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The Role of High Resolution Ultrasonography in Detection of Neglected or Missed Radiolucent Foreign Body in Foot and Ankle Region

by Reyaz Ahmad Dar (MS)1emailsm, Mubashir Maqbool Wani (MS)2emailsm, pdflrgMubashir Rashid Beig (MS)1, Muzaffer Ahmad Ganaie (MS)1

The Foot and Ankle Online Journal 6 (3): 2

A prospective case series was undertaken to assess the role of high resolution ultrasonography to detect radiolucent foreign bodies in the foot and ankle region. Out of 30 suspected foreign bodies, ultrasonography was able to detect 28 foreign bodies with 2 false negatives. The overall sensitivity was 93.33%. The false negatives were attributed to the foreign body being obscured by bone.

Key words: , foot, ankle, ultrasound,

Accepted: February, 2012
Published: March, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0603.002


Address correspondence to: Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018

1Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018
2Hospital for bone and joint surgery Barzulla Srinagar Kashmir India – Pin 190005


Missed or neglected foreign body and subsequent complications in the extremities is a challenging complaint in the orthopedic outpatient department. Most of these cases present with soft tissue mass, granuloma, abscess, corns, osteomyelitis, fasciitis, cellulitis, chronic discharging sinus, and tendon contracture with or without pain.[1,2,3] The initial investigation is usually done with a plain radiograph, which however, cannot detect radiolucent foreign bodies such as those of wood, plastic and rubber.

Of the other imaging modalities, xeroradiography provides better edge enhancement, but it requires special equipment and is inadequate in detecting radiolucent foreign bodies.[4,5]

Computerized tomographic (CT) scan has the ability to detect the radiolucent foreign bodies with limitations of ionizing radiation, cost and poor sensitivity in detecting small foreign bodies.[6,7] Magnetic Resonance Imaging (MRI) can detect radiolucent foreign bodies but has the limitations of being inaccessible, expensive, and a concern regarding magnetic foreign bodies as well as time consuming.

USFBFig1 USFBFig2

Figure 1 and Figure 2 High-resolution ultrasound of a foot suspected of having a foreign body.

There is an added disadvantage of not detecting foreign bodies with low signal intensity from tissues such as scar tissue, tendon and calcifications.[8,9] Sonography, on the other hand, is easily accessible, inexpensive and a time saving image modality.

We undertook our study on thirty patients who presented to our outpatient department at two hospitals with a definite history of foreign body injury to the foot and ankle region. Patients presented with varied signs and symptoms which included pain, soft tissue mass, abscess, corn, chronic discharging sinus with duration of symptoms ranging from four months to eight years.

Most of these patients were initially managed by primary care givers and missed or often self treated themselves removing only a part of foreign body and subsequently neglected. Our aim was to assess the role of foreign body detection in these patients with high resolution ultra sonography (USG).

Materials and Methods

Thirty symptomatic patients who had a definite history of foreign body injury of the foot and ankle region were included in this study. The symptoms of these patients varied from simple pain to chronic discharging sinus and all had a normal plain radiograph. All of them underwent high resolution ultra sonography of the affected part followed by surgical exploration.

Sonography was conducted by four specialist doctors who had a minimum of four years of experience in the radiology department. Sensitivity of USG was determined with respect to that found on surgical exploration.

Results

Thirty consecutive patients presented to our outpatient departments from May 2008 to May 2012 with history of foreign body injury. Patients presented with persistent pain, soft tissue mass, granuloma, abscess or chronic discharging sinus with a normal radiograph. Nineteen patients were male. Twenty two patients were younger than twenty years of age. Twenty eight patients had symptoms in the foot; two had symptoms in the ankle region. Twenty three patients had a history of nail insertion in the foot through a rubber sole. There was thorn injury in six patients with five having it in the foot and one in the ankle region. One patient had injury to the ankle with a wood. Three patients had multiple surgical interventions for chronic discharging sinuses.

All these patients were sent to radiology for the high resolution ultra sonography of the affected part. In all our cases a frequency of 7.5 MHz to 13 MHz was employed. Foreign bodies were reported as hyperechoic masses with surrounding hypo echoic rim with an acoustic shadow in twenty eight patients (Fig. 1 and Fig. 2).

USFBFig3

Figure 3 Foreign body seen at the time of surgery.

Two patients which were reported negative had chronic discharging sinus with one having it on the lateral malleolus and another on the dorsal aspect of the foot. All patients underwent surgical exploration under general or regional anaesthesia with tourniquet control. Preoperative methylene blue injection into the sinus was used in three patients with chronic discharging sinus. Foreign bodies were recovered from all the patients (Fig. 3 and Fig. 4). Two patients who were labeled by the sonologist of not having a foreign body had foreign bodies close to or obscured by the bone. One of the patients had injury to the right lateral malleolar area with a wooden foreign body with persistent sinus discharge, and on exploration the foreign body was found very close to and abutting the cortex. Another patient had a history of nail insertion through the sole of the shoe with persistent sinus discharge on the planter aspect of the foot, and on surgical exploration a piece of rubber was found abutting the second metatarsal shaft cortex on the dorsal aspect. Out of the total thirty suspected radiolucent foreign bodies, high resolution ultra sonography was able to detect the foreign body in 28 patients with two false negatives with an overall sensitivity of 93.33%.

USFBFig4

Figure 4 Foreign body after removal.

Discussion

The basic principle of ultra sound is the use of a transducer to penetrate tissues with ultrasonic waves at various frequencies. When the wave strikes the denser component of tissue, they bounce (echo) back to the transducer. The ultrasound can then interpret the speed and intensity of the sound wave to determine the location and composition of the object. Structures are plotted on the screen based on their depth and location relative to the transducer. Superficial structures are plotted at the top and deeper ones at the bottom of the screen. The larger the surface area toward the transducer the greater it will reflect. Sonographic features of the foreign bodies in the soft tissues have three components. Firstly, the appearance of the foreign body; secondly, the changes in the soft tissues surrounding the foreign bodies. Thirdly, the appearance of soft tissues distal to the foreign bodies.

All foreign bodies on ultrasonography appear as hyperechoic foci. The reflectivity depends on acoustic impedance of the foreign body which in turn varies with the density of the object. In general, metal, mineral, glass, wood, and rubber reflect sound, appearing white on the screen. The changes surrounding the foreign bodies are due to inflammatory reaction which may range from edema to abscess formation.

This reaction takes some time to develop and is shown as hypo echoic rim around the foreign body. Distal to the echo rich foreign body acoustic shadowing is noted. This is due to failure of the ultrasound to pass through the foreign body.[10,11]

Despite their size, foreign bodies are no small matter. When left untreated they cause pain, swelling, infection, nerve and tendon injury.[2,3,12] Although USG has been a well-established diagnostic tool for foreign bodies in the soft tissues, it has been underutilized in this part of the world. While evaluating the usefulness of USG in the detection of unsuspected foreign bodies followed by CT, MRI, bone and labeled red cell Scintigraphy, it has been found that the later investigations added no relevant information and were time consuming and costly.[12] The sensitivity of USG in detecting different foreign bodies has been reported to be 70% to 100%. Cases which turned out to be false negatives had either a very deep foreign body, gas around foreign body, or a foreign body too close to the bone [8,13,14,15] as was the case in two of our patients.

Several studies have demonstrated the effectiveness of USG in detecting non-opaque foreign bodies in the soft tissues. The power of USG is as important as the depth of penetration of wave into soft tissues. The shorter wave length with high frequency penetrates less as most of energy is absorbed by the medium.[15] The authors do not believe that the results could be different if the USG was done by the same radiologists. Differences in the comparative accuracy, sensitivity and specificity of foreign body detection by radiologist and USG technician has not been found to be statistically significant in the previous studies.[16]

Conclusion

The authors do not recommend replacing plain radiography with ultrasonography in the evaluation of suspected foreign bodies of the foot and ankle region. But Sonography should definitely be considered part of diagnostic work up of patients in whom we strongly suspect the presence of radiolucent foreign bodies based on history and symptomatology.

References

  1. Lammers RL. Soft issue foreign bodies. Ann Emerg Med 1987 17:1336-1346.[PubMed]
  2. Dhar SA, Dar TA, Sultan A, , Butt MF, Mir MR, Kawoosa AA, Farooq S. Delayed manifestations of the nail –slipper injury. Chir Organi 2009 93 149-153.[PubMed]
  3. Dar TA, Sultan A, Hussain S, Dhar SA, Ali MF. Contracture of the third toe as delayed manifestation of foreign body in the foot. Foot Ankle Specialist 2011 4: 298-300. [PubMed]
  4. Anderson MA, Newmeyer WL, Kilgore Jr ES. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1992 144: 63-65. [PubMed]
  5. Flom LL, Ellis GL. Radiologic evaluation of foreign bodies. Em Med Clinics North Am 1992 10 163-177. [PubMed]
  6. Russell RC, Williamson DA, Sullivan JW, Suchy H, Suliman O. Detection of foreign bodies in hand. J Hand Surg 1991 16A: 2-11. [PubMed]
  7. Mizel MS, Steinmetz N, Trepman E. Detection   of wooden foreign bodies in the muscle tissue: experimental comparison of computerized tomography, magnetic resonance imaging and ultra sonography. Foot Ankle 1994 15: 437-443. [PubMed]
  8. Tedric D. Boyce, David P. Fessell, Jon A. Jacobson. Lin J, van Holsbeeck MT, Hayes CW. Foreign bodies and associated complications with surgical correlation. Radiographics 2001 21:1251-1256. [PubMed]
  9. Jon A. Jacobson, Powell A, Craig JG, Bouffard JA, van Holsbeeck MT. Wooden foreign bodies in soft tissues. Radiology 1998 206: 45-48. [PubMed]
  10. Lisa D Mills, Christy Butts. Capturing elusive foreign bodies with ultrasound. Emergency Medicine 2009 36-42. [Website]
  11. Banerjee B, Das RKD. Sonographic detection of foreign bodies in the extremities.  Brit J Radiology 1991 64: 107-112. [PubMed]
  12. Soudack M, Nachtigal A, Gaitini D. Clinically unsuspected foreign bodies, The importance of sonography. J Ultrasound Med 2003 22:1381-1385.[PubMed]
  13. Crankson S, Oratis P, Al Mazaid G. Ultrasound in the diagnosis and treatment of wooden foreign bodies in the foot. 2004 Ann Soudi Med 24. [PubMed]
  14. Lyon M, Brannam L, Johnson D, Blaivas M, Duggal S. Detection of soft tissue foreign bodies in the presence of soft tissue gas. J Ultrasound Med 2004 23: 677-681. [PubMed]
  15. Turkcuer I, Atilla R, Topacoglu H, Yanturali S, Kiyan S, Kabakci N, Bozkurt S, Cevik AA. Do we really need plain and soft tissue radiography to detect radiolucent foreign bodies in the ED. American Journal of emergency medicine. 2006 24: 763-768. [PubMed]
  16. Orlinsky M, Knittel P, Feit T, Chan L, Mandavia D. The comparative accuracy of foreign body detection using ultrasonography. Am J Emerg Med 2000 18: 401-403. [PubMed]

