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The influence of great toe valgus on pronation and frontal plane knee motion during running

by Richard Stoneham PhD1, Gillian Barry PhD1, Lee Saxby BSc2, Mick Wilkinson PhD1*

The Foot and Ankle Online Journal 13 (1): 7

Injury rates in running range from 19.4‐79.3%, with injuries at the knee comprising 42.1%. Pronation and altered frontal plane knee joint range of motion have been linked to such injuries. The influence of foot structure on pronation and knee kinematics has not been examined in running. This study examined associations between great toe valgus angle, peak pronation angle and frontal plane range of movement at the knee joint during overground running while barefoot. Great toe valgus angle while standing, and peak pronation angle and frontal plane range of motion of the dominant leg during stance while running barefoot on an indoor track were recorded in fifteen recreational runners. There was a large, negative association between great toe valgus angle and peak pronation angle (r = -0.52, p = 0.04), and a strong positive association between great toe valgus angle and frontal plane range of motion at the knee joint (r = 0.67, p = 0.006). The results suggest that great toe position plays an important role in foot stability and upstream knee-joint motion. The role of forefoot structure as a factor for knee-joint injury has received little attention and could be a fruitful line of enquiry in the exploration of factors underpinning running-related knee injuries.

Keywords: great toe valgus, pronation, frontal plane knee range of motion, running

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0007

1 – Department of Sport, Exercise and Rehabilitation, Northumbria University, UK
2 – LeeSaxby.com, Suffolk House, Louth, Lincolnshire, UK
* – Corresponding author: mic.wilkinson@northumbria.ac.uk


Injury incidence in running ranges from 19.4‐79.3% [1, 2]. The knee is the most injured site, comprising 42.1% of all running‐related injuries [2, 3]. Patellofemoral Pain Syndrome (PFPS) is the most common running‐related knee injury, followed closely by Iliotibial Band Syndrome (ITBS) [3].  Altered frontal plane hip and knee joint kinematics and pronation during the stance phase of running have been linked to these injury types, and differentiate injured from uninjured runners [4-6]. Knee abduction, femoral internal rotation, tibial external rotation, and foot pronation, have been theoretically linked to injury in a population of patients with PFPS [7]. As such, interventions to normalise altered frontal plane kinematics during running might be valuable for rehabilitation of this type of knee injury. Interventions have tended to focus on proximal areas linked to altered knee kinematics. However, training studies to increase hip abduction and external rotation strength have not decreased hip or knee frontal plane peak joint angles or joint excursions during the stance phase of running [8-10]. Moreover, associations between hip strength and frontal plane hip and knee peak angles and joint excursions while running and jumping are weak [9, 11]. These findings suggest that proximally-based interventions are not effective at altering lower extremity running mechanics and risk of running related injury. Studies exploring the distal end of the kinetic chain have utilised barefoot and minimal footwear, and hip and foot muscle strengthening interventions to reduce surrogate measures associated with injury at the knee and other sites [10, 12-14]. Injury rates, however, remain high [15]. The influence of foot structure on pronation and knee joint kinematics in running has, by contrast, received little attention.

Data comparing foot structure in habitually-barefoot and habitually-shod populations have reported consistent differences in the spread/abduction of the great toe from the other toes [16-19]. Based on Newtonian physics, larger areas of support provide greater stability. It has been suggested that an abducted great toe position might be important for controlling the direction of body weight during running, secondary to improved stability of the foot [20, 21]. Running is essentially a series of alternate single-leg jumps, where multiples of bodyweight must be supported and controlled using a spring-like action of the supporting foot and limb [22, 23]. Early research showed an active role of the toes, the great toe in particular, from midstance to toe off in running [24]. More recent data comparing habitually barefoot to habitually shod populations suggested that the abducted great toe position, characteristic of the barefoot group, reduced peak forefoot pressures during running by increasing the area of support [19]. Another comparative study from the same lab [25] found larger ankle eversion and internal rotation (which together comprise pronation) during the landing phase of jumping in habitually shod compared to habitually-barefoot participants, attributing differences to the abducted great toe position characteristic of the barefoot group. Together, these studies suggest a link between great toe position and foot and ankle stability in running, and dynamic tasks with similar demands to running. Given evidence of the link between pronation, altered frontal plane motion at the knee joint and risk of knee injury [7], there is a possible mechanistic link between great toe position, pronation and frontal plane knee joint kinematics.

Previous research suggests that the toes have a stabilising function, and that great toe position influences area of support in running, and the extent of pronation in the landing phase of jumping. The influence of great toe position on pronation and on kinematics at the knee joint has not been examined in running. The aim of this study was to examine associations between great toe valgus angle, peak pronation angle and frontal plane range of movement at the knee joint during overground running while barefoot, the latter being necessary to avoid toe position being constrained by shoes.

Methods

Participants

With institutional ethics approval, 15 volunteers (ten male, five female) participated. Mean and SD age, stature and mass of all participants were 26±7 yrs, 1.71±0.01 m and 69±10.9 kg respectively. Inclusion criteria were aged 18-45 years and participation in endurance running more than once per week as part of habitual-exercise regimes, with at least one run longer than 30 minutes. Participants were excluded if they had an injury to the lower limbs in the previous six months, or any condition that could affect their normal running gait.

Design

An observational design assessed the relationship between great toe valgus angle relative to the first metatarsal, peak pronation angle and frontal plane range of movement at the knee joint of the dominant leg during stance, while running barefoot on an indoor runway. The barefoot condition was chosen as it was the only way to ensure that the toe angle recorded in standing was not altered by footwear while running. Data were collected in a single visit. Participants were provided with a short-sleeved compression top and shorts to improve skeletal representation in biomechanical modelling, and were instructed to be well rested before testing. Reflective markers were attached in ‘Plug-In gait’ and ‘Oxford-Foot Model’ formations to assess lower-limb kinematics of the dominant limb. Participants were habituated to running barefoot with a 30-minute, self-paced run. After habituation, participants ran over a 20-m runway where kinematic data were captured by 14 optoelectronic cameras. Electronic timing gates (Brower timing gates, Utah, USA) placed in the data capture area (2.7m apart) were used to record speed in each trial. The average running speed was 2.48±0.38 m·s-1.

Procedures

Great toe valgus angle

Participants stood barefoot on top of a 0.35-m high platform covered in graph paper. The non-dominant foot was placed on the platform first, aligning the most posterior aspect with a horizontal reference line on the graph paper. The dominant foot was positioned next, shoulder width apart from the other foot, and with the most posterior aspect on the same horizontal reference line. The first metatarsal proximal-and distal-dorsal protrusions, and the central and dorsal point of the interphalangeal joint of the great toe were identified by palpation, and marked using a permanent pen. A digital camera (CX240, Sony, Japan) positioned 0.3m above the platform on a tripod was aligned with the first metatarsophalangeal joint, and the zoom was adjusted so that bony prominences defining great toe angle were visible. A still image was captured and saved for analysis of great toe valgus angle.

Kinematics

Prior to habituation, anthropometric measures were recorded for use in biomechanical modelling (stature (mm), mass (kg), bilateral-leg length (mm), and knee and ankle joint width (mm)). For assessment of lower-limb joint kinematics, participants had a series of markers (Ø=14mm) attached in ‘Plug-In gait’ and ‘Oxford-Foot Model’ formations. Anatomical locations of the ‘Plug-In gait’ and ‘Oxford-Foot Model’ were sacrum, bilateral anterior-and posterior-superior iliac spines, the bilateral distal-lateral thigh, bilateral femoral-lateral epicondyle, the bilateral distal-lateral lower-leg, the bilateral lateral malleoli, the left/right toe (dorsal aspect of the second metatarsal head) and the calcaneus of the non-dominant limb at the same height as the toe marker. The following markers were placed on the dominant limb only, lateral head of the fibula, tibial tuberosity, anterior aspect of the shin, the medial malleoli, the proximal aspect of the calcaneus, a ‘peg marker’ extending from the most posterior aspect of the calcaneus, the inferior aspect of the calcaneus, sustentaculum tali, proximal and dorsal aspect of the first metatarsal head, the medial and distal aspect of the first metatarsal head, the proximal-and distal-lateral aspects of the fifth metatarsal and the medial aspect of the first phalanx. Fourteen infrared-optoelectronic cameras (Vicon 10 xT20 and 2 x T40, Oxford, UK) captured kinematic trajectories at 200Hz. 

Data treatment

A trial was deemed successful when running speed was ± 5% of the predetermined running speed from the habituation run. Dominant limb data for peak pronation angle and frontal plane range of motion at the knee joint were exported to Microsoft Excel (Microsoft, USA). Foot structure images were loaded to Dartfish ClassroomPlus (version 7.0, Fribourg, Switzerland) where great toe valgus angle was measured using the angle tool. (Chicago, USA).

Statistical analysis

Statistical analysis was undertaken using JASP 0.10.2. Following verification of assumptions of linearity and uniformity of errors using Q-Q and residuals versus predicted value plots respectively, linear regression assessed associations between great toe valgus angle, peak pronation angle and frontal plane range of motion at the knee joint. Strength of associations were judged against Cohen’s effect size categories for Pearson’s  r i.e. small association 0.1-0.3; moderate association 0.3-0.5; large association 0.5-1.0 [26]   Significance was accepted at p < 0.05.

Results

Mean and SD great toe valgus angle, peak pronation angle and frontal plane knee range of motion were 9.5±6.1°, -5.2±6.6° and 6.2±2.2° respectively.

Association between great toe valgus and peak pronation angle.

There was a large, negative association of great toe valgus angle and peak pronation angle during stance (r = -0.52, p = 0.04). As great toe valgus angle increased (more positive = more valgus), peak pronation angle decreased (more negative = increased pronation) (see Figure 1). The regression equation showed a 0.59° increase in peak pronation for every additional degree of great toe valgus (95% CI 0.01 to 1.12°).

Figure 1 Association between great toe valgus angle and peak pronation angle during overground barefoot running on an indoor track in 15 recreational runners.

Association between great toe valgus and frontal plane knee range of motion.

Great toe valgus angle was strongly and positively associated with frontal plane range of motion at the knee joint (r = 0.67, p = 0.006). As great toe valgus angle increased, frontal plane knee range of motion also increased (see Figure 2). The regression equation showed a 0.24° increase in frontal plane knee joint excursion for every one degree increase in great toe valgus angle (95% CI 0.01 to 0.40°).

Figure 2 Association between great toe valgus angle and frontal plane range of motion at the knee joint during overground barefoot running on an indoor track in 15 recreational runners.

Discussion

The aim of this study was to examine associations between great toe valgus, peak pronation and frontal plane range of motion at the knee joint during overground running. There was a strong, negative correlation between great toe valgus angle and peak pronation such that increased great toe valgus was associated with a more negative peak pronation angle (increased pronation). There was also a strong, positive correlation between great toe valgus angle and frontal plane range of motion at the knee joint such that increased great toe valgus was associated with larger knee joint excursions in the frontal plane. Altered frontal plane hip and knee joint kinematics and pronation during the stance phase of running have been linked to running-related knee injury, and can differentiate injured from uninjured runners [4-6]. Knee abduction and foot pronation have also been theoretically linked to patellofemoral pain [7]. In light of this evidence, our results suggest that forefoot structure might be an important but largely unexplored factor in running-related knee injury.

As this is the first study to explore the association between great toe valgus, pronation and frontal plane knee joint excursions during running, there are no studies with a similar approach for comparison. Nevertheless, the strong relationships observed broadly support findings from previous comparative cross-sectional studies of habitually barefoot and habitually shod participants that differed in forefoot structure with respect to the spread/abduction of the great toe [19, 25]. Shu et al. [25] observed larger ankle eversion and internal rotation (which together comprise pronation) in habitually shod compared to habitually barefoot participants in the landing phase of jumping. As running is essentially a series of single-leg jumps, the strong association of great toe valgus angle with peak pronation observed in running in our study is not surprising. The reduced and more evenly distributed forefoot peak pressures of habitually barefoot participants reported by Mei et al. [19] alludes to greater forefoot stability during the period of stance when forces are highest. It is possible that as the stability provided by the great toe decreases with increasing valgus angle, instability of the foot could manifest as higher peak pronation. Increased forefoot instability with increased great toe valgus is a plausible mechanism that could explain the strong correlation of great toe valgus angle and peak pronation that we observed. Increased postural instability with great toe valgus [27] and with splinting of the great toe into flexion [28] have been observed in single-leg balance tasks. Though these studies examined static balance and not the dynamic single-leg balance characteristic of running, the underpinning link between the area of the base of support and subsequent stability could be assumed to be common to both. Instability at the foot could have kinematic consequences further up the kinetic chain, resulting in increased frontal plane motion at the knee. The strong, positive association of great toe valgus angle with frontal plane knee joint excursion observed in the current study is consistent with this suggestion. Moreover, the kinematic links between pronation and frontal plane knee joint range, as well as the link between these factors and running-related knee injury suggested here have been suggested previously elsewhere [7] and supported by previous studies [4-6].

The main limitation of this study is that the correlational design prevents any suggestion of a causal link between great toe valgus, peak pronation and frontal plane knee joint excursions. Another limitation is that great toe valgus angle was measured during static stance, not while running, so an assumption that valgus angle remains relatively unchanged when the foot is loaded during running is implicit in the interpretation of the results. Previous research, however, suffers from similar limitations, comprising only comparative studies of foot and ankle function and pressure distributions of groups with mean abducted versus mean valgus great toe positions. As such, a correlational study like this one does add to the understanding of how foot structure might relate to pronation and knee joint kinematics in dynamic tasks like running by examining a ‘dose-response’ type association, in addition to the ‘with and without’ type evidence of previous comparative studies. Moreover, there are plausible mechanisms of action for both key findings in this study, so the data provide both direct and mechanistic evidence towards establishing a causal link [29]. A logical next step for this area of research would be randomised control trials where pronation and knee kinematics are evaluated before and after an intervention to alter great toe valgus angle in one group, with the control group foot structure remaining unchanged. Interventions could potentially include corrective surgery or corrective devices that reposition the great toe. Additional comparative studies that measure knee joint kinematics during running would, however, be a useful intermediate step.

In summary, this study observed strong associations between great toe position, peak pronation and frontal plane range of motion at the knee joint during over-ground barefoot running. The results suggest that great toe position plays an important role in foot stability and subsequent knee-joint motion. Both pronation and frontal plane knee-joint motion have been implicated in the etiology of knee injuries. The role of forefoot structure as a factor for knee-joint injury has received little attention and could be a fruitful line of enquiry in the exploration of factors underpinning running-related injuries.

This study formed part of a PhD program collaboratively funded by Northumbria University and VivoBarefoot. VivoBarefoot had no input to the design, analysis or interpretation of studies or data, or the preparation of this manuscript.

