Monthly Archives: December 2016

December 2016


9 (4), 2016


Intramedullary rodding of a toe – hammertoe correction using an implantable intramedullary fusion device – a case report and review
by Christopher R. Hood JR, DPM, AACFAS, Jason R. Miller, DPM, FACFAS


The effects of CrossFit and minimalist footwear on Achilles tendon kinetics during running
by Jonathan Sinclair, and Benjamin Sant


Coronal plane talar body fracture associated with subtalar and talonavicular dislocations: A case report
by Barıs YILMAZ, MD, Baver ACAR, MD, Baran KOMUR, MD, Omer Faruk EGERCI, MD, Ozkan KOSE MD, FEBOT, Assoc. Prof.


Atraumatic acute compartment syndrome secondary to group C Streptococcus infection
by Amelia Aaronson, Malcolm Podmore, Richard Cove


Effects of high and low cut on Achilles tendon kinetics during basketball specific movements
by Jonathan Sinclair, Benjamin Sant


Use of an external vibratory device as a pain management adjunct for injections to the foot and ankle
by Joseph D. Rundell, BS, Joshua A. Sebag, BA, Carl A. Kihm, DPM, FACFAS, Robert W. Herpen DPM, Tracey C. Vlahovic DPM


Use of an external vibratory device as a pain management adjunct for injections to the foot and ankle

by Joseph D. Rundell, BS1, Joshua A. Sebag, BA1, Carl A. Kihm, DPM, FACFAS2, Robert W. Herpen DPM3, Tracey C. Vlahovic DPM3*pdflrg

The Foot and Ankle Online Journal 9 (4): 6

Objectives:  Pain modulation through the combined effect of vibratory stimulation of Aβ mechanoreceptors and cold thermal stimuli has been demonstrated to reduce the pain associated with injections and IV cannulation.  Although past reports have focused on its use on the upper extremity, there are no current studies to evaluate the efficacy of these combined modalities for lower extremity injections.    The authors propose the combined use of vibratory stimulation with cold thermal stimulation will yield lower reported pain values associated with injection compared to cold thermal stimulation alone.  
Methods:  In this multicenter, randomized, prospective clinical trial, 108 patients necessitated a lower extremity injection for the treatment of their presenting condition and was randomized into a treatment (vibration and cold spray) or control (cold spray only) groups.  The primary outcome was pain, subjectively measured on a 10-point numerical pain rating scale (NPRS) by the patient.  Pain was also ranked by an observing physician via the Wong-Baker Pain Faces Ranking Scale (WBPFRS).
Results:  Forty treatment subjects and 68 control subjects were included in this study.  Pain scores were significantly lower in the treatment group receiving the vibratory device and the cold spray compared to the cold spray alone (NPRS mean values:  Treatment: 3.39, Control: 4.46; p=0.022.  WBPFRS mean values: Treatment: 2.29, Control: 4.05; p=0.030).  
Discussion:  Utilizing a combination of cold spray with vibratory stimulation produced a statistically significant decrease in pain associated with lower extremity injections.  Due to the relatively small size of our study, further investigation is needed to assess effect on specific injection site.  

Keywords:  injection, vibratory stimulation, foot and ankle, lower extremity, buzzy

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0006

1 – Fourth year student, Temple University School of Podiatric Medicine, 148 N 8th Street, Philadelphia, PA 19107
2 – Private practice, University Foot & Ankle, 3 Audubon Plaza Dr Ste 510, Louisville, KY 40217
3 – Faculty, Temple University School of Podiatric Medicine, Philadelphia, PA, 19107
* – Corresponding author: traceyv@temple.edu


Injection therapy has been a mainstay intervention for addressing musculoskeletal pain for over 50 years [1]. Foot and ankle physicians commonly perform office procedures which are made tolerable by first injecting local anesthetics. Unfortunately, injections to the foot and ankle often elicit exquisite pain due to a greater density of sensory nerve endings in that area of the body [2] and the depth of some of the injections. The pain and anxiety from needle injections can have deeper consequences such as impaired patient compliance[3], deferral due to needle phobia [4] or lack of follow-up due to fear of future injections [5]. There can be value in utilizing interventions to reduce the pain associated with injections. Therapeutic outcomes could possibly improve by increasing patient compliance and reducing fear avoidance if injections are perceived as less painful. Increased patient satisfaction and the overall patient experience could be maximized.

Although there are distinct benefits from decreasing the pain associated with needle injections, there remains a dogma that injection pain reduction modalities are deficient [6].  There are options available that deserve consideration utilizing various mechanisms.  Pharmacological intervention via topical or injectable anesthetics, are commonly used.  While this intervention has been shown to alleviate pain associated with injections [3,7,8], it is not without drawbacks.  The use of topical anesthetics can cost $20 or more [9].  Additionally, these can prolong time in the office and procedure times, since it takes time for the induction of effective analgesia [7]. The drug cost can present concerns regarding the stewardship of already strained healthcare resources.  In addition to pharmacological interventions, there exist other modalities which utilize the gate theory of pain control.  Cold therapy [10] and activation of Aβ sensory fibers through vibratory stimulation [11] of mechanoreceptors are believed to cause presynaptic inhibition of the dorsal horn.  This therefore “closes the gate” and reduces the transmission of nociceptor signals.  Cold therapy has demonstrated efficacy in reducing injection pain in both adult [12] and pediatric [7, 13] groups.  Cold therapy sprays are commonly used in an office setting for immediate but temporary analgesia for the time of injection.  In addition, vibratory stimulation to manage pain from injections has yielded positive results in adult [9,14] and pediatric [15-17] populations.  

Reusable devices that produce a combination of cold and vibratory stimulation to manage injection pain have been developed; one such device is called “Buzzy®” (MMJ Labs Atlanta, GA).  There have been a number of studies which have demonstrated its efficacy in reducing injection pain, but these studies have focused particularly on pediatric IV access [9,16,18,19].  This device has the advantage of being reusable, easy to use and does not require much additional time.  The clinician uses a built-in Velcro strap to apply the device proximal to the injection site.  While there is evidence this device can reduce injection pain related to venipuncture access, no studies have investigated the efficacy of this device for pain management of injections to the foot and ankle.  It was the goal of this study to determine whether pain associated with injections to the foot and ankle is decreased when using the Buzzy® (or vibratory) device.   

Materials and Methods

Our study was a multicenter, prospective clinical trial using 108 patients needing an injection to the foot or ankle.  The study was explained to every patient and consent to participate was obtained.  This study was performed at the Temple University School of Podiatric Medicine’s Foot and Ankle Institute (FAI) clinic (n=42) and in a separate private practice podiatry clinic (n=66).  Participants were excluded if they had: skin compromise over the vibratory device application site, history of peripheral neuropathy, fibromyalgia, complex regional pain syndrome, cognitive or verbal impairment, patients who were blind or not fluent in English, and those impaired via narcotics/analgesics within 4 hours prior to the office visit.

Data Collection and Outcomes

The primary outcome variable was pain, which was measured utilizing an 11-point Numerical Pain Rating Scale (NPRS).  The patient reported their pain on a scale of 0-10 where 0 is no pain and 10 is the worst pain imaginable.  As a secondary variable outcome, pain was assessed via the Wong-Baker Pain Faces Rating Scale (WBPFRS).  It should be noted WBPFRS was only collected on the FAI patients by an observing physician.   The patients were not made aware of the WBPFRS measurement to minimize chances of altering their facial expressions in front of the physicians.   

Randomization

After informed consent was obtained, patients were randomly assigned into the treatment or control group.  The treatment population was treated with external vibratory stimulation delivered through the vibratory device and cold spray prior to injection.  The control population was treated solely with cold spray prior to injection.  Determination of randomization was performed immediately before injection.  At the FAI, randomization was performed via drawing an opaque envelope whereby the instructions inside would assign the group.  At the private practice clinic, randomization was achieved by randomly assigning subject numbers with control or treatment groups.  As patients presented for an injection, the patients were assigned the next consecutive subject number.

Procedure

Demographic information consisting of age, gender, and whether they have had an injection to the foot or ankle previously was recorded on the questionnaire.  The attending physician instructed the patient on using the NPRS.  In order to maintain consistency of the pain data, the patient was instructed to rank the pain associated with the initial needle stick, but to not watch the injection being performed.  The injection site was first prepped with alcohol or betadine.  If the patient was assigned to the treatment group, then the vibratory device unit was applied 5-10cm proximal to the injection site over the anatomical location of the appropriate sensory nerve(s).  The vibratory device was turned on for approximately 1 minute prior to and maintained during the injection.  

In both groups, Gebauer’s Ethyl Chloride® (Cleveland, OH) was applied to the injection site, and then a 25 gauge needle was inserted.  The injection was performed under the supervision of an attending physician (TV or RH).  At the private practice clinic, all injections were performed by 1 attending physician (CK).  During the injection, the attending physician at the FAI assessed pain utilizing the WBPFRS.  In the private practice setting, the attending was visually focused on the injection and not the face; therefore WBPFRS was not recorded.  After the injection, the patient was asked to rank their pain on the NPRS, and if the injection was better or worse than anticipated.  It should be noted, the vibratory device does come with reusable ice-packs to provide the cryothermal stimulation; however, cold spray was utilized in its place in order to minimize deviation from the clinic’s standard of care.  

Statistical Evaluation

The outcome variable was pain.  This was ranked primarily via the NPRS between the treatment and control groups.  Pain ranked by WBPFRS was utilized as a secondary outcome variable.  The unpaired t-test was used to evaluate the statistical significance of the NPRS and WBPFRS values between the treatment and intervention groups.  The criteria for significance between the values was a p value <0.05.   Statistical calculation was performed utilizing GraphPad® statistical software.

Results

One hundred and eight consenting patients were recruited to participate in this study.  Based on our parameters, no patients required exclusion from the study.  The treatment group (n=40) was composed of 18 (45.0%) males and 22 (55.0%) females with a mean age of 39.2 ± 20.9 years (range 12-79 years).  The control group (n=68) was composed of 32 (47.0%) males and 36 (53.0%) females with a mean age of 43.5 ± 23.2 years (11-92 years).  There was no statistically significant difference in age or gender between the groups (Table 1).   The material injected was as follows:  for the intervention group 14 received a steroid cocktail (acetate and phosphate-based steroid, diluted in local anesthetic) and 54 were injected with only local anesthetic (1% lidocaine or 0.5% marcaine plain).   

table1

Table 1 Demographic and Injection Data.

table2

Table 2 Pain Measurements using both scales.

table3

Table 3 Pain Rating Mean Values.