Malignant Fibrous Histiocytoma of the Ankle: A Case Report

by Katherine Neiderer, DPM, MPH1, Jodi Walters, DPM, James Dancho, DPM, FACFAS, Margaret Rennels, MD

The Foot and Ankle Online Journal 5 (3): 1

Malignant fibrous histiocytomas are a rare soft tissue sarcoma that present as indolent tumors in adults. Treatment consists of wide surgical excision. Local recurrence and metastasis is common and patients must be followed for such. We describe the case of a 49 year-old male that presented with a painless “lump” on the front of his ankle. Magnetic resonance imaging showed a 2.6 x 3.5 x 4.3 cm lesion that displayed high intensity on the T2 weighted image. The mass partially encased the tibialis anterior tendon along the medial aspect without invading the body of the tendon. The radiologist suspected a possible malignant neoplasm including synovial sarcoma or giant cell tumor of the tendon sheath. The patient underwent wide excision of the lesion and pathology diagnosed it as malignant fibrous histiocytoma at the anterior ankle. The patient underwent limb sparing surgery without adjuvant chemotherapy and after 2 years of follow-up he has had no recurrence or metastasis.

Key words: Ankle, histiocytoma, malignant fibrous, neoplasms, sarcoma

Accepted: February, 2012
Published: March, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0503.0001


Malignant fibrous histiocytomas (MFH) are the most common soft tissue sarcomas in adults.[1,2] MFH is a rare sarcoma that has no predilection for age and affects both genders equally. In a recent major review of 458 soft tissue sarcomas 11% were in the thigh (the most common location) while 3% were in a distal extremity, either distal to the knee or elbow.[3] Prognosis is correlated to tumor size, depth and location and has been discovered along with gouty tophi and internal fixation.[4-7]

MFH most commonly metastasizes to the lungs and patients should be followed with regular chest radiographs. Recurrence most commonly occurs within 2 years.[3] The treatment consists of primary resection with adjuvant chemotherapy depending on clear margins, depth and lymph node involvement.[8]

Case Report

A 49 year-old gentleman presented to our clinic with a complaint of a “bump” of the anterior medial ankle. The patient noted only minimal discomfort with high topped shoes or work type boots, as they would press directly on the lesion and cause irritation.

Figure 1 Magnetic resonance image of the soft tissue sarcoma. (A) Axial view (B) Longitudinal view.

The lesion had been present for at least one year, and was progressively growing over the past few months. No history of trauma to the area was noted and he had no previous treatment for the lesion.

The medical history was significant for hypertension, sleep apnea and chronic back pain. He had previous umbilical and inguinal hernia repair, a knee arthroscopy and mucocele removal. He denied any other lesions, similar to the one on his foot, anywhere on his body.

On physical examination, there was a round, mildly fluctuant, rubbery golf-ball sized lesion measuring approximately 3.5 cm in diameter along the lateral aspect of the tibialis anterior tendon. The lesion was fairly mobile underneath the skin and transillumination was not possible. It was fairly painless to palpation, leading to the suspicion that the mass was merely irritated by rubbing, or direct pressure from shoegear. There was no surrounding erythema, edema, ulceration or telangiectasias associated with the lesion.

Dorsalis pedis and posterior tibial pulses were palpable and capillary filling time was instantaneous to all digits bilaterally. Tinel’s sign was not elicited on percussion of the mass and sharp-dull, light touch and vibratory sensation were intact. Manual muscle testing was within normal limits and the lesion was noted to translocate with dorsiflexion and plantar flexion of the ankle.

Plain films revealed a large soft tissue rounded density anteriorly and medially overlying the right ankle without any definitive underlying bony abnormality. The patient was then sent for magnetic resonance imaging (MRI) to determine the characteristics of the lesion. The lesion measured 2.6 x 3.5 x 4.3cm and displayed high signal intensity and intense enhancement on the T2 weighted image. (Fig. 1) The mass partially encased the tibialis anterior tendon along the medial aspect without invading the body of the tendon. The radiologist suspected a possible malignant neoplasm due to the intense enhancement and size with differential diagnoses including synovial sarcoma or giant cell tumor of the tendon sheath.

Due to the suspicious nature of the lesion and for surgical planning a core needle biopsy was performed to obtain a clearer diagnosis.

It revealed a relatively cellular sample containing a few somewhat atypical cells with moderate mitotic activity and simple excision was performed. The patient was taken to the operating room and a linear incision was made over the underlying lesion. The lesion was dissected free of the surrounding soft tissue and appeared to be part of the medial branch of the superficial peroneal nerve. The lesion was a yellow/tan color and seemed well encapsulated. The tumor was easily separated from the surrounding tissues, but we were unable to remove it from the nerve, so the nerve had to be sacrificed. The final specimen measured 4.8 x 4.0 x 2.8cm. (Fig. 2)

Figure 2 Gross specimen of soft tissue sarcoma. Although it appeared to be encapsulated, it was not entirely circumscribed and included a transected margin with mitotically active pleomorphic cells.

Gross examination showed slight lobulation of the lesion with focal hemorrhage and no sign of necrosis. Sectioning the specimen revealed a soft, yellow/tan, vaguely lobulated mass with broad, fine, and indiscrete, fibrous septae. Microscopic examination noted an extremely cellular tumor with pleomorphic, mitotically active cells with a mitotic rate of 9 per high powered field with a histologic grade of 3. It was also noted at this time that despite the apparent encapsulation of the tumor, there was transection of the tumor margin and aggressive mitosis in the area that suggested a malignant fibrous histiocytoma of high grade malignancy. (Fig. 3)

Figure 3 Histological assessment reveals an area of pleomorphic tumor with bizarre giant cells and very high mitotic rate including abnormal mitoses (10x power/hematoxylin and eosin stain).

Due to the malignant finding and the incomplete margin a surgical oncologist was consulted. The patient returned to the operating room where a wide local excision of the area was performed. The resected tissue was examined, and no further remnants of the lesion were seen at the margins. A full thickness skin graft of the area was taken from the patient’s thigh and subsequently placed on the wound bed. The patient was kept non-weight bearing in an off-loading boot and subsequent local wound care was performed until complete healing was achieved.

Approximately 5 months later the patient developed a firm, well-demarcated lesion directly adjacent to the previous surgical margin. An MRI revealed a 5.1 x 4.5 x 4.0 mm mass just superficial but abutting the extensor digitorum longus tendons. This lesion was intermediate on T1 and increased on T2, showing a relatively homogenous enhancement. Due to its small nature it was difficult to differentiate between the vessels in the vicinity. Because of the patients’ history he was taken back to the operating room. A 5cm linear incision was made over the mass. The incision was deepened to the level of the superficial peroneal nerve where the mass was visualized within the nerve’s fibers.

It was traced proximally and distally and the entire nerve and lesion were removed in toto. Further inspection of the area revealed no additional lesions. Pathologic exam identified the 1.2 x 0.9 x 0.3cm specimen as a traumatic neuroma of the intermediate branch of the superficial peroneal nerve.

The patient is currently being followed for another pea-sized lesion that was discovered 3 months after his second surgery. It is approximately 2 mm in diameter, is movable and lies just proximal to the second surgical margin along the course of the superficial peroneal nerve. We are following him for any growth in this lesion and do not have any current plans for further surgical intervention.

Due to both of his surgeries the patient has numbness to the dorsum of his foot. He has no residual weakness to any of the muscle groups to his foot and has noticed no other lesions anywhere else on his body, with exception to the foot. The patient has also had serial chest radiographs that have shown no metastases.

Discussion

Malignant fibrous histiocytoma (MFH), first described in the sixties, is the most common soft tissue sarcoma in adults. It occurs most often in the proximal portions of the extremities including the thigh and buttocks.1 The mean age is 55.8 with a range of 18 to 84 years and equally affects males and females. Most patients present with an asymptomatic tumor that they have noticed in less than a year.[3]

Initial diagnosis is frequently attained by biopsy and MRI is useful in surgical planning. This requires sampling from several areas of the tumor as the histological sample can vary from location to location. There is no specific immunohistochemical marker for MFH, so the diagnosis is usually one of exclusion.8 MFH are classified using immunohistochemical methods for type and grade according to the system of Enzinger and Weiss with the lower grades signifying level of differentiation.[2]

The histology of MFH is variable and several subtypes including storiform-pleomorphic, myxoid, giant cell and inflammatory exist with the storiform-pleomorphic being the most common.[9] All variants may be locally aggressive and surgical excision is required.

Resection achieving tumor-free margins of at least 1-1.5cm is the goal for every case and has been shown to be the strongest risk factor of local recurrence.[8] For patients without clear margins, further surgical resection is preferred before using other treatment modalities.10 Local recurrence has reported to range from 31-38%, with 73-100% occurring within 24 months.[3,8] Postoperative radiation therapy has been shown to decrease local recurrence rate although it has also been associated with increased morbidity due to difficulty in wound healing.[11-13]

Metastasis is a significant concern in patients diagnosed with MFH. Peiper, et al., found of 458 patients 29 developed metastases after a median of 12 months, with the most common, 80%, seeding to the lungs. Prognostic risk factors for distant metastases include tumor size, depth and grade (based on the classification of Enzinger and Weiss). The annual risk of distant metastases was 3.5 times higher in patients with higher grade tumors.[3]

Peiper, et al., recommends chemotherapy to those patients with synchronous pulmonary or regional lymph node metastases after resection of the primary tumor. After 6 courses of chemotherapy, resection of the pulmonary lesion was then performed. Even with aggressive resection and adjuvant chemotherapy, cumulative 5-year survival rates are 65%-80%.[8,14,15]

In conclusion, although MFH is the most common soft tissue sarcoma in adults, it is still a rare diagnosis especially in the distal extremity. In 24 months of follow-up our patient had an additional lesion diagnosed as a traumatic neuroma although approximately 30% of patients will have a second MFH.[3] He has had no evidence of metastasis to this date and is monitored every 3 months with a physical exam and chest radiograph.