References

  1. Louw M and Deary C. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners – A systematic review of the literature. Phys Ther Sport. 2014 15(1): 64-75.
  2. van Gent RN, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med 2007 41: 469-480. 
  3. Taunton J, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002 36(2): 95-101. 
  4. Tiberio D. The effects of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports Phys Ther. 1987 19(4): 160-165. 
  5. Stefanyshyn DJ, et al. Knee angular impulse as a predictor of patellofemoral pain in runners. Am J Sports Med 2006 43(11): 1844-1851. 
  6. Nakagawa TH, et al. Frontal plane biomechanics in males and females with and without patellofemoral pain. Med Sci Sports Exer 2012 44(9): 1747-1755. 
  7. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: A theoretical perspective commentary. J Orthop Sports Phys Ther 2003 33: 639-646. 
  8. Snyder K, et al. Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clin Biomech 2009 24(1): 26-34. 
  9. Ferber R, Kendall K, and Farr L. Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome. J Athl Train 2011 46(2): 142-149. 
  10. Willy RW and Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther 2011 41(9): 625-632. 
  11. Dierks T, et al. Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. JOrthop Sports Phys Ther 2008 38(8): 448-456. 
  12. McKeon PO, et al. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med 2015 49(290): 1-9. 
  13. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech 2014 29(4): 395-399. 
  14. Roper JL, et al. The effects of gait retraining in runners with patellofemoral pain: a randomized trial. Clin Biomech 2016 35: 14-22. 
  15. Videbaek S, et al. Incidence of running-related injuries per 1000h of running in different types of runners: A systematic review and meta-analysis. Sports Med 2015 45(7): 1017-1026. 
  16. Shu Y, et al. Foot Morphological difference between habitually shod and unshod runners. PLoS ONE 2015 10(7). 
  17. Hoffman P. Conclusions drawn for a comparative study of the feet of barefooted and shoe-wearing peoples. J Bone Joint Surg 1905 3: 105-136. 
  18. D’Aout K, et al. The effects of habitual footwear use: foot shape and function in native barefoot walkers. Footwear Sci 2009 1(2): 81-94. 
  19. Mei Q, et al. A comparative biomechanical analysis of habitually unshod and shod runners based on foot morphological difference. Hum Mov Sci 2015 42: 38-53. 
  20. Wilkinson M and Saxby L. Form determines function: Forgotten application to the human foot? . Foot Ank On J 2016 9(2): 5-8. 
  21. Wilkinson M, Stoneham R, and Saxby L. Feet and footwear: Applying biological design and mismatch theory to running injuries. Int J Sport Exer Med. 2018 4(2). 
  22. Srinivasan M and Ruina A. Computer optimization of a minimal biped model discovers walking and running. Nature 2006 439: 72-75. 
  23. Mann RA and Hagy JL. Biomechanics of walking, running and sprinting. Am J Sports Med 1980 8: 345-350. 
  24. Mann RA and Hagy JL. Function of toes in walking, jogging and running. Clin Orthop Relat Res 1979 142: 24-29. 
  25. Shu Y, et al. Dynamic loading and kinematics analysis of vertical jump based on different forefoot morphology. SpringerPlus 2016 5: 1999. 
  26. Cohen J, Statistical power analysis for the behavioural sciences. 1969, New York: Academic Press.
  27. Hoogvliet P, et al. Variations in foot breadth: effects on aspects of postural control during one-leg stance. Arch Phys Med Rehab 1997 78(3): 284-289. 
  28. Chou S, et al. The role of the great toe in balance performance. J Orthop Res 2009 27: 549-554. 
  29. Howick J, Glasziou P, and Aronson JK. The evolution of evidence hierarchies: What can Bradford Hill’s “Guidelines for Causation” contribute? J R Soc Med 2009 102: 186-194.

Case study of idiopathic degeneration of the talonavicular joint

by Ryan Allen, DPM1*; William Arthur, DPM1; Christina Ma, BS2; Charles Parks, DPM, FACFAS3; Monara Dini, DPM, FACFAS3

The differential diagnosis for chronic pain out of proportion is broad, and a final diagnosis of Mueller-Weiss syndrome is often a diagnosis of exclusion. We present a patient who experienced pain out of proportion following minor trauma. This progressed into worsening pain that affected his day-to-day activities and ability to perform work. Eventually, there was destruction of his talonavicular joint and early stages of idiopathic fusion. Multiple specialties were involved in this case including infectious disease, rheumatology, and neurology. Excluded diagnoses were septic joint, osteomyelitis, complex regional pain syndrome, Charcot arthropathy, and rheumatoid arthritis. We present a rare case of a patient who experienced idiopathic destruction and fusion of his talonavicular joint following minor trauma, with Mueller-Weiss syndrome suspected. The patient would make significant recovery following arthrodesis of the talonavicular joint.

Keywords: Mueller-Weiss-syndrome, complex regional pain syndrome, idiopathic fusion, talonavicular joint

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0006

1 – Podiatric Surgery Resident, Department of Veteran Affairs at San Francisco
2 – Podiatric Medical Student, California School of Podiatric Medicine
3 – Assistant Professor, Department of Orthopaedic Surgery, University of California at San Francisco
* – Corresponding author: ryandylanallen@gmail.com


Müller-Weiss syndrome is a rare disease that is described as a spontaneous adult-onset tarsal navicular osteonecrosis [1]. Symptoms include chronic midfoot pain, swelling, and tenderness on the dorsal and medial midfoot. It is commonly found bilaterally and is found more frequently in women [1]. Its pathogenesis remains controversial. Some believe it to be caused by secondary compressive forces acting on the tarsus or possibly a congenital defect, while others believe it to be an ischemic process[2]. The characteristic findings for Müller-Weiss syndrome include a dorsomedial dislocation along with the collapse of the lateral navicular bone, resulting in a comma-shaped.

The first description of this condition was in the early twentieth century in Europe. In 1925, Schmidt reported on a patient with pluriglandular endocrine failure with deformities at the tarsal navicular. Walther Müller described this condition in 1927, where he suggested that the disease developed from a forceful compression of the lesser tarsus. Müller later suggested a congenital defect was the cause of the disease the following year [3]. Also, in 1927, an Austrian radiologist, Konrad Weiss, described similar findings in two patients suggesting osteonecrosis as the cause for the condition [4]. Although Schmidt was the first to describe this condition, the disease is named after Müller and Weiss.

The exact prevalence and incidence of this disease is currently unknown. However, there are isolated case reports throughout the literature. It is commonly present in the fourth to sixth decade of life. It is also frequently bilateral and usually found in patients with a higher body mass index. There is limited data suggesting an environmental and nutritional component [5]

The pathogenesis of this condition is poorly understood. However, the literature suggests that there are two contributing factors; a delay in ossification of the navicular and atypical compressive forces on the midfoot. 

There are multiple factors that can contribute to a delay in ossification including poor nutritional status, endocrinopathies, metabolic disease, or malabsorption disease [5]. When there is a delay in the ossification of the navicular, the weak outer chondral surface is susceptible to abnormal development from excessive compressive forces. Current literature suggests a large compressive force would contribute to plastic deformation of the navicular during ossification [5]. However, it is possible that persistent low compressive forces on the pliable chondral surface puts the navicular at risk of ossifying in an irregular orientation. 

The second contributing factor is a result of the biomechanical insult on the navicular. As mentioned previously, excessive compressive forces on the navicular is suggested to contribute to this condition. This is particularly true when these forces are applied to the lateral half of the navicular between the talar head and the cuneiforms. There are several conditions which can lead to compressive forces to the lateral aspect of the navicular including: primary subtalar joint varus, first ray brachymetatarsia (both congenital or acquired), and clubfoot deformities [5]. Other biomechanical factors such as a short hallux metatarsal, shortening of the entire medial column due to internal rotation of the navicular in the transverse plane, or retroposition of the first tarsometatarsal joint in relation to the second tarsometatarsal joint can also contribute to lateralization forces [5]. When the first ray is hypermobile, loading forces transfer to the second ray which may also lead to compressive forces into the intermediate cuneiform and lateral navicular [5]. 

Case Report

A 41-year-old male with a past medical history of right foot plantar fasciitis, depression, and insomnia was brought in by ambulance to the Emergency Department of San Francisco General Hospital with a chief complaint of 10/10 right foot pain accompanied by swelling. Two days prior, the patient had been exercising at his gym. He did not recall any particular injury apart from his right foot slipping off exercise equipment onto the floor, without any immediate pain. Several hours after exercising, he noticed a gradual increase in right foot pain. In the Emergency Department, plain films did not demonstrate fracture, there was diffuse soft tissue swelling on the dorsum of the foot (Figure 1),  labs were not drawn, however, the patient’s vital signs were all within normal limits. He was discharged from the ED with an ankle brace, crutches, and Tylenol for pain relief.

He again visited the ED 3 days later, with a further increase in pain and edema; he was not found to have any underlying fluctuance or erythema. He remained unable to bear weight on his right foot. He remained in an ankle brace and had been using ibuprofen without any significant pain relief, and he continued to not have any constitutional symptoms. Radiographs demonstrated increased soft tissue swelling from prior films, however, no evidence of fractures, soft tissue calcifications, or joint effusions were seen. He was recommended to continue use of the ankle brace, to stop ibuprofen, and trial Tylenol.  

Nearly one month later he presented to the ED with continued pain, however now able to bear weight. He had plain films which demonstrated even further increase in soft tissue swelling as well as a CT (Figure 2) with findings of prominent osteopenia involving the midfoot. Orthotics and Prosthetics was consulted and he was dispensed a CAM boot. The podiatry service was notified, and an appointment was made for the following day in the clinic. He was dispensed opioid pain medication, as well as ibuprofen, at discharge.

The next day, he presented to the Podiatry Clinic. His right dorsal foot was edematous and erythematous from the metatarsal heads to the level of the ankle joint. Fluctuance was not appreciated. The right dorsal foot was tender to palpation.


Figure 1 Radiographs of patient’s foot. Diffuse swelling on the dorsum of the foot without evidence of fracture or dislocation.

Figure 2 Sagittal CT demonstrating further soft tissue swelling with prominent osteopenia of the midfoot.

Allodynia was present. Pain increased with plantarflexion of the right ankle joint. Pain was also present with eversion and inversion of the right subtalar joint. He was unable to wear the CAM boot, dispensed to him the prior day, as this increased his pain. A CBC, ESR, CRP, BMP, and HgA1c, and a MRI with contrast were ordered to assess for abscess or osteomyelitis. His ESR and CRP were >130 mm/h and 198.0 mg/L, respectively. His HgA1C was 5.9%, and his uric acid level was 3.7 mg/dL. He was without leukocytosis and his remaining labs were unremarkable. An ACE wrap was applied from the foot to the tibial tuberosity to compress the foot. The patient was given strict instructions to elevate, do ROM exercises, and wear the CAM walker boot at a 90 degree angle to prevent worsening flexion contracture. He was given explicit instructions to return to the ED if he developed any fever, chills, nausea, and vomiting or any worsening pain. He was dispensed gabapentin to be taken at bedtime for pain. 

The previously ordered MRI was taken and reviewed. Findings were reviewed with radiology, and they were suggestive of broad diagnoses. Clinically and radiographically there was support of complex regional pain syndrome.  It showed destruction of joint spaces at the TN joint, subtalar joint, as well as deep marrow edema within the midfoot outside of the talonavicular joint (Figure 3). The navicular bone was almost entirely replaced with edema and enhancement.The MRI findings were also consistent to support Charcot arthropathy and osteomyelitis as well. Septic joint was also on the differential due to minimal fluid within joint spaces. Interventional Radiology was consulted for urgent bone biopsy. There would be no growth from the cultures of the specimen acquired.

The patient then underwent a right foot irrigation and debridement with bone biopsy approximately one week later with the presumption of infection versus complex regional pain syndrome. At this time the symptoms began 3 months prior. Gout was lowest on the differential due to a prior uric acid level of 3.7 mg/dL. In the operating room, a 4 cm incision was made dorsally to gain access to the talonavicular joint. A Rongeur forceps was used to collect a sample of synovial tissue which was noted to appear inflamed and thickened; this was sent to microbiology. The talus and navicular were assessed and noted to be hard and viable. A sample of cartilage and bone was taken from both the talus and the navicular and sent to microbiology. Bone specimens were also sent to pathology from both talus and navicular. The patient would subsequently be admitted to the hospital. 

Figure 3 Sagittal and transverse T2 MR imaging demonstrating destruction of the talonavicular joint with extensive marrow edema that was also present to the calcaneus and cuneiforms.

During his hospital stay, neurology was consulted to rule out CRPS. He was noted to not have any evidence of neuropathy with “intact afferent and efferent limbs of reflex arc.” Neurology assessed a low suspicion of neuropathic etiology of symptoms. In terms of the acquired specimens from the OR, there was no growth noted from any of the specimens (C&S, AFB, and fungal). The synovial tissue final pathologic diagnosis was noted to be “lymphoplasmacytic inflammation.” Excised bone of both the talus and the navicular were noted to be without any evidence of acute osteomyelitis.  

Figure 4 Radiographs demonstrating focal osteopenia and erosive changes of the talonavicular joint.

The patient remained in-house for 5 days; he was then discharged home. Two days after discharge he returned to the clinic; he was now one week status post biopsy. He remained without constitutional symptoms.  The differential diagnosis remained the same at this point, with complex regional pain syndrome as most likely diagnosis despite low suspicion from the Neurology team. New labs were ordered. Rheumatoid factor was noted to be within normal limits <3.5 IU/mL and antinuclear antibody was noted to be negative as well. His ESR had decreased to 68 mm/h and his CRP had decreased to 6.4 mg/L. The patient was encouraged to continue ambulating with a CAM boot and to practice ROM exercises. He would later follow up with the infectious disease clinic who noted that “osteopenia and marrow enhancement on imaging, elevated inflammatory markers, and absence of evidence for neuropathy on exam (making Charcot arthropathy unlikely) are concerning for infectious etiology.” 

Figure 5 Immediate post-operative films of the talonavicular fusion.

However, both cultures and pathology were without evidence of osteomyelitis and he did not have a systemic illness which could have led to hematologic seeding or skin breaks down allowing for direct inoculation. Serologies were sent to rule out less common infectious agents, such as TB and coccidioides. The serologies were noted to be negative for both TB and coccidioides.  The patient returned to the Podiatry Clinic two weeks later, now 3 weeks status postbiopsy and almost four months from the time of onset of symptoms. He attempted to ambulate in his CAM boot but was unable to do due 5/10 throbbing pain along his medial arch. He continued to not have any constitutional symptoms. He was encouraged to transition to regular shoes and discontinued the CAM boot. His sutures were removed at this visit. Since he had been discharged from the hospital, he had begun taking a new pain management regimen of gabapentin 300 three times daily which he noted to help alleviate some pain.

The patient returned to the clinic 5 weeks status post the open biopsy. He was still unable to walk in regular shoe wear and remained in his CAM boot utilizing a knee scooter. It had been two months since he last tried physical therapy and he wished to restart therapy. New plain film imaging was taken, and noted to be without any interval changes. He was encouraged to ambulate in regular shoe wear and to mobilize the foot as much as possible. It was stressed that weight bearing was imperative to make a recovery.

Two weeks later the patient returned to the clinic with new plain films. He was now 7 weeks status postbiopsy. He attempted to ambulate only utilizing the CAM boot but remained unable to bear weight on his right foot in regular shoe wear. On plain film imaging he was noted to have unchanged severe osteopenia from prior films, however with more focal osteopenia/erosion involving the talonavicular joint (Figure 4). X-ray findings correlated with TNJ degenerative joint disease.  

At this point in summary, neurology had evaluated the patient and had very low suspicion for complex regional pain syndrome. Medical workup had also been negative for inflammatory arthritis. Of note, the patient had no risk factors for Charcot arthropathy. The case was discussed on multiple accounts with the orthopaedic department and the patient was then placed in a short leg cast, made non-weight bearing, with a plan of serial casting with imaging to promote autofusion of the TNJ. If the patient was to continue to have pain, surgical fusion of the TNJ would be considered. 

The patient returned to the clinic 2 weeks, now 6 months status-post the initial onset of pain, and now with new assessment of TNJ degenerative joint disease secondary to unknown etiology with differential of CRPS, Müller-Weiss syndrome, septic joint, or osteomyelitis. 

Figure 6 Eight weeks post-operative films demonstrating trabeculation across the arthrodesis site.

He had remained in a short leg cast and NWB as instructed, and ambulating with a knee scooter. He remained without constitutional symptoms. At this time, surgery for fusion was discussed, as well as conservative treatment of serial casting. Patient opted to go with the latter. It was discussed that 6-8 weeks of serial casting may be adequate for fusion. Patient was again casted and he followed up again 2 weeks later. Again, surgery was discussed as the patient had no change in his symptoms, and was placed in a CAM boot with a plan for incisional biopsy.

The patient then opted to undergo a right foot incisional biopsy of the talus and a TN joint preparation for fusion. The patient returned to the operating room now just over 8 months from the initial onset of pain and symptoms. An incision was made through the prior incision site and deepend down to the talonavicular joint and a capsulotomy was performed. A pseudoarthrosis was noted. The articular surface of the navicular and talus were exposed and the surfaces were noted to have patchy areas of hyaline and fibrocartilage. A curette was then used to resect three separate specimens consisting of cortical bone from the articular surfaces of the navicular and the talus. This procedure’s goal was to prepare the joint for fusion and for a final biopsy. Fungal, bacterial, and acid fast bacilli would all be negative for growth.