For the treatment group, the mean NPRS value was 3.39 ± 2.67 (0-10) and the mean WBPFRS was 2.29 ±1.59 (0-6).  Seventeen patients reported the injection was “better” than expected while 6 reported it was “same” and 1 “worse” than expected.

With regards to the control group, the mean NPRS value was 4.64 ± 2.72 (0-10) and the mean WBPRFS was 4.05 ± 3.13 (0-10) (Table 2).  Twenty six reported the injection was “better” than expected while 8 reported it was “same or worse” than expected.  

In terms of anatomical location of the injection, an injection into an intermetatarsal space the addition of vibratory stimulation to cold spray provided the largest percent difference in NPRS scores, whereas hallux block showed the least reduction in pain (Table 3).

Discussion

It is recognized that control of pain contributes to improved clinical outcomes and patient satisfaction.  This right unfortunately comes with added costs monetarily (i.e. cost of of topical lidocaine) and in time (delay for topical anesthesia induction)[20, 21].  These can provide added cost and personnel burdens to an already resource-strained healthcare system.  These barriers, combined with attitudes that injections will cause pain, hamper the use of interventions to reduce injection pain.  It has been reported that only 6% of pediatricians utilize available interventions to reduce the pain associated with injection therapy [21].

In our study, we investigated the use of eliciting the pain gating theory to activate descending noxious stimuli inhibition to manage pain associated with injections to the foot and ankle.  The pain gating phenomenon was first described in 1965 where Aδ pain fibers shared a final common pathway with thermal and Aβ, and stimulation of thermal and Aβ would effectively “close the gate” to noxious stimuli from Aδ nociceptors [10].  By combining the use of vibratory stimulation and cold spray it may be possible to maximize pain reduction.  The hope of our study is to demonstrate if this is possible in our clinics (Table 3).

Through the combined use of the vibratory device with cold spray, we demonstrated an appreciable decrease in pain associated with injections to the foot and ankle.  Our primary outcome was pain reported by the patient utilizing the NPRS.  We report a mean drop in NPRS scores from 4.64 to 3.39; this represents a 31.3% decrease in pain associated with injections between the treatment and control group.  Our secondary outcome was an observer physician-recorded pain utilizing the WBPFRS; mean scores dropped from 4.0 to 2.29 representing a 54.4% decrease in mean pain recorded through this scale.  Both of these outcomes were statistically significant with p values of 0.022 and 0.03 respectively.

While a statistically significant decrease in pain through this or any intervention might seem like a definitive success, it is still imperative to consider whether this significance translates into a clinically relevant context versus a purely numerical context.  There exists a number of studies that address this matter.  Todd et al [22] determined a decrease of 13mm on the 100mm VAS yielded a clinically relevant decrease in pain.  There are other arguments that relative decrease in pain is more clinically relevant than the decrease in the absolute value of the pain.   Campbell et al [23] within the setting of a dental surgery practice, determined a decrease in VAS score by “between 31% and 48%, depending on its initial intensity” is requisite to be considered clinically relevant.  In a study by Farrar et al [24] 10 clinical control trials for chronic pain interventions were reviewed, and it was concluded a 30% decrease in pain scores indicated a significant decrease; furthermore, this 30% decrease was determined to correspond to a 2-point decrease on the NPRS.  Comparing our data to that of the studies mentioned here, utilizing the vibratory stimulation in addition to cold spray did produce a clinically significant reduction in pain.   

Comparing patients’ expectations (better or worse than expected) between treatment and control groups was performed by Fisher’s Exact Test which yielded a p value of 0.76, thus no statistical significant outcome can be drawn from this.  In terms of patient’s tolerance of the vibratory stimulation, it was tolerated well as only one commented that, “It felt annoying.”  With regards to ease of use, no one in either clinic reported any difficulty in using the vibratory device.    

This study is not without limitations.   The first of which is pain scores were only from one patient encounter.  Pain is well noted to be an extremely subjective sensation in terms of perception and tolerance with wide variation between people. Additionally, it is well known that pain has multidimensional contributing factors, such as anxiety or recent pain sensations [25].   As such, measuring the pain of a heel injection between various people can elicit widely different values, even if no intervention is used.  Another limitation of this study was for the injections performed at the FAI.  There may be differences in injection technique, ability, and apparent confidence between attending physicians.  Finally, this study included injections to any anatomical location to the foot and ankle.  It is likely an injection to certain parts of the foot or ankle will naturally just elicit more pain than other areas would.  This is expected due to the possible sources of sensory nerve distribution and the vibratory device’s ability to effectively target more than one sensory nerve simultaneously.  In the future, the device may be better contoured for the ankle so as to prevent slippage and simultaneously affect numerous nerves. Injection techniques were not standardized as well.  For instance, one of the clinicians prefers a medial glabrous skin junction approach for painful heel injections while the other prefers a plantar approach.  Also, there may be inherent differences based on the composition of local anesthetic and injectable corticosteroid, which varied greatly in makeup proportion and delivered amount.  Temperature of injectable, pH of injectable, needle gauge and quantity injected are possible covariables which were not studied.

The investigators did find that it was harder to apply the vibratory device to some parts of the foot versus others due to anatomical contouring of the unit. This may have affected the ability of the device to work optimally and target the desired areas.  As seen in Table 3, there is marked variation between pain scores and location of the injection.  Lastly, although it was attempted to not influence a known effect of the vibratory unit, it is possible that natural bias was placed on the patient to downplay perceived pain.  This could have been avoided with a double-blind study protocol.

The authors believe further studies are needed to better understand and quantify potential benefit of such devices.  Future modifications of such units may optimize use and benefit also.  This pilot study suggests that the combination of vibratory stimulation and cold sensation does reduce the pain associated with injections to the foot and ankle.  Further control of cofactors is necessary to conclude how effective and specifically which injections (injectable and location) and patient demographics are most affected.  

Conclusion

The combination of external vibratory stimulation in addition to cold spray produced an appreciable reduction in the pain in comparison to cold spray alone for our patients undergoing foot and ankle injections.  Further investigation is warranted for injections of the lower extremity.   

References

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Effects of high and low cut on Achilles tendon kinetics during basketball specific movements

by Jonathan Sinclair1*, Benjamin Sant1pdflrg

The Foot and Ankle Online Journal 9 (4): 5

The aim of the current investigation was to examine the influence of high and low-cut specific basketball footwear in relation to minimalist and conventional athletic footwear on the loads experienced by the Achilles tendon during basketball specific movements. Ten males performed run and 45˚ cut movements whilst wearing low-cut, high-cut, minimalist and conventional athletic footwear. Achilles tendon forces were calculated using Opensim software allowing the magnitudinal and temporal aspects of the Achilles tendon force to be quantified.  Differences in Achilles tendon load parameters were examined using 4 (footwear) x 2 (movement) repeated measures ANOVA. The results show that a main effect was evident for peak Achilles tendon force, which was significantly larger in the minimalist (run = 5.74 & cut = 5.85 BW) and high-cut (run = 6.63 & cut = 6.01 BW) footwear in relation to the low-cut (run = 5.79 & cut = 5.47 BW) and conventional (run = 5.66 & cut = 5.34 BW) conditions. In addition a main effect was also evident for Achilles tendon load rate, which was significantly larger in the minimalist (run = 48.84 & cut = 43.98 BW/s) and high-cut (run = 54.31 & cut = 46.51 BW/s) footwear in relation to the low-cut (run = 43.15 & cut = 31.57 BW/s) and conventional (run = 44.74 & cut = 31.15 BW/s) conditions. The current investigation indicates that minimalist and high-cut footwear may place basketballers at increased risk for Achilles tendon pathology as a function of their training/ competition. Furthermore, it appears that for basketballers who may be susceptible to Achilles tendinopathy that low-cut and conventional conditions are most appropriate.

Keywords: basketball, Achilles tendon, biomechanics

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0005

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


At all levels of play basketball is becoming a uniquely popular athletic discipline throughout the world [1]. Basketball is regarded as a physiologically demanding sport in which players are required to perform a series of different motions that typically include running, jumping and rapid changes of direction [2]. A typical competitive basketball season will require players to train frequently and perform >60 games, a regimen which serves to place high physical and mechanical demands on those involved [3].

Basketball has in recent years gained more research attention from the scientific community regarding players’ susceptibility to injury. Research investigating the prevalence of injuries in basketball players has shown that in relation to other non-contact sports basketball is associated with a comparatively high rate of injury. Information from aetiological analyses indicates that 11.6 injuries occur per 1000 appearances, and that the vast majority (65 %) are confined to the lower extremities [4]. Athletic disciplines which include frequently jumps, foot strikes and changes in direction such as basketball, place high loads on the Achilles tendon placing it at high risk from injury [5].

Given the highly physical nature of modern basketball, court footwear must now fulfill a range of biomechanical parameters such as traction, support, stability and shock attenuation [6]. Traditionally basketball specific footwear designs were available only with high-cut ankle supports which are utilized in order to promote mediolateral stability during landing [7]. In recent times however, low-cut footwear models have also been introduced and utilized at all levels of play, meaning court specific footwear can be selected based on individual preference. Recreational level players are also known to use low-cut conventional athletic footwear which may serve to enhance improve impact loading but at the expense of medio-lateral stability [7]. In comparison to other sports such as running there is currently a paucity of scientific research examining the efficacy of basketball footwear.

Appropriate footwear selection has been cited as a mechanism by which the risk from Achilles tendon pathologies during sport can be mediated. Considerable research has examined the effects of different footwear on the forces experienced by the tendon during different sports. Sinclair examined the effects barefoot and in minimalist footwear on Achilles tendon kinetics in relation to conventional running shoes [8]. Their results showed that conventional footwear significantly reduced peak Achilles tendon forces in relation to barefoot and minimalist conditions. Similarly, Sinclair et al., [9] examined the effects of minimalist and netball specific conditions on the forces experienced by the Achilles tendon during running and cutting movements. They showed that the peak force and rate of force application was significantly reduced in the netball specific condition. Finally, Sinclair et al [10] investigated the effects of minimalist energy return and convention athletic footwear on Achilles tendon loads during depth jumping. They showed the footwear did not significantly affect Achilles tendon forces during this movement. However, despite the wealth of peer reviewed literature examining the effects of different footwear on Achilles tendon kinetics there is currently no information available regarding the influence of basketball specific shoes.

Therefore, the aim of the current investigation was to examine the influence of high and low-cut specific basketball footwear in relation to minimalist and conventional athletic footwear on the loads experienced by the Achilles tendon during basketball specific movements. The findings from the current investigation may provide basketball players with important clinical information regarding the selection of appropriate footwear, which may ultimately help to attenuate their risk from developing Achilles tendon pathologies.