References

1. Enjoji M, Hashimoto H, Tsuneyoshi M, Iwasaki H. Malignant fibrous histiocytoma. A clinicopathologic study of 130 cases. Acta Pathol Jpn 1980 30:727-741. [PubMed]
2. Enzinger F, Weiss S. Soft Tissue Tumors. 4th Ed St. Louis, Mosby, 2001. [Website]
3. Peiper M, Zurakowski D, Knoefel WT, Izbicki JR. Malignant fibrous histiocytoma of the extremities and trunk: An institutional review. Surgery 2004 135: 59-66. [PubMed]
4. Richter H, Vinh TN, Mizel MS, Temple HT. Malignant fibrous histiocytoma associated with remote internal fixation of an ankle fracture. Foot Ankle Int 2006 27: 375-379. [PubMed]
5. Carnero S, Teran P, Trillo E. Malignant fibrous histiocytoma arising in a gouty tophus at the second metacarpophalangeal joint. J Plast Reconstr Aesthet Surg 2006 59:775-778. [PubMed]
6. Gibbs JF, Huang PP, Lee RJ, et al. Malignant fibrous histiocytoma: an institutional review. Cancer Invest 19: 2003 23-27, 2001. [PubMed]
7. Le Doussal V, Coindre JM, Leroux AHacene K, Terrier P, Bui NB, Bonichon F, Collin F, Mandard AM, Contesso G. Prognostic factors for patients with localized primary malignant fibrous histiocytoma: a multicenter study of 216 patients with multivariate analysis. Cancer 1996 77:1823-1830. [PubMed]
8. Issakov J, Kollender Y, Soyfer V, Bickels J, Flusser G, Meller I, Merimsky O. A single-team experience of limb sparing approach in adults with high-grade malignant fibrous histiocytoma. Oncol Rep 2005 14:1071-1076. [PubMed]
9. Fletcher C, Unni, KK and Mertens, F. World Health Organization Classification of Tumours. Pathology and genetics of tumours of soft tissue and bone. Lyon, IARC Press, 2002.[Website]
10. Pezzi CM, Rawlings MS, Jr., Esgro JJ, Pollock RE, Romsdahl MM. Prognostic factors in 227 patients with malignant fibrous histiocytoma. Cancer 1992 69: 2098-2103. [PubMed]
11. Bujko K, Suit HD, Springfield DS, Convery K. Wound healing after preoperative radiation for sarcoma of soft tissues. Surg Gynecol Obstet 1993 176:124-134. [PubMed]
12. Sadoski C, Suit HD, Rosenberg A, Mankin H, Efird J. Preoperative radiation, surgical margins, and local control of extremity sarcomas of soft tissues. J Surg Oncol 1993 52: 223-230. [PubMed]
13. Spiro IJ, Rosenberg AE, Springfield D, Suit H. Combined surgery and radiation therapy for limb preservation in soft tissue sarcoma of the extremity: the Massachusetts General Hospital experience. Cancer Invest 1993 13: 86-95. [PubMed]
14. Bramwell VH. Current perspectives in the management of soft-tissue sarcoma. The role of chemotherapy in multimodality therapy. Can J Surg 1988 31: 390-396. [PubMed]
15. Engellau J. Prognostic factors in soft tissue sarcoma. Tissue microarray for immunostaining, the importance of whole-tumor sections and time-dependence. Acta Orthop Scand 2004 5(Suppl): 2 p preceding table of contents-52, backcover. [PubMed]


Address correspondence to: Katherine Neiderer, DPM,MPH
Email: Katherine.Neiderer@va.gov

1 Southern AZ VA Health Care System, 3601 S. 6th Ave. (2-112) Tucson, AZ  85723

© The Foot and Ankle Online Journal, 2012

Ankle arthrodesis as a salvage procedure: A case of secondary ankle arthritis using Charnley’s compression device

by Narayana B.S. Gowda, D Ortho, DNB Ortho, MNAMS, Mohan J. Kumar, MS Ortho

The Foot and Ankle Online Journal 5 (2): 1

Ankle arthrodesis is commonly considered to be the standard operative treatment for end stage ankle arthritis. The purpose of this study was to perform a clinical and radiographic review to determine functional outcome for a group of patients in whom an ankle arthrodesis had been performed using Charnley’s compression device. A functional assessment of fifteen patients after ankle arthrodesis for post traumatic arthritis was carried out by means of an extensive clinical evaluation after an average follow up of 2 years and 8 months.

Key words: Ankle arthrodesis, ankle arthritis, Charnley’s compression device, secondary arthritis ankle.

Accepted: January, 2012
Published: February, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0502.0001


Ankle arthrodesis is considered by many to be the standard operative treatment for end stage ankle arthritis. [1] A patient with ankle arthritis and deformity can experience severe pain and functional disability. Treatment options include the use of walking aids, orthotic devices, intra-articular steroids, open rather than arthroscopic debridement, periarticular osteotomy, and arthroplasty, all of which have provided inconsistent relief. Ankle arthrodesis has been accepted by many as yielding good long term clinical results. [2]

Since 1879, when Albert first described arthrodesis of the ankle [8], more than thirty different techniques have been described. The open technique with compression and internal fixation is still widely used for ankle arthrodesis with major deformity. [9] Ankle arthrodesis is an alternative for cases with intact subtalar joint. [10] This study presents intermediate term follow up functional outcome of patients with ankle arthrodesis performed using Charnley’s compression device.

Materials and methods

We reviewed fifteen patients, 10 males and 5 females, who had undergone ankle arthrodesis between January 2006 to December 2009 at the People’s Education Society (PES) Medical College and Research Center, Kuppam, Andhra Pradesh (AP), India (6 cases of post traumatic AVN talus (Fig. 1), 4 cases malunited bimalleolar fracture, 3 cases of distal tibial plafond fractures, 2 cases of medial malleoli non-union). All the fifteen patients who had secondary ankle arthritis have undergone open ankle fusion with anterolateral approach (Fig. 2) in supine position under tourniquet control and spinal anaesthesia.

Figure 1  Preoperative radiograph right ankle showing arthritic changes secondary to non union talar neck fracture.

Figure 2  Intraoperative photo showing anterolateral approach to ankle.

Compression was achieved using Charnley’s compression device and a calcaneotibial Steinman pin was applied to maintain the alignment and to increase the stability of fixation (Figs. 3 and 4). Suction drain was removed after 48 hours and the patient was made ambulant with non weight on operated site. All the patients were evaluated clinically and radiologically at 6 weeks and tibiocalcaneal Steinman pin was removed and the patients were allowed to bear weight as tolerated. All the fixators were removed after 12 weeks once the arthrodesis site was united radiologically. We had 3 cases of cellulitis of ankle and foot which was treated successfully with antibiotics, and 5 cases of superficial pin tract infection which were healed completely after fixator removal. None of these pin tract infections caused osteomyelitis. The mean age at the time of surgery was 40.52 years (24 – 56 years) and the time interval between the date of fusion and date of follow up examination ranged from 1 year to 5 years and 7 months, the average being 2 years 8 months.

Figure 3  Immediate post operative radiograph showing Charnley’s compression device.

Figure 4  Clinical photo showing Charnley’s compression device.

Clinical Evaluation

The clinical evaluation was based on a personal interview and physical examination. The patients were questioned as to their pain during daily activities such as running or walking on the level ground and going up and down the hills and stairs. A complete orthopaedic examination evaluated stance, gait, limb length discrepancy, circumference, range of motion of the knees, ankles, and subtalar joints; neurovascular status muscle strength and presence or absence of tenderness and swelling. Special attention was directed to the position of the fused ankle and the motion of the subtalar and mid tarsal joints. Any valgus or varus deformities of the heel and the presence of the callosities were also determined. The contralateral extremity was used as a control. Ankle anterior posterior and lateral radiographs were taken to assess the fusion and position of the arthrodesis (Fig. 5).

Figure 5   Two year follow up radiographs shows solid union at the arthrodesis site.

To quantitate the results of the clinical examination the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used. The main emphasis of this system was on pain and the functional activities. A normal person would score 100 points. Because of lack of ankle motion, the maximum score that the patient with an ankle fusion could have was 92, since they could not earn the 8 points given for the full range of motion.

A score of 80 to 92 was considered an excellent result: 70 to 79, a good result; 60 to 69, a fair result; and score less than 60 was considered a poor result.

Results

All patients studied had a solidly fused ankle and had no complications related to the surgery (Fig 6). They were all improved as a result of ankle fusion and returned to their pre injury activities. Wearing shoes with appropriate heels, all the patients could walk on level ground without support. All the patients stated that they could walk up and down the stairs without much difficulty. Limb length discrepancies were insignificant (0.5 to 1.5 cm) except in one patient who had 2.5 cm secondarily due to distal tibial plafond fracture. The radiographs showed that 6 cases showed some evidence of degenerative changes in the subtalar joints which did not correlate with the symptoms.

Figure 6  Two year follow up clinical photo of right ankle arthrodesis showing very litte difference compared to left normal side.

Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that eleven of the 15 had excellent results; two good; and two fair results. All of them could walk with relatively good velocity and with a consistently rhythmic gait.

Discussion

The patients with solid ankle fusion in this study functioned very well during the activities of normal daily living. All of them could walk on the level ground without pain. The fusion had permitted them to return to their former occupations and recreational activities. On this basis all the patients could be classified as having very satisfactory results.

Based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, these patients had appreciable limitations when walking barefoot but only mild to moderate limitations when wearing proper footwear. Patients were assessed not only under normal conditions but also under stressful conditions such as walking long distances, climbing up and down the stairs, and running. Six of the 15 could not run. Three had some minor discomfort after walking long distance.

When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [9] As a fused ankle provides a painless ankle joint with limited functional disability, ankle arthrodesis is still the treatment of choice for most disabling ankle arthritis. [10]

Charnley’s compression devise is still a simple, cost effective and excellent external fixator which can be used easily by every orthopaedic surgeon. After removal of the fixator, there is no indication for additional surgery to remove the implant compared to internal fixation. There are no hardware problems as all the hardware was removed. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis using Charnley’s compression device, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis. [11] Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction. [12-13] In studies ranging in size from 12 to 101 patients, rates of successful primary ankle fusion of 80% to 100% have been reported earlier. [14-18] However an average follow up time of 2 years and 8 months is relatively short to comment on the future secondary osteoarthritic changes in the subtalar and mid foot joints.

To be considered as an alternative preferable to arthrodesis, a total ankle replacement should give better results than those presented here, without other disadvantages. Patients with rheumatoid arthritis and involvement of ankle may not meet the criteria for an ankle arthrodesis may be because they have involvement not only of the ankle but also of the small joints of the foot, so that these joints cannot compensate for the fused ankle. Therefore, patients with rheumatoid arthritis may be better candidates for the total ankle replacement. [19]

Conclusion

Subjectively and objectively, the patients with ankle fusion function quite well in activities of daily living provided that, they have enough compensatory motion in the Chopart’s and Lisfranc joints of the foot, the other ankle has a normal range of motion, they wear footwear with appropriate height. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function; however, it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of ipsilateral hindfoot arthritis. Charnley’s compression device can still be considered as the fixator of choice compared to other modalities available with respect to cost, simplicity and good outcome.