The patient returned to the operating room for a third and final time, to undergo a right foot talonavicular arthrodesis with iliac crest bone graft at 9 months from onset of symptoms. An incision was made approximately 10 cm from the talar neck to the base of the first metatarsal. Dissection was carried down to the talonavicular joint was prepared utilizing curettes, fish scaled with osteotomes, and fenestrated using 0.062 K-wire. Attention was then directed to the right anterior superior iliac spine to acquire autograft. The talonavicular site was temporarily fixated and a combination of cancellous autograft, cancellous allograft bone chips, and 10 cc of Stimulan Biocomposite calcium sulfate were placed into the talonavicular arthrodesis site around the structural iliac crest autograft. Next, the talonavicular arthrodesis site was then fixated with a small Wright Medical medial column fusion plate and 3.5 mm fully threaded locking and nonlocking screws (Figure 5). The patient was then subsequently admitted for 48 hours for observation. Intraoperative bacterial cultures from bone were acquired but would be negative for growth.

The patient remained non-weight bearing for a total of 12 weeks, both with a short leg cast for the first 8 weeks followed by a CAM boot with ROM exercises for an additional 4 weeks. Serial radiographs demonstrated uneventful healing of the arthrodesis site (Figure 6). 

He continued to be followed weekly in the Podiatry Clinic. He continued to have interval changes of healing of the arthrodesis site on serial x-rays. The patient continued to work with physical therapy, primarily range of motion exercises. At 11 months he was noted to have significant improvement in pain during ambulation. He was able to transition to regular shoe wear at this time. At 13 months, he was noted to have 1/10 level of pain. At this point, he felt that he could return to day to day activities without restriction. There were no complications from any of the surgical interventions at his last follow up visit of this review, 13 months from the onset of symptoms. 

Discussion

This is an atypical presentation of Müller-Weiss. The inciting event was minor trauma, however, this is per the patient’s report, and therefore is subjective. The first ray mobility was not evaluated prior to the initial presentation. The patient had swelling and pain of the midfoot, however, this was unilateral. Although the patient did not have a higher than average BMI, he was athletic and he had exceedingly high midfoot torque on his foot during exercise routines. The appropriate steps in the management of other diseases including  complex regional pain syndrome were met.  Biopsies were taken to rule out infectious causes, and multiple serologies were taken, even to exclude TB.  Multiple imaging modalities were also used.  The patient was directed to pain management, and he was treated by physical therapy before and prior to the talonavicular fusion; he improved following the procedure of a talonavicular joint arthrodesis. 

Apart from minor trauma, the unilateral destruction of the talonavicular joint is what makes this case unique. Müller-Weiss syndrome is often bilateral and not following any incidence of trauma.  It is possible in this case that the initial inflammatory phase of this disease process leads to the eventual destruction of this patient’s talonavicular joint, resulting in the need for an arthrodesis. This would explain why he would make a recovery following this procedure in conjunction with continuing physical therapy. We therefore believe that this is an atypical case of complex  Müller-Weiss Syndrome, although atypical. 

Conflict of Interest Declaration

The corresponding and contributing authors have no relevant financial interest in this manuscript.

References

  1. Sharp RJ, Calder JDF, Saxby TS. Osteochondritis of the navicular: a case report. Foot Ankle Int 2003; 24:509–513  
  2. Müller W. Uber eine eigenartige doppelseitige Verãnderung des os naviculare beim Erwachsenen. Deutsche Zeitschrift fur chirurgie Leipzig 1927; 201:84-7.
  3. Nguyen, AS, Tagoylo GH, Mote GA. Diagnostic imaging of the Mueller-Weiss syndrome: findings of a rare condition of the foot.  J Am Podiatr Med Assoc. 2014 Jan-Feb;104(1):110-4.
  4. Weiss K. Über die “malaizie” des os naviculare pedis. Fortschritte auf dem Gebiete der Röntgenstrahlen 1927;45:63-7.
  5. Mohiuddin T, Jennison T, Damany, D. “Müller-Weiss disease. Review of Current Knowledge” Foot and Ankle Surgery, 2014, 20;79-84.
  6. Harden RN, et al. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 4th Edition. Pain Med 2013 Feb;14(2):180-229. doi: 10.1111/pme.12033. Epub 2013 Jan 17.

The geographic distribution of podiatrists in Perth, Western Australia

by Sara Hashemi1*, Estie Kruger1, Marc Tennant1

The Foot and Ankle Online Journal 13 (1): 5

This study examined the spatial accessibility of podiatry services to aged people living in the Greater Perth area, and access to these services for people from different socioeconomic groups, using geographic information systems (GIS). All persons older than 65 years (n=216 062) were included in the study and divided into two subgroups (retirees and elders) by age. Census data, bus stops (high and medium accessible stops) and train station data were integrated with GIS to analyse population spatial accessibility. The study found that most of the aged population resided within 2 kilometers of podiatry clinics, and the podiatry services are well distributed. In terms of access to buses, around three-fifths of aged people lived within 1 kilometer of high-access bus stops, and more than four-fifths of this population resided within 1 kilometer of medium-access bus stops. The distribution of podiatrists among people from different socioeconomic areas showed the density of podiatry services was higher in more affluent areas, therefore, the Inverse Care Law is evident in access to podiatry services in the Greater Perth region. 

Keywords: aged population, podiatry services, spatial accessibility, density, buses,  trains

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0005

1 – International Research Collaborative – Oral Health and Equity, Department of Human Sciences, The University of Western Australia.
* – Corresponding author: 21642772@student.uwa.edu.au


Western Australia is geographically the largest state in Australia, with a total area of more than 2.5 million square kms (a third of the total area of Australia) and a population (in 2011) of 2.2 million people [1]. Of this population 1.7 million people (77%) are living in the capital city, Perth.  In recent years, the population growth was double that of other cities in Australia [2].  A little over 200,000 residents of Perth are over the age of 65 years, and it is forecasted that the age structure in Perth will change consistent with the global trend in developed countries. The predictions are that there will be a decrease in the working-age population from 89% to 64%, and an increase in retirement age proportion of people to 66% by 2026 [3]. Clearly this shift in population demographics will require substantial and rapid planning for health and welfare services over the next decade. Australia is thus facing the classic developed country issues of an aging population whilst being relatively wealthy and it being substantially a healthy population [4]. Many health services are available, both public and private, but the use of these services depend on geographic accessibility. Australian cities are not densely packed cities and the reliance on vehicle transport is high.  Geographical accessibility to healthcare services is one of the fundamental components of healthcare [5]. The ageing of the Australian population has already, and will continue to drive strong growth in podiatry services (https://www.aihw.gov.au/). This study examined the spatial accessibility of podiatry services to the population of the Australian metropolis of Perth, using a geographic information system (GIS) approach, with a focus on the retired and elders, and taking transport options into consideration. 

Methods

As only openly accessible and freely available data were used in this study, no ethics approval was required.

Podiatry practice locations: The podiatry directory from November 2015 was used to determine public service locations [7]. This directory updates every year and shares information about the Department of Health (DOH) and publicly funded podiatry services available in Western Australia. The private services were gathered from the yellow pages and addresses were confirmed with Google maps.

Population data: All population data (including age distribution) were obtained from the 2011 Census. The data frameset for this study include all people living within 50 km of the Central Post Office in Perth. Population groups were categorized according to age, with a focus on retirees and elders. Retirees included all people older than 65 years old, and elders include all those older than 85 years. 

Train systems in Perth: Perth, like the other Australian capital cities, has a comprehensive local train network. There are four Perth train lines, radiating out from the main Perth city train station [8]. All the train stations were included in this study. The geographic data for train stations is available on the TransPerth website  (http://www.transperth.wa.gov.au).

Bus system in Perth: Two bus terminals are located in the Perth metropolis: the Wellington street bus station and the City Bus port. The Wellington street bus station is approximately 200m from the main city centre train station, and services the northern suburbs. The geographic data for bus stations were available from the Transperth website (http://www.transperth.wa.gov.au).  High and medium frequency bus stops were considered separately. The “high” frequency stops were where busses stop at least 48 times per day (every 15 minutes) and “medium” had a lower frequency of less than 48  busses per day.

Population data and socioeconomics: Census data from the most recently available (and geo-coded) census (2011) were used for the study (http://www.abs.gov.au). A total of 1976 Perth SA1’s (the smallest geographic area the census data is divided into) had centroids within 50 km of the central post office. Consistent with previous studies this was deemed to be the Greater Perth region and used in the study as the definition of Perth.

The socioeconomic status of the population was analyzed using the Socioeconomic Index for Areas (SEIFA). The Australian Bureau of Statistics (ABS) uses SEIFA, a composite index of relative socioeconomic disadvantage, and determined from indicators collected by the ABS within each set of census data. In this research the deciles of SEIFA will be dichotomized, with deciles 1-5 classified as low socioeconomic, and the deciles 6-10 classified as high socioeconomic.
Data integration and analysis: All data were integrated using QGIS (version 10.0), and analyses were completed using Excel (version 2010;Microsoft Corporation, Seattle, WA, USA). QGIS software was used to formulate an integrated buffer zone around each podiatry service location, train and bus stations. Two optional zone radii were applied; zone A was 1 km wide, and zone B was within a 2 km radius from a podiatry service location. 

Results

The aged population and podiatry locations: The aged population (65 years and over) living in the Greater Perth area was 216,062, of which 187,925 were retired (65-84 years old) and the others, 28 137, were elders (over 85 years old). A total of 104,928 adults (retiree and elderly) lived within zone A (within 1km of a podiatry service), whilst 73,875 adults lived within zone B (between 1 km and 2 km of a podiatry clinic). These, respectively, constituted 48.6% and 34.2% of the total retirees and elders’ population of Greater Perth. For retirees, 89,21 (47.6%) lived within zone A, and 64,118 (34.1%) lived within zone B. For the elders, 15,407 (54.7%) and 9,757 (34.7%), respectively, resided in zone A and B (Table 1).

The aged population and bus stops (high and medium stops): In this study high and medium bus stops have also been investigated (the stations with high and medium numbers of times that the bus stops, or frequency of stops). 

Adults Within 1 km 

(Zone A)

Within 2 km

(Zone B)

Outside 2 km Total
Retirees 89,521 

(47.6%)

64,118 

(34.1%)

34,286

(18.3%)

187,925

(100)

Elderly 15,407

(54.7%)

9,757

(34.7%)

2,973

(10.6%)

28,137

(100)

Total 104,928

(48.6%)

73,875

(34.2%)

37,259

(17.2%)

216,062

(100)

Table 1 The number and percent of retirees (65-84 years old) and elderly (over 85 years old) living within 1 km, 2 km and outside 2 km of a podiatry service in Greater Perth.

Figure 1 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink for public services),  and  1 km buffer zones around  high frequency bus stops (blue circles).

A total of 129,485 retirees and elderly lived within 1km of high frequency bus stops (Figure 1), and 182 459 adults lived within 1 km of medium frequency bus stops (Figure 2). These, respectively, constituted 60% and 84% of the 216,062 total retirees and elders’ population of Greater Perth. For retirees, 110,426 (59%) lived within 1 km of high frequency bus stops, and 157,778 (84%) lived within 1 km of medium frequency bus stops. For the elders, 19,059 (68%) and 24,681 (88%), respectively, lives within 1km of high and medium frequency bus stops (Table 2). 

The aging population and train stations: This study identified the density of the aging population living next to train stations (Table 3). A total of 35,273 retirees and elders lived within 1km of train stations, and this amounts to around 16% of the aged population in Greater Perth (Figure 3). 

Adult Within 1km of high bus stops Within 1km of medium bus stops
Retirees 110,426

(59%)

157,778 

(84%)

Elderly 19,059 

(68%)

24,681 

(88%)

Total 129,485 

(60%)

182,459 

(84.4%)

Table 2 The number and per cent of the aging population living within 1 km of high and medium bus stops in Greater Perth.

Figure 2 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink  for public services),  and  1 km buffer zones around medium frequency bus stops (orange circles).

Within 1km Within 2km Outside 2km Total
Retirees 29,547 

(15.7%)

37,762

 (20.1%)

120,616 (64.2%) 187,925 

(100)

Elderly 5,726 

(20.35%)

6,280 

(22.3%)

16,131 

(57.3%)

28,137 

(100)

Total 35,273 

(16.3%)

44,042 

(20.4%)

136,747 (63.3%) 216,062 

(100)

Table 3 The number of older people living next to 1km of train stations.

Around 20% of this population lived within 2km of train stations and the rest (63%) lived outside 2km of train stations.

Socioeconomics: SEIFA was used to examine the relative socioeconomic status and proximity to podiatry services and public transport, and found lower percentages of the most disadvantaged half of the population (the first five deciles) lived closer to podiatry services, compare to the least disadvantaged half of the population (Table 4).

Figure 3 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink  for public services),  and  1 km buffer zones around train stations. 

Table 4 The number and percent of retirees (older than 65 years old) and elderly (older than 85 years old) living within zone A, zone B, high and medium bus stops and 1km and 2km of a train station, divided by Socioeconomic Index for Areas (SEIFA) deciles* in metropolitan Perth. Note: The percent shows the percentage of total aging population. * Decile 1=poorest, decile 10 =wealthiest.

Discussion

Spatial accessibility to healthcare facilities has been the focus of many studies in Australia, with the distance to facilities being highlighted as a barrier to access and subsequent utilisation of services (10). In total, 82% of retired (48% in zone A and 34.1% in zone B) and 89.4% of elders (55% in zone A and 35% in zone B) lived within 2 km of podiatry clinics, which it is 82.8% of the total aging population in Greater Perth. This information shows that podiatry services are distributed relatively uniformly among this population (Table 1) and most aged people have access to a podiatrist within a 2 km distance at most. Most of the aging population resided within 1km of high and medium bus stops, and therefore most of the retired and elders can use buses to visit podiatrists (Table 2).

There was a different trend in the distribution of train stations among the retired and elders, compared to proximity of them to bus stops, the train stations were not a suitable selection to access podiatry locations. In total, 36% of the retired population lived within 2km of train stations (15.7% within 1km and 20.1% within 2km) and 43% of elders resided within 2km (20% within 1km and 22% within 2km). In total, 36.7% of the whole aging population resided within 2 km of a train station.

In conclusion, access to podiatry services via train stations, does not seem to be a suitable option (Table 3), because 63% of total aging people resided outside of 2km from a train station. This study also focused on the public transportation accessibility of aged people from different socioeconomic backgrounds. Public transportation is very important to the older population in general, as they depend more on public transportation than young people. Also, older people, (especially after 70 years of age) start to surrender their driving licenses and depend on others to transport them to health facilities (11). They have limitations of using and driving personal vehicles, whilst at the same time experiencing a greater need for health care (12). However although retirees and elders depend on public transport, a lower proportion of them were living in close proximity to train stations.

The relative socioeconomic status and proximity to podiatry clinics, bus stops and train stations have been investigated, and the most disadvantaged of the retired and elders were less likely to live within up to 2 km of podiatry services (zone A and B) compared to wealthier older people. This data shows that the distribution of podiatrists were more likely to be among wealthier people, than people from lower socioeconomic areas. Only 17.4% of the total aged population lived outside of zone B. In terms of accessibility to bus stops (high and medium) within 1km, the wealthier groups had more spatial accessibility to both high and medium bus stops (34.4% and 48% respectively), while the low income people had less accessibility to bus stops, 25.5% for high and 36.5% for the medium stops. This difference is not too significant. In comparison between poor and wealthy aged people and access to train stations (within 2km) has shown that there were significant differences between these two groups., Only 14.4%  of retired and elders from disadvantaged areas  were located within 1 and 2 km of train stations (12.2% retired and 2.2% elders). The percentage of the aging population with high socioeconomic status was 22% within up to 2km of train (19% retired and 3.3% elders). This study indicated that the higher percentage of the aging population (63.3%) with different socioeconomic resided outside of 2km of train stations. According to this data, the Inverse Care Law applies to the  aged population in the Greater Perth metropolitan area. The definition of this law is “The availability of good medical care tends to vary inversely with the need for it in the population served”(13). On the other hand, public transportation was located closer to wealthier populations. It should be investigated to determine if  people from wealthier areas suffer from higher burdens of foot problems or diseases associated with foot health (such as diabetes), than those from poorer areas.   It might be that those from more disadvantaged areas are more unaware of feet health, or that the cost and affordability of podiatric care act as a barrier to obtain care. 