Methods

Participants

Ten male participants, volunteered to take part in this study. All were free from musculoskeletal pathology at the time of data collection and provided written informed consent. The mean characteristics of the participants were; age 24.26 ± 4.05 years, height 1.77 ± 0.07 cm and body mass 78.66 ± 7.43 kg. The procedure utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee.

Footwear

The footwear used during this study consisted of minimalist (Vibram five-fingers Original;), high-cut (Nike Lebron XII), low-cut (Nike Lebron XII Low) footwear and conventional (New Balance 1260 v2) (shoe size 9–10 in UK men’s sizes).

Procedure

Participants completed five repeats of two sport specific movements; run and cut in each of the four footwear conditions. To control for any order effects the order in which participants performed in each footwear/ movement condition were counterbalanced. Kinematic information from the lower extremity joints was obtained using an eight camera motion capture system (Qualisys Medical AB, Goteburg, Sweden) using a capture frequency of 250 Hz. To measure kinetic information an embedded piezoelectric force platform (Kistler National Instruments, Model 9281CA) operating at 1000 Hz was utilized. The kinetic and kinematic information were synchronously obtained and interfaced using Qualisys track manager.

To define the anatomical frames of the thorax, pelvis, thighs, shanks and feet retroreflective markers were placed at the C7, T12 and xiphoid process landmarks and also positioned bilaterally onto the acromion process, iliac crest, anterior superior iliac spine, posterior superior iliac spine, medial and lateral malleoli, medial and lateral femoral epicondyles, greater trochanter,  calcaneus, first metatarsal and fifth metatarsal. Carbon-fibre tracking clusters comprising of four nonlinear retroreflective markers were positioned onto the thigh and shank segments. Static calibration trials were obtained with the participant in the anatomical position in order for the positions of the anatomical markers to be referenced in relation to the tracking clusters/markers. A static trial was conducted with the participant in the anatomical position in order for the anatomical positions to be referenced in relation to the tracking markers, following which those not required for dynamic data were removed.

Data were collected during the run and cut movements according to below procedures:

Run

Participants ran at 4.0 m.s-1 ±5% and struck the force platform with their right (dominant) limb. The average velocity of running was monitored using infrared timing gates (SmartSpeed Ltd UK). The stance phase of running was defined as the duration over > 20 N of vertical force was applied to the force platform[11].

Cut

Participants completed 45° sideways cut movements using an approach velocity of 4.0 m.s-1 ±5% striking the force platform with their right (dominant) limb. In accordance with McLean et al.,[12] cut angles were measured from the centre of the force plate and the corresponding line of movement was delineated using masking tape so that it was clearly evident to participants. The stance phase of the cut-movement was similarly defined as the duration over > 20 N of vertical force was applied to the force platform [11].

Processing

Dynamic trials were digitized using Qualisys Track Manager in order to identify anatomical and tracking markers then exported as C3D files to Visual 3D (C-Motion, Germantown, MD, USA). Ground reaction force and kinematic data were smoothed using cut-off frequencies of 25 and 12 Hz with a low-pass Butterworth 4th order zero lag filter.

Data during the stance phase were exported from Visual 3D into OpenSim software (Simtk.org), which was used give to simulations of muscles forces. Simulations of muscle forces were obtained using the standard gait 2392 model within Opensim v3.2. This model corresponds to the eight segments that were exported from Visual 3D and features 19 total degrees of freedom and 92 muscle-tendon actuators.

We firstly performed a residual reduction algorithm (RRA) within OpenSim, this utilizes the inverse kinematics and ground reaction forces that were exported from Visual 3D. The RRA calculates the joint torques required to re-create the dynamic motion. The RRA calculations produced route mean squared errors <2°, which correspond with the recommendations for good quality data.  Following the RRA, the computed muscle control (CMC) procedure was then employed to estimate a set of muscle force patterns allowing the model to replicate the required kinematics 13. The CMC procedure works by estimating the required muscle forces to produce the net joint torques.

Achilles tendon force was estimated in accordance with the protocol of Almonroeder et al [14] by summing the muscle forces of the medial gastrocnemius, lateral, gastrocnemius, and soleus muscles. Achilles tendon load rate was quantified as the peak Achilles tendon force divided by the time to peak force. All Achilles tendon load parameters were normalized by dividing the net values by body weight (BW).

Analyses

Differences in kinetic and kinematic parameters between footwear were examined using 4 (footwear) x 2 (movement) repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Follow up comparisons on significant interactions were examined using simple main effects and post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v22.0 (SPSS Inc., Chicago, USA).

Results

Tables 1 and Figure 1 present the footwear differences in Achilles tendon kinetics both movements. The results indicate that the experimental footwear significantly affected Achilles tendon load parameters.

 

Minimalist High-cut Low-cut Conventional
Run Cut Run Cut Run Cut Run Cut
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean
Peak Achilles tendon force (BW) 5.74 0.75 5.85 1.03 6.63 1.19 6.01 0.69 5.79 0.78 5.47 1.00 5.66 0.90 5.34
Time to peak Achilles tendon force (s) 0.12 0.01 0.16 0.04 0.13 0.02 0.16 0.02 0.14 0.01 0.19 0.04 0.13 0.02 0.18
Achilles tendon load rate (BW/s) 49.84 8.70 43.98 18.68 54.31 17.49 46.51 14.71 43.15 9.16 31.57 11.96 44.74 11.97 31.15

Table 1 Achilles tendon kinetics as a function of footwear and movement conditions.

fig1

Figure 1 Achilles tendon kinetics during the stance phase (a. = run & b. = cut) (black = minimalist, black dash = high-cut, grey dot = low-cut & grey = conventional).

For peak Achilles tendon force a significant main effect (P<0.05, pη2 = 0.64) was observed for footwear. Post-hoc pairwise comparisons showed that peak Achilles tendon force was significantly larger in the high-cut footwear in relation to the minimalist, low-cut and conventional athletic conditions. In addition it was also revealed that peak force was significantly larger in the minimalist footwear in comparison to the conventional condition.

For time to peak Achilles tendon force significant main effects were observed for both footwear (P<0.05, pη2 = 0.55) and movement (P<0.05, pη2 = 0.70). Post-hoc analysis for footwear showed that time to peak force was significantly greater in the low-cut footwear in comparison to the minimalist, high-cut and conventional conditions. Furthermore, it was also demonstrated that time to peak force was significantly greater in the conventional athletic footwear in relation to the minimalist and high-cut conditions. Finally, it was shown that time to peak force was significantly greater in the high-cut footwear in comparison to the minimalist condition. In addition post-hoc analysis for movement indicated that time to peak Achilles tendon force was significantly greater when performing the cut movement.

For Achilles tendon load rate significant main effects were observed for both footwear (P<0.05, pη2 = 0.42) and movement (P<0.05, pη2 = 0.47). Post-hoc analysis for footwear showed that Achilles tendon load rate was significantly larger in the minimalist and high-cut footwear in relation to the low-cut and conventional conditions.  

Discussion

The current study aimed to examine the effects of different basketball footwear on the loads experienced by the Achilles tendon during sport specific movements. To the authors knowledge this investigation is the first comparative examination of the effects of different footwear on Achilles tendon kinetics during basketball specific movement. The findings from this work may provide basketball players with important information regarding the selection of appropriate footwear to attenuate their risk from developing Achilles tendon pathologies.

The primary observation from the current work is that Achilles tendon loading parameters were shown to be significantly larger in the minimalist and high-cut footwear in comparison to the conventional low-cut conditions. This observation is in agreement with those of Sinclair [8] and Sinclair et al [9] who showed that minimalist footwear were associated with significant increases in Achilles tendon loading.

This observation may provide important clinically meaningful information regarding the aetiology of Achilles tendon pathologies. Achilles tendon pathologies are considered to be initiated by high loads which are experienced too frequently by the tendon itself 15. Tendon loading at an appropriate level can initiate collagen synthesis and positively influence the mechanical properties of the tendon [16]. However, when mechanical loads exceed the physiological threshold for collagen synthesis and the remodeling threshold is exceeded, this facilitates tendon degradation and ultimately leads to injury [16]. Therefore the findings from the current investigation indicate that minimalist and high-cut footwear may place basketballers at a greater risk from Achilles tendon pathologies as a function of their training/ competition.

In conclusion, although the effects of different footwear on Achilles tendon forces have been examined previously, our current knowledge of differences in Achilles tendon kinetics when performing sport specific movements in basketball footwear is limited. The current study therefore sought to provide an evaluation of Achilles tendon forces when performing sport specific movements in different basketball specific footwear. This work shows importantly that peak Achilles tendon force and the rate of Achilles tendon load rate were significantly larger in minimalist and high-cut footwear in relation to the low-cut and conventional conditions. As such given the association between Achilles tendon loading and tendon pathology the current investigation indicates that minimalist and high-cut footwear may place basketballers at increased risk for Achilles tendon pathology as a function of their training/ competition. Furthermore, it appears that for basketballers who may be susceptible to Achilles tendinopathy that low-cut and conventional conditions are most appropriate.