References

1. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. JBJS 2001 83A: 219-28. [PubMed]
2. Mazur JM, Schwartz E, Simon SR Ankle arthrodesis, long term follow up with gait analysis. JBJS 1979 61A: 964-975. [PubMed]
3. Helm R, Stevens J. Long-term results of total ankle replacement. J Arthroplasty 1986 1: 271-277. [PubMed]
4. Kofoed H, Lundberg-Jensen A. Ankle arthroplasty in patients younger and older than 50 years: a prospective series with long-term follow-up. Foot Ankle Int 1999 20: 501-506. [PubMed]
5. Saltzman CL. Total ankle arthroplasty: state of the art. Instr Course Lect1999 48: 263-268. [PubMed]
6. Huang PJ, Fu YC, Lu CC, Wu WL, Cheng YM. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci 2007 23: 120-127.[PubMed]
7. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: Long-term follow-up with gait analysis. JBJS 1979 61A: 964-975. [PubMed]
8. Albert E. Zur Resektion des Kniegelenkes. Wien Med. Press, 1879 20: 705-708.
9. Abidi NA, Gruen GS, Conti SF. Ankle arthrodesis: indications and techniques. Am Acad Orthop Surg 2000 8: 200-209. [PubMed]
10. Cheng YM, Lin SY, Tien YC, Wu HS. Ankle arthrodesis. Kao Hsiung I Hsueh Ko Hsueh Tsi Chih 1993 9: 524-531. [PubMed]
11. Smith R, Wood PLR. Arthrodesis of the ankle in the presence of a large deformity in the coronal plane. JBJS 2007 89B: 615-619. [JBJS, Full article]
12. Ahlberg A, Henricson AS. Late results of ankle fusion. Acta Orthop Scand 1981 52: 103-105. [PubMed]
13. Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand 1981 52: 107-110. [PubMed]
14. Ahlberg A, Henricson AS. Late results of ankle fusion. Acta Orthop Scand 1981 52: 103-105. [PubMed]
15. Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the ankle with a free vascularized autogenous bone graft: Reconstruction of segmental loss of bone secondary to osteomyelitis, tumor, or trauma. JBJS 1995 77A: 1867-1875. [PubMed]
16. Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand 1981 52: 107-110. [PubMed]
17. Buck P, Morrey BF, Chao EYS. The optimum position of arthrodesis of the ankle: A gait study of the knee and ankle. JBJS 1987 69A: 1052-1062. [PubMed]
18. Lynch AF, Bourne RB, Rorabeck CH. The long-term results of ankle arthrodesis. JBJS 1988 70B: 113-116. [PubMed]
19. Hopgood P, Kumar R, Wood PLR. Ankle arthrodesis for failed total ankle replacement. JBJS 2006 88B: 1032-1038. [PubMed]


Address correspondence to: Asst Professor, Dept of Orthopaedics, PES Medical College, Kuppam, Chittore dist, Andra Pradesh, India, 517425. Email: drnarayan999@yahoo.com, Mob: 00 91 7702990696

1  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.
2  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.

© The Foot and Ankle Online Journal, 2012

Clinical Review of Adhesive Capsulitis of the Ankle: An introductory article and clinical review

by Bilal Shamsi, BS, Jennifer-Nicole Falk, BS, Steven J. Pettineo DPT, OCS, CSCS, Sayed Ali MD, FRCR4

The Foot and Ankle Online Journal 4 (10): 2

Adhesive capsulitis is a well known ailment that most often affects the shoulder, but can occur in the hip, wrist, and the ankle. As it relates to the ankle joint, the condition is commonly referred to as ‘frozen ankle’ and presents as a challenge in both its diagnosis and treatment. Although there is much literature regarding the etiology, pathology, and treatment of ‘frozen shoulder’, there is little with regards to the ankle, with most being case reports. The purpose of this article is to provide a clinical review of the concept of adhesive capsulitis, its impact as it relates to the ankle, diagnostic criteria, and current treatment modalities.

Key words: Adhesive capsulitis, frozen ankle, ankle pain, adhesions.

Accepted: September, 2011
Published: October, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0410.0002


Adhesive capsulitis is a broad term that can be confusing at times since it is often used synonymously for “frozen shoulder”. In order to better understand adhesive capsulitis of the ankle, we begin with a brief review of a better documented phenomenon concerning the shoulder.

Adhesive capsulitis of the shoulder is a common condition that will cause pain and restrictions during active and passive range of motions (ROM).

Though motion loss is global, a typical capsular pattern is usually present with motion into external rotation being most limited followed by abduction and finally internal rotation. [1]

Frozen shoulder can be categorized into two categories: primary, or idiopathic, and secondary. Primary adhesive capsulitis presents without any underlying cause, while secondary adhesive capsulitis occurs as a result of other causative factors, such as trauma to soft tissue and bone. Pre-disposing factors to developing idiopathic frozen shoulder include diabetes, female, and being in the fifth or sixth decade of life. Incidence is reported as being 10-36% in the diabetic population, with a 40% chance of developing the condition if an individual is Type I diabetic. [1,2,3]

For the glenohumeral joint, 3 distinct phases have been described in staging this condition. The first is an early painful phase, or “freezing stage,” with a duration of 2 to 9 months. This is followed by an intermediate stiffening or adhesive phase, which has duration of 4 to 12 months. In this phase, patients typically experience increasing stiffness, but less pronounced pain. The final phase is known as the recovery, or “thawing” phase, which lasts anywhere from 5 to 24 months. Here, patients display a gradual return of movement. [3,4]

Adhesive Capsulitis of the Ankle (ACA) is infrequently reported in the literature, but the few reports that do exist suggest that it occurs secondary to trauma such as ankle or pilon fractures or chronic ankle sprains.

Some cases are thought to be idiopathic, or to have some underlying association with diabetes, inflammatory arthropathies, connective tissue disease, heart disease, infection, or autoimmune processes. [5,6,7]

Pathophysiology

With regards to pathophysiology, the literature between adhesive capsulitis of the shoulder and that of the ankle appears to be synchronous. Not only is the site of injury affected, but the entire joint capsule is disturbed, resulting in a global loss of motion.

Initially, there is proliferation of synovial inflammatory cells and infiltration of lymphocytes. Within 3 to 4 weeks, the capsular fibrous layer becomes thickened, destroying the integrity of the anterior and posterior joint recesses, and the presence of new collagen inhibits the availability of joint ROM. [1,6,8]

This proliferation of inflammatory infiltrate and the subsequent ankle joint contracture that follows is thought to be the result of cytokines, which allow for initiation and progression of the fibrous thickening process. Patients will often report a tight, sharp stretching sensation, and they may report a cracking, or popping sound with motion of the joint. [7]

Diagnosis

Currently, there exists no clinical criteria for diagnosing ACA; however, the literature does show some similarities with respect to patients presenting with frozen shoulder. Patients usually complain of ankle pain, swelling, and difficulty walking. The onset of symptoms is variable and may present anywhere from immediately after an incident to weeks later, when the patient resumes weight bearing and ambulation after having been immobilized for an extended amount of time. [5,6]

Observation of significant deficits of ankle ROM is the key to further investigation into a possible diagnose of adhesive capsulitis. A study by Lui, et al., recorded ankle dorsiflexion and plantarflexion in patients with diagnosed ankle adhesive capsulitis and found that ankle dorsiflexion was limited to an average of 1°, while plantar-flexion averaged 16° pre-op. In addition to limited ankle ROM, calf atrophy may also be present if there was prolonged immobilization. [5]

Currently, conventional arthrography is the most accepted diagnostic tool. In 1976, Goldman, et al., proposed arthrography criteria for diagnosing adhesive capsulitis of the ankle, which included the following:

1) decreased joint space volume (n = 10-25 mL fluid, pathologic accepts < 3-5 mL)
2) obliterated ankle recesses (anterior & posterior)
3) resistance with injection of contrast
4) backflow of contrast medium [8]

Due to convenience, and the invasive nature of the procedure, arthrography is not typically the diagnostic tool of choice amongst physicians, but has demonstrated value in evaluating shoulder adhesive capsulitis. [9] Radiographs are nonspecific and are, therefore, of no benefit in diagnosing adhesive capsulitis. [5]

Although there is no established criteria for diagnosing ACA on magnetic resonance imaging (MRI), in the appropriate clinical setting a paucity of ankle joint fluid and thickening of the joint capsule on MRI (Figs. 1 and 2), as seen in conventional ankle arthrography and non-contrast shoulder MRI in shoulder adhesive capsulitis, will raise the suspicion for ACA. Since there is often a communication between the posterior subtalar joint and the ankle joint, there can also be a paucity of fluid in the posterior recess of the posterior subtalar joint. (Figs. 1 and 2) Further work is required to establish the role of ankle MRI in the diagnosis of ACA. [8,9]

Figure 1  Sagittal FSE T2 weighted image in a patient with post traumatic and postsurgical ACA showing complete paucity of synovial fluid in the ankle joint (long arrow) and in the posterior subtalar joint (short arrow). Note magnetic susceptibility artifact (star) from surgical hardware.

Figure 2  Normal ankle with normal fluid in the ankle (long arrow) and posterior recess of the posterior subtalar joint (short arrow).

Additionally, a hallmark technique in the diagnosis and treatment at the level of the shoulder is the feeling of a capsular end feel with passive range of motion testing, or in stage 3; a rigid end point. [10]  This diagnostic exam technique along with acknowledging restricted joint play on attempted anterior, posterior, and distraction joint mobilization can be applied in the diagnostic approach to the ankle as well.

Treatment

In order to understand the treatment of the ankle, it is necessary to review how treatment is based on staged criteria for frozen shoulder. In stage 1, which involves no capsular tightness but is progressively painful, the treatment strategy consists of soft tissue mobilizations, with an emphasis on reducing inflammation as no adhesions have yet formed. In the adhesive stage 2, there is an emphasis on reducing inflammation, and minimizing capsular adhesions through active and passive range of motion exercises as well as joint mobilization techniques. In stage 3, there is an eventual slow and steady recovery of motion, with the course of disease taking anywhere from one to three years to resolve fully. [10,11]

Currently, treatment options for the ankle include physical therapy focusing on active and passive range of motion as well as ankle joint mobilization techniques. (Figs. 3A, 3B and 3C) Shaffer, et al., showed that after 8 weeks of immobilization post-ankle fracture, 10 weeks of mobilization with physical therapy can successfully restore ROM, strength, and function of the ankle joint. [12] If conservative care is unsuccessful, arthroscopic debridement may be necessary. Lui, et al., found that ankle ROM may improve up to 18° with DF and up to 23° with PF post-arthroscopic debridement.