References

  1. Western Australia. Available from: http://www.lookatwa.com.au/AboutPerth/.
  2. Population of Perth in 2016. [Cited 2016 Jan 7]. Available from: http://australiapopulation2016.com/population-of-perth-in-2016.html
  3. City of Perth. Population and age structure. Available from:  http://forecast.id.com.au/perth/population-age-structure
  4. Zainab U, Kruger E, Tennant M. Major metropolis rail system access to dental care for the retired and elderly: a high- resolution geographic study of Sydney, Australia. Gerodontology. [Serial online]. 2014. Doi: 10.1111/ger.12157.
  5. Lara J, Sanders a, Glenn D, Aguilar b, Catherine J. Bacon. A spatial analysis of the geographic distribution of musculoskeletal and general practice healthcare clinics in Auckland, New Zealand. Applied Geography. 2013; 44: 69-78.
  6. What is a Podiatrist? John J. Swierzewski, D.P.M. [cited 1999 31 Dec]. Available from: http://www.healthcommunities.com/foot-pain/what-is-podiatrist.shtml#sthash.oGDU4mGG.dpuf.
  7. Podiatry services. DoH and public funded podiatry services WA Metro and Rural. Version 5, Nov 2015. P: 25-35.
  8. Perth Train. Available from: http://www.getting-around-perth.com.au/perth-trains.html.
  9. Look at WA. Perth’s online portal. Available from: http://www.lookatwa.com.au/Transport/buses.html.
  10. Kruger E, Tennant M, George R. Application of geographic information systems to the analysis of private dental practices distribution in Western Australia. Rural Remote Health 2011; 11: 1736.
  11. Kihl MR. The need for transportation alternatives for the rural elderly. In: Bull CN ed. Aging in Rural America. Thousand Oaks, CA: Sage; 1993: 84–98.
  12. Rocha CM, Kruger E, McGuire S, Tennant M. The geographic distribution of patients seeking emergency dental care at the Royal Dental Hospital of Melbourne, Australia. Community Dent Health 2013; 30: 149–54. 
  13. Hart JT. The inverse care law. The Lancet 1971:297;405-412.

The psychology of pain: A retrospective study examining correlation between number of listed allergies on patients’ medical charts and PACU pain rating

by Justin D. Guiliana, DPM1*; Rebekah Cherian, DPM2; Brent H. Bernstein, DPM3

The Foot and Ankle Online Journal 13 (1): 4

Pain is a complex entity of any pre- or postoperative workup, and serves as a subject matter comprised of several aspects. Some make an argument that pain should be considered as the “5th vital sign”. Effective pain control pre- and postoperatively is an important aspect to patient care. However, the ability to properly control pain can be limited based on the amount of allergies the patient has. The goal of this paper was to examine if a correlation exists between the number of listed allergies on a patient’s medical chart, and immediate postoperative pain rating in PACU. We believed that a correlation would exist between patient reported allergies (PRAs), and PACU pain rating. The results of this study showed that patient reported allergies (PRAs) did not serve as a prognostic indicator for PACU pain rating status post lower extremity podiatric surgical procedures. 

Keywords: postoperative pain rating, allergies, podiatry, psychology, pain management

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0004

1 – Resident, St. Luke’s University Health Network, Bethlehem, PA
2 – Texas Foot & Ankle Specialists, Mesquite, TX
3 – St. Luke’s Podiatry, Bethlehem, PA
* – Corresponding author: jguiliana28@gmail.com


Plato believed that pain arose from within the body and indicated it to be more of an emotional experience with sensory, cognitive, motivational, and affective qualities. Pain is known to surpass literal tactile sensation, or the physical awareness of pain. In addition, it also includes perception, learned behaviors, and subjective interpretation of perceived discomforts [1,2]. In the past, studies have examined patient-reported allergies in association with satisfaction scores after lower extremity total knee and total hip arthroplasties [3]. These studies revealed that PRAs did serve as a prognostic indicator in patient reported satisfaction, however no such study had been performed in the podiatric surgical population. The purpose of this paper is to further evaluate the relationship between the number of patient reported allergies and postoperative pain rating to see if a correlation exists.   

Patients and Methods 

A retrospective study was conducted examining surgical patients over the span of a little over 3 months, from July 3rd, 2017 through October 3rd, 2017. A total of 122 patients were utilized in the study. All patients were consecutively selected utilizing Epic analytics from a surgical podiatric practice. Each patient’s chart was examined to gather the number of patient-reported allergies after which PACU pain rating was rated. This includes all listed allergies, be they true allergies eliciting an anaphylactic type of reaction or be they “allergies” eliciting more a side effect type of reaction. The PACU pain rating was obtained by each patient, and documented by the PACU nursing staff.

Anesthesia Type Total
General Anesthesia General with popliteal block IV sedation
Surgery  Type ST # of patients 29 1 7 37
Row percent 23.97% 0.83% 5.79% 30.59%
B # of patients 49 3 19 71
Row percent 40.50% 2.48% 15.70% 58.68%
B + ST # of patients 8 3 2 13
Row percent 6.61% 2.48% 1.65% 10.73%
Total # of patients 86 7 28 121
Row percent 71.07% 5.79% 23.14% 100%

Table 1 Cross Tabulation of Two Variables.

Allergies Pain
Spearman’s Rho Allergies Correlation coefficient 1.000 0.041
Sig. (2-tailed) 0.656
n 122 122
Pain Correlation coefficient 0.041 1.000
Sig. (2-tailed) 0.656
n 122 122

Table 2 Correlations.

Figure 1 Scatterplot results.

The type of surgery was also evaluated, whether it was soft tissue alone (ST) (ie: endoscopic plantar fasciitis, ganglion cysts remove, tenotomy, soft tissue mass excision) vs. bone alone (B) (ie: hammertoe, Austin bunionectomy, osteotomy) vs. both soft tissue and bone (B+ST) (ie: Austin with extensor hallucis brevis (EHB) tenotomy). As seen in Table 1, there were a total of 37 patients that received soft tissue procedures alone, 71 patients that received bone procedures alone, and 13 patients that received bone and soft tissue procedures. 

Type of anesthesia was noted and grouped into 3 categories: general without popliteal block, general with popliteal block, or IV sedation. The total number of patients receiving each type of anesthesia are also displayed in Table 1. Spearman’s correlation was run to evaluate if PRAs had prognostic value for PACU pain rating. In addition, the type of anesthesia received pre-emptively was utilized to evaluate if one form of anesthesia over another in relation to procedure type had prognostic value in PACU pain rating. 

Results 

All statistical analyses were conducted in IBM SPSS for Windows Version 18.
A Spearman’s correlation was computed to assess the relationship between the number of patient’s allergies and their pain scale. These results can be seen tin Table 2. Results showed that there was no correlation between the two variables (r=0.04, n=122, P-value =1.00). The scatter plot in Figure 1 summarizes the results. P-value <0.05 was considered significant. These results show there is no correlation between the number of patient’s allergies and their pain scale. 

To see any association between type of surgery and anesthesia, a cross tabulation was done. These results can be seen in Table 1. Since more than 20% of the cells had less than four patients, a Chi Square Test was not recommended. Instead, it was best to report descriptive statistics only. 

Discussion 

Pain is an extremely complex aspect of medicine not only to evaluate, but to effectively manage as well. Pain is a biological, as well as learned aspect. Pain can be learned from cultural, psychological, emotional, and financial backgrounds. Prior studies have shown that how we experience a painful event is strongly influenced by our prior learning history [1,2]. Therefore, effectively managing and addressing a patient’s pain, especially in the postoperative time frame, serves as a challenge to the physician and treatment team. 

This retrospective study sought to evaluate if there exists a correlation between the number of listed allergies on a patient’s medical record and their PACU pain rating scale. The Spearman’s correlation revealed no correlation between the two variables. No correlation could be found regardless of the type of surgery was performed, or what type of anesthesia the patient received preoperatively. 

Although our hypothesis did not hold true, the results serve as an indicator in the fact that pain is indeed extremely complex and serves as a challenge for medical professionals to effectively manage. Although the authors do not necessarily believe that pain should be considered the “5th vital sign”, it is believed that more emphasis should be given to patient’s allergy list in properly addressing preemptive pain management for surgical patients. 

Although an increasing number of patient-reported allergies was not seen to be associated with worse pain ratings, several limitations were present during this study. Some limitations of this study were inclusive of population size, and the challenge of objectively analyzing such a subjective topic. Only having utilized data from one surgical practice limits our study. In addition, different factors which have been known to contribute with subjective outcome measures include: race and ethnicity, education levels, and learned behaviors drawn from past-life experiences. In the future, to more accurately assess and predict the outcome of rated pain postoperatively in podiatric surgeries, this study can delve further into individual demographic, experiences, and learned behaviors

Disclosure: The authors declare that they have no relevant or material financial interests that relate to the research described in this paper

References

  1. Koban L, Kusko D, Wager TD. Generalization of learned pain modulation depends on explicit learning. Acta Psychologica. 75-84, 2017.
  2. Horn-Hofmann C, Scheel J., Dimova V., Parthum A., Carbon R., Griessinger N., Sitti R., Lautenbacher S. Prediction of persistent postoperative pain: Pain- specific psychological variables compared with acute postoperative pain and general psychological variables. European Journal of Pain, 191-202, 2017.
  3. McLawhorn AS, Bjerke-Droll BT, Blevins JL, Sculco PK, Lee Y., Jerabek SA. Patient-Reported Allergies Are Associated With Poorer Patient Satisfaction and Outcomes After Lower Extremity Arthroplasty: A Retrospective Cohort Study. Journal of Arthroplasty, 1132-1136, 2018.

A 12-month review of patients with advanced metatarsophalangeal joint osteoarthritis undergoing synthetic cartilage hemi implant arthroplasty

by James Lee Harmer FCPodS, MSc, BSc (Hons)1*; Anthony John Maher FCPodS, MSc, BSc (Hons)2 

The Foot and Ankle Online Journal 13 (1): 3

The aim of this study was to present patient reported outcomes (PROMS) and complications at 6 and 12 months following metatarsophalangeal joint (MTPJ) hemiarthroplasty with a synthetic cartilage hemi implant in patients with advanced MTPJ arthritic degeneration treated by a surgery team in the English National Health Service. Over a 12-month period between January 2016 and February 2017 a total of 20 patients underwent MTPJ hemiarthroplasty with a synthetic cartilage hemi implant. Patients were reviewed at both 6 and 12 months. All outcome data were collected using the PASCOM-10 audit database, an online resource which is able to report clinical and patient reported outcomes for selected cohorts. At 6 months, 65% of patients felt that their original complaint was now better or much better, while 4 patients (20%) felt their foot condition had deteriorated. At 12 months, 60% of patients felt better or much better and only 1 patient (5%) reported a deterioration in their foot condition. At 6 months 80% of patients felt that their original expectations from before surgery had been met or partly met and 95% reported they would be prepared to have surgery performed under the same conditions again; this reduced to 75% and 80% respectively by 12 months. The most common complication was joint pain and stiffness (60%) at 6 months, and 25% of the cohort had the implant revised to a joint destructive procedure by 12 months. Initial results for the synthetic cartilage hemi implant arthroplasty for the surgical treatment of advanced MTPJ arthritic degeneration were disappointing and did not compare well with previous studies. Although validated PROMS demonstrate a subtle improvement in health related quality of life and patient satisfaction at 6 months and 12 months, the results were not convincing and both complication and revision rates were high. 

Keywords: metatarsophalangeal, osteoarthritis, implant arthroplasty

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0003

1 – Specialist Registrar in Podiatric Surgery, Nottinghamshire Healthcare NHS Foundation Trust, Department of Podiatric Surgery, Park House Health Centre.
2 – Consultant Podiatric Surgeon, Nottinghamshire Healthcare NHS Foundation Trust, Department of Podiatric Surgery, Park House Health Centre. 
* – Corresponding author: james.harmer@nottshc.nhs.uk


Historically arthrodesis for advanced arthritis of the 1st metatarsal phalangeal joint (MTPJ) was considered as the gold standard, with good reduction in pain and high patient satisfaction levels reported [1]. However, sacrificing the range of motion of the MTPJ following arthrodesis is not ideal, it can restrict footwear, interfere with activities that require joint motion, can lead to transfer metatarsalgia, and arthritic degeneration in adjacent joints [2]. A desire to preserve joint motion has prompted the development of several joint implants, unfortunately many have not lived up to expectations and have demonstrated high rates of failure as a result of loosening, malalignment, dislocation, subsidence, implant fragmentation, and bone loss [3-4]. The advancement of technology has led to the introduction of novel new implants one of which is the Cartiva® synthetic cartilage hemi implant arthroplasty (SCHIA) (Cartiva® Wright Medical Group N.V.). This is a polyvinyl alcohol (PVA) hydrogel MTPJ hemi implant. PVA has been used with great success in several different medical devices but it is particularly useful as a joint implant material as its viscoelasticity and tensile strength are very similar to healthy human articular cartilage [5-8]. 

Initial outcomes for the SCHIA appear promising, Buamhauer and colleagues in an industry funded prospective, randomised, multi-centred, clinical trial named ‘the Motion study’ followed 202 patients at two years and found the implant to be equivalent to 1st MTPJ arthrodesis for advanced hallux rigidus with the added advantage of maintaining dorsiflexion, reducing pain and having few safety concerns [9]. The study used 2:1 randomised allocation in favor of the implant group, 23% of the arthrodesis control group withdrew after initially consenting to randomisation, 152 implant patients and only 50 arthrodesis patients started the trail with a further 4% lost to follow-up by the end of the study. Although unfortunate, this disproportionate ratio of patients between the two groups may bias the results in favor of the implant group. A total of 11% of patients in the implant group underwent revision surgery with 9.2% of the implants failing and having to be converted to a 1st MTPJ arthrodesis. The root cause of the implant failure was not determined or discussed. Although implant patients’ VAS pain scores improved by >30% at 1 and 2 years follow-up these scores were higher than the MTPJ arthrodesis group at all time points, though not statistically significant. 

In a subset of 27 first MTPJ SCHIA patients followed up at five years, Daniel et al., showed an impressive 96% implant survivorship with only one implant having to be removed and converted to arthrodesis [10]. They also demonstrated continued improvements in function and pain scores over the five-year period compared to baseline scores for those patients with retained implants. Postoperative radiographs evaluation showed no bone loss, loosening or wear of the implant, and patient tolerance and satisfaction were high. They conclude that the SCHIA was a viable alternative to first MTPJ arthrodesis in the treatment of patients with advanced hallux rigidus, however generalizability of these results is limited, as only the first 43% of patients from the original RCT were evaluated, and no control group was included to compare results against. More recently the group have published their complete multi-centred midterm results for the SCHIA. They found that clinical and safety outcomes observed at two years were maintained at 5.8 years [11]. It is difficult to determine the relevance of these results as over 15% of patients were removed from the trial following revision to arthrodesis and it is unclear how a further 12% of patients progressed as they were lost to follow-up, hence results for almost a third of the original cohort were absent from the 5-year study.