References

  1. Cumps, E, Verhagen R, and Meeusen R. “Prospective epidemiological study of basketball injuries during one competitive season: ankle sprains and overuse knee injuries.” J Sport Sci Med 6: 204-211, 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3786241/
  2. Montgomery PG, Pyne DB and Minahan CL. The physical and physiological demands of basketball training and competition. Int J Sports Physiol Perform. 15: 75-86, 2010. https://www.ncbi.nlm.nih.gov/pubmed/20308698
  3. Narazaki K, Berg K, Stergiou N and Chen B. Physiological demands of competitive basketball. Scand J Med Sci Sport. 19: 425-322, 2009. https://www.ncbi.nlm.nih.gov/pubmed/18397196
  4. Deitch JR, Starkey C, Walters SL and Moseley JB. Injury Risk in Professional Basketball Players; A Comparison of Women’s National Basketball Association and National Basketball Association Athletes. Am J Sport Med. 34: 1077-1083, 2006. https://www.ncbi.nlm.nih.gov/pubmed/16493173
  5. Wertz, J., Galli, M., and Borchers, J. R. Achilles Tendon Rupture Risk Assessment for Aerial and Ground Athletes. Sport Health. 5: 407-409, 2013. https://www.ncbi.nlm.nih.gov/pubmed/24427410
  6. Caselli MA. Selecting the proper athletic shoe. Pod Manag. 25: 147-149, 2006.
  7. Commons AT and Low DC. Understanding the effect of high-cut shoes, running shoes and prophylactic supports on ankle stability when performing a v”-cut movement. Sport Exerc Med Open J. 1: 1-7, 2014.
  8. Sinclair, J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech. 29: 395-399, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24636307
  9. Sinclair, J., Atkins, S., Taylor, P. J., and Vincent, H. Effects of conventional and minimalist footwear on patellofemoral and Achilles tendon kinetics during netball specific movements. Comp Ex Phys. 11: 191-199, 2015.
  10. Sinclair, J., Hobbs, S. J., and Selfe, J. (2015). The Influence of Minimalist Footwear on Knee and Ankle Load during Depth Jumping. Research in Sports Medicine, 23(3), 289-301. https://www.ncbi.nlm.nih.gov/pubmed/26053415
  11. Sinclair, J., Edmundson, C.J., Brooks, D., and Hobbs, S.J. Evaluation of kinematic methods of identifying gait Events during running. Int J Sport Sci Eng. 5: 188-192, 2011.
  12. Thelen, D.G., Anderson, F.C., and Delp, S.L. Generating dynamic simulations of movement using computed muscle control. J Biomech. 36: 321–328, 2003. https://www.ncbi.nlm.nih.gov/pubmed/12594980
  13. Almonroeder, T., Willson, J.D., and Kernozek, T.W. The effect of foot strike pattern on Achilles tendon load during running. Annals Biomedical Eng. 41: 1758-1766, 2013. https://www.ncbi.nlm.nih.gov/pubmed/23640524
  14. Selvanetti, A.C.M., and Puddu, G. Overuse tendon injuries: basic science and classification. Op Tech Sport Med. 5: 110–17, 1997.
  15. Kirkendall, D.T., and Garrett W.E. Function and biomechanics of tendons. Scandinavian. J Med Sci Sport. 7: 62–66, 1997. https://www.ncbi.nlm.nih.gov/pubmed/9211605

Atraumatic acute compartment syndrome secondary to group C Streptococcus infection

by Amelia Aaronson1*, Malcolm Podmore1, Richard Cove1pdflrg

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

A 74 year-old female presented to the emergency department with sudden onset severe foot pain and was diagnosed with an acute, atraumatic compartment syndrome. The patient had urgent surgical decompression and washouts in theatre. Microbiological samples grew group C hemolytic Streptococcus; she was treated with high dose intravenous antibiotics and made a good recovery.

Keywords: atraumatic compartment syndrome, foot, group C hemolytic Streptococcus

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0004

1 – North Devon District Hospital, Raleigh Park, Barnstaple EX31 4JB
* – Corresponding author: amelia.aaronson@nhs.net


This case is important for two reasons; Firstly, because regardless of cause, compartment syndrome is a surgical emergency and is a diagnosis which requires early recognition and appropriate treatment. Secondly and most important, because it is an unusual presentation and pathophysiology of compartment syndrome. Cases of atraumatic compartment syndrome have been reported previously [1], with causes including reperfusion injuries, bleeding, animal toxins, and intravenous drug use [2], and have been reported in the literature [1], but the majority of acute cases are due to trauma. When searching the literature for infectious causes, there are even fewer cases [3,4], and no cases have been previously described due a group C Streptococcus infection.

Case Presentation

A 74 year-old female presented to A&E with a five-hour history of acute left foot pain, which had increased in severity to a subjective 10/10 and required intravenous morphine and nitrous oxide. The patient described pain all over her left foot, especially the big toe and dorsum of the foot. There was no history of trauma, the patient was systemically well, and had no other notable symptoms.

Past medical history included hypertension, atrial fibrillation, and a previous laparoscopic cholecystectomy. The patient had no known drug allergies, and her only medication was 5 mg Ramipril QD. The only relevant family history was gout.

On examination the patient’s foot was swollen throughout the dorsal and plantar aspect, slightly warm to touch, and extremely tender to palpation. There was acute pain with all passive movements of the foot and toes, and ankle movements were restricted due to pain. The foot exhibited no neurovascular compromise and had no lacerations or wounds. She was afebrile, and observations were all normal.

Investigations

On admission white cell count was 13.5/mL and C-reactive protein 10 mg/L. Other blood values (including uric acid and creatine phosphokinase) were normal.

Left foot radiographs revealed no acute abnormalities, and an MRI showed a large amount of high signal over the dorsum of the foot. However, only one long axis STIR sagittal acquisition was obtained due to patient discomfort and difficulty remaining still.

The patient was referred to the trauma and orthopedics team due to severe pain out of proportion to the history, where the differential diagnosis included infection and compartment syndrome.

Treatment

Despite an inconclusive MRI, due to a high clinical suspicion of compartment syndrome the patient went to surgery the same day for a fasciotomy of her left foot. Due to dorsal swelling and the MRI result, the four interosseous compartments were decompressed through two dorsal incisions. The compartments deep to these were decompressed through the same incisions. The muscles appeared viable, there was no collection, and a small amount of fluid was found in the lateral deep compartment. This fluid was sent for microbiological analysis, and the wound was left open with a vacuum dressing and the leg kept elevated post-operatively.

Outcome and Follow-Up

The patient’s pain was much improved postoperatively; nerve blocks were not performed. Two days later the patient’s pain increased, this time more focussed on the medial foot. She was taken back to surgery for a medial fasciotomy to release the medial compartment. The muscles were viable, with no suggestion of infection.

Despite this, the patient began to spike temperatures and had high inflammatory markers. CRP peaked on day 5 at 474 mg/L, although white cell count did not rise higher than the admission level. Cultures of fluid from both fasciotomies grew group C hemolytic Streptococcus. It was therefore thought that this patient’s compartment syndrome was secondary to infection – although there was no history of any wound or animal bite, and on examination no entry site for infection had been found. She was treated with intravenous amoxicillin, initially 1g TID, which was later increased to 2g QID on day ten of admission.

Three days later she had a planned third surgery. The medial wound was clean and therefore closed, but the two dorsal wounds were irrigated with saline and left open. Four days after this the patient had a planned fourth surgery with the medial wound healing, and the dorsal wounds had no pus although the dorsum was still very swollen. The wounds were washed out and left to heal by secondary intention.

A repeat MRI was performed on day twelve because of persistently high inflammatory markers, which showed no evidence of soft tissue or intraosseous collection. She continued high dose intravenous antibiotics, and started to recover. CRP tailed off following this, and her pain settled. The patient was discharged after a twenty-five day admission with outpatient follow up.

Discussion

Compartment syndrome is caused by an increase of pressure in a closed compartment bounded by fascia and bone  compromising vascular supply to that compartment. It is usually due to bleeding or edema secondary to trauma or reperfusion injury [5,6] and can be acute or chronic. The majority of acute cases are secondary to trauma [7] including fractures, crush injuries and surgery [8]. A study looking at causation showed that the most common cause in over two-thirds of patients was fracture, followed by soft tissue injury and then bleeding disorder or use of oral anticoagulants [9]. Other causes include tight casts, burn injuries, and vascular injuries. The treatment of choice for acute compartment syndrome is immediate decompression by fasciotomy [5].

A diagnosis of compartment syndrome is suggested by history and examination; pain is thought to be the first and most sensitive sign [10], although other symptoms include paraesthesia, limb paresis, lack of pulses, and pallor [11]. However, when the diagnosis is in doubt other investigations include measuring tissue pressure and nerve stimulation [12]. Compartment pressures within 30-mmHg of diastolic pressure would suggest compartment syndrome [11]. There should be a low threshold for surgical intervention and clinical symptoms alone are usually enough to justify surgery.

Acute compartment syndrome most commonly involves the lower limb and cases involving the foot have been reported previously [13]. There is no consensus on the number of compartments in the foot, but it is most commonly argued that there are nine compartments in the foot – four interosseous compartments, three central (superficial, central and deep), the medial compartment and the lateral compartment [8, 14, 15]. Effective decompression can be achieved from dorsal incisions, as was done in this case because of the dorsal swelling and MRI findings; however a single medial incision can be used to decompress all nine foot compartments [15].

There has been debate amongst foot and ankle orthopaedic surgeons as well as military surgeons about surgical decompression versus conservative treatment for compartment syndrome of the foot. A recent survey of military surgeons concluded that if compartment syndrome is suspected, it should be decompressed with the aim of preventing chronic pain and deformity [16].

Atraumatic compartment syndrome of the foot is a rare condition; case reports of compartment syndrome secondary to infection have been described, but no cases due to group C hemolytic Streptococcus. One paper describes three case reports of acute, atraumatic compartment syndrome in the lower limb, one seemingly spontaneous, and two secondary to gastrocnemius hematomas and subsequent edema [1]. A small number of case reports have described similar cases of compartment syndrome of the upper limb secondary to infection (group A hemolytic Streptococcus) requiring decompression and antibiotics and, in one case, amputation [3,4].

Group C Streptococcus (and group G Streptococcus) of human origin are thought to be a single subspecies, Streptococcus dysgalactiae subspecies equisimilis. They are a normal commensal flora of the upper respiratory tract, skin, gastrointestinal tract, and female genital tract, and have been identified in pharyngitis, septic arthritis and osteomyelitis, soft tissue infections and meningitis [17].

Atraumatic cases can be easily missed, risking complications such as contractures or deformities of the foot, weakness, paralysis, sensory neuropathies and rarely amputation [8]. There is high morbidity and mortality [2], and it is now thought that serious complications such as muscle necrosis can occur as early as within three hours [18]. The risk of long-term complications is reduced the earlier a compartment syndrome is decompressed, although as acute compartment syndrome is relatively uncommon, there are no large studies describing chronic sequelae and overall patient outcomes [11].

There are several learning points from this case report, primarily that acute foot compartment syndrome is a limb threatening emergency which needs rapid recognition and often surgical decompression. Although the majority of acute cases are secondary to trauma, it is important to remember that there can be atraumatic causes as these are more likely to be missed. If a diagnosis is in doubt from the clinical history and examination, there are other investigations – such as measurement of compartmental pressures, but it is important not to delay fasciotomy due to associated morbidity and mortality of untreated acute compartment syndrome.