Figure 3A, 3B and 3C   From top to bottom: Posterior talo-crural glide mobilization for dorsiflexion range of motion return. (A) Anterior talo-crural glide mobilization for plantarflexion range of motion return. (B)  Talo-crural joint distraction mobilization. (C)

They also showed that corticosteroid injections were ineffective alone.[5] Based on current understanding of the pathological process of ACA, Cui, et al., proposed a diagnostic and treatment algorithm which we have produced here.(Fig. 4)

Figure 4  A diagnostic and treatment algorithm adapted from Cui, et al., Copyright © 2011 by the American Orthopaedic Foot and Ankle Society, Inc., originally published in Foot & Ankle International,  26(8):606 and reproduced here with permission.

Conclusion

Adhesive capsulitis of the ankle is a difficult condition to diagnose and manage. Careful review of existing literature reveals limited research on the subject, with most studies being directed towards adhesive capsulitis of the shoulder. Such shoulder pathology is host to wide range of etiologies, resulting in decreased shoulder ROM (External rotation > Abduction > Internal rotation) and increased pain along all aspects of the shoulder joint capsule.

Though adhesive capsulitis of the ankle appears to present in a similar fashion, there is currently no clinical criteria to properly diagnose or stage ACA. Today, radiographic arthrograms remain the standard for definitive diagnosis, although their use is limited due to the invasive nature of the procedure. Goldman, et al., defined ACA based on similar arthrogram findings between 3 patients suspected of ACA.

With ACA presenting similarly to the pathology seen the shoulder (decreased ROM and increased pain around the involved joint), current treatment options have followed similar suit. Currently, physical therapy, focusing on active and passive range of motion, as well as ankle joint mobilization techniques, is showing to be the most beneficial for patients identified early on.

Further controlled studies are needed in order to better properly diagnose and treat ACA. Given the serious lack of literature regarding this condition, more studies are needed and perhaps more rigorous diagnostic criteria to clinically diagnose ACA with more modern radiographic techniques.

More importantly, better treatment protocol can be implemented and the possibility of staging the condition would aid physicians in earlier intervention, thereby preventing progression.

References

1. Tasto J.P., Elias D.W. Adhesive capsulitis. Sports Med Arthrosc Rev 2007 15: 216-221.
2. Rookmoneea, M., Dennis, L., Brealey, S. The effectiveness of interventions in the management of patients with primary frozen shoulder. JBJS 2010 92B: 1267-72.
3. Manske, R.C., Prohaska, D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2008 1:180-189.
4. Buchiner R Green, S. Effect of arthrographic shoulder joint distension with saline and corticosteroid for adhesive capsulitis. Br J Sports Med 2004 38:384-385.
5. Lui TH, Chan WK, Chan KB. The arthroscopic management of frozen ankle. J Arthro Rel Surg 2006 22: 283-286.
6. Cui Q, Milbrandt T, Millinton S, Anderson M, Hurwitz S. treatment of posttraumatic adhesive capsulitis of the ankle: A case series. Foot Ankle International 2005 26: 602-606.
7. Banks A. Downey MS. Martin DE, Miller SJ. McGlamry’s Foot & Ankle Textbook 2001 1:3 1095-1097.
8. Goldman, A.B., Katz, M.C. Posttraumatic adhesive capsulitis of the ankle: Arthrographic diagnosis. Am J Roentgenol 1976 127: 585-599.
9. Jung JY, Jee WH, Chun HJ, Kim YS, Chung YG, Kim JM. Adhesive capsulitis of the shoulder: evaluation with MR arthrography. Eur Radiol 2005 16: 791-796.
10. Andrews J, Wilk K, Reinold M. The Athlete’s Shoulder 2008, Churchill Livingstone Press 2: 293-301.
11. Davies GJ, Wilk K, Ellenbecke T, Tyler T, Reinhold M. Current concepts of orthopaedic physical therapy. 2006 (2). The shoulder: physical therapy patient management utilizing current evidence. Orthopedic Section APTA: 38-42.
12. Shaffer MA, Okereke E, Esterhai JL, Elliott MA, Walter GA, Yim SH, Vandenborne K. Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture. Phys Ther 2000 80:769-780.


Address correspondence to: Temple University School of Podiatric Medicine, 8th & Race St., Philadelphia, PA 19107. Department of Podiatric Medicine and Orthopedics
Email: spettineo@tuspm.temple.edu

1  4th year student, Temple University School of Podiatric Medicine. Philadelphia, PA
2  4th year student, Temple University School of Podiatric Medicine, Philadelphia, PA
3  Clinical Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA
4  Assistant Professor, Department of Radiology, Temple University School of Medicine, Philadelphia, PA

© The Foot and Ankle Online Journal, 2011

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

by Sarah Shogren, DPM, Sara Zelinskas, DPM, Byron Hutchinson, DPM, Vineet Kamboj, DPM

The Foot and Ankle Online Journal 4 (8): 3

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Accepted: July, 2011
Published: August, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0408.0003


Charcot neuroarthropathy when left untreated can progress to combined deformity of the ankle and subtalar joints. The treatment goal in these cases is to produce a stable, plantigrade foot that is braceable.

When conservative treatments such as bracing and shoe gear modifications fail, tibiotalocalcaneal (TTC) arthrodesis is typically the salvage procedure of choice. Bone quality in Charcot patients is often poor due to osteoclastic activity. The decision on the type of stable fixation to use can often be a challenge.

Ahmad et al., described humeral locking plates to have a high rate of fusion at 94.1%. [1] Several forms of stable fixation have been used to achieve TTC arthrodesis, including screws, intramedullary nails, [3] blade plates, [3] external fixation, [4,6] and humeral locking plates, [5] to name a few.

According to Pelton and Carvaggi, intramedullary nails are a good method for TTC arthrodesis with 88% and 92.8% fusion rates respectively. [2,7]

Distal femoral locking plates, like humeral locking plates, are not made specifically for this reconstruction, but are stable with a viable architecture to encompass both ankle and subtalar joints. The locking plate technology allows for a more stable construct in patients with questionable bone quality and combined deformities as in Charcot neuroarthropathy. (Figs. 1A and 1B)

 

Figure 1A and 1B  Pre-operative radiograph (A) and patient (B) with combined Charcot ankle valgus and subtalar deformities.

The purpose of this retrospective chart review was to evaluate the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Methods

A retrospective chart and radiographic review of four patients with Charcot neuroarthropathy with associated ankle valgus was studied. Inclusion criteria for this case series were patients with Charcot neuroarthropathy and a painful deformity at the ankle and subtalar joints. Exclusion criteria included active infections, significant bone loss from trauma and osteonecrosis. All patients failed conservative treatments, including bracing and shoe gear modifications, and all requested definitive treatment. Due to the retrospective review of these patients pain scales were not compared before and after surgery.

All four patients underwent tibiotalocalcaneal arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. Follow-up was obtained for up to 12 months. Frames were removed after approximately three months, after which patients began progressive weightbearing in a postoperative boot.

All four TTC arthrodeses were performed by the same surgeon, including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic and clinical evidence of consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation.

Surgical Method

A linear incision was made adjacent to the course of the fibula. An oblique osteotomy was made at the distal third of the fibula. The fibula was resected and removed from the operative table. The tibiotalar joint was then resected with the sagittal saw. (Figs. 2A and 2B) An ankle arthrotomy was performed medially and the medial malleolar articular surface was resected with a sagittal saw forming a miter at the medial aspect of the tibial surface. (Fig. 3) The subtalar joint was denuded of cartilage using a curette.

 

Figures 2A and 2B  Surgical resection of the fibula (A) is performed prior to resection of the tibiotalar joint. (B)

Figure 3  Application of the distal femoral locking plate to stabilize the Charcot ankle is technically simple.

The tibiotalocalcaneal arthrodesis was temporarily fixated with a Steinman pin placed through the plantar aspect of the foot crossing both joints into the tibia. The distal femoral locking plate was applied to the lateral aspect of the tibia, talus and calcaneus. Multipotential cellular bone matrix as well as platelet rich plasma were added to the autogenous bone graft which was placed in the tibiotalar arthrodesis site.

Accurate placement of the plate was verified using intraoperative fluoroscopy, and the Steinman pin was removed from the plantar foot. The circular fixator frame was then applied to the lower extremity with wires and half pins using standard technique. (Fig. 4) Axial compression was applied through the external fixator.

Figure 4:  Application of external fixator to aid in axial compression of the Charcot Ankle.

Outcomes

All four patients remained non-weightbearing for roughly three months in the external fixator. The fixator was then removed and patients remained non-weightbearing for an additional two weeks in a CAM boot. Patients began progressive weightbearing in a post-operative boot to full weightbearing for 3 additional months.

Once radiographic consolidation was seen, patients were progressed to full weightbearing in a CROW (Charcot Restraint Orthotic Walker) boot or similar device. These patients were ambulating with minimal pain at the end of the postoperative recovery period and able to perform their daily living requirements.

Three patients (75%) had satisfactory outcomes with only minor complications. Two patients (50%) required blood transfusion following surgery, and one (25%) had mild pin tract infections which responded quickly to oral antibiotics. One patient (25%) had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. This patient did not have an active infection at the time of surgery however; this patient had a history of prior osteomyelitis from previous procedures and was in renal failure. These pre-operative factors ultimately could have contributed to the patients post- operative wound dehiscence and ultimate recurrence of osteomyelitis. On average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. (Fig. 5) The patients with successful outcomes were able to ambulate pain free in a CROW boot. Table 1 summarizes the four patient outcomes.

Figure 5  Clinical presentation during 3-month course in external fixators.

Table 1  Tibiotalocalcaneal fusion outcomes for the four patients included in this retrospective case series.

Discussion

Approaching the treatment for a patient with Charcot arthropathy can be very difficult and controversial. These patients generally have multiple comorbidities making healing potential for ulcerations, as well as surgical procedures, more difficult. If ulceration prevention and adequate mobility is achieved using a bracing method this should be done as first line treatment. [8]

Attaining rigid fixation in a tibiotalocalcaneal arthrodeses can be difficult in patients with Charcot neuroarthropathy. Chiodo, et al., in 2003, compared the biomechanical properties of blade-plates and intramedullary rod fixation for TTC arthrodesis, and found the blade-plate to be a more rigid construct. [3] It is important to note that while blade plates do give a more rigid construct, they do not offer multiple planes of fixation. Intramedullary rods have been shown to have high fusion rates however they are technically difficult with risk of stress risers, fractures and neurovascular injury.

