticosteroid can provide adequate, extended and uninterrupted pain relief.

Although TA achieved greater reductions of postoperative pain when compared to DSP, no significant differences were observed between DSP and TA in the time to postoperative oral analgesic consumption and proportion of participants requiring postoperative analgesia. Several possible explanations exist as to why the results were inconsistent. Even though a longer duration of action was observed in TA group compared to DSP as represented by extended time to postoperative oral analgesia, the mean difference of 3 days does not justify the theoretical duration of action of TA (14-21 days). Most participants receiving TA were seen to administer postoperative oral analgesic medications on postoperative day 0 or day 1 despite adequate analgesia (pain scores lesser than 4). One probable reason for the pre-emptive administration of oral analgesics is the fear of pain, thus the use of oral medication prophylactically as a preventative measure rather than a pain relief. Individual differences in pain sensitivity must also be considered as plausible contributing factor. Lastly, the theorized duration of action of TA might not be adequately demonstrated when injected in small quantities around the hallux.

All of the above factors can in turn correlate with the overall increase in the proportion of participants who consumed postoperative oral analgesics. The null hypothesis that TA would exhibit the same analgesic efficacy as DSP in hallux valgus surgery was therefore partially rejected.

The relationship between age and intensity of postoperative pain remains controversial. Our study showed significant difference in age group between the two treatment arms. While several studies have suggested higher postoperative pain in a younger age population [25,26], some have failed to show any correlation [27-30]. Gagliese et al. [29] had proposed that the controversy may be secondary to a series of confounding factors which indirectly affect pain intensity across age groups. Nonetheless, all of the studies mentioned above included a wide variety of surgeries under their methodologies which can contribute to multiple confounders. In addition, there is no current literature which identifies age as a predictive factor for postoperative pain following foot and ankle surgery.

On a side note, many participants reported taking other pain-relief medications during intervention period rather than the recommended oral analgesics. Upon further investigation, opioid-related side effects such as nausea, vomiting and constipation were identified to be the main reasons associated with noncompliance. While these findings did not affect study outcomes, they correlate to previous literatures which highlighted the importance of non-opioid analgesia to improve quality of postoperative recovery [1,3,8]. Therefore, future efforts require better study designs to enable a more accurate assessment and comparison of opioid sparing effect between the two corticosteroids.
The findings of this study should be interpreted in light of its limitations. Firstly, the absence of a placebo group in this study is a limitation, but withholding analgesia for a painful procedure raises ethical concerns. Secondly, the small study population limited the power and reliability to detect the mean differences between the corticosteroids. Further studies using larger sample sizes are therefore warranted.

Thirdly, as inter-participant comparison of the two corticosteroids was done in this study, individual participant tolerance to pain was a variable and pain scores might not accurately reflect the general population.  In order to increase the accuracy of the study, intra-participant comparison of the two corticosteroids should be conducted. We propose preoperative administration of different corticosteroids on each foot for patients with bilateral hallux valgus to minimize inter-participant variables. The sex ratio of the participants in this study was strongly skewed towards the female gender. Therefore, results obtained may possess certain biases towards female patients. We suggest the use of a sample size with equal sex ratio to counter this problem. Lastly, due to time constraints, we were unable to investigate for any possible long-term side effects associated with corticosteroid use. As such, we propose having a longer follow-up duration in future studies to explore into the probability of these complications.

Conclusion

This is the first randomized, prospective, single-blind pilot study investigating and comparing the postoperative analgesic efficacy of DSP versus TA in hallux valgus surgery. In this study, TA was associated with lower pain severity and pain interference scores compared to DSP, suggesting its use as a promising postoperative analgesia in relieving pain following hallux valgus surgery. However, large, adequately powered studies are needed before the effects of TA and DSP in hallux valgus surgery can be established definitively.

Abbreviations

DSP: Dexamethasone sodium phosphate; TA: Triamcinolone acetonide; BPI-SF: Brief Pain Inventory-Short Form

Acknowledgements

The authors acknowledge Professor Alan Bryant for his help in performing hallux valgus surgeries and Dr Andrew Knox for his assistance throughout the study.