References

  1. Cara JA, Narvaez A, Bertrand ML, Guerdo E. Acute atraumatic compartment syndrome in the leg. Int Orthop. 1999; 23(1): 61 – 62
  2. Stracciolini A, Hammerberg EM. Acute compartment syndrome of the extremities. http://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities (accessed 16 June 2016).
  3. Taylor J, Wojcik A. Upper limb compartment syndrome secondary to Streptococcus pyogenes (group A Streptococcus) infection. J Surg Case Rep. 2011; 3: 3
  4. Schnall SB, Holtom PD, Silva E. Compartment syndrome associated with infection of the upper extremity. Clin Orthop Relat Res. 1994 (306): 128–31 
  5. Matsen FA, III. Compartmental syndrome. An unified concept. Clin Orthop Relat Res. 1975;(113):8-14.
  6. Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World J Surg. 2003; 27(6):744 – 747
  7. Bonutti PM, Bell GR. Compartment syndrome of the foot. A case report. J Bone Joint Surg Am. 1986; 68 (9): 1449 – 1451
  8. Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int. 2003; 24(2): 180 – 187
  9. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome – Who is at risk? J Bone Joint Surg Br. 2000; 82(2): 200-3
  10. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. 2002; 16: 572 – 577
  11. Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clin Ortho Relat Res. 2010; 468(4): 940 – 950
  12. Matsen FA IIIWinquist RAKrugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980; 62(2):286-91.
  13. Myerson MS. Management of compartment syndromes of the foot. Clin Orthop Relat Res. 1991; 239 – 248
  14. Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990; 10: 267 – 275
  15. Karadsheh M. Foot compartment syndrome. http://www.orthobullets.com/trauma/1065/foot-compartment-syndrome (accessed 02 June 2016).
  16. Middleton S, Clasper J. Compartment syndrome of the foot – implications for military surgeons. J R Army Med Corps. 2010; 156(4): 241-4
  17. Wessells MR. group C and group G streptococcal infection. http://www.uptodate.com/contents/group-c-and-group-g-streptococcal-infection (accessed 15 August 2016)
  18. Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM. 2004; 6: 147 – 154

Coronal plane talar body fracture associated with subtalar and talonavicular dislocations: A case report

by Barıs YILMAZ, MD1, Baver ACAR, MD2, Baran KOMUR, MD3, Omer Faruk EGERCI, MD2, Ozkan KOSE MD, FEBOT, Assoc. Prof.2pdflrg

The Foot and Ankle Online Journal 9 (4): 3

Talar body fractures usually occur as a result of high-energy trauma and variety of different type of talar fractures may occur. Most of the talar fractures are included in classification systems.  Even though it is possible to observe talar fractures with concomitant dislocations, together by reason of their functional relationship with the tibiotalar, subtalar and talonavicular joints, such observations are only addressed in literature in the form of case studies.  The present case, exhibiting talar body fracture in the coronal plane observed together with subtalar and talonavicular dislocations, is of importance due to the rarity of the diagnosis, treatment, and 2-year follow-up results.

Keywords: Talar body fracture, subtalar dislocation, talonavicular dislocation, talus

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0003

1 – Fatih Sultan Mehmet Training and Research Hospital, Orthopedics and Traumatology Department, Istanbul, Turkey
2 – Antalya Training and Research Hospital, Orthopedics and Traumatology Department, Antalya, Turkey
3 – Kanuni Sultan Suleyman Training and Research Hospital, Orthopedics and Traumatology Department, Istanbul, Turkey
* – Corresponding author: drozkankose@hotmail.com


Talar fractures and fracture-dislocations are uncommon compared to other injuries to the ankle because of the location of the talus in the ankle joint and its anatomical structure. Talar fractures represent 0.32% of all fractures, 2% of lower-extremity fractures, and 5-7% of ankle fractures. However, the talus is the second most frequently fractured bone of all the tarsal bones[1, 2]. In the literature, the incidence of talar body fractures has been reported to be in the range of 7-38% of all talus fractures, and as 0.062% of all body fractures [3, 4].

The majority of these injuries occur as a result of high-energy trauma [5, 6]. The lack of muscle attached to the talus and that a large part of the surface is covered with articular cartilage create a predisposition to talus fractures and concurrently observed dislocations. The treatment of talar body fractures is rather problematic due to the complex anatomy and the diversity of fracture patterns [7, 8]. Treatment becomes even more difficult when these fractures are accompanied by dislocations of adjacent joints. The case presented in this paper emphasizes the importance of emergent open or closed reduction and stable fixation with lag screws and Kirschner wires.

The concurrency of talar body fractures specifically with dislocations of adjacent joints has been addressed with only a few case studies in literature. This case study presents a subtalar and talonavicular joint dislocation of a talar body fracture in the coronal plane and is of paramount significance in that it was treated with open reduction and internal fixation and the clinical follow-up results of 2 years are available.  

Case report

A 32-year-old male was brought to our Emergency Department after sustaining a motorcycle accident with complaints of intense pain and deformity of the right ankle. On physical examination, the ankle was seen to be in an inverted position and there was distinctive deformity accompanied by local paleness arising from skin tightness on the lateral side (Figure 1). The neurovascular examination results were normal. The patient had no accompanying additional injuries. Direct radiographs of the ankle revealed a talar body fracture accompanied by subtalar and talonavicular dislocations (Figure 2). Under conscious sedation, closed reduction was attempted twice in the Emergency Room with no success.  Computed Tomography (CT) was performed and demonstrated a coronal plane talar body fracture associated with subtalar and talonavicular dislocations. A distal fragment of the talus was dislocated, twisted and locked (Figure 3). Thereafter, open reduction and internal fixation of the fracture was planned.

fig1

Figure 1 Clinical image of the case in ED.

fig2

Figure 2 Pre-operative radiographic evaluation of the case.

fig3

Figure 3 Pre-operative CT scan.

Once the surgical preparations had been completed, the patient was taken to the operating room approximately 3 hours after the trauma. Under spinal anesthesia and tourniquet application, an anterolateral incision was used to expose the fracture. The talar head was observed to be locked in the form of a button and a hole in the anterior capsule.  The capsule was retrieved from the talar head and reduction was secured. The talus was fixed with two cannulated screws. The subtalar and talonavicular joints were seen to be unstable, and could be dislocated with a weak inversion strain. Therefore, both the subtalar and talonavicular joints were fixed with K-wires (Figure 4). The achievement of anatomic reduction of both the fracture and the subtalar and talonavicular reduction was monitored postoperatively through a CT scan.  The patient was discharged from the hospital with a short leg brace on the 2nd postoperative day.  The sutures were removed on the 20th day and the K-wires were removed and active ankle exercises were started in the 6th week of follow-up. Full weight bearing was started in the 8th week following the observation of complete healing of the fracture.

fig4

Figure 4 Post-operative radiographs.

The final clinical and radiological follow-up was performed in the second postoperative year (Figure 5). The patient had already returned to work and social life and his AOFAS score was 87 with no significant finding of arthrosis or any other complaint.

fig5

Figure 5 Post-operative CT examination of the case.

fig6

Figure 6 Radiographic evaluation of the case 2 years postoperatively.

Discussion

Fractures of the Talus typically involve the tibiotalar joint. In their simplest clinical forms, they can be classified as fractures of the talar head, talar neck, talar body, and talar process.  In the AO/OTA classification, however, talus fractures are defined as extra-articular fractures covering neck fractures and avulsion fractures, partial intra-articular fractures covering split or compression fractures, and intra-articular fractures divided into non-displaced, displaced and segmental fractures. The distinction between talar body and neck fractures is of great importance.  A relevant evaluation defined body fracture as a case with the fracture line lying proximal to the lateral process of the talus and neck fracture as a case with the fracture line lying distal to the lateral process of the talus [9, 10].

Talar body fractures have various classifications.  The generally utilized Sneppen classification divided these fractures into five main headings: Type I, osteochondral or transchondral; Type II, coronal, sagittal horizontal, non-segmental; Type III posterior tubercle; Type IV lateral process; and Type V, crush fractures [11]. The Fortin classification defines talar body fractures under three headings: Type 1, talar body fracture on any plane; Type 2, talar process or tubercle fracture; or Type 3 compression or impaction fracture of the talar body [12]. Apart from these headings, these fractures involving the talar dome can also be classified as sagittal, coronal, transverse or segmental fractures depending on the main fracture line. Certain types of fractures and fracture-dislocations not included in the aforementioned fracture classifications can at times be provided in the literature as case reports [13-18]. Identification and classification efforts are still ongoing for these fractures and accompanying dislocations [19]. However, there are some authors who argue that these means of classification do not contribute to the selection of suitable treatment or treatment results [2, 8, 12, 20]. The current case was defined as a talar body fracture on the coronal plane accompanied by subtalar and talonavicular dislocations outside the scope of these classifications. Therefore, these types of fracture-dislocations can be indicated as a rare injury where the fracture type has been classified in literature without any dislocation type specified.  

The mechanism of injury in talar body fractures is generally defined as the exposure of the talar region to axial load or shear forces between the tibia and calcaneus  [21]. This frequently occurs in motorcycle accidents, as in the current case, or incidents of individuals falling from height.  Moreover, these fractures may be accompanied by calcaneus, tibia and talar neck fractures since most of them are induced by high-energy injuries. The observation of dislocations and ligament injuries in various adjacent joints is not surprising with such a mechanism of injury. As an example, a case of medial total subtalar dislocation was reported without a fracture in the ankle [22]. Similarly, another case was defined as a talar body fracture accompanied by anterior talofibular ligament and peroneal longus tendon injuries [23]. Although the literature does not include a high number of series pertaining to dislocations observed together with talar body fractures, a series of 23 talus fractures provided the finding of 7 peritalar dislocations [24]. Adjacent joint fractures accompanying talar body fractures are addressed in the literature with only a few cases [13-18].

Talus fractures can be diagnosed through standard radiographies in general.  However, adjacent joint dislocations clearly add difficulty to the diagnosis of such fractures.  Hence, a good radiological evaluation from the beginning is of great value for prospective surgical planning.  At this stage, CT is of extreme importance to undertake a complete evaluation of the structure of the fracture and to guide the course of treatment.  At times, MRI might be required for the additional evaluation of soft tissue injuries in surrounding ligaments and tendons.