Although not quite as common and certainly not as well covered in the literature as hallux rigidus lesser MTPJ degenerative joint disease can be equally debilitating and just as challenging for surgeons to treat [12]. Etiology can follow a similar course as a consequence of trauma, either acute or repetitive, and can lead to an interruption in the blood supply commonly affecting the 2nd metatarsal head, but any metatarsal can be affected resulting in avascular necrosis better known as Freiberg’s Infraction [12,13]. Freiberg’s is characterised radiographically by fissuring and fracture of the articular cartilage, leading to collapse and flattening of the metatarsal head, and finally resulting in severe arthritic degeneration of the joint, as described by Smillie in 1914 [13]. Surgical management is driven by the stage of the deformity and presence of arthritic degeneration. In advanced lesser MTPJ arthritic degeneration surgeons tend to shy away from arthrodesis and prefer to opt to maintain joint function with either excisional arthroplasty or implant arthroplasty [12]. The SCHIA is available in several sizes and although it has not received clearance in the USA for use in joints other than the 1st MTPJ, there is potential for it to be used as an alternative surgical option for advanced lesser MTPJ degeneration [14].    

The initial results from the MOTION study look promising, however further studies are still required to help substantiate their findings. The purpose of this study was to present patient reported outcomes and complications at 6 and 12 months following MTPJ SCHIA in patients with advanced MTPJ arthritic degeneration treated by a foot surgery team in the English National Health Service.  

Method

A retrospective case series review of patients and their records was carried out at 6 and 12 months following MTPJ SCHIA. All patients over the age of 18 and who underwent surgery with the synthetic cartilage implant to address painful moderate to severe arthritic degeneration of an MTPJ, were included in the study. Patients with early MTPJ arthritic degeneration with minimal cartilage loss or those who had not previously received conservative care, or had marked transverse plane deformity were not offered surgery with the SCHIA. Over a 12-month period (Between January 2016 and February 2017) a total of 20 patients underwent MTPJ SCHIA. Surgical technique for SCHIA in the 1st MTPJ has previously been described in the literature [4,15].  Our surgical technique for implanting lesser MTPJ synthetic cartilage implants was no different except for the mobilisation of the sesamoid apparatus required in 1st MTPJ’s, all surgeries were combined with a dorsal joint cheilectomy. Surgeries were carried out under local anaesthesia with an ankle tourniquet by one of the department’s three surgeons. All patients were fit and healthy at the time of surgery and classed as either American Society of Anesthesiologists (ASA) 1 or ASA 2 [16] (Table 1). Mean Body Mass Index (BMI) was 27.9 ranging from (18.7 – 39.1) a third of the cohort had a BMI above 30. 

All patients underwent preoperative x-ray evaluation, patients diagnosed with hallux rigidus had their joint degeneration graded using the Coughlin and Shurnas classification system for hallux rigidus [17]. Patients diagnosed with lesser MTPJ degenerative disease were graded according to the Smillie classification system for Freiberg’s infraction [13] (Table 1). Subsequently seventeen 1st MTPJ, two 2nd MTPJ and one 3rd MTPJ hemi-arthroplasties were performed using a size appropriate synthetic cartilage implant. As long as wounds were healed patients returned to supportive footwear at two weeks and started a post-operative physiotherapy programme of 1st MTPJ strengthening and range of motion exercises.   Patients returned to the clinic on request and were reviewed by the authors at 6 months and 12 months following their surgical procedures. Governance approval for the study design was sought from Nottinghamshire Healthcare NHS Foundation Trust Research and Development Department.

All outcome data were collected using the PASCOM-10 audit database, an online resource which is able to report clinical and patient reported outcomes for selected cohorts [18]. PASCOM-10 benefits from the inclusion of a patient satisfaction questionnaire, the PSQ-10 [16]. For the measurement of patient-reported outcomes, PASCOM-10 uses the Manchester Oxford Foot/Ankle Questionnaire (MOXFQ), which is a validated measure of health-related quality of life (HRQOL) [19]. The MOXFQ assesses patient outcomes across 3 domains; pain, walking/standing, and social interaction with a maximum score of 100 in each domain. High scores signify poor HRQOL [20]. The PASCOM-10 system includes a reporting package, which was used to extract summary descriptive data for the cohort, this was then transferred into Microsoft Excel for further analysis. Descriptive statistics are presented throughout for demographic and outcome data. 

Minimal clinically important change (MCIC) scores were interrogated for all MOXFQ domains at each postoperative measurement point (6 months and 12 months). MCIC is an anchor based estimate of score change where a patient notices an actual, rather than statistical improvement in their foot health status. In the context of foot surgery, Dawson et al. [21] determined the MCIC estimate to be a 13-point score change across each of the 3 domains. 

Results 

All 20 patients completed preoperative MOXFQ questionnaires, 19 patients returned at six months and 18 patients returned at 12 months to complete postoperative MOXFQ, and patient satisfaction PSQ-10 questionnaires. Two patients (10%) were lost to follow-up at 12 months but the remaining 18 patients did return for a final review at a mean 18.95 months (range 11- 24 months). Only one case was a revision procedure following moderate 1st MTPJ degeneration after a hallux valgus correction with scarf and Akin osteotomies. MOXFQ scores improved at 6 months and a further improvement was recorded at 12 months across all three domains compared to baseline scores (See Figure 1). The MOXFQ score change at both 6 and 12 months exceeded the threshold for MCIC demonstrating an actual improvement in patients HRQOL (See Table 2). 

Demographics Measure Number Percentage %
ASA 1 8 40
ASA2 12 60
Female 17 85
Male 3 15
Mean Age 51 years
Age Range 35-72
Joint involvement Hallux Rigidus stage 2* 8 47
Hallux Rigidus stage 3* 8 47
Hallux Rigidus stage 4* 1 6
Lesser Metatarsal II** 2 67
IV** 1 33

Table 1 Patients diagnosed with lesser MTPJ degenerative disease were graded according to the Smillie classification system for Freiberg’s infraction. *Hallux Rigidus Classification (0-IV) Coughlin & Shurnas (2003). **Lesser Metatarsal – Smillie Classification (I-V).

Domain Pre-op 6/12 

Post-op

Score change 12/12 

Pot-op

Score Change Minimal clinical important difference
Walking 67 47 20 33 34 16
Pain 80 45 35 32 48 12
Social  60 33 27 20 40 24
Mean PSQ-10 76 78

Table 2 Six- and 12-month follow-up: Summary of Mean MOXFQ and PSQ10 Scores.

Sequelae Number Percentage %
6 Months
Joint Pain & Stiffness 12 60
Swelling 2 10
Transfer Metatarsalgia 1 5
Implant failure revised to joint destructive procedure  3

1st MTPJ Arthrodesis

1st MTPJ Primus Implant

2nd MTPJ Interplex Rod

15
12 Months 
Joint restriction 4 20
Joint Pain & Stiffness 5 25
Implant failure revised to joint destructive procedure  2

1st MTPJ Arthrodesis 

10

Table 3 Six- and 12-month complications.

Figure 1 MOXFQ scores improved at 6 months and a further improvement was recorded at 12 months across all three domains compared to baseline scores.

Table 2, illustrates patient satisfaction scores recorded using the PSQ10 questionnaire at both 6 and 12 months, scores did meet the benchmark suggested for UK podiatric surgery of 75 and above [22]. Further descriptive data from the PSQ10 questionnaires demonstrated that at 6 months post operation, 65% of patients felt that their original complaint was now better or much better, while 4 patients (20%) felt their foot condition had deteriorated. At 12 months, 60% of patients felt better or much better and only 1 patient (5%) reported a deterioration in their foot condition. At 6 months 80% of patients felt that their original expectations from before surgery had been met or partly met and 95% reported they would be prepared to have surgery performed under the same conditions again, this reduced to 75% and 80% respectively by 12 months.

Within the first six months following surgery 12 patients, 60% of the cohort, had returned complaining of joint pain and stiffness and subsequently underwent MUA with intra-articular corticosteroid injection. Marked swelling was noted in two patients (10%), and one patient (5%) developed transfer metatarsalgia, there were no episodes of suspected or proven post-operative infection (See Table 3). Three implants failed and had to be revised to a joint destructive procedure in the first 6 months, this equated to 15% of the cohort and by 12 months the revision rate had risen to 25% a significantly higher figure than reported by the MOTION study. A further 25% of patients continued to experience pain and stiffness within the joint, and only 20% noticed an improvement in joint ROM at 12 months. Table 3 details the full list of complications recorded at 6 and 12 months following surgery.

Discussion   

In our study population, initial results for SCHIA in the surgical treatment of advanced MTPJ arthritic degeneration were suboptimal and not as good as previous studies stating positive outcomes in over 90% of patients [9-12]. Although validated PROMS demonstrate a subtle improvement in HRQOL and patient satisfaction at 6 months and 12 months, our results were not convincing and both complication and revision rates were high compared to the MOTION study group [9-11]. To our knowledge this is the first study to indicate suboptimal results for the SCHIA. 

Level I evidence from Baumhauer et al., demonstrated extremely promising results for the SCHIA. They found that clinical outcomes of pain, function and safety were equivalent to the gold standard 1st MTP joint arthrodesis, for treating advanced hallux rigidus at two-year follow-up, with the added advantage of improving joint dorsiflexion [9]. Two subsequent studies carried out by the MOTION study group showed these positive outcome scores were consistently maintained at 5.8 years when compared with those observed at two years [9-11]. The improvements from baseline exceeded the MCID for each outcome measure for the vast majority of patients at 5.8 years (90.5%-97.2%) [11]. 

It is difficult to directly compare our results to the previous studies as the study design, methodology and outcomes are dissimilar, however, it is still apparent that our early outcomes for SCHIA did not fare as well as the original study [9]. Within the first six months following surgery 12 patients (60% of the cohort) returned complaining of joint pain and stiffness and subsequently underwent MUA with an intra-articular corticosteroid injection. In a recent retrospective study of 60 patients undergoing 64 SCHIA’s for the management of stage 2-4 hallux rigidus yielded an overall neutral patient satisfaction, mild pain and dysfunction at an average follow up of 15.2 months [23]. Over half of their cohort had at least one injection of corticosteroid for joint pain postoperatively at 2 or more months after surgery, for a total of 79 injections and 82% of injections were given within the first year. As a consequence of our initial results we now routinely counsel patients about the risk of persistent pain and swelling and the potential need for a manipulation under anaesthetic with intra-articular corticosteroid injection within the first 6 months of surgery. 

The MOTION study noted few safety concerns at 2 or 5 years, with overall survivorship of the SCHIA reported to be 84.9% at 5.8 years [11]. Our study noted a lower implant survivorship of 75% at 12 months. Surgical revision rate was therefore high in-comparison with 25% of the cohort having the implant removed and converted to a joint destructive procedure as a result of persistent or recurrent joint pain and stiffness.

A 9.2% surgical revision rate and conversion to a 1st MTPJ arthrodesis at 24 months was reported by the MOTION study. Daniel et al., showed an impressive 96% implant survivorship with only one implant having to be removed and converted to arthrodesis [10]. It should be noted that this was a small subgroup of patients taken from the MOTION study followed up at 5 years, and therefore may not be a true representation of the original cohort. Glazebrook et al., did publish the complete midterm results for the MOTION study and, although there was a loss to follow-up of 17%, they reported a more realistic implant survivorship of 84.9% by 5.8 years [11]. Cassinelli et al., also found excellent implant survivorship of 92%, however they had a reoperation rate of 20% in their short-term follow-up study [23]. A third of patients underwent magnetic resonance imaging (MRI) postoperatively due to persistent pain. Revision surgery included implant removal and conversion to arthrodesis (5 patients), lysis of adhesions (4 patients), Moberg osteotomy (1 patient), and implant exchange with bone grafting for impinging soft tissue or implant subsidence (3 patients). It was not made clear if postoperative MRI imaging was helpful in determining if reoperation was necessary and whether it played a part in deciding whether to retain or remove the implant, but it is clear that this would have added a further expense to an already expensive procedure. A longer-term follow-up of these patients would be useful to evaluate the reoperation success rate and to determine how implant removal and arthrodesis compared with the less aggressive procedures, including implant exchange. All of our revision surgeries involved a joint destructive procedure of either MTPJ arthrodesis or total implant arthroplasty, intraoperatively in all cases the implant was found to have subsided below the cortical bone of the metatarsal head with resultant bony contact between the proximal phalanx and metatarsal head. Due to the advanced arthritic degeneration and the fact that the SCHIA had already failed, we felt that a joint destructive procedure would yield the most reliable surgical outcome for these patients.

Rothermel et al., carried out a systematic review of the available literature and compared the cost of SCHIA and 1st MTPJ arthrodesis. The total direct cost of MTPJ arthrodesis was $3632, using a conservative failure rate of 9.2% with subsequent conversion to MTPJ arthrodesis, the total cost of SCHIA was $4565. They concluded that significantly higher inclusive costs were associated with the SCHIA, and sensitivity analysis revealed that MTPJ fusion was more cost-effective even if the failure rate increased to 15% and SCHIA failure rate was 0% [24].

Other than secondary surgeries carried out for implant failure, the original prospective randomised study does not provide any other information on postoperative complications, nor does it give an explanation for implant failure [9]. Cassinelli et al., thought that implant failure was largely a result of the implant subsiding, they recommended only using SCHIA in patients with adequate bone stock and that leaving the implant prominent may reduce the risk of subsidence [23]. Given our study demographics that included 85% women with a mean age of 51, hence a high portion of our cohort were at high-risk of osteoporosis. This may offer some explanation for the high rate of implant subsidence and our high implant failure rate compared to other studies with a lower female to male ratio and age comparison [9-11]. 

In our study, all patients underwent six-month postoperative x-ray evaluation, typical findings showed marked narrowing of the joint space, proximal impaction of the synthetic cartilage implant into the head of the metatarsal and there was significant arthritic involvement of the sesamoid apparatus. Daniels et al., reviewed 23 of the 27 patients radiographs at five-year follow-up. They reported no signs of implant loosening or subsidence and no evidence of implant wear. Radiographs did show signs of further arthritic joint degeneration compared to baseline films, however none required further surgery [10].    

One of the main reasons patients choose a joint implant procedure over an arthrodesis is to maintain or improve function and joint ROM [2,3,4,8,9,10,11,25]. The MOTION study demonstrated a mean improvement of 27.3% in 1st MTPJ dorsiflexion at 24 months, these improvements in dorsiflexion were maintained at 5.8 years following surgery compared to baseline results [9-11]. In our study 60% of patients noticed an improvement in symptoms at 12 months, however only 20% of patients noticed an improvement in joint ROM, 80% had no improvement or a deterioration in joint ROM with the SCHIA. Cassinelli et al., reported that 14% of patients noticed a restriction in 1st MTPJ ROM postoperatively and were provided with a dynamic splinting device to aid postoperative rehabilitation and improve joint ROM. A further 19% were found to have restricted 1st MTPJ ROM intraoperatively and in these patients in addition to releasing the sesamoids they also added a Moberg dorsiflexion osteotomy of the proximal phalanx in an attempt to restore normal MTPJ ROM and kinematics, none of these patients complained of restricted joint ROM at short-term follow-up [23]. 

Another explanation for our suboptimal results may at least in some part be due to technical error. We feel that whilst being described as a joint resurfacing implant, in actual fact the synthetic cartilage implant has more of a buffer effect and if the Implant is inserted too deep within the metatarsal head there is a greater risk of subsidence due to the softer trabecular bone found in the metatarsal diaphysis. Leaving the Implant significantly prouder will not only reduce the risk of subsidence, as stated by Cassinelli et al., but also distend the joint and increase the implants buffer effect. We found that SCHIA limited the size of the dorsal metatarsal head exostectomy that could be taken, subsequently dorsal joint impingement was more likely, leading to reduced joint dorsiflexion and increased pain at end range of motion. Reducing the size of the implant or placing the implant more plantarly within the metatarsal head may address this issue, further studies on implant position and subsidence are needed. Finally, in advanced hallux rigidus, the sesamoids are often involved, showing significant hypertrophy on x-rays and clinically being ankylosed to the base of the metatarsal head, causing joint pain and stiffness. In our experience despite releasing the sesamoids intraoperatively, SCHIA does not address the sesamoid apparatus and continued plantar joint pain and stiffness was a recurrent issue in our cohort at 6 and 12 month follow-up. 