References

  1. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med 2010 Mar; 83(1):11-25. (PubMed)
  2. Sinatra R. Causes and consequences of inadequate management of acute pain. Pain Med 2010 Dec; 11(12):1859-71. (PubMed)
  3. Shoar S, Esmaeili S, Safari S. Pain management after surgery: a brief review. Anesth Pain Med 2012 Jan; 1(3):184-6. (PubMed)
  4. Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol 2014 Jun; 28(2):191-201. (http://www.ncbi.nlm.nih.gov/pubmed/24993439)
  5. Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet 2011 Jun; 377(9784):2215-25. (PubMed)
  6. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Post-operative Pain Experience: Results from a National Survey Suggest Post-operative Pain Continues to Be Undermanaged. Anesth Analg 2003 Aug; 97(2):534-40. (PubMed)
  7. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin 2014 Apr; 30(1):149-60. (PubMed)
  8. White PF. The Changing Role of Non-Opioid Analgesic Techniques in the Management of Post-operative Pain. Anaesth Analg 2005 Nov; 101(5):5-22. (PubMed)
  9. Buland K, Zahoor MU, Asghar A, Khan S, Zaid AY. Efficacy of Single Dose Perioperative Intravenous Steroid (Dexamethasone) for Postoperative Pain Relief in Tonsillectomy Patients. J Coll Physicians Surg Pak 2012 Jun; 22(6):349-52. (PubMed)
  10. Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal antiinflammatory medication for the management of pain and inflammation after third molar surgery: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 May; 107(5):630-40. (PubMed)
  11. Gao W, Zhang QR, Jiang L, Geng JY. Comparison of Local and Intravenous Dexamethasone for Postoperative Pain and Recovery after Tonsillectomy. Otolaryngol Head Neck Surg 2015 Mar; 152(3):530-5. (PubMed)
  12. Salerno A, Hermann R. Efficacy and Safety of Steroid Use for Post-operative Pain Relief. Update and Review of the Medical Literature. J Bone Joint Surg Am 2006 Jun; 88(6):1361-72. (PubMed)
  13. Miller SL, Wertheimer SJ. A comparison of the efficacy of injectable dexamethasone sodium phosphate versus placebo in post-operative podiatric analgesia. J Foot Ankle Surg 1998 May-June; 37(3):223-6. (PubMed)
  14. Curda GA. Post-operative analgesic effects of dexamethasone sodium phosphate in bunion surgery. J Foot Surg 1983; 22(3):187-91. (PubMed)
  15. Bryant A, Marino N, Tinley P. The efficacy of injectable dexamethasone sodium phosphate in reducing the need for post-operative pain medication following podiatric surgery. Aus J Pod Med 1999; 33:117-21.
  16. Wang JJ, Ho ST, Lee SC, Tang JJ, Liaw WJ. Intraarticular triamcinolone acetonide for pain control after arthroscopic knee surgery. Anesth Analg 1998 Nov; 87(5):1113-6. (PubMed)
  17. Kwon SK, Yang IH, Bai SJ, Han CD. Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty. Yonsei Med J 2014 Mar; 55(2):493-8. (PubMed)
  18. Sean VW, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singapore Med J 2011 Jan; 52(1):19-23. (PubMed)
  19. Pang HN, Lo NN, Yang KY, Chong HC, Yeo SJ. Peri-articular steroid injection improves the outcome after unicondylar knee replacement: a prospective, randomised controlled trial with a two-year follow-up. J Bone Joint Surg Br 2008 June; 90(6):738-44. (PubMed)
  20. Chia SK, Wernecke GC, Harris IA, Bohm MT, Chen DB, Macdessi SJ. Peri-articular Steroid Injection in Total Knee Arthroplasty: A Prospective, Double Blinded, Randomized Controlled Trial. J Arthroplasty 2013 Apr; 28(4):620-3. (PubMed)
  21. Cleeland CS. The Brief Pain Inventory User Guide. Texas: The University of Texas, MD Anderson Cancer Centre; 2009. Available from: Link
  22. Cleeland CS. Measurement and prevalence of pain in cancer. Semin Oncol Nurs 1985 May; 1(2): 87-92. (PubMed)
  23. Stephens MB, Beutler AL, O’Connor FG. Musculoskeletal Injections: A review of the Evidence. Am Fam Physician 2008 Oct; 78(8):971-6, 2008. (PubMed)
  24. Ikeuchi M, Kamimoto Y, Izumi M, Fukunaga K, Aso K, Sugimura N, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014 Jul; 22(7):1638-43. (PubMed)
  25. Gramke HF, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Sommer M, et al. Predictive Factors of Postoperative Pain After Day-case Surgery. Clin J Pain 2009 Jul-Aug; 25(6):455-60. (PubMed)
  26. Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, et al. Predictors of acute postoperative pain after elective surgery. Clin J Pain 2010 Feb; 26(2):87-94. (PubMed)
  27. Roth ML, Tripp DA, Harrison MH, Sullivan M, Carson P. Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Res Manag 2007; 12(3):185-94. (PubMed)
  28. De Cosmo G, Congedo E, Lai C, Primieri P, Dottarelli A, Aceto P. Preoperative Psychologic and Demographic Predictors of Pain Perception and Tramadol Consumption Using Intravenous Patient-controlled Analgesia. Clin J Pain 2008 Jun; 24(5):399-405. (PubMed)
  29. Gagliese L, Gauthier LR, Macpherson AK, Jovellanos M, Chan VW. Correlates of Postoperative Pain and Intravenous Patient-Controlled Analgesia Use in Younger and Older Surgical Patients. Pain Med 2008 Apr; 9(3):299-314. (PubMed)
  30. Mamie C, Bernstein M, Morabia A, Klopfenstein CE, Sloutskis D, Forster A. Are there reliable predictors of postoperative pain? Acta Anaesthesiol Scand 2004 Feb; 48(2):234-42. (PubMed)