Early emergency reduction should be performed for all fracture-dislocations of the talus with a view to preventing soft tissue damage and not to disrupt the circulation in the talus.  Specifically displaced talar neck and body fractures should be treated with open reduction and stable internal fixation in the early stage.  Closed or percutaneous reduction may be attempted immediately after sufficient analgesia and relaxation.  However, repeated unsuccessful attempts at reduction may increase the damage in fracture-dislocations with already severe damage in soft tissues. However, open reduction is mandatory for locked dislocations, as in the present case or for dislocations with soft tissue in between which cannot be managed with close reduction. If a patient cannot be taken into open reduction for patient-related or other reasons such as in the case of polytrauma patients, the fracture should undergo initial reduction through minimally invasive methods to the extent possible and then be fixed with Kirschner wires [25]. As is the case in other open fractures, open talus fractures require surgical intervention [26]. Furthermore, if the foot is diagnosed with compartment syndrome, dorsomedial dermatofasciotomy should also be performed through upper and lower extensor retinacula.  This approach will also allow for open reduction and fixation.  Some cases may require medial malleolar osteotomy for anatomic reduction depending on the medial location and extension of the fracture. Patients with severe soft tissue damage and fracture-dislocations may have tibia-metatarsal external fixators applied and the necessary follow-up [25]. In the present case, it was decided to perform immediate open surgical reduction due to failure in the initial closed reduction and reduction was obtained by retrieving the talar head from the point where it was interlocked like a button and a buttonhole in the capsule by employing an anterolateral incision which could facilitate reduction. Open reduction approaches which have been suggested for anatomic reduction includes posteromedial, medial and anteromedial approaches.  Some authors have also reported the use of an anteromedial and anterolateral double incision [21]. These approaches provide various advantages. As an example, a posterolateral incision is known to disrupt the blood flow to a lesser extent, but makes it difficult to position the patient and offers a limited approach. Whereas a medial incision provides a more convenient approach specifically together with medial malleolar osteotomy, as there are known problems associated with osteotomy, in addition to the risks to the regional anatomic structures. Similarly, an anterolateral incision also has its own specific advantages and disadvantages. In general, the type of fracture and the experience level of the surgeon are considered to be more important for the approach to be selected [21]. Another important preference is the method of arthroscopic assisted internal fixation method, which has been defined in literature as a less invasive option specifically for the talar transchondral dome [21, 27].

Fixation with headless or bioabsorbable screws is recommended due to the anatomical structure of the talar bone and the articular nature of the major part of the surface.  In the current case, fracture fixation was secured with cannulated screws.  In cases where the fracture is accompanied by unstable joints and loss of reduction even after a small-scale strain, additional support may be provided to improve stability through the fixation of both subtalar and talonavicular joints with K-wires as in the current case. Consequently, talar body fractures involving distinct displacement pose a difficulty in treatment especially if they are accompanied by dislocation in an adjacent joint and long-term results are generally poor unless a good course of surgical treatment is followed.  Talectomy is not always practical because of problems such as pain on weight-bearing and instability, and should only be considered for adults. In this case, better results could be obtained when calcaneotibial fusion and talectomy are implemented concurrently [34].  Nevertheless, this should be included in the treatment as a final step.

Surgical complications pertaining to talus fractures notably include avascular necrosis [AVN], post-traumatic osteoarthritis, non-union, malunion, and infection. In a study of 26 cases of talar body fractures, poorest results were reported based on 1-year follow-up radiographs with AVN in 38%, with post-traumatic tibiotalar osteoarthritis in 65%, with post-traumatic subtalar osteoarthritis in 34%, and with segmental and severely displaced fractures [28]. Particularly after talar neck and body fractures, the AVN risk remains almost the same, while the risk of post-traumatic subtalar arthrosis is higher. Moreover, one study in literature reported the incidence of AVN for talar body fractures without dislocations to be 25% and the risk of AVN accompanying dislocation to be 50% [29]. Another meta-analysis indicated these rates as 10% without dislocation and 25% with dislocation [30]. The previously higher incidence of AVN has been reduced due to improved surgical approach methods that have been implemented in more recent literature [31, 32]. It has also been demonstrated that the waiting period for internal fixation does not create a significant effect in terms of the development of AVN in studies undertaken at various centres [32, 33]. Another study reported post-traumatic osteoarthritis at 50% in the ankle after compression fractures, at 41% after shear fractures and at 24% in the subtalar joint [11]. The incidence of osteoarthritis in talar body fractures is closely associated with the type of fracture and injury.  

Consequently, it is as difficult to diagnose talar body fractures as it is to apply treatment and to follow up the results of treatment. Even though extremely poor results have been reported for the treatment of such fractures in the past, much better results can be observed through accurate and meticulous surgical interventions in place today.  A study in literature reporting the results of talus fractures after a period of 30 months stated poorer AOFAS results for body fractures with an average score of 58 when compared to neck fractures with an average score of 79 and process fractures with an average score of 85.  The same study also noted the worse Maryland foot scores and Hawkins evaluation criteria for body fractures [ 2].  Another reference defined the average score in AOFAS as 68.4. [35]. The high value and successful AOFAS result obtained in the current case after a 2 year follow-up period can be considered to be due to the accurate interpretation of the fracture-dislocation,  anatomic reduction with early surgery, and good fixation.  However, there is still a need in literature for long-term results pertaining to such uncommon cases.

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The effects of CrossFit and minimalist footwear on Achilles tendon kinetics during running

by Jonathan Sinclair1, and Benjamin Sant1pdflrg

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

The aim of the current investigation was to comparatively assess the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during running. Twelve male runners (27.81 ± 7.02 years, height 1.77 ± 0.11 cm and body mass 76.22 ± 7.04 kg) ran at 4.0 m·s-1 in each of the four footwear conditions. Achilles tendon forces were calculated using a musculoskeletal modelling approach allowing the magnitudinal and temporal aspects of the Achilles tendon force to be quantified. Differences between footwear were examined using one-way repeated measures ANOVA. The results showed the peak Achilles tendon force was significantly larger when running barefoot (5.81 ± 1.21) and in minimalist footwear (5.64 ± 1.03 BW) compared to conventional footwear (5.15 ± 1.05 BW). In addition it was revealed that Achilles tendon impulse was significantly larger when running barefoot (0.77 ± 0.22 BW.s) and in minimalist footwear (0.72 ± 0.16 BW.s) in comparison to both conventional footwear (0.64 ± 0.15 BW.s). Given the proposed association between high Achilles tendon forces and tendon degradation, the outcomes from the current investigation indicate that CrossFit athletes who select barefoot and minimalist footwear for their running training may be at increased risk from Achilles tendon pathology in comparison to conventional footwear conditions.

Keywords: Footwear, Achilles tendon, running, CrossFit

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0002

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


CrossFit represents a relatively new activity associated with aerobic exercises, calisthenics, and Olympic weightlifting [1]. CrossFit as a discipline has expanded to become an international sport which has been linked to significant gains in aerobic and anaerobic fitness [1]. Given the novelty of CrossFit in relation to more established sports it has received a paucity of published attention in the sports science and strength and conditioning literature.

A key feature of CrossFit training is aerobic conditioning and the manner in which this is examined during competition is via distance running events. Engagement in distance running mediates numerous physiological benefits but it is known to be associated with a high rate of chronic pathologies, with around 70 % of runners experiencing an injury injured during the course of a year [2,3]. Shorten proposes that athletic footwear with suitable mechanical features may be able to manage the incidence of chronic running related injuries [4].

CrossFit athletes are able to select from a wide range of different footwear conditions with distinct design characteristics. There has been no peer reviewed research which has examined the biomechanical influence of different footwear available to CrossFit athletes. CrossFit specific footwear represents a hybrid footwear designed to incorporate the stability characteristics of a weightlifting shoe with the cushioning and flexibility of a running trainer. Currently, there is a trend for CrossFit athletes to opt to train and compete either barefoot or minimalist footwear in lieu of traditional footwear options, although the efficacy of barefoot and minimalist footwear is not yet fully established.

The effects of different footwear on the loads experienced by the Achilles tendon have been examined previously. Sinclair examined the effect running barefoot had on minimalist and conventional footwear on Achilles tendon kinetics during the stance phase of running [5]. The findings showed that peak Achilles tendon kinetics were significantly larger when running barefoot and in minimalist footwear. Similarly Sinclair et al, examined the effects of minimalist, maximalist and conventional footwear on the loads borne by the Achilles tendon during running[6] . Their findings confirmed that peak Achilles tendon force and Achilles tendon impulse were significantly larger in minimalist footwear in relation to the conventional and maximalist conditions. Currently there are no published scientific investigations regarding the effects of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon.    

Therefore the aim of the current study was to comparatively examine the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during the stance phase of running. Given that running activities are associated with a high incidence of chronic Achilles tendon pathologies, the current investigation may deliver key information to CrossFit athletes concerning the selection of suitable footwear.

Methods

Participants

Thirteen male participants took part in this investigation. All uninjured at the time of data collection and written informed consent was obtained. The mean and standard deviation (SD) characteristics of the participants were: age 27.81 ± 7.02 years, height 1.77 ± 0.11 cm and body mass 76.22 ± 7.04 kg. The research design utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee. 

Procedure

Participants ran at 4.0 m·s-1 (±5%), while striking an embedded piezoelectric force platform (Kistler, Kistler Instruments Ltd., Alton, Hampshire) which sampled at 1000 Hz. Participants struck the platform with their right foot which was used for analysis. Running velocity was monitored using infrared timing gates (Newtest, Oy Koulukatu, Finland). The stance phase was delineated as the duration over which 20 N or greater of vertical force was applied to the force platform. Runners completed five trials in each footwear condition. The order that participants ran in each footwear condition was randomized. Kinematics and ground reaction forces data were synchronously collected. Kinematic data was captured at 250 Hz via an eight camera motion analysis system (Qualisys Medical AB, Goteburg, Sweden). Dynamic calibration of the motion capture system was performed before each data collection session.

Lower extremity segments were modelled in 6 degrees of freedom using the calibrated anatomical systems technique [7]. To define the segment coordinate axes of the foot and shank, retroreflective markers were placed unilaterally onto the 1st metatarsal, 5th metatarsal, calcaneus, medial and lateral malleoli, medial and lateral epicondyles of the femur. A carbon fiber tracking cluster was positioned onto the shank segment and the foot was tracked using the 1st metatarsal, 5th metatarsal and calcaneus markers. The center of the ankle joint was delineated as the midpoint between the malleoli markers[8] . Static calibration trials were obtained allowing for the anatomical markers to be referenced in relation to the tracking markers/ clusters. The Z (transverse) axis was oriented vertically from the distal segment end to the proximal segment end. The Y (coronal) axis was oriented in the segment from posterior to anterior. Finally, the X (sagittal) axis orientation was determined using the right hand rule and was oriented from medial to lateral.

Processing

Dynamic trials were digitized using Qualisys Track Manager in order to identify anatomical and tracking markers then exported as C3D files to Visual 3D (C-Motion, Germantown, MD, USA). Ground reaction force and marker trajectories were smoothed using cut-off frequencies of 50 and 12 Hz using a low-pass Butterworth 4th order zero lag filter. All data were normalized to 100% of the stance phase then processed trials were averaged. Joint kinetics were computed using Newton-Euler inverse-dynamics. To quantify net joint moments anthropometric data, ground reaction forces and angular kinematics were used.  