Limitations of this study lie with its single center retrospective design, small sample size, and short- term follow up, which undermines the reliability of these results. Due to the small cohort of patients we were unable to perform any statistical analysis and instead used descriptive analysis. The low patient numbers were because we quickly stopped using SCHIA to treat advanced arthritic degeneration of the MTPJ’s, as a consequence of cost and suboptimal results noted at early follow-up. We are unable to comment regarding mid to long-term results and perhaps patient satisfaction rates, complications and revision rates may all improve with time in our study population and measures have already been put in place to follow these patients up at 3 and 5 years. 

We acknowledge that combining the outcomes of the 1st MTPJ and lesser MTPJs may be a methodological error, as they are different pathologies and there is no equivalent of the 1st MTPJ sesamoid apparatus in the lesser MTPJs and, moreover, it is not typically salvageable by arthrodesis. However, reviewing the conditions separately would have reduced the numbers in the study further and we do not believe that combining the results in this case has detracted from the purpose of this study, which was to present our initial experience including patient reported outcomes and complications relating to MTPJ SCHIA. 

In conclusion, our initial results for the SCHIA were suboptimal, complication and revision rates were high and did not compare well with previous results published by the MOTION study group. From our experience, we would recommend judicious use of the SCHIA in the surgical treatment of patients with advanced MTPJ arthritic degeneration. We feel that further work around patient selection, implant positioning and subsidence is necessary. 

References

  1. Maher AJ, Metcalfe SA. First MTP joint arthrodesis for the treatment of hallux rigidus: results of 29 consecutive cases using the foot health status questionnaire validated measurement tool. Foot (Edinb). 2008;18(3):123-30
  2. Goldberg A, Singh D, Glazebrook M, Blundell CM, De Vries G, Le IL, Nielsen D, Pedersen ME, Sakellariou A, Solan M, Younger AS, Daniels TR, Baumhauer JF. Association between patient factors and outcome of synthetic cartilage implant hemiarthroplasty vs first metatarsophalangeal joint arthrodesis in advanced hallux rigidus: Foot Ankle Int. 2017;38(11):1199-1206
  3. Yee G, Lau J. Current concepts: hallux rigidus. Foot Ankle Int. 2008;29(6):637-646
  4. Younger ASE, Baumhauer JF. Polyvinyl alcohol hydrogel hemiarthroplasty of the great toe: Technique and indications: Tech Foot Ankle Surg. 2013;12(3):164-169
  5. Baker MI, Walsh SP, Schwartz Z, Boyan BD. A review of polyvinyl alcohol and its uses in cartilage and orthopedic applications. J Biomed Mater Res Part B Appl Biomater. 2012; 100(5):1451-1457
  6. Baumbauer JF, marcolongo M. The science behind wear testing for great toe implants for hallux rigidus. Foot Ankle Clin. 2016;21(4):891-902
  7. Noguchi T, Yamamuro T, Oka M, et al. Poly(vinyl alcohol) hydrogel as an artificial articular cartilage: evaluation of biocompatibility. J Appl Biomater. 1991;2(2):101-107
  8. Kobayashi M, Hyu HS. Development and evaluation of polyvinyl alcohol-hydrogels as an artificial articular cartilage for orthopaedic implants. Materials. 2010;3(1):2753-2771  
  9. Baumhauer JF, Singh D, Glazebrook M, Blundell C, De Vries G, Le ILD, Nielson D, Pedersen ME, Sakellariou, A, Solan M, Wansbrough G, Younder ASE, Daniels T. Prospective, Randomised, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus: Foot Ankle Int. 2016;37(5):457-469
  10. Daniels TR, Younger ASE, Penner MJ, Wing KJ, Miniaci-Coxhead SL, Pinsker E, Glazebrook M. Midterm outcomes of polyvinyl alcohol hydrogel hemiarthroplasty of the first metatarsophalangeal joint in advanced hallux rigidus: Foot Ankle Int. 2017; 38(3):243-247 
  11. Glazebrook M, Blundell CM, O’Dowd D, Singh D, de Vries G, Le IL, Neilson D, Pedersen M E, Sakellariou A, Solan M, Wansbrough G, Younger AS, Baumhauer JF, Daniels TR. Midterm Outcomes of a synthetic Cartilage Implant for the First Metatarsophalangeal joint in advanced hallux Rigidus.Foot Ankle Int. 2018;1-10
  12. Schade V L. Surgical Management of Freiberg’s Infraction. Foot Ankle Spec. 2015;8 (6): 498-519
  13. Smillie IS. Freiberg’s Infraction. Proc R Soc Med. Jan 1967;60(1):29-31
  14. De Cesar Netto C, et al. The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2018.12.009 
  15. Younger AS, Baumnauer JF, Glazebrook M. Polyvinyl alcohol hemiarthropathy for first metatarsophalangeal joint arthritis. current Orthopaedic Practice. 2013; 24(5):493 – 49
  16. Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;2:111-115 College of Podiatry. PASCOM 10 – The Podiatry Audit Tool. 2016. http://www. pascom-10.com/. Accessed December 17th, 2018. 
  17. Coughlin MJ, Shurnas PS. Hallux rigidus grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003;85-A(11): 2072-2088
  18. Rudge G, Tollafield D. A critical assessment of a new evaluation tool for podiatric surgical outcome analysis. Br J Podiatry. 2003;6:109-119. 
  19. Dawson J, Coffey J, Doll H, et al. A patient- based questionnaire to assess outcomes
of foot surgery: validation in the context
of surgery for hallux valgus. Qual Life Res. 2006;15:1211-1222. 
  20. Maher AJ, Kilmartin TE. An analysis of Euroqol EQ-5D and Manchester Oxford Foot Questionnaire scores six months following podiatric surgery. J Foot Ankle Res. 2012;5:17. 
  21. Dawson J, Boller I, Doll H, et al. Minimally important change was estimated for the Manchester-Oxford Foot Questionnaire after foot/ankle surgery. J Clin Epidemiol. 2014;67:697-705. 
  22. Maher & Wilkinson. Clinical Audit Report: Doncaster Podiatric Surgery Service. Podiatry Now. 2011;14(11):20-25.
  23. Cassinelli SP, Chen NP, Charlton TP, Thordarson DB. Early Outcomes and Complications of Synthetic Cartilage Implant for Treatment of Hallux Rigidus in the United States. Foot Ankle Int.2019; 13 (6):1-9
  24. Rothermel SD, King JL, Tupinio MT, Kempland CW, Juliano PJ, Aynardi MC. Cost Comparison of Synthetic Hydrogel Implant and First Metatarsophalangeal Joint Arthrodesis. Foot Ankle Spec.2019; 10 (6): 1-5
  25. Brodsky JW, ptaszek AJ, Morris SG. Salvage first MTP arthrodesis utilizing ICBG: clinical evaluation and outcome. Foot Ankle Int. 2000;21 (4):290-296

A variant of screwless scarf osteotomy for hallux valgus: Clinical and radiographic outcomes

by Taoufik Cherrad1*, Hicham Bousbaä1, Mohammed Ouahidi2, Hassan Zejjari3, Jamal Louaste3, Larbi Amhajji4

The Foot and Ankle Online Journal 13 (1): 2

Scarf osteotomy is a versatile procedure for the correction of moderate and advanced hallux valgus. This technique has benefited from many improvements to allow translation and angulation correction of the deformity. We describe in our study a scarf variant without osteosynthesis material in which proximal fixation is made by interlocking and distal fixation with nonabsorbable suture. We retrospectively reviewed 33 feet in 30 patients with an average follow-up duration of 35 months (range: 4-60 months). On the latest follow up, 94 % of the patients were satisfied with the result. American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 56/100 to 87/100. The average improvement of HV angle was from 35° to 12°. The intermetatarsal angle improved from 19° to 7°. The DMAA improved from 27° to 8°. Neither delayed union nor osteonecrosis were observed. This variant of screwless scarf technique gives very good results in severe Hallux valgus by safe and large translation authorizing rotation and supination with low iatrogenicity.

Keywords: hallux valgus, scarf osteotomy, screwless

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0002

1 – Orthopaedic surgeon, Military Hospital Moulay Ismail Meknes (HMMIM). Morocco.
2 – Resident in Orthopedic Surgery and Traumatology, HMMIM. Morocco.
3 – Professor in Orthopedic Surgery and Traumatology, HMMIM. Morocco.
4 – Professor Head of the Department of Orthopedic Surgery and Traumatology, HMMIM. Morocco.
* – Corresponding author: taoufikcherrad@gmail.com


Hallux valgus (HV) is the main forefoot deformity. Non-operative treatment may relieve symptoms but the basis of management is surgery. The HV corrective surgery history is marked by various surgical techniques that currently enumerate over 150 procedures [1].

The scarf osteotomy is a powerful and mechanically stable procedure to correct moderate and severe forms of HV. This Z-shaped osteotomy of the first metatarsal was first proposed by Meyer [2]. Weil was the first to use the term ‘Scarf’ [3] and Barouk popularized it in Europe [4]. The scarf osteotomy is very versatile and stable, therefore it allows rotational and translation corrections. Originally this osteotomy was stabilized with two screws. Maestro proposed eliminating the proximal screw by locking the two fragments distally: a notch was created via a medial extension of the cephalic part of the osteotomy, the plantar fragment was displaced laterally, and the distal end of the proximal fragment was then fit into the notch (secondary cut and interlocking joint technique [5]. In 2012, Leemrijse et al optimized this technique to increase the potential range of translation. The procedure consists of distal locking and proximal stabilization without shortening. This was possible by impaction of a corticocancellous bone graft taken from the medial overhanging edge of the proximal fragment [6].

Our study presents the results of a retrospective series involving 33 feet (30 patients) operated for HV according to scarf technique without osteosynthesis material with proximal fixation by interlocking and distal fixation with nonabsorbable suture.

The aim of this study is to evaluate the safety, feasibility, and reproducibility of screwless scarf osteotomy by comparing our clinical and radiographic outcomes to the literature data.

Patients and methods

This is a retrospective study regarding 33 feet of HV from 30 patients treated with Scarf osteotomy without osteosynthesis material and followed in the orthopedic trauma surgery department of the military hospital Moulay Ismail Meknes between January 2014 and December 2018. The average follow-up duration was 35 months (range: 4-60 months). All subjects have given informed consent. Exclusion criteria were; HV treated with other operative techniques than scarf screwless, or a scarf procedure with internal fixation.

Twenty men and ten women had an average age of 37 years (range, 16-65 years) at the time of surgery. Six patients had bilateral HV and only 3 patients have been operated on the two sides by a screwless scarf.   

Pain with irritation at the bunion was present in 29 feet (88%). The unaesthetic deformity was a serious reason for consultation in 14 patients (47%). All of our patients had metatarsalgia and difficulty with shoes wear. Finally, 67% of our feet were Egyptian type (22 cases).

A standardised surgical technique was used in all cases. The foot was positioned on the operative table in spontaneous external rotation position, with a thigh tourniquet inflated to 300 mmHg.

The surgical procedure involves a standard medial incision over the first MTPJ and along the shaft of the first MT. Skin incision is done at the dorsal and plantar skin junction, avoiding to extend too far proximally and stopped distally at about 1 cm from the joint. The dorsal collateral sensitive nerve will be visible and protected. It is normally not necessary to visualise the collateral plantar nerve.

Figure 1 a: The medial capsulotomy with resection of the medial eminence. b: The sesamoid release by medial approach. c: The Z-shaped osteotomy.

After a medial capsulotomy, the medial eminence of the metatarsal head is removed (Figure 1a).

Then, by the same medial approach (Figure 1b). We release and reduce lateral sesamoid according to the Maestro approach; above and under the lateral collateral ligament (LCL) which is respected.

  • Above LCL: to free the extensor hallucis longus (EHL), the fibrous sling is cut.
  • Under LCL: the metatarso-sesamoïd ligament is cut principally with the lateral part of the conjoint ligament close to the base of the phalanx [7] 

The exposure of the plantar aspect of the metatarsal shaft by rugination must respect the soft tissue below the head for blood preservation.

Regarding the scarf osteotomy; the longitudinal section is made along the medial side of M1. The osteotomy begins proximally to 5 mm from the beginning of the proximal plantar exposure and on average at the junction of the dorsal two-thirds and plantar one-third of the shaft. It ends distally at the junction of the dorsal one-third and plantar two-thirds of the head just proximal to the cartilage of the joint (normally approximately 5mm from the joint surface). In the frontal plane, the osteotomy has an oblique direction downwards and outwards. The degree of dorsoplantar slope is chosen to obtain the desired amount of lowering. The saw is directed generally parallel to the metatarsal plantar surface of which has an average inclination from 40° relative to the horizontal; the focus is to respect the lateral beam from the dorsal fragment, which ensures the stability of the osteotomy. The longitudinal cut must be at least 2cm long to eliminate all risk of secondary displacement.

The distal transverse cut is done just behind the dorsal synovial recessus attachment which is respected. This cut is through the distal metaphysis (presence of spongiosa avoids the dorsal fragment to be fit into the distal fragment). The cephalic cut is dorsal and directed from within outward, proximally oblique and angled at 70°or 80° relative to longitudinal limb. If the distal transverse cut is perpendicular to the axis of the second metatarsal, pure translation is achieved and stabilization is required, either via a screw or via interlocking of the two fragments after a secondary cut, which shortens the first metatarsal bone. Finally the position and the obliquity of this distal cut give the osteotomy more stability (Figure 1c). 

The proximal transverse cut is performed, at an angle of 60° relative to the longitudinal limb and perpendicularly to the axis of the second metatarsal bone. A dovetail notch is then created at the proximal part of the plantar fragment to allow interlocking of the proximal plantar part of the osteotomy. This interlocking allows us not to use a proximal screw. This method is mainly used to acquire pure translation without correction of the distal metatarsal articular angle (DMAA). And, as Leemrijse et al recommended, when the DMAA must be corrected, a shorter osteotomy with a greater rotational effect is made and the proximal part of the cut is not impacted, to ensure marked proximal translation. 

After a complete Z cut, we translate easily the lower part of the plantar metatarsal associated with medial rotation which allows to correct the orientation of the metatarsophalangeal cartilage (DMAA).

Figure 2 a: Removal of medial overhanging bone. b: Reshaping and rotation of bony wedge. c: Superior view of screwless scarf osteotomy with a proximal fixation by impaction of bony wedge and distal fixation with nonabsorbable suture through a transosseous tunnel. 

Figure 3 Medial view of first metatarsal showing screwless scarf osteotomy with suture travelling through a transosseous tunnel in distal and proximal stabilisation by interlocking with impaction of the medial overhanging edge.

Once the desired displacement is obtained, the proximal fixation is done by interlocking from the proximal transverse cut, while the distal attachment is held temporarily by a modified Jospin forceps. The 10/10 Kirschner wire is then inserted from top to bottom which will lead the non-resorbable thread N°2 and allows the distal fixation by a transosseous suture under moderate tension avoiding shear of thread in the spongy bone. The medial overhanging wedge of bone is resected and impacted proximally, conferring perfect stability to the construct (Figure 2 and 3). The medial capsulorrhaphy is then performed to center the sesamoid bones which are released by the lateral side.

Figure 4 Postoperative strapping to be kept for 2 weeks.

Primary stability must be compatible with good mobility of the first metatarsophalangeal joint which enables it to maintain satisfying postoperative amplitude. Moreover one patient received an Akin osteotomy of P1 associated with Scarf osteotomy.

Postoperatively, strapping was kept for 2 weeks (Figure 4). Patients were allowed to walk with a Barouk boot for 6 weeks. At week 6, patients were able to walk and stand on the operated foot with full weight bearing.

Patients were assessed preoperatively and postoperatively for clinical and radiological parameters. The clinical evaluation included both subjective and objective assessment with American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological assessment included IMA (angle M1M2), HV angle (HVA: angle M1P1), DMAA (distal metaphyseal articular angle), angle M1M5 and situation of sesamoids. Measurements were taken with radiographs at weight-bearing dorsoplantar and lateral views.

Statistical analysis was performed using the paired z test to analyze the radiological parameters with the P value set at 0.05 to determine statistical differences.