Lisfranc-like injury involving lateral tarsometatarsal joints: a case report

by Mir Tariq Altaf1*, Muhammad Haseeb2, Varun Narula3, Aakash pdflrgPandita4

The Foot and Ankle Online Journal 9 (2): 2

Lisfranc injuries or fracture-dislocation of tarsometatarsal joints are uncommon injuries. Isolated involvement of lateral tarsometatarsal joints is very rare. We present a case of plantar disruption of cuboid – fourth and fifth metatarsal joints in a 16yr old boy following a vehicular accident with injuries to head and left foot. A standing AP & lateral radiograph of left foot was suggestive of disruption of cuboid-4th/5th metatarsal joints with plantar displacement. Evidence of head injury on CT scan of head took precedence over foot injury. Patient was managed conservatively for foot injury. Patient made a reasonable recovery by conservative means only. This is an unusual case as there was an isolated lateral tarsometatarsal joint involvement. In addition, the displacement was plantar, whereas in isolated lateral Lisfranc injuries, the displacement usually is dorsal. Lisfranc-like injuries involving lateral tarsometatarsal joints are very rare. These injuries can be easily missed. Strong clinical suspicion and proper investigations are needed to diagnose these subtle injuries.

Key words: Lisfranc joint, lateral tarsometatarsal joint

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0002

1* – DNB Orthopedics trainee, Center for Bone and Joint, Kokilaben Dhirubhai
Ambani Hospital, Four Bungalows, Andheri West, Mumbai-400053, India. mirtariqaltaf@gmail.com
2 – MS Orthopedics, Government Medical College, Bakshinagar, Jammu-180001, India.
3 – DNB Orthopedics trainee, Center for Bone and Joint, Kokilaben  Dhirubhai Ambani Hospital, Four Bungalows, Andheri West, Mumbai-400053, India.
4 – MD Pediatrics, Government Medical College, Bakshinagar, Jammu-180001, India.


The spectrum of tarsometatarsal joint injuries (Lisfranc injuries) encompasses stable sprains to clinically apparent grossly unstable deformities. It is important to recognise and treat these injuries early and aggressively for best results. There are several variations from the classic injury patterns, and we present one such variant. This case report describes a lateral tarsometatarsal disruption with neither diastasis between first & second metatarsals nor injury to first, second & third tarsometatarsal joints. Dislocations of lateral tarsometatarsal joints are rare and are almost always dorsal. To the best of our knowledge only one such case has been reported in literature before.