Achilles tendon force (BW) was determined using a musculoskeletal modelling approach. This model has been used previously to resolve differences in Achilles tendon force between different footwear [5, 6]. Achilles tendon force was quantified as a function of the plantarflexion moment (PFM) divided by the Achilles tendon moment arm (MA). The moment arm was quantified as a function of the ankle sagittal plane angle (ak) using the procedure described by Self and Paine [9]:

Achilles tendon force = PFM / MA

MA = -0.5910 + 0.08297 ak – 0.0002606 ak2

Average Achilles tendon load rate was quantified as the Achilles tendon force divided by the time over which the peak force occurred. Instantaneous Achilles tendon load rate was also determined as the peak increase in Achilles tendon force between adjacent data points. In addition to this Achilles tendon force, impulse  was quantified during running by multiplying the Achilles tendon force estimated during the stance phase by the stance time.

Experimental footwear

The footwear used during this study consisted of conventional footwear (New Balance 1260 v2), minimalist (Vibram five-fingers, ELX) and CrossFit (Reebok CrossFit CR) footwear, (shoe size 8–10 in UK men’s sizes).

Analyses

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

Results

Table 1 and Figure 1 present the Achilles tendon loads during the stance phase of running, as a function of the different experimental footwear. The results indicate that the experimental footwear significantly influenced Achilles tendon force parameters.

Barefoot CrossFit Conventional Minimalist
Mean SD Mean SD Mean SD Mean SD
Peak Achilles tendon force (BW) 5.81 1.21 5.50 1.32 5.15 1.05 5.64 1.03
Time to peak Achilles tendon force (s) 0.13 0.02 0.14 0.02 0.15 0.02 0.14 0.02
Achilles tendon average load rate (BW/s) 45.54 12.76 42.37 14.44 35.76 10.49 40.84 9.07
Achilles tendon instantaneous load rate (BW/s) 128.84 42.10 153.23 51.56 115.45 40.08 136.21 25.93
Achilles tendon impulse (BW.s) 0.77 0.22 0.69 0.20 0.64 0.15 0.72 0.16

Table 1 Achilles tendon forces as a function of footwear.

fig1

Figure 1 Achilles tendon forces during the stance phase as a function of footwear (black = barefoot, dash = minimalist, grey = conventional, grey dot = CrossFit).

A main effect (P<0.05, pη2 = 0.21) was shown for the magnitude of peak Achilles tendon load. Post-hoc pairwise comparisons showed that peak Achilles tendon force was significantly larger in the barefoot (P=0.01) and minimalist (P=0.04) conditions in relation to conventional footwear. A main effect (P<0.05, pη2 = 0.43) was shown for the time to peak Achilles tendon load. Post-hoc pairwise comparisons showed that time to peak Achilles tendon force was significantly larger in the barefoot (P=0.001) and minimalist (P=0.007) conditions in relation to conventional footwear. In addition time to peak Achilles tendon force was significantly shorter in the barefoot condition (P=0.007) in relation to the CrossFit footwear.  In addition a main effect (P<0.05, pη2 = 0.29) was evident for average Achilles tendon load rate. Post-hoc analysis showed that average load rate was significantly larger in the barefoot (P=0.004), CrossFit (P=0.04) and minimalist (P=0.02) conditions in relation to the conventional footwear. A main effect (P<0.05, pη2 = 0.25) was found for instantaneous Achilles tendon load rate. Post-hoc pairwise comparisons showed that instantaneous Achilles tendon load rate was significantly larger in the barefoot (P=0.01), CrossFit (P=0.003) and minimalist (P=0.01) conditions in relation to the conventional footwear. Finally, a main effect (P<0.05, pη2 = 0.34) was observed for Achilles tendon impulse. Post-hoc analyses indicated that Achilles tendon impulse was significantly larger in the barefoot (P=0.007) and minimalist (P=0.04) conditions in relation to conventional footwear.

Discussion

The aim of the current investigation was to comparatively examine the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during running. To the authors knowledge the current study represents the first comparative examination of Achilles tendon kinetics when running in these specific footwear conditions.

The key observation from the current study is that Achilles tendon force parameters were significantly larger in the barefoot and minimalist conditions in relation to the conventional running shoes. This observation is in agreement with those of Sinclair [5] and Sinclair et al. [6] who similarly noted that barefoot and minimalist footwear conditions were associated with significant increases in Achilles tendon kinetics in relation to more substantial running footwear. This observation may provide important clinical information with regards to the etiology of Achilles tendon pathologies as a function of running activities in CrossFit athletes. The initiation and progression of Achilles tendonitis is mediated by excessive tendon loads that are applied without sufficient cessation between activities [10]. Mechanisms of tendon loading that are above the systematic threshold for collagen related synthesis lead ultimately to degradation of the collagen network as the rate of resynthesis is not able to keep pace with the rate of breakdown [11]. Therefore the findings from the current investigation indicate that running barefoot and in minimalist footwear may place CrossFit athletes performing running activities at a greater risk from Achilles tendon pathology.

The specific findings from the current study may be explained by taking into account the effects of running barefoot and in minimalist footwear on the sagittal plane mechanics of the ankle joint. When running barefoot and wearing minimalist footwear, runners adopt a more plantarflexed foot position throughout the stance phase in relation to more structured running shoes [12, 13].  Increased ankle plantarflexion serves to reduce the length of moment arm of the Achilles tendon [9]. If the moment arm is shortened, this mediates an increase in the load which must be borne by the tendon when running barefoot and in minimalist footwear.

Research which has examined the influence of different footwear condition on the loads borne by the Achilles tendon during the stance phase of running, habitually examines only the peak forces experienced per footfall. Because running barefoot and in minimalist footwear mediates alterations in stance times and step frequencies, the time integral of loads experienced by the Achilles tendon are not quantified. The current study addresses this by quantifying the impulse experienced by the Achilles tendon during the stance phase which is a reflection of both the load experienced and the time interval of the load. The findings from the current investigation in relation to the Achilles tendon impulse mirror those of Sinclair et al., in that barefoot and minimalist footwear were associated with significantly larger impulse in relation to conventional running shoes [6]. This therefore further supports the notion outlines above that running barefoot and in minimalist footwear may increase the likelihood of experiencing an Achilles tendon injury compared to conventional running shoes.   

In conclusion, although differences in Achilles tendon loading as a function of different footwear conditions has been examined previously, the current knowledge with regards to the effects of minimalist, barefoot, CrossFit and conventional footwear on Achilles tendon forces is limited. As such the present study therefore adds to the current knowledge by providing a comprehensive evaluation of Achilles tendon load parameters when running in minimalist, barefoot, CrossFit and conventional footwear. On the basis Achilles tendon load and impulse parameters were shown to be significantly greater when running barefoot and in minimalist footwear, the outcomes from the current investigation indicate that CrossFit athletes who select barefoot and minimalist footwear for their running training may be at increased risk from Achilles tendon pathology in comparison to conventional footwear conditions.

References

  1. Weisenthal, B. M., Beck, C. A., Maloney, M. D., DeHaven, K. E., & Giordano, B. D. (2014). Injury rate and patterns among CrossFit athletes. Orthopaedic Journal of Sports Medicine (In press).
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  4. Shorten, MA. Running shoe design: protection and performance. pp 159-169 in Marathon Medicine (Ed. D. Tunstall Pedoe). 2000; London, Royal Society of Medicine.
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  6. Sinclair, J., Richards, J., & Shore, H. (2015). Effects of minimalist and maximalist footwear on Achilles tendon load in recreational runners. Comparative Exercise Physiology, 11(4), 239-244.
  7. Cappozzo A, Catani F, Leardini A, Benedeti MG, Della CU. Position and orientation in space of bones during movement: Anatomical frame definition and determination. Clinical Biomechanics 1995; 10: 171-178. http://www.ncbi.nlm.nih.gov/pubmed/11415549
  8. Graydon, R, Fewtrell, D, Atkins, S, Sinclair, J. The test-retest reliability of different ankle joint center location techniques. Foot Ankle Online J. 2015; 8: 1-11. doi: 10.3827/faoj.2015.0801.0011
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  12. Lieberman, D.E., Venkadesan, M., Werbel, W.A., Daoud, A.I., D’Andrea, S., Davis, I.S., & Pitsiladis, Y. (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 463, 531-535.
  13. Sinclair, J., Greenhalgh, A., Brooks, D., Edmundson, C. J., & Hobbs, S. J. (2013). The influence of barefoot and barefoot-inspired footwear on the kinetics and kinematics of running in comparison to conventional running shoes. Footwear Science, 5, 45-53.

Intramedullary rodding of a toe – hammertoe correction using an implantable intramedullary fusion device – a case report and review

by Christopher R. Hood JR, DPM, AACFAS1, Jason R. Miller, DPM, FACFAS2pdflrg

The Foot and Ankle Online Journal 9 (4): 1

Development of a hammertoe is a commonly encountered problem by the foot and ankle surgeon. In long-standing deformity, the pathologic toe becomes fixed with patient complaints of pain, corns, and calluses and, in the immunocompromised patient, ulceration with potential infection and amputation. A common correction of the deformity is through lesser toe interphalanageal arthrodesis, commonly performed at the proximal joint. There are numerous techniques and new devices on the market to help assist in holding position until fusion is achieved.  The author demonstrates a case report utilizing a fixation device that has characteristics similar to that of an intramedullary rod. Additionally, a retrospective, observational study involving 35 toes that have undergone an arthrodesis procedure of the proximal interphalangeal joint using an intramedullary fusion device to stabilize the fusion site is reviewed. This device imparts its stability in a manner similar to that of intramedullary rods in long bone fixation.

Keywords: ArrowLokTM, arthrodesis, digit(al), fusion, hammertoe, implantable device, intramedullary, surgery, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0001

1 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Malvern, PA
2 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Fellowship Director, Pennsylvania Intensive Lower Extremity Fellowship, and Residency Director, Phoenixville Hospital PMSR/RRA, Phoenixville, PA
* – Corresponding author: Christopher R. Hood JR, DPM, AACFAS, crhoodjr12@gmail.com


The hammertoe deformity is one of the most common presenting problems and surgical corrections encountered and performed by the foot and ankle surgeon [1,2]. Correction through lesser interphalangeal (proximal interphalangeal joint, PIPJ, or distal interphalangeal joint, DIPJ) resection and fusion was first described by Soule in 1910 [1]. Since then many modifications have been made to the procedure from various methods of bone preparation at the fusion site to extramedullary (EM) Kirschner wires (KW) and intramedullary (IM) fusion devices (IMFD) to stabilize the fusion site until osseous healing has been achieved [1, 3-6].