For the situation of the sesamoids, we used the following classification [8]:

  • Grade 0: no dislocation;
  • Grade 1: lateral sesamoid beyond the lateral border of the first metatarsal;
  • Grade 2: the lateral sesamoid is fully apparent in 1st metatarsal space;
  • Grade 3: both sesamoid bones are located in the 1st metatarsal space.

Results

At the time of the latest follow up (mean: 35 months; range: 4-60 months), 94% of the cases were satisfied and very satisfied with the result (64% very satisfied and 30% satisfied), 6% were not satisfied. 

The average preoperative AOFAS score was 55 (range: 36-71), postoperative AOFAS score was 87 (range: 63-95), 

The average preoperative M1P1 angle of 35.06° (range: 24°-46°) improved to 12° (range: 2° to 22°) postoperatively (p < 0.001). The average reduction of M1P1 angle was 23.06 ° (66% from M1P1 angle

The average preoperative M1M2 angle of 19° (range: 12°- 28°) improved to 7.03° postoperatively (range: 4°-16°; p <0.001).The average reduction of the M1M2 angle was 11.96° (63% from M1M2 angle).

The average preoperative DMAA of 27.27 ° (range: 14 °- 32 °) improved to 8.3° postoperatively (range: 3°-16°; p <0.001).The average reduction of the DMAA was 18.96° (70% from DMAA angle).

Preoperatively the average value of the M1M5 angle was 32.51 ° (range: 20 ° to 42 °). While in postoperative, the average value of the angle M1M5 was 20.57 ° (12 ° to 32 °; p <0.001). The average reduction of the M1M5 angle was 11.93° (22% from DMAA angle).

In preoperatively, the grade 2 was predominant with 22 cases (66.67%) followed by grade 3 with 6 cases (18.18%) and finally the grade 1 with 5 cases (15.15%). 

Authors Procedures M1P1 Angle pre-operative M1P1 Angle post-operative M1M2 Angle

pre-operative

M1M2 Angle

post-operative

DMAA

pre-operative

DMAA

post-operative

Jardé [12] (1996) Soft tissue +/- P1 33.3° 24.5° 14.2° 12°   –
Coughlin & Carlson [13] (1999) Double osteotomy 34° 12° 15° 23°
Veri [14] (2001) Proximal osteotomy 37° 13° 16°
Bauer [15] (2010) Reverdin-Isham Percutaneous Osteotomy 30° 15° 14° 11° 15°
Mahadevan et al [16] (2016) Chevron 32.3° 14.3° 15.2 ° 5.8° 16.5° 8.5°
Our series  Screwless scarf osteotomy 35.06° 12° 19° 27°

Table 1 Anatomical results of several series using different techniques.

  Authors  Pre-operative

M1P1

Post-operative

M1P1 

Pre-operative

M1M2

Post-operative

M1M2

Pre-operative

DMAA

Post-operative

DMAA 

Classical

Scarf 

 

Gayet [17] 37° 21° 15° 10°
Crevoisier [18]   32° 17° 16° 10° 13° 10°
Freslon [8]  31.2° 17.5° 12.1° 7.5° 13.3° 11.1°
Lipscombe [19] 31.4° 11° 13°
Law Kin-Wing [9] 37.9° 10° 16.1° 8.4°
Screwless

Scarf

 

Leemrijse [6] 38.5° 10.6° 15.1° 8.7° 15.4° 5.4°
Dries Van Doninck [11] 27,9 ° 4,2° 13.5 ° 4.8°
Our series  35.06° 12° 19° 27°

Table 2 Radiographic outcomes in the Scarf osteotomy series of the literature.

Authors Year Technique Number of feet Follow-up  Satisfaction Preoperative AOFAS score Postoperative AOFAS score
Veri [14] 2001 Proximal metatarsal osteotomy 37 12.2 years 90% 37 92
Schneider[20] 2004 chevron 112 12.7 years 46.5 88.8
Freslon [8] 2005 Scarf 123 4.8 years 84.6%
Bauer [15] 2009 Percutaneous Reverdin-Isham osteotomy 104 2 years 89% 49 87.5
Leemrijse [6] 2012 Screwless scarf 12 7.7 years 100% 80
K.-W. Law [9] 2014 scarf 31 17 months 77% 88
Raymond D. Pollock [21] 2016 Shortening scarf osteotomy 20 25 months 100% 29.2 82.2
Our series 2017 Screwless scarf  33 35.15 months 94% 55 87

Table 3 Comparison of the functional and objectives results of different series.

While in postoperative the grade 0 was found in 18 cases (54%), grade 1 in 13 cases (40%) and grade 2 in 2 patients (6%).

Complications were observed in three patients: Residual pain was reported in two patients (who have been disappointed), while the stiffness of the MP was objectified in one patient. No disorders of consolidation for osteotomy (delayed healing of bone, pseudarthrosis) were noted.

Discussion

Currently, foot surgery requires rapid functional recovery that cannot be conceived without a primary stability and solidity of an osteotomy. Scarf osteotomy is designed to be versatile, authorizing the restoration of multiplanar HV anomaly. It allows horizontal displacement, lengthening, rotation, elevation, and lowering of the MT head [9].

Various modifications of the traditional scarf osteotomy were proposed to improve the biomechanics and to reduce complications. This evolution is motivated by deficiencies and complications of chevron osteotomies, basal osteotomies and Lapidus arthrodesis and by the superiority of scarf osteotomy results compared to these techniques [10] (Table 1).

Many studies have focused on the surgical treatment of hallux valgus by Scarf osteotomy, with or without osteosynthesis material (Table 2). Maestro in 2007 [5] and Leemrijse in 2012 [6] were the first to use the Scarf osteotomy without internal fixation. Leemrijse et al. developed an original technique involving distal locking without shortening and proximal stabilisation by impaction of a cortical-cancellous bone graft [6], whereas in our technique the fixation was ensured  proximally by interlocking and distally by nonabsorbable suture. Compared to other series, our results lead to consider this procedure reliable for correction of the significant hallux valgus (Figure 5 and Tables 1-3).

The screwless scarf osteotomy is a diaphyseal-metaphyseal osteotomy which allows a very wide lateral translation; we don’t need more space for placing a screw which could limit our translation capacity. It also allows sufficient medial rotation to correct the DMAA [5, 6, and 11].

Figure 5 Example of correction of hallux valgus by screwless scarf osteotomy; a: preoperative. b: postoperative.

Figure 6 Scarf osteotomy without internal fixation with 45 days apart, a: preoperative anterior-posterior radiograph. b: Postoperative anterior-posterior radiograph. 

This surgical procedure has clear advantages [6, 11]: 

  • Fewer complications related to screw insertion mostly in porotic bones which can lead to  fragility fracture of  the 1st metatarsal
  • No loss of reduction due to the compressive effect of the screw 
  • Less risk for complications in case of  superficial infection 
  • Less cost because no screw is used

At last, the screwless technique provides high-quality remodeling at the osteotomy site, without stress shielding [6] (Figure 6). The mean follow-up of our series was 35.15 months which is a significant duration for a procedure whose practice is still recent. However, although this period is sufficient to consider the correction for granted, it would be interesting to pursue the follow up of these patients (as in the case of Leemrijse series [6]) to quantify the importance of late recurrence and whether corrections obtained with this procedure are superimposed in terms of efficiency in time to other techniques with an important follow up.

Conclusion

The screwless scarf osteotomy is the favored technique in moderate and severe hallux valgus, on the condition that technique fundamental principles are respected. The absence of screws allows a wide lateral translation and therefore reduces a considerable preoperative metatarsus varus.

Finally in our study, we confirm the efficiency of this recent technique in the treatment of HV with almost 94% excellent and good results in our series. The learning curve of this surgery remains long. Respect and application of various technical artifices is essential for the realization of this economic, reliable and biological procedure.

References

  1. Laffenêtre O, Solofomalala GD, De lavigne C, Bauer THallux valgus : définition, physiopathologie, études clinique et radiographique, principes du traitement. Enc. Med. Chir, 2009 ; 14-1236-A10, 9p. 
  2. Meyer M. Eine neue modifikation der hallux-valgus-operation. Zen Fur Chir. 1926; 53:3265–8.
  3. Weil LS, Borelli AN. Modified Scarf bunionectomy, our experience in more than 1000 cases. J Foot Surg. 1991; 30:609–22.
  4. Barouk LS. Scarf osteotomy for hallux valgus correction: local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000 Sep;5(3):525–58.
  5. Besse JL, Maestro M. Ostéotomie de Scarf du 1er métatarsien. Rev Chir Orthop. 2007; 93:515-23
  6. Leemrijse T, Maestro M, Tribak K, Gombault V, Bevernage BD, Deleu PA. Scarf osteotomy without internal fixation to correct hallux valgus. Orthopaedics & Traumatology: Surgery & Research. 2012 Dec 31; 98(8):921-7.
  7. Maestro M. The ruled lateral release of the metatarsophalangeal and metatarso sesamoïd joint in hallux valgus by the medial approach. Poster EFAS Paris 23-25 octobre 1997.
  8. Freslon M, Gayet LE, Bouche G, Hamcha H, Nebout J. Ostéotomie Scarf  dans le traitement de l’hallux Valgus : à propos de 123 cas avec un recul moyen de 4,8 ans. Rev Chir Orthop. 2005 January; 91:257-266.
  9. Law Kin-Wing, Li Hok-Yin Alwin, Li Pang-Hei, Qunn Jid-Lee, Wai Yuk-Leung. Scarf Osteotomy in Treating Hallux Valgus: Clinical and Radiographical Outcome and Technical Notes. Journal of Orthopaedics, Trauma and Rehabilitation. 2014; 18 (1):22-26. 
  10. Trnka HJ, Mühlbauer M, Zembsch A, Hungerford M, Ritschl P, Salzer M. Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10-to 22-year follow-up. Foot & ankle international. 1999 Mar 1; 20(3):171-7.
  11. Dries Van Doninck et al. Screwless Scarf osteotomy for hallux valgus: evaluation of radiologic correction. Foot and Ankle Surgery. 2017;23 (4): 255–260
  12. Jarde O, Trinquier-lautard JL, Meire P, Gabrion A, Vives P. Hallux valgus traité par ostéotomie de varisation de la première phalange associée à la plastie de l’adducteur. Rev Chir Orthop. 1996; 82:541-548. 
  13. Coughlin MJ, Carlson RE. Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle Int. 1999 Dec; 20(12):762-70.
  14. Veri JP, Pirani SP, Claridge R. Crescentic. Proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study. Foot Ankle Int 2001; 22:817-22.
  15. Bauer T, Biau D, Lortat-Jacob A, Hardy P. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthopaedics & Traumatology: Surgery & Research. 2010; 96(4):407-416.
  16. Mahadevan D, Lines S, Hepple S, Winson I, Harries W. Extended plantar limb (modified) chevron osteotomy versus scarf osteotomy for hallux valgus correction: A randomised controlled trial. Foot and Ankle Surgery. 2016; 22:109–113.
  17. Gayet LE, Vaz S, Muller A, Avedikian J, Pries P, Clarac JP. L’ostéotomie Scarf dans le traitement de l’hallux valgus: à propos de 71 cas. Rev Chir Orthop. 1997; 83(suppl II):81.
  18. Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M. The Scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int. 2001; 22:970-976.
  19. Lipscombe S, Molloy A, Sirikonda S, Hennessy MS. Scarf osteotomy for the correction of hallux valgus: midterm clinical outcome. J Foot Ankle Surg. 2008; 47:273–277. 
  20. Schneider W, Aigner N, Pinggera O, Knahr K. Chevron osteotomy in hallux valgus. Ten-year results of 112 cases. J Bone Joint Surg Br. 2004; 86(7): 1016-20.
  21. Prasad Karpe, Marie C. Killen, Raymond D. Pollock, Rajiv Limaye. Shortening scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome? . The Foot. 2016; 29:45-49.

Arthroscopy of septic ankle and subtalar joints: A case report

by Karl Dunn, DPM, FACFAS1; Jordan Haber2*

The Foot and Ankle Online Journal 13 (1): 1

Infection of the ankle and subtalar joints is a serious and potentially debilitating condition. Of the few reported cases, results have varied. Traditionally open procedures have been performed, some of which even led to amputation. In the case presented, the authors demonstrate a successful result utilizing arthroscopic techniques in combination with intravenous antibiotic therapy. At two-year follow-up the patient has remained infection free.

Keywords: arthroscopy, infection, osteomyelitis, septic joint, pyarthrosis

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0001

1 – Mid-Michigan Orthopaedic Institute, A Division of Compass Healthcare; East Lansing, MI 
2 – Undergraduate Researcher of the Honors College of Michigan State University; East Lansing, MI
* – Corresponding author: haberjor@msu.edu


Joint sepsis is a severe condition with an annual incidence of 2-10 per 100,000 individuals per year [1]. Possible morbidity following joint sepsis includes chronic pain, irreversible joint damage, dysfunction, disability and a mortality rate in 11.5% of cases [2]). The prognosis is directly influenced by the promptness of the diagnosis and initiation of antibiotics [3]. Although administration of culture specific antibiotics with joint decompression are the cornerstones of treatment in a septic joint, debate in the literature exists between open versus arthroscopic approaches.

Larger, over smaller, joints seem to have a predilection, with the hip and knee constituting the majority (60%) of all septic joints [4]. Several risk factors are associated with the development of a septic joint: history of joint prostheses, rheumatoid arthritis, intravenous drug abuse, alcoholism, diabetes, previous intra-articular corticosteroid injection, immunosuppression therapy, among others [5]. 

Interestingly, the false perception is that pyarthrosis is overwhelmingly monoarthritic, as the literature supports polyarticular sepsis 22% of the time [6]. Pyarthrosis has also been reported within the ankle [7,8], metatarsal-phalangeal joints [9], and interphalangeal joints [10]. The presence of joint sepsis in the subtalar joint is extremely rare, as only two other cases have been recorded in the medical literature [5,11]. To the authors’ knowledge, the case presented is the only polyarticular septic arthritis report in which arthroscopic methods were utilized in successful treatment of the subtalar joint.

Case Study

A 68-year-old female presented to the author’s clinic, in May 2016, for evaluation of a tender and swollen left foot and ankle. She reported 9 days prior to arrival, while living in her retirement home in Florida, she suffered a severe and sudden amount of pain to her left foot and ankle while attempting to stand. As a result of the pain, she then fell to the ground. She denied a history of trauma as the inciting event, as the pain occurred prior to her fall. Due to her inability to bear weight, the patient presented to an urgent care clinic, in which radiographs were noted to be negative for fracture. She was placed in a supportive ankle brace and was given non-steroidal anti-inflammatories. She states over the next several days it was difficult to bear weight while her ankle became more edematous. She states she was concerned about her condition and elected to drive back to her permanent residence. Seven days following her first episode of pain she stopped en route to Michigan at a major university hospital in Ohio due to increased pain during her travels. Standard repeat ankle radiographs were negative and she was started on an oral methylprednisolone course. A venous Doppler was negative for deep venous thrombosis.

Upon arrival in the office, the patient was non-diaphoretic, afebrile and in pain. Her past medical history was pertinent for rheumatoid arthritis, treated with bi-weekly injections of adalimumab. Physical examination revealed a mildly edematous foot and ankle, without calor or erythema. Neurovascular status was intact. Range of motion to her ankle and midtarsal joints was severely painful and limited. There was diffuse tenderness of her entire foot and ankle, with maximum tenderness to her lateral foot and posterior ankle. As a result, a lower extremity magnetic resonance image (MRI) was ordered for the patient.

Two days after her MRI, she reported a dramatic increase in pain and presented to her closest emergency department. The patient was afebrile, and her vitals and lab markers revealed no findings of sepsis or leukocytosis. The emergency department physicians’ primary differential diagnosis was continued pain due to ankle sprain. She was discharged from the hospital and was sent directly to our office again as the MRI report was still pending. Upon review of the MRI the radiologist was unable to determine if the large joint effusions were infectious or aseptic due to lack of contrast in the imaging study (Figure 1). There were joint effusions and reactive synovium noted at the ankle, as well as the subtalar joint, with a large expansion noted at the posterior recess (Figure 2). As a result, a joint aspiration was performed from the anterior aspect of the ankle joint. Greater than 3 cc of yellow purulent material was aspirated and the patient was directly admitted to the hospital upon findings of a septic joint. 