Case History

A 16-year-old boy had a road traffic accident sustaining injury to the head and left foot. The patient reported to our emergency department with pain and swelling of left foot (Figure 1). Lateral tarsometatarsal joints were exquisitely tender to palpation, whereas no tenderness could be elicited over the medial tarsometatarsal joints. There were no clinical signs or  symptoms of head injury. A neurosurgery consultation was sought as per our trauma protocol. Patient underwent CT scan of the head along with standing anteroposterior and lateral radiograph of left foot (Figure 2). The radiograph of the foot revealed lateral tarsometatarsal joint disruption with plantar dislocation. The patient was given a short-leg posterior slab initially along with analgesia.

Fig1

Figure 1 Clinical photo on admission.

Fig2

Figure 2 Radiographs on admission.

CT scan of the head was suggestive of depressed fracture of right frontal bone with extradural hematoma with pneumocephalus. Patient was referred to an outstation neurosurgical center for further management of the head injury. There the foot injury was neglected. Patient was cleared after 2 weeks from neurosurgery. At 2-weeks follow-up, probable nature of foot injury, diagnostic modalities available, its severity and morbidity, treatment options available and complications associated were discussed with relatives and the patient. Respecting patient’s decision, no further confirmatory investigations were undertaken and conservative treatment was continued. The posterior slab was changed into a cast. Regular follow-up radiographs were taken which revealed satisfactory recovery (Figure 3).

Fig3

Figure 3 Follow-up radiographs at 3 months.

Fig4

Figure 4 Clinical photo at last follow-up.

Discussion

‘Lisfranc joint’ refers to the medial articulation of first and second metatarsals with medial cuneiforms and ‘Lisfranc joint complex’ refers to tarsometatarsal articulations. It derives its name from Jacques Lisfranc, a French field surgeon in Napoleon’s army, who was the first to describe amputations through this joint. Fractures and dislocations of tarsometatarsal joints are frequently overlooked or misdiagnosed because of variations in the pattern of injury and clinical presentation. Road traffic accidents are the most common cause of Lisfranc fracture dislocations, while twisting injury to the foot is the most common cause for simple dislocation without fracture [1]. Clinical suspicion and radiographic evaluation is crucial in the diagnosis and treatment of this injury.

If possible at the time of presentation, weight-bearing films of the foot in anteroposterior, lateral and 30-degree medial oblique position should be obtained. Because of the possibility of spontaneous reduction in these injuries, non-weight-bearing films provide no loading of the ligaments to test their integrity [2]. In some cases, computed tomography scans and magnetic resonance imaging may be necessary to detect comminution and subtle malalignment.  Chiodo and Meyerson classified the tarsometatarsal joint injuries according to columnar theory emphasizing the motion segments of mid-foot [3]. According to this classification, metatarsals within a column function as a unit. They concluded that it is unusual for one (fourth metatarsal) to dislocate while the other (fifth metatarsal) remains in anatomic position. This was demonstrated in our patient too. Lisfranc injuries are associated with high potential for chronic disability, so precise anatomical reduction is a must either by closed or open methods [4]. The literature is divided over specific recommendations for treatment of these subtle injuries [5]. In our case, though surgical treatment would have been ideal, conservative treatment was undertaken with cast immobilization and strict non-weightbearing for 6 weeks, followed by removal of the cast and partial weight bearing with the help of a cane for another 4 weeks. Full weight bearing was allowed at 10 weeks. Return to sports and other high demanding activities was allowed at 12 weeks. Patient used to get swelling in the foot after walking a distance of more than a mile and running for one-half mile. Ipsilateral ankle range of motion was comparable to the normal side at last follow up of 9 months. Result of such treatment in our case was malunion with acceptable functional disability.

We used clinical judgement and stress radiographs only to rule out associated medial joint (lisfranc joint) involvement, although stress radiographs at best have a sensitivity of 85% but we were restrained by patient refusal for further investigations like MRI.