The choice to adapt fixation from EMKW to IMFD buried inside the bone stemmed from the desire to improve surgical outcomes, namely decreasing surgical site infection (SSI) rates among other inherent problems with KW use [5]. Since their introduction onto the market, many of these new have held true in decreasing these complication rates, achieving similar outcomes regarding fusion rates, with the bonus of higher patient satisfaction and a decreased (almost eliminated) infection rate [2, 7-10].

Here we present an example of an IMFD, different in construct than others on the market, which has not yet been reported on. This device gives another option to the surgeon when it comes time for digital fusion procedures with the added versatility of various lengths when multiple digital joints need to be fused simultaneously. The construct of this device, unlike others, garners its strength and stability from its length, purchasing the subchondral bone plate and acting in a manner similar to an intramedullary rod used in other orthopaedic fixations scenarios.

Methods

Case Report

Our patient, a 49 year-old female, presented with a chief complaint of a right second toe deformity. Conservative measures of strapping, padding, and shoe modifications were attempted, but ultimately failed. She elected to proceed with arthrodesis of the digit. She was followed at post-op weeks 2, 4, and 8. At week 8, osseous bridging was noted across the osteotomy site (Figure 1). The patient had no complaints and was discharged. She returned to the office 2 years later for a different complaint and x-rays revealed fusion across the PIPJ with no loss in hardware fixation (Figure 2).

fig1a fig1b

Figure 1 Case report patient at (left) 2 weeks and (right) 8 weeks post-operation. Note fusion on medial side of arthrodesis site at 8 weeks.

fig2

Figure 2 Case report patient seen 2 years later. Complete fusion with no loss of fixation.

 

Surgical Technique

A #15 blade is used to make an incision across the PIPJ of the digit. This is dissected down to the deep capsule taking care to create a surgical plane between the superficial and deep fascial layers. Retraction is utilized to protect neurovascular structures located around the digit. A transverse tenotomy of the long extensor is performed just proximal to the PIPJ and soft tissues are freed up from the proximal phalanx head and middle phalanx base. Cartilage resection is performed with a sagittal saw at the head of the proximal phalanx and base of the middle phalanx.

Implantation of the IMFD is performed per the devices surgical technique guide. First, the IM canals of the proximal and middle phalanx are reamed with the supplied 1.6mm diameter reaming device down to but not through the subchondral plate into the adjacent joint. This position is checked on fluoroscopy and length is measured off of the wire, summing the proximal and middle phalanx measurements and choosing the sized implant available. Next the proximal phalanx is broached with the supplied 2.7mm broaching device. The depth of the broach is noted per the ruler on the device (7-10mm depth). The appropriate implant is positioned at the corresponding proximal phalanx reaming depth and placed within the proximal phalanx IM canal. The digit is then grasped and manipulated to place the distal end of the implant into IM canal of the middle phalanx. Once inserted, the implant can be released and the bones are manually compressed across the resection point. Closure consists of re-approximation of the extensor tendon and capsule around the fusion site for extra-medullary stability, and layered closure of the superficial fascia and skin.

Patient Audit

A CPT code audit of 28285 (correction hammertoe, eg. Interphalangeal fusion, partial, or total phalangectomy) from March 1, 2011, to July 15, 2015, was performed. Over that time period, the resulting search yielded 60 patients who had 89 digital surgeries. Patients that had arthroplasty, arthrodesis not performed with the studied device, the studied device plus KW, or isolated DIPJ arthrodesis were excluded. Ultimately, 35 toes in 23 patients had isolated PIPJ fusions using this technique.

Results

The case patient was seen at post-operation weeks 2, 4, and 8. Signs of fusion were noted at week 4 and complete fusion was noted at week 8 radiographically. No loss of fixation was noted at any point. Patient satisfaction was high at discharge.

The CPT audit identified 35 toes that underwent PIPJ arthrodesis using the studied device. Average follow-up was 110 days. There was zero (0%) cases of hardware failure noted. In a single instance (2.8%), the device appeared to have rotated 90 degrees on its long axis, but fixation was still maintained. Two toes (5.7%) were misaligned with  slight medial angulation of the digit. There were zero occurrences of either a superficial or deep incisional infection as defined by the CDC [11]. No patient required revision surgery or a return to the operating room for a complication secondary to the index digital arthrodesis procedure.

Discussion

One of the biggest problems with arthrodesis of the PIPJ can be attributed to the use of EMKW for temporary stabilization across the fusion site until osseous union is achieved. The use of KW for fixation was first described by Taylor in 1940 [1]. Since that time, surgeons have battled against the complications of this technique such as pin-tract infections, digital edema, delayed or non-union of the arthrodesis site due to lack of compression, rotational instability, bent or broken wires, and patient dissatisfaction and apprehension due to the protruding wire and its impending removal [2,10]. External wire exposure infection rates range from 0-18% [1,5,12]. Studies have reported 40% of the wire infections were related to external factors through irritation at the skin-pin interface secondary to trauma and water-contamination [5]. Because of this, Creighton et al (1995) first presented a new technique of the single buried KW in digital fusion [5]. In more recent times, various IMFDs have been manufactured to give the surgeon options of fixation other than the aging gold standard KW. Canales et al (2014) in a recent paper noted 68 IMFDs on the market as of February 1, 2014 [6]. Normal incidence of surgical site infection after foot and ankle surgery has been reported between 1% and 5.3% [13, 14]. Creighton et al (1955) reported an infection rate of 3.5% with his buried KW technique while more recent fusion products have reported similar results ranging from 0%-5% [2,5,7,10]. Our results were similar with a 0% superficial or deep infection rate for the 35 toes at average patient follow-up of 110 days.  No patient at any point or length of follow-up presented for care of digital infection.

One such product for IM digital fusion is the Arrow-LokTM Hybrid implant (Arrowhead Medical Device Technologies, LLC., Collierville, TN) and is the specific implant used by the senior author and reviewed in this article. The implant is made of one solid piece of ASTM F-138 stainless steel, has a core diameter of 1.5mm (0.059”) with a proximal 3-dimensional (3-D) barbed arrow-shaped head 3.0mm by 3.5mm or 2.5mm and distal 3-D arrow-shaped head 3.0mm by 3.5mm. It comes in variable lengths ranging between 13mm and 50mm and in 0° and 10° plantar bend angles [15-17] (Figure 3). There is no special handling or pre-operative storage restriction placing a handling time limitation on implementation [17]. Its use in various clinical situations (PIPJ and DIPJ arthrodesis) as well as surgical tips and tricks have been published on, but to the authors best knowledge no literature exists on loss of correction and infection rates [15,18].

fig3

Figure 3 Intramedullary fusion device comes in straight (top) or 10° angulation (bottom). Key regions include (A)overall length, 13-50-mm; (B) distal tip diameter, 3.5-mm; (C) proximal tip diameter, 2.5-mm or 3.5mm; (D) length of proximal angle segment, variable 6-9-mm; (E) length of proximal angle segment, variable 10-26-mm.

 

The theory of construct of the ArrowLokTM is similar to that of an intramedullary rod (IMR) in fracture care (Figure 4). One of the biggest benefits of the ArrowLokTM device is due to the various available lengths ranging from 13mm to 50mm, the largest identifiable span on the market. Both transfer loads across a break in long bones, whether it be a fusion (ArrowLokTM) or fracture (IMR) site [19]. This IM position is closer to the anatomic axis of the bone and aids to resist bending while the circular round construct resists loads equally in all planes. Mechanical load testing at a quarter of a million cycles at up to 89N showed no signs of wear or fatigue of the ArrowLokTM  or bone [16]. Furthermore, in instances where both PIPJ and DIPJ fusion is needed, one longer device can be used versus two separate devices to be squeezed into a tight space [15]. This results in a location of potential stress riser in the middle phalanx between the distal and proximal ends of the two implants as described in the above situation. This is important when a common results regarding digital fusion (either implanted devices and percutaneous k-wires), the bulk of the non-osseous fusions are made up of fibrous unions which rarely impact the outcome of the surgery and are still considered a surgical success [7,8]. When osseous fusion is not achieved and weaker fibrous tissue fills the fusion interface, much of the strength of the fusion lies in the inherent strength of the implant device.

fig4a fig4ab fig4c

Figure 4 Like an IM rod (left), the ArrowLokTM device (right) garners its strength through its length spanning the osteotomy site to transfer loads and end arrow tips acting as a locking screw, preventing rotation, shortening and gapping, all reasons for failure of fixation.

 

figure-5

Figure 5 DIPJ arthrodesis with the ArrowLokTM device.

The 3-D arrow-ends of the ArrowLokTM act similar to proximal and distal locking screws in IMRs. This secures the device and prevents rotation, compression, shortening, or gapping, resulting in loss of fixation. Compared to a standard 1.6mm  (0.0062”) EMKW, the ArrowLokTM has comparable resistance to bending, increased resistance to pull-out (21x more resistant), and increased resistance to rotational forces (12x more resistant) [16]. These problems are inherent to EMKW use due to the design lacking IM compressive purchase and inability to prevent rotation, leading to potential non-solid fusion and mal- or non-union.

IMRs bending rigidity is based off of diameter and in solid, circular nails, is proportional to nail diameter to the third power [20]. Diameter also affects nail fit with a well fitting nail, reducing movement between the nail and bone, friction between the two maintaining reduction [20]. Reaming with the initial KW and broach help increase this contact relationship. With a 1.5mm core diameter, the ArrowLokTM is a tight fit within the phalangeal canal and increases bending rigidity and construct strength. The long, solid, one-piece design differs from others on the market in not having regions of thinner diameter metal and having two pieces that snap together at the junction of the fusion site – both which lead to sites of potential breakdown [9]. One study demonstrated a 20.7% rate in fracture at internal fixation site using Smart Toe® (Stryker Osteosythesis, Mahwah, NJ) versus 7.1% in 0.062-inch buried IMKW use [9].

Conclusion

The recent literature has demonstrated that utilization of these newer devices like the ArrowLokTM for correction of the hammertoe deformity provide a safe method with low complication rates similar to other products on the market.8 Furthermore, with the decrease and almost elimination of infection rates, despite the higher cost of the implant compared to a KW, the potential for infection complications and the associated cost is avoided. In our retrospective case review, ArrowLokTM showed a lack of hardware failure, zero infection rate, and high patient satisfaction. Due to its available lengths, IMR type construct, and ability to cross two fusion sites at once, this device offers another option for the surgeon in digital fusion.

Conflict of Interest

Dr. Jason R. Miller is a consultant for Arrowhead Medical. Arrowhead Medical Device Technologies had no knowledge or influence in study design, protocol, or data collection related to this report.

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