Figure 1 Axial MRI T2 weighted image displaying posterior abscess.

Figure 2 Sagittal MRI image which displays reactive bone marrow edema consistent with early osteomyelitis, large posterior fluid collection adjacent to subtalar and ankle joint consistent with abscess.

Upon arrival at the hospital, broad spectrum antibiotics were initiated with previous cultures pending. Infectious disease was consulted for management of antibiotics. Pertinent laboratory findings revealed a white blood count (WBC) of 9,300 WBC/mcL, a C-reactive protein (CRP) of 11.1 mg/L, and an erythrocyte sedimentation rate (ESR) of 47 mm/hr. Except for a small abrasion to her index finger two weeks prior, the patient did not have any other portals of infection. Blood cultures were taken upon presentation and were negative. Due to the patient’s immunosuppression on adalimumab, the medication was stopped indefinitely as this was thought to have predisposed the patient to the infection. She was taken to the operating room the next day for an arthroscopic debridement of the septic joints.

Initial Surgery

After general anesthesia was administered, a well-padded thigh tourniquet was placed. The ipsilateral thigh was placed in a thigh holder and the limb was held in a gravity dependent position. The limb was prepped, draped, and the tourniquet was inflated to 325 mmHg. The subtalar joint was first approached with aspiration to confirm the presence of joint sepsis in this location. An 18-gauge needle was placed on a leur-locked syringe, and the subtalar joint was first accessed for aspiration. The subtalar joint was approached from the sinus tarsi, upon which purulent fluid was aspirated (Figure 3). We traced the distal aspect of the fibula posteriorly, and the 18-gauge needle was placed from posterior to anterior just lateral to the Achilles tendon. Approximately 5 mL of purulent fluid was extracted from the posterior recess of the subtalar joint. Arthroscopic portals were then established, two to the lateral hindfoot at the level of the sinus tarsi, with a third at the posterior recess for an auxiliary suction portal. Upon initial evaluation, the joint was cloudy with purulent material. The joint had elements of infected synovium which was debrided. After establishing a view of the interosseous ligament, the debridement then continued from anterior to posterior and into the posterior facet. There was noted to be loose and degraded cartilage, which exposed the underlying subchondral bone. All loose material was debrided, and the subchondral bone was noted to be firm without obvious signs of infection. After a thorough debridement, 3 liters of fluid was used for irrigation until the joint fluid appeared translucent.

Attention was then directed to the ankle joint for arthroscopy. Anteromedial and anterolateral portals were established and a standard 21-point examination ensued. 

Figure 3 Subtalar joint aspiration with purulence; the accessory portal during arthroscopic irrigation and debridement placed in the same posterior recess.

The joint fluid was initially cloudy, with a lesser degree of loose bodies as the subtalar joint. The ankle cartilage was largely intact, and less irrigation was needed than the subtalar joint to establish a lucent joint and a clear picture with the arthroscopic equipment. Following the thorough irrigation, debridement, and removal of infected synovium, all equipment was removed from the ankle. The portals from the subtalar and ankle joints were left open to allow for joint decompressions and continue to drain.

On postoperative day one, the patient reported an immediate reduction in pain and no postoperative events recorded. The patient remained improved on post-operative day two as well. Culture results from the initial aspiration yielded a Methicillin-resistant Staphylococcus aureus (MRSA) pathogen which was sensitive to vancomycin. She reported a mild increase in pain on postoperative day three and as a result a repeat MRI was ordered with and without contrast to further scrutinize the septic joints. There was noted contrast enhancement of the synovium of the ankle and subtalar joints was noted with joint effusion, with new findings of marrow edema and contrast enhancement of the joint surfaces of the subtalar and ankle joints indicative of acute osteomyelitis. Following a lengthy discussion with the patient regarding possible limb salvage potential with a conversation regarding further arthroscopic versus an open approach, the patient agreed to a second arthroscopic approach to her ankle and subtalar joints.

Second Surgery

The subtalar joint was again approached first with an attempted aspiration. No fluid or purulence was able to be extracted from the sinus tarsi nor the posterior recess of the joint. Arthroscopic equipment was re-introduced in the similar approach, with the posterior drainage portal established as well. There was continued loose cartilage and infected synovium, and an aggressive debridement was performed to the joint. Following copious irrigation, the equipment was removed and the ankle was inspected as well. The joint fluid remained relatively clear, and the cartilage was intact. Following an aggressive synovectomy and irrigation all instrumentation was removed. The portals were again left open to decompress the joint.

Recovery

The patient recovered well following the second arthroscopic procedure, and was prescribed a 6-week course of intravenous vancomycin. Two days following the second procedure, the patient was discharged home with a peripherally inserted central catheter (PICC) line for continued antibiotic administration. Inflammatory lab markers were followed on a weekly basis. Four weeks after discharge, her CRP and ESR normalized and did not re-elevate following her course of antibiotics. Her skin incisions healed without complications by three weeks succeeding the second surgery.

The patient was gradually able to increase her weight bearing status, first with a fixed walking boot for 4 weeks following her hospitalization, and transitioning to an ankle brace thereafter. The patient was sent for extensive physical therapy to aid in her recovery back to full weight bearing. She was eventually able to forego any bracing or assistance 6 months following her hospitalizations with mild pain which was treated with oral NSAIDs. Upon most recent follow-up at fourteen months, she was able to return to all pre-injury activities. No continued signs of infection were noted on clinical exam.

Discussion

The subtalar joint is a highly complex articulation of the talus and calcaneus. There are usually three distinct facets (anterior, middle, posterior) which may differ in the context of a tarsal coalition. There is a degree of variability in the ligamentous contents and joint capsular attachments as well. Arthroscopic evaluation of the subtalar joint remains a lesser utilized procedure, likely due to the complexity of the joint and the relatively small surface area which may be difficult for an unfamiliar arthroscopist to visualize. 

To the authors’ knowledge, no other cases have been reported in the literature in the successful arthroscopic treatment of a septic subtalar joint. Two other cases were identified in the literature but utilized an open approach in combination with antibiotic therapy. A Danish report displayed an isolated septic subtalar joint caused by Neisseria gonorrhoeae [5]. A second, more recent case study depicted an open approach to an infection caused by Mycoplasma hominis [12]. In both cases the infection was rapidly identified, treated, and the patients recovered fully. In the present case, two major risk factors were identified which likely predisposed the patient to her septic joint: rheumatoid arthritis and concomitant immunosuppression therapy. Patients with RA are more likely to develop joint sepsis both due to the disease process itself and due to the immunosuppressive therapy that they receive. Dissimilar to the previous reports is the fact that the patient was successfully treated with an arthroscopic approach, which did not require an open method with antibiotics, to cure the infection.

A joint aspiration of a joint is considered the gold standard in diagnosis of a septic joint, and should be performed with a low threshold when pyarthrosis is considered as a differential diagnosis. Once the diagnosis has been confirmed, rapid initiation of antibiotics should be employed. Arthroscopic and open approaches are useful tools in the irrigation and debridement of the septic joint. Advantages are inherent to an arthroscopic versus open approach: decreased soft tissue damage, which may lead to a shorter hospital stay, possible overall faster patient recovery. Repeat open versus arthroscopic lavage and debridement may be required until the infection has been controlled. This especially holds true when there has been a delay in the diagnosis and initiation of antibiotics from time of initial presentation, such as the case presented.

Conclusion

Due to the proximity of the ankle and subtalar joint, which share a capsular connection, the authors advocate that the subtalar joint may be affected more commonly than previously thought when a septic ankle is encountered. Prognosis of a septic ankle shows probable infection of the subtalar joint, causing a septic subtalar joint. The pyarthrosis of the septic ankle can be polyarthritic [6]. The infection can spread from the septic ankle to the subtalar joint through the sinus tarsi, causing infection of the subtalar joint. Performing a procedure to prevent infection transmission through the sinus tarsi may hinder the ease of the infection to spread; the procedure would counteract the close proximity of the ankle and subtalar joints, preventing a monoarthritis diagnosis from developing into a polyarthritic case.

Given the case encountered, an arthroscopic approach may be beneficial over an open approach when a septic subtalar joint is encountered. An arthroscopic approach is less invasive, leading to a less cumbersome recovery and quicker recovery time for the patient. Arthroscopic aspiration of purulent fluid is more effective in comparison to an open approach. A late diagnosis of a septic subtalar joint is more effectively combated by an arthroscopic approach, as multiple open lavages and debridements are required to accomplish what could be completed by a single arthroscopic approach. Although the literature does not have copious studies regarding open irrigation vs. arthroscopic irrigation, when comparing both methods used during treatment of acute native knee septic arthritis, 71% of the open treatment group required repeat irrigation compared to 50% in the arthroscopic treatment group [12]. Lowered chance of repeated irrigation serves as an assuring factor that an arthroscopic approach would withhold the need of multiple joint irrigations, leading to a quickened overall patient recovery.

The septic subtalar joint cases described in the literature used a combination of an arthroscopic and open procedure to eradicate infection. This is the first described case of a 68-year-old patient with a septic ankle and subtalar joint that was successfully treated with an arthroscopic approach alone. Open procedures are not necessary for proper treatment of septic arthritis. An open procedure combined with antibiotic therapy will likely lead to a more arduous path for patient recovery. Although up to physician preference, research is spreading the belief that arthroscopic procedures are less invasive and more efficient for patient recovery.  

Acknowledgements: None

Funding Declaration: None

Conflict of Interest Declaration: None

References

  1. Kaandorp CJE, Dinant HJ, van de Laar MAFJ, Moens HJB, Prins APA, Dijkmans BAC. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997;56:470–475
  2. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis. 1999;58:214–219.
  3. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis 1999; 58:214–219.
  4. Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008;20(4):457-62.
  5. Wynes J, Harris IV W, Hadfield RA, Malay DS. Subtalar Joint Septic Arthritis in a Patient with Hypogammaglobulinemia. Journal Foot and Ankle Surgery 2013; 52:242-248.
  6. Dubost JJ, Fis I, Denis P, et al. Polyarticular septic arthritis. Medicine (Baltimore) 1993; 72:296–310.
  7. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis?. JAMA. 2007;297(13):1478-88.
  8. Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis 35:198–205, 1976.
  9. Velilla-Moliner J, Martinez-Burgui JA, Cobeta-Garcia JC, Fatahi-Bandpey ML. Podagra, is it always gout? Am J Emerg Med 22:320–321, 2004.
  10. Brower AC. Septic arthritis. Radiol Clin North Am 34:293–309, 1996.
  11. Larsen LS, Nielsen DC, Terslev L, Amris K. Infectious monoarthritis in the subtalar joint due to N. gonorrhoeae. Ugeskr Laeger 169:324–325, 2007.
  12. Johns, B P, et al. “Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee.” PubMed.gov, NCBI, 15 Mar. 2017, www.ncbi.nlm.nih.gov/pubmed/28291

Erythema nodosum in a quiescent phase of ulcerative colitis

by Kevin D. Driscoll DPM1, Mohammed K. Hassan DPM2*, Lawrence G. Karlock DPM FACFAS3, Chelsea Schwartz DO4

The Foot and Ankle Online Journal 12 (4): 4

Erythema nodosum is inflammation of subcutaneous fat tissue. It presents secondary to many etiologies such as infection, drugs, malignancy, and inflammatory bowel disease. We report a 28-year-old male, with a past medical history of ulcerative colitis, presenting with erythematous, warm, tender nodules and plaques on his anterior ankles and feet bilaterally. The initial thought was an infectious etiology, but the lesions did not resolve with multiple antibiotics. The lesions did significantly improve after one treatment of glucocorticoids. Erythema nodosum was the most likely diagnosis and can rarely present in the absence of an ulcerative colitis flare. 

Keywords: inflammation, erythema, nodules, pain, plaques

ISSN 1941-6806
doi: 10.3827/faoj.2018.1204.0004

1 – East Liverpool City Hospital, East Liverpool, OH PGY-2
2 – East Liverpool City Hospital, East Liverpool, OH PGY-3
3 – Attending physician, Austintown Podiatry Associates, Inc. Austintown, OH
4 – Resident physician, Christ Hospital, Cincinnati, OH
* – Corresponding author: web4all@gmail.com


Erythema nodosum (EN) is the most common type of septal panniculitis, which is inflammation of subcutaneous fat tissue [1]. EN can be idiopathic or could be a sign of an underlying systemic disease such as infection, drugs, pregnancy, malignancy, and inflammatory conditions such as sarcoidosis and inflammatory bowel disease [2]. Clinically, EN presents as tender, erythematous, subcutaneous nodules that are usually located bilaterally on the anterior surface of the lower extremities. As stated previously, EN can be a manifestation of IBD such as ulcerative colitis (UC). UC is an inflammatory disease usually involving the rectum and may extend continuously to the more proximal colon. UC clinically presents with fever, fatigue, abdominal cramping, abdominal pain, diarrhea, hematochezia, and weight loss [4,5]. EN is the most common dermatological manifestation of IBD, occurring in 3-10% of patients with ulcerative colitis. EN usually resolves on its own without any scarring or ulceration [5].

Case Report 

A 28-year-old Caucasian male presented to the emergency department for ongoing, bilateral lower extremity pain, swelling, and discoloration for three weeks duration. His past medical history was only significant for ulcerative colitis. The patient stated that he presented to an ED three weeks prior to this visit for a deep tissue abscess on his posterior left thigh, which was unable to be drained. He was prescribed ciprofloxacin. He denied any relief of his symptoms and stopped taking the antibiotic. He followed up with his primary care physician and was diagnosed with cellulitis and prescribed doxycycline. His leg pain and swelling continued to worsen.  In the ED, the patient admitted to fever, chills, fatigue, weakness, joint stiffness and swelling, but denied abdominal pain, change in bowel habits, and all other review systems. The patient also reported he has not had an ulcerative colitis flare over the past year. On exam, erythema, swelling, and warmth surrounding his ankles bilaterally was noted . Labs and imaging were obtained and remarkable for a WBC elevated at 18.5, platelets elevated at 609, alkaline phosphatase elevated at 132, erythrocyte sedimentation rate (ESR) elevated at 88, and C-reactive protein (CRP) elevated at 13.2. All other labs were within normal limits. An x-ray of his ankles was remarkable for diffuse bilateral soft tissue swelling. The patient was admitted and started on Ancef and Dilaudid. 

Upon admission, the patient’s vitals were as follows, temperature 99.8F, pulse 120, respirations 16, blood pressure 107/59, and pulse oximetry of 95 on room air. The patient’s condition continued to worsen and he did not respond to Ancef clinically. He reported his bilateral swelling, erythema, ecchymosis, and warmth of his lower extremities continued to worsen and there were areas of erythema that were not noted the day prior (Figure 1). He was unable to bear weight secondary to pain. At this time, he continued to deny fever, chills, trauma, and all other review of systems. On exam, there were tender, firm, erythematous nodules on the dorsal aspect of his feet and tender, firm, erythematous and violaceous plaques on his anterior, inferior lower legs and ankles bilaterally (Figure 2). Lower extremity edema and 1+ pulses were also noted. His prior abscess on the posterior left thigh was resolved. His WBC count decreased from 18.5 to 13.5, platelets decreased from 606 to 506, but his ESR and CRP increased from 88 to 90 and 13.2 to 15.5. Rheumatoid factor and ANA were within normal limits. Blood culture was negative for any bacterial growth. The patient had a lower extremity venous duplex scan that was negative for DVT. Chest CTA was unremarkable for a pulmonary embolism. Bilateral lower extremity MRI was only remarkable for diffuse edema. The patient continued to receive Ancef and Dilaudid. 

Figure 1 Left foot showing swelling, erythema, ecchymosis.

Figure 