Our case is unique because the frequency of such injuries is very low.

Conclusion

Lisfranc-like injuries involving lateral tarsometatarsal joints are very rare. These injuries can be easily missed. There is scarcity of literature on treatment of these injuries. Further studies in future are warranted on these rare injuries. These injuries, however, don’t seem to have unacceptable results with conservative modality of treatment.

References

  1. Jeffreys T. Lisfranc`s fracture-dislocation. J Bone Joint Surg Br. Aug. 1963;45:546-51. (Pubmed)
  2. Faciszewski T, Burks R, Manaster B. Subtle injuries of Lisfranc joint. J Bone Joint Surg Am. 1990;72:1519-22. (Pubmed)
  3. Chiodo CP, Meyerson MS. Developments and advances in diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am. 2001;32:11-20. (Pubmed)
  4. Mann R, Prieskorn D, Sobel M. Midtarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996 Sep;78:1376-85. (Pubmed)
  5. Goossens M, De Stoop N. Lisfranc fracture dislocation: etiology, radiology, and results of treatment. A review of 20 cases. Clinic Orthop Relat Res. 1983;176:154-62. (Pubmed)

Modified Scarf osteotomy for treatment of hallux valgus

by Saad R. El Ashry1, M. S. Sidhu2*, Abhay Tillu3pdflrg

The Foot and Ankle Online Journal 9 (2): 1

With over a hundred described surgical procedures for the management of hallux valgus, it is the purpose of this article to describe a new technique – the modified scarf osteotomy. This technique involves the combined use of a “closing wedge’’, with the original two individual cut features of the scarf osteotomy in the surgical correction of hallux valgus. It has been performed for 24 months, and retrospective analysis of the last 12 patients, found it to be an effective means to improve the distal metatarsal articular angle (DMAA) at mean 7°, whilst also improving functional outcome by way of the American Orthopaedic Foot and Ankle Society (AOFAS) score at mean 31.4.

Key words: Hallux valgus, DMAA, Scarf, AOFAS

ISSN 1941-6806
doi: 10.3827/faoj.2016.0902.0001

1 – Registrar, FRCS(Tr-Orth), Sandwell and West Birmingham Hospitals NHS Trust, UK
2* – Registrar, MRCS, Royal Orthopaedic Hospital Birmingham, UK, Manpreet.sidhu@doctors.org.uk
3 – Consultant, FRCS, Sandwell and West Birmingham Hospitals NHS Trust, UK


Hallux valgus is one of the most common forefoot deformities, most commonly affecting females between the ages of 20-64 [1]. Presenting with discomfort, pain and affecting patients’ day-to-day activities, it is a common cause for referral to the foot surgeon. Surgical correction of the condition comprises a variety of different procedures. The author describes a Modified Scarf Osteotomy, which has been used over the last 24 months to create a “closing wedge” within the first metatarsal, to improve both the patient’s distal metatarsal articular angle (DMAA), and American Orthopedic Foot and Ankle Society (AOFAS) score – a proven demonstrator of functional outcome [2].

The treatment of hallux valgus using a scarf osteotomy is well described in the literature, and a well understood procedure to correct the DMAA [3].  The DMAA defines the relationship of the articular surface of the distal metatarsal to the longitudinal axis of the first metatarsal.

The scarf osteotomy is a technically demanding procedure with a steep learning curve [4]. It was initially described in 1926 by Meyer who published an operative technique that included a diaphyseal Scarf-like osteotomy of the first metatarsal bone for hallux valgus correction [3,5]. While the surgical technique of an articular preserving Scarf osteotomy for forefoot management was described in detail by Barouk [6].

Nyska et al evaluated the change in position of the first metatarsal head using saw-bone models [7]. They observed that Scarf osteotomy provided less angular correction and shortening but similar lateral displacement in comparison to the basilar angular osteotomies and Ludloff osteotomy [8,9], angular correction is best brought about by rotation of the z-wing. They concluded that Scarf osteotomies are more reliable for patients with mild to moderate deformities, a short first metatarsal or an intermediate deformity with large DMAAs.

79899673

Figure 1 Exposure of the first metatarsal head.