Pinzure and Kelikian reported 21 ankles with Charcot arthropathy treated using the intramedullary nail. Ninety per cent of these patients went on to fusion. The authors concluded this as an excellent means of obtaining ankle fusion in Charcot patients. In comparison, another form of fixation are locking plates which are less technically demanding and offer fixation in multiple planes. [5] Fixation in multiple planes is important because it limits rotational forces. Ahmad, et al., proved that using a PHILOS locking plate to achieve TTC arthrodesis does provide bone union and deformity correction. In patients with Charcot neuroarthropathy, greater rigidity is ideal to maintain the correction through the arthrodesis and we believe the locking plate will do this.

The greatest limitation to our case series is a small population size. Further research needs to be done in a prospective manner. This would give the advantage of determining a standardized pre-operative pain score (AOFAS) which is another limiting factor in this retrospective review.

The use of distal femoral locking plates for tibiotalocalcaneal arthrodesis is a viable rigid internal form of fixation. The locking plate technology allows for a stable construct in patients with questionable bone quality. In comparison to other forms of arthrodesis, it has a more rigid construct with better boney apposition and fixation in multiple planes.

In summary, the use of distal femoral locking plates in conjunction with external fixation is an acceptable option to create a plantigrade braceable foot as a limb salvage procedure in Charcot neuropathy patients.

References

1. Ahmad J, Pour AE, Raikin SM. The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis. Foot Ankle International 2007 28: 977-983.
2. Carvaggi C. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rearfoot. J Foot Ankle Surg 2006: 45(1), 20-24.
3. Chiodo CP, Acevedo JI, Sammarco VJ, Parks BG, Boucher HR, Myerson MS, Schon LC. Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: A biomechanical investigation JBJS 2003 83A: 2425-2428.
4. Colgrove RC, Bruffey JD. Ankle arthrodesis: Combined internal-external fixation. Foot Ankle International 2001 22: 92-97.
5. Lowery NJ, Alison JM, Burns PR. Tibialtalocalcaneal arthrodesis with the use of a humeral locking plate. Clinics Podiatric Medicine Surgery. 2006 26: 485-492.
6. Misson JR, Anderson JG, Bohay DR, Weinfeld SB. External fixation techniques for foot and ankle fusions. Foot Ankle Clinics 2004 9: 529-539.
7. Pelton K. Tibiocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle International 2008: 27: 759-763.
8. Pinzure M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle International 2004 25: 545-549.
9. Pinzure MS, Kelikian A. Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle International 1997: 18, 699-704.


Address correspondence to: Sarah Shogren, DPM, Franciscan Foot and Ankle Institute, 34509 9th Ave S. Ste 306 Federal Way WA 98003. Email: SarahShogren@fhshealth.org

1-4  Franciscan Foot and Ankle Institute, 34509 9th Ave S. Ste 306 Federal Way WA 98003.

© The Foot and Ankle Online Journal, 2011

Hardware Related Pain and Hardware Removal after Open Reduction and Internal Fixation of Ankle Fractures

by Johan H. Pot1  , Remco J.A. van Wensen1, Jan G. Olsman1

The Foot and Ankle Online Journal 4 (5): 1

Objectives: To assess the incidence of hardware related pain after open reduction and internal fixation (ORIF) after ankle fractures through functional outcomes scores in patients with or without hardware related pain. Design: Retrospective study.
Setting: Regional trauma center.
Patients: One hundred and seventy six patients undergoing ORIF of an ankle fracture with a minimal follow up of 18 months were sent questionnaires. In total, 80 responding patients were available for analysis.
Main Outcome Measurements: Visual Analog Pain Score, Foot and Ankle Outcome Score (FAOS).
Results: In seventeen patients (21%), the hardware was removed because of pain. In another seventeen patients (21%), the hardware was not removed, but pain was reported. Patients with hardware related pain had significantly worse functional outcome scores than patients without hardware related pain. After elective hardware removal, pain reduction was achieved in 71 % of the patients. Mean Visual Analog Score was 7.0 before and 3.9 after elective hardware removal for pain.
Conclusions: Hardware related pain is a significant issue after ORIF of ankle fractures. Patients with hardware related pain have significantly worse functional outcome scores. Although pain reduction is achieved in 71% of the patients after elective hardware removal, a substantial number of patients have persistent complaints. Patients should be well informed about the expectations and risks of elective hardware removal.

Key words: Hardware, hardware removal, hardware related pain, ankle fracture, ORIF ankle, FAOS.

Accepted: April 2011
Published: May 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0405.0001


Fractures of the distal tibia and fibula are one of the most common types of fractures in adults. [1] Whereas stable and non or minimally displaced fractures can be treated with cast immobilization, unstable dislocated ankle fractures require open reduction and internal fixation (ORIF) with plate and screws.

Long term functional outcome is satisfying in most patients, but a number of patients have persistent ‘hardware related’ complaints and tenderness that ‘require’ elective hardware removal. Aside from painful hardware, some asymptomatic patients also want their hardware removed for other reasons. Although hardware removal is frequently undertaken, it is not without risk and the results are often unpredictable. [2]

The more commonly reported risks of hardware removal are iatrogenic (nerve) injury, infections, delay in wound healing and re-fractures. In addition to medical considerations there is also an economic impact such as physician costs, hospital fees, patient loss of work and productivity. [2] Reports in literature are not consistent concerning the incidence of painful hardware and the outcome and pain relief after hardware removal. [3-5] This study was designed to document the incidence of late pain after ORIF of ankle fractures and to analyse the outcome, expectations and complications after hardware removal.

Patients and Methods

In October 2010, all patients with surgically treated unstable ankle (malleolar) fractures between April 2007 and April 2009 were reviewed. A total number of 176 patients were included with a minimum follow up of 18 months assuming the end stage of rehabilitation after the ankle fracture was achieved. Demographic data, patient’s age, sex and medical history, were obtained from the hospital database and clinical notes. All patients were sent a questionnaire. One part consisted of the Foot and Ankle Outcome Score (FAOS) which is designed to asses a number of foot and ankle related problems. It consists of 5 subscales; Pain, other Symptoms, Function in daily living (ADL), Function in sport and recreation (Sport) and foot and ankle-related Quality of Life (QOL). The second part of the questionnaire consisted of specific questions about pain at the site of the hardware material and specific questions about the removal of osteosynthesis material. Patients that underwent elective hardware removal were asked to indicate pain before and after hardware removal by a Visual Analog Scale (VAS) pain score. Surgical stabilization consisted of open reduction and internal fixation (ORIF).

All surgeries were performed in the Jeroen Bosch Hospital, a 600 bed teaching hospital, by or under direct supervision of one of the trauma surgeons. AO-fixation material was used including small-fragment plates and screws and sometimes K-wires on the fibula or tibia if necessary. Fixation of the posterior malleolus was performed if more than one-third of the joint surface on the lateral radiograph was affected. Syndesmotic fixation was performed in cases of widened mortises on stress-testing after ORIF. Most of the time, one hook test was performed.

Postoperative therapy was overall direct functional and non-weight bearing for a minimum of six weeks. Sometimes a below-the-knee plaster cast was applied for 1 week due to wound protection. After 6 weeks, patients were allowed to bear weight as tolerated and were referred for outpatient physical therapy if necessary. Patients that were treated with a syndesmotic screw remained non-weight bearing until the syndesmotic screw had been removed. According to one of the trauma-surgeons, weight bearing was allowed after 6 weeks without removal of the syndesmotic screw. Indications for hardware removal include infection, failure of osteosynthesis material, severe pain and tenderness on the location of hardware and specific demands in asymptomatic patients. Before the procedure was performed, fracture consolidation was assessed by a radiograph. Functional outcome scores for each FAOS subscale were correlated with the presence of local pain. Statistical analysis was performed by using the Student t test. Results were considered significant if p

Results

The questionnaire was sent to 176 patients. The response rate was 46% (n=80 patients). In the response group there were 24% males and the mean age was 44 ±23 years. The mean follow up was 30 months and 29 patients (36%) reported hardware removal. (Table 1) The indication for removal was pain or discomfort in 60% (n=17).

Table 1 Patients with hardware removed and painful or painless hardware.

In one patient it was removed because of infection and syndesmotic screws were removed in 37% (n=11) as a standard procedure before weight bearing was allowed. In patients that did not have osteosynthesis material removed (n=51), 33 % had local pain or tenderness on the location of the osteosynthesis material. In total, 34 patients had pain at the hardware site after ORIF (42%). (Table 1)

FAOS score were compared between patients having local pain or tenderness overlying the hardware, patients who did not and patients that underwent hardware removal because of pain. Lower scores indicate a lower functional level and these scores are shown in Figure 1.  The FAOS scores of patients without hardware related pain was significantly higher in all the 5 subscores. (P<0.05) compared to patients with hardware related pain. Patients that underwent elective hardware removal however did not have significantly different scores than those with painful hardware.

Figure 1 FAOS scores of all patients with surgically treated ankle fractures. Patients without painful hardware have significantly higher FAOS score in all subscores compared to patients with hardware related pain (removed or not).

In 71% of the patients that underwent elective hardware removal because of pain, reported a decrease of their complaints after hardware removal.

These patients had a mean pain VAS (visual analog scale) of 7.0 (±2.1) before hardware removal and a mean VAS of 3.9 ±2.8 after hardware removal. This was a significant pain reduction. (p=<0.05)  However in 27% of the patients VAS scores did not change after elective hardware removal and only 24% became pain-free with a VAS of 0. (Table 2)

Table2   Change in pain after elective hardware removal (for painful hardware).

Recovery time from the secondary surgery was approximately 9 weeks (±10). Range of motion improved in 56% of the patients, whereas 6 % reported a decreased range of motion after hardware removal. 39% of the patients did not notice any change in range of motion. In 20% of the patients a superficial wound infection was reported that required additional treatment. No re-fractures or pseudoarthrosis were reported. Furthermore 25 % of the patients reported new complaints after hardware removal, such as other pain or instability.

Discussion

After a mean follow up of 2.5 years 21% of the patients reported to have their hardware removed because of pain and 21% of the patients had significant and specific local pain at the site of the hardware. Obviously, hardware is not always the main contributor of this pain as scar tissue, post-traumatic changes and malalignment can also play a role. This should not be underestimated by (orthopedic) trauma surgeons. One study found similar results with 31% painful hardware and 17% removal. [4] However other studies report lower rates of painful hardware [6,7], especially among the elderly.8 Patients with painful hardware and also patients who had their hardware removed have significantly lower functional scores than patients without complaints.

In fact, all FAOS subscores were significantly worse in these patients suggesting a serious impact on quality of life and on daily activities. This is supported by Brown, et al., [4] who found significantly better outcome scores in patients that did not have hardware related pain. The results of hardware removal are comparable to Jacobsen, et al., [3] who found a 75% improvement after hardware removal. Brown on the other hand found a pain reduction in only 50% of the patients. A success rate of 71% in this study appears to be a promising statistic. However, in 76% of patients, they do not become pain free and have persistent pain. Patients should be informed correctly about the significant risk of persistent pain.

Range of motion is similar or better in most patients, but 25% of the patient had new or other complaints after removal of the hardware. Other studies that do not specifically investigate hardware removal of the ankle but hardware removal in general find other results. A prospective review about outcome of different types of hardware in different body parts found a significant pain relief, improved function and improved SMFA scores (Short Musculoskeletal Function Assessment Questionnaire). [5] Hardware in ankles, however can lead to location specific problems due to mechanical characteristics of the ankle and the lack of surrounding tissue in the ankle. Indications for elective hardware removal could be a pitfall. Local tenderness and pain can be due to the hardware, but can also be caused by posttraumatic changes in the ankle. Hence the surgeon and patient should also be well informed about specific complaints and a radiograph is mandatory to evaluate posttraumatic changes. If in doubt, an intra-articular injection with a local anaesthetic can help to differentiate between intra articular (post traumatic) and extra-articular (e.g. hardware) causes. Arthroscopic evaluation can be useful to assess degenerative changes, intra-articular malalignments or to remove loose bodies or adhesions.

Routine removal of hardware in patients with surgically treated ankle fractures is not recommended, because most patients do not have hardware related pain or may have minimal symptoms. Not only would routine hardware removal lead to more complications, increased health care costs, lost work and productivity, it can also lead to new complaints or increased pain. [2]

The type of implant or material may influence the amount of hardware related symptoms. Obviously bulky implants are more likely to cause symptoms, but smaller implants can lead to bony overgrowth which makes hard removal more difficult. Intramedullary nailing may be beneficial in some fractures, because soft tissue is less manipulated and also these implants can be easier to remove. [9]

Biodegradable osteosynthetic material have been proposed as a new method to avoid a secondary procedure to remove the material. [10] Although materials are improving, clinical results thus far are not encouraging. Petrisor, et al., concluded that patients with biodegradable osteosynthesis material had a higher risk (OR 2.63) for adverse events, such as osteosynthesis failure, compared to metal implants in patients with ankle fractures. [11] Ahl, et al., [10] found that patients treated with traditional titanium implants had better radiological measured stability, although clinical results did not differ. It is not clear whether these biodegradable materials result in less tenderness on palpation in short and long term.

Conclusion

Hardware related pain is a big issue in patients with a surgically treated ankle fracture that must not be underestimated. Functional outcome scores are significantly worse in patients with hardware related pain. Pain reduction can be achieved in 71% of the patients with hardware related pain but only 24% of the patients became pain-free after hardware removal. Similar results were found in literature. The most important conclusion that can be drawn is that the patient should be informed correctly about the risks and expectations of this second operation.

References

1.Daly PJ, Fitzgerald RH, Jr Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 58: 539-544, 1987.
2.Busam ML,Esther RJand Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg 14: 113-120, 2006.
3.Jacobsen S,Honnens de Lichtenberg M,Jensen CM, Torholm C. Removal of internal fixation–the effect on patients’ complaints: a study of 66 cases of removal of internal fixation after malleolar fractures. Foot Ankle Int 15: 170-171, 1994.
4.Brown OL, Dirschl D, Rand Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 15: 271-274, 2001.
5.Minkowitz RB,Bhadsavle S,Walsh M, Egol KA. Removal of painful orthopaedic implants after fracture union. JBJS 89A: 1906-1912, 2007.
6.Bostman O and Pihlajamaki H, Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units. J Trauma 41: 846-849, 1996.
7.Michelson JD. Fractures about the ankle. JBJS 77A: 142-152, 1995.
8.Koval KJ,Zhou W,Sparks MJ, Cantu RV, Hecht P, Lurie J. Complications after ankle fracture in elderly patients. Foot Ankle Int 28: 1249-1255, 2007.
9.Guo JJ,Tang N,Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. JBJS 92B: 984-988, 2010.
10. Ahl T, Dalen N, Lundberg A, Wykman A. Biodegradable fixation of ankle fractures. A roentgen stereophotogrammetric study of 32 cases. Acta Orthop Scand 65: 166-170, 1994.
11.Petrisor BA, Poolman R, Koval K, Tornetta P 3rd, Bhandari M; Evidence-Based Orthopaedic Trauma Working Group. Management of displaced ankle fractures. J Orthop Trauma 20: 515-518, 2006.


Address correspondence to: Johan Pot, Jeroen Bosch Hospital, Location Groot Ziekengasthuis, Postbus 90153, 5200 ME ’s-Hertogenbosch, The Netherlands. Email: johanhpot@gmail.com

1  Jeroen Bosch Hospital, ’s-Hertogenbosch, the Netherlands. Department of Surgery, Postbus 90153, 5200 ME ’s-Hertogenbosch The Netherlands. tel: (+31) 73-6992000; fax:(+31) 73-6992163.

© The Foot and Ankle Online Journal, 2011

Measurement Reliability of Swelling in the Acute Ankle Sprain

by Cameron P. Watson, MAppSc1,4, Robert A. Boland, PhD1,3 , Kathryn M. Refshauge, PhD2

The Foot & Ankle Journal 1 (12): 4

Background: Swelling and painful restriction of dorsiflexion characterize acute ankle sprain, and require accurate measurement to monitor effectiveness of intervention. Reliability of the figure of eight tape method for swelling and the weight-bearing lunge for dorsiflexion are highly reliable in the laboratory, but untested in the less predictable clinical setting.
Materials and Methods: We determined intra and interrater reliability and standard error of measurement (SEM) of both methods in the clinical environment, using 4 physiotherapists as raters. Measurements were taken twice within a session and at a follow-up session from the uninjured ankle in 22 participants with unilateral ankle sprain, and from a randomly selected ankle in 11 uninjured participants.
Results: Within session intrarater reliability was very high for both figure of eight (Intraclass correlations coefficients [ICC] = 0.99) and weight-bearing lunge (ICC = 0.97) methods. Between-session inter-rater reliability was also very high (ICC > 0.99). The SEM was small for all measurements: ±0.2cm for figure of eight, and ±0.4cm for dorsiflexion lunge methods within a session, and ±0.3cm and ±0.4cm respectively for between-session measurements.
Conclusions: Using simple techniques, swelling and dorsiflexion can be measured with high reliability in the clinic by different clinicians and can detect small changes in status between and within treatments.
Clinical Relevance: Clinically meaningful changes (>0.5cm) can be detected by clinicians with varying levels of expertise and can confidently be attributed to the intervention rather than measurement error.

Key words: Swelling, ankle, inversion, sprain, standard error of measurement

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: November, 2008
Published: December, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0112.0004

Ankle sprain is one of the most common injuries amongst sporting populations [9], and possibly in the general community. In addition to pain, the earliest symptoms are swelling and restricted dorsiflexion range of motion, and these symptoms can persist for years in up to 70% of people after a sprain. [14] To determine efficacy of treatment and monitor progress, it is essential that these impairments be measured reliably and accurately in the clinic.

Swelling secondary to sprain of the lateral ankle ligaments is commonly localized, usually around the lateral malleolus [18,19], but can also accumulate around the subtalar, talocrural and inferior tibiofibular joints.

Measurement of swelling therefore needs to specifically include measurement of volume in these areas. The gold standard for such measurement is the water displacement method [13, 16], but this method may be too time-consuming to use efficiently in the clinic. Although an indirect method of measuring ankle swelling, the figure of eight method [13] is time-efficient, cost-effective, and easy to apply in clinical settings. The therapist wraps a tape measure over standardized anatomical landmarks around the ankle and the distance provides a circumferential estimate of volume. [13, p. 131] (Fig. 1)

Figure 1 The figure of eight tape method for measuring ankle swelling.

The figure of eight method is highly reliable for measuring ankle swelling in the laboratory: within-session intra and interrater reliability ranged from 0.98 to 0.99 (intraclass correlation coefficients [ICC] for asymptomatic and swollen ankles. [13,16,21] Furthermore, the method correlates highly (r>0.88) with the water displacement method for both injured [13,16] and uninjured [11] ankles, thereby conferring some validity for the figure of eight method.

Ankle dorsiflexion range of motion (ROM) during weight bearing is also commonly limited following ankle sprain [10,17] , with consequent high impact on functional activities such as walking [2,3,5,8] , and ascending and descending stairs. [1,12] Restoration of ankle dorsiflexion ROM is therefore a priority of early rehabilitation. [2,3,8]

Measurement of dorsiflexion in standing4 simulates the ROM achieved during these functional tasks. [1,6] This is particularly relevant because the torques applied to the ankle in weight-bearing are clearly greater than in non-weight-bearing, and the resultant measurement may be more indicative of the range available for functional activities. [4,5]

Measurement of ankle dorsiflexion ROM using the weight bearing lunge method has been shown [4] to be highly reliable in the laboratory (between-session intra-rater reliability ICC(3,3) 0.97 to 0.98, within-session inter-rater reliability ICC(2,3) 0.99. However, it is unclear whether these methods are efficient and reliable in uncontrolled clinical environments, where high reliability is essential for monitoring of progress and treatment effects.

The aim of the current study therefore, was to assess in the clinical environment the reliability of: i) the figure of eight method; and ii) the weight bearing lunge method for measurements taken within- and between-sessions. The unaffected ankle of participants was investigated because it is not possible to determine between-session reliability on the injured ankle, given the expected rapid changes in swelling and dorsiflexion range [10] and associated confounding effects of intervention on repeatability. Nevertheless, this information is important clinically, because, similar to Phase I and II trials, laboratory results cannot necessarily be generalized to the clinical environment.

Methods

Design

A repeated measures design was used to test reliability. When a participant was attending for treatment of an injured ankle, the treating therapist and a second rater measured outcomes on the uninjured ankle before treatment commenced for the affected ankle.

On the first test occasion, raters took two measurements of both ROM and swelling within a 1-hour period. Repeat measurements for between-session reliability were taken approximately one week later. To minimize unblinding, raters used a new data sheet to record each measurement before sealing each data sheet in an opaque envelope for later analysis.

Participants

The raters were four physiotherapists of varying post-graduate experience (range 4 -15 years, mean 8.2 years). The participants (patient group) consisted of 15 males and 18 females aged 10 to 76 years (mean, standard deviation [SD]: 28, 14.3 years), recruited from staff and patients attending a physiotherapy and sports injury clinic in Sydney, Australia. Eleven participants (3 male, 8 female) were injury-free and asymptomatic. Twenty-two (12 male, 10 female) had sustained a recent unilateral ankle sprain, fifteen while participating in competitive sport, and seven while walking on an uneven surface. The asymptomatic contralateral ankle was measured in injured participants and a randomly selected ankle in healthy participants. While raters routinely used the figure of eight and dorsiflexion lunge methods in their clinical practice, they were familiarized with the standardized protocols for measurement before undertaking data collection.

Protocols

i) Figure of eight method for measuring swelling

The protocol used in the current study was based on that described by Mawdsley. [13] Participants were positioned in long-sitting on a bed with the experimental foot resting over the end. (Fig. 1) The following standardized landmarks were marked with a pen prior to measurement: a) the point midway over the anterior ankle between the tibialis anterior tendon and lateral malleolus, b) the navicular tuberosity, c) the base of the fifth metatarsal, and d) the inferior tip of the medial malleolus.

To blind therapists during measurements, one surface of a double-sided retractable plastic tape measure was blackened leaving the zero point visible. The rater placed the zero point over the mark on the anterior aspect of the ankle and pulled the tape medially over the navicular tuberosity, and then infero-laterally across the medial arch to the proximal aspect of the base of the fifth metatarsal. The tape was then pulled superiorly and medially over the tarsal bones across the inferior aspect of the medial malleolus, and postero-laterally around the Achilles tendon over the distal lateral malleolus to finish at the zero point. The rater tightened the tape measure and then released tension slightly to ensure there was no indentation of soft tissue. To obtain the measurement, a clip was placed at the point of intersection between the zero and finish points of the tape. (Fig. 1) The examiner removed and turned over the tape and recorded the result to the nearest millimeter.

ii) Weight-Bearing lunge for range of ankle dorsiflexion

The weight-bearing lunge used to measure ankle dorsiflexion range was based on that described by Bennell, et al., [4]. Each participant stood on an apparatus consisting of a horizontal footplate attached to a vertical board . (Fig. 2)

Figure 2  The weight-bearing lunge method for measuring ankle dorsiflexion.

Participants aligned the great toe and heel of the test leg over a line marked along the center of the footplate. Participants were instructed not to lift the test heel, checked by the examiner who gently palpated for lifting [4] while the participant moved the knee forward into a lunge position, until the patella touched the midline of the vertical board. To prevent forward movement of the great toe as the knee moved forward over the foot, a block was placed in front of the great toe. The measurement recorded was the distance (cm) from the vertical board to the great toe. Participants were given up to five attempts and the best performance was used for further analysis.

Data Analysis

SPSS for Windows™ was used to calculate ICCs (ICC(1,1) and ICC(2,1)) and 95% confidence intervals (CI)20 for each method, within- and between-raters and within- and between-sessions. The ICC values were interpreted according to the definition of Munro and Page [15]: ICC values 0.00 to 0.25 indicated little, if any correlation; 0.26 to 0.49 low correlation; 0.50 to 0.69 moderate correlation; 0.7 and 0.89 high correlation, and 0.9 to 1.0 indicated very high correlation.

The SEM [15], was calculated for repeated measurements on the same participant, within- and between-sessions, and was expressed in the original units of measurement to provide error data in clinically relevant terms. Paired t-tests were used to compare the means for each measurement occasion.

Results

Intra-rater reliability: within session

Measurements of swelling using the figure of eight method and ankle dorsiflexion using the weight-bearing lunge were taken by the same rater one hour apart. For the figure of eight method, ICC(2,1) values were > 0.90 (Table 1), consistent with very high correlation. [15]

Table 1  Intraclass correlation coefficient (ICC(1,1)) (ICC(2,1)) with 95% Confidence Interval (CI) for intra- and inter-rater reliability of figure of eight and weight bearing lunge measurements respectively.  Data are shown for within and between sessions (n = 4 raters).

There was no difference in mean swelling between the first and second measurements (p = 0.32). The SEM was 0.2cm (Table 2) indicating that a therapist taking a repeat measurement of swelling after treatment could be confident on 95% of occasions that any reduction >0.4cm (1.96 x SEM) would be due to the treatment. Alternatively, an increase of ≥0.4cm would indicate that swelling had increased.

For the dorsiflexion lunge method of measuring range of motion, ICC(1,1) values were also >0.90 (Table 1), consistent with very high correlation. There was no difference in mean dorsiflexion range between the first and second measurements (p=0.5). The SEM was 0.4cm (Table 2). Thus, a therapist taking a repeat measurement after treatment using the weight-bearing lunge could be confident on 95% of occasions that any change in range of motion of >0.8cm could be attributed to treatment.

Table 2  Means (standard deviation) for the 2 measurement occasions and standard error of the measurement (SEM) for figure of eight swelling and weight bearing lunge dorsiflexion lunge measurements (n = 4 raters).

Intra-rater reliability: between session

Measurements of ankle swelling and ankle dorsiflexion were repeated, on average, 6.8 days (range 2 – 28 days) after the first measurement occasion. For the figure of eight method, ICC(2,1) values were > 0.90, consistent with very high correlation (Table 1). There was no difference in mean swelling between measurement occasions (p = 0.29). The SEM was 0.3cm (Table 2), indicating that a therapist taking measurements between treatment sessions could be confident on 95% of occasions that a difference in swelling of > 0.7cm between treatments would not be due to error.

For the dorsiflexion lunge method of measuring range of motion, ICC(1,1) values were > 0.90, consistent with very high correlation (Table 1). There was no difference in mean dorsiflexion range of motion between sessions (p = 0.2). The SEM was 0.4cm (Table 2) indicating that a therapist taking repeat measurements between occasions could be confident on 95% of occasions that a difference in ROM of > 0.8cm would not be due to error.

Inter-rater reliability: between sessions

To determine inter-rater reliability, two different raters made the repeat measurements of swelling and range of motion, on average 6.8 days (range 2 – 28 days) apart. For the figure of eight method, ICC(1,1) values were > 0.90, indicating very high reliability (Table 1). There was no difference in mean swelling (p = 0.2) between the two measurement occasions. The SEM was 0.3cm (Table 2), indicating that a different therapist repeating the measurement one week later could be confident on 95% of occasions that a change in swelling of > 0.6cm would not be due to error.

Similarly, for the dorsiflexion lunge method of measuring range of motion, ICC(1,1) values for inter-rater reliability were > 0.90, consistent with very high correlation (Table 1). There was no difference in mean range of motion for dorsiflexion (p = 0.09). The SEM was 0.4cm (Table 2), indicating that a therapist taking a repeat measurement one week after the first occasion could be confident on 95% of occasions that any difference in ROM of >0.8cm after treatment would not be due to error.

Discussion

The current results indicate that intra- and inter-rater reliability were very high for measurements taken in the clinic for both the figure of eight method (ankle swelling) and the weight-bearing lunge method (ankle dorsiflexion). Whilst previous research has reported acceptable reliability in a well-controlled laboratory environment, the current study demonstrated reliability of these methods in the variable clinical environment. Very high intra and interrater reliability was observed for measurements repeated within a single session, and after a one-week interval. Therefore, clinicians can use both techniques with confidence within and between sessions to determine the effects of interventions to improve ankle swelling and dorsiflexion range following ankle sprain. The results presented here will assist clinicians with decisions regarding the management of ankle sprain and monitoring progress with treatment.

Despite the inherent differences between the demands of the clinical environment and the laboratory environment, such as time constraints during measurement procedures and a more unpredictable environment [7], the current findings for the figure of eight tape method are comparable to data derived from laboratory studies. Very high intra- and inter-rater reliability (ICC values 0.98 – 0.99) have been reported using the figure of eight method for injured [13,16] as well as asymptomatic [11, 21] ankles. However, previous research has only documented the reliability of the figure of eight method for repeated measurements taken within a single session. [11,13,16] The current study observed very high intra and interrater reliability both within and between-sessions, with a comparable SEM of 0.4 to 0.5cm [11,13], and therefore has demonstrated that different therapists can treat the same patient on different occasions and use the figure of eight method to confidently determine treatment effects. Furthermore, the small SEM observed in the current study informs clinicians that changes in swelling of greater than 0.7cm are more likely due to intervention effects than error. This suggests that the error is considerably less than changes that would be considered clinically worthwhile.

The figure of eight method has been reported to correlate well with water displacement methods for measurements of ankle swelling after lower limb injury. [13,16] While water displacement is the gold standard method for measuring lower limb volume [11,13,16], the method is time consuming, requiring between 5 and 6 minutes to perform, whereas the figure of eight method requires approximately 30 seconds to perform. [11] It also requires relatively sophisticated equipment, unlike the tape measure method. Therefore, the figure of eight method may not only be a more time-efficient method for measuring ankle swelling, but also can be used without sacrificing reliability; even between raters, and between sessions.

Similarly, very high15 intrarater reliability results have been reported for the weight bearing lunge method of measuring dorsiflexion in participants with asymptomatic ankles, within and between sessions, and for different raters taking repeat measurements within a single session.4 The current data recorded in a clinical environment are comparable to previous data collected in a laboratory environment, and again indicate that use of a cost and time-efficient method does not sacrifice reliability. Clinicians can therefore be confident that the weight-bearing lunge method for measuring dorsiflexion range is robust in the clinical environment. Furthermore, the small SEM suggests that clinicians detecting changes in ROM of greater than 1cm are more likely to be observing intervention effects than error.

Conclusions

Whereas previous studies using the figure of eight method for measuring ankle swelling and weight bearing lunge for measuring dorsiflexion have been conducted in laboratory settings, the current study was conducted in a clinical setting characterized by more variable environmental conditions and constraints that replicated conditions likely to be encountered by clinicians during rehabilitation of ankle sprain. In the current study, intra and interrater reliability for each method was observed to remain very high for both within and between sessions data. Therefore, with adequate familiarization, these simple, reliable, and time efficient methods can be used with confidence by clinicians with varying levels of expertise to assess treatment effects on swelling and ankle dorsiflexion in clinical populations.

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Address correspondence to: Robert A. Boland, PhD
University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy. PO Box 170, Lidcombe, NSW 1825, Australia.
Email: R.Boland@usyd.edu.au

1 University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy. East St., Lidcombe, NSW, Australia.
2 University of Sydney, Faculty of Health Sciences, Lidcombe, NSW, Australia.
3 Prince of Wales Medical Research Institute, Randwick, NSW, Australia.
4 ELITE Physiotherapy Exercise & Rehabilitation, Menai, NSW, Australia.

© The Foot & Ankle Journal, 2008