Methods

The original z-scarf osteotomy comprises of two individual cuts – a proximal dorsal fragment, and a plantar fragment – and it is this plantar fragment, which notably comprises the metatarsal head. Two transverse cuts, around 60 degrees to the longitudinal are then performed to create a double chevron.

The author describes a method, whereby medial wedges are cut from the distal and proximal cuts of the scarf osteotomy. After the routine cuts for scarf osteotomy are performed, 2 mm of bone is then cut to form a “closing wedge” from the proximal and distal transverse cuts. This affords the benefit of simultaneous correction of a range of angles, including the DMAA, the intermetatarsal angle (IMA) and the hallux valgus angle (HVA).  

79899673

Figure 2 Z-cut and medial wedging of scarf osteotomy.

8898993

Figure 3 Medial wedging of Scarf osteotomy.

5011907283064730

Figure 4 Pre-op and post-op radiographs displayed on computer system GE CentricityTM, to highlight the DMA, IMA and, HVA respectively.

Results

Over a 6 month period, 12 patients, all female, with an average age of 52 years underwent surgery with the above mentioned modified scarf osteotomy using a closing wedge. The AOFAS score was completed pre-operatively and 6 months post procedure, at these intervals antero-posterior radiographs of the patients were also studied. The results are demonstrated in the table below.

N=12 Pre-operative Post-operative
AOFAS score (mean) 50.3 81.7
DMAA(degrees) (mean) 19.3 12.3

Table 1 Pre- and post-operative results of modified scarf osteotomy.

Discussion

Recurrent hallux valgus deformity is probably the most frequent complication of bunion surgery. Recurrence of the deformity can be associated with failure to correct the DMAA [10,11].

Different techniques have been described in the literature to correct the DMAA. A rotational scarf osteotomy is a modification of the traditional scarf osteotomy also has the advantage of decreasing troughing which is a known complication of scarf osteotomy [12]. Another technique using mini-external fixator to correct the DMAA was described by Oznur in 2006 [13].

Our technique is another modification of the traditional scarf osteotomy. All 12 patients had an improved AOFAS score, with a mean improvement of 31.4. All 12 also demonstrated an improvement in the DMAA, with a mean improvement of 7°. Of the 12 patients, none said they regretted undergoing the procedure.

This modified scarf with closing wedges as described, allows for the simultaneous correction of the DMAA, IMA and HVA. It is a simple and effective technique to reproduce, which delivers good outcomes.

References

  1. Nguyen US, Hillstrom HJ, Li W, et al. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthr Cartil. 2010;18(1):41-6.
  2. Thordarson D, Ebramzadeh E, Moorthy M, Lee J, Rudicel S. Correlation of hallux valgus surgical outcome with AOFAS forefoot score and radiological parameters. Foot Ankle Int. 2005;26(2):122-7.
  3. Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int. 2002;23(3):221-9.
  4. Weil LS. Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results. Foot Ankle Clin 2000; 5: 559–580
  5. Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br. 2004;86:830–6
  6. Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000;5:525–58.
  7. Nyska M, Trnka HJ, Parks BG, Myerson MS. Proximal metatarsal osteotomies: a comparative geometric analysis conducted on sawbone models. Foot Ankle Int. 2002;23:938–45.
  8. Mau H. Hallux valgus. Dtsch Med Wochenschr. 1971;96:1144.
  9. Cisar J, Holz U, Jenninger W, Uhlig C. Ludloff’s osteotomy in hallux valgus surgery. Aktuelle Traumatol. 1983;13:247–9.
  10. Coughlin MJ, Carlson RE. Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle Int. 1999;20(12):762-70.
  11. Coughlin MJ. Surgery of the Foot and Ankle. St. Louis : Mosby, c1999; 1999. pp150 – 269.
  12. Murawski CD, Egan CJ, Kennedy JG. A rotational scarf osteotomy decreases troughing when treating hallux valgus. Clin Orthop Relat Res. 2011;469(3):847-53.
  13. Oznur A. Technical Tip: mini-fixator assisted correction of DMAA in hallux valgus surgery. Foot Ankle Int. 2006;27(10):849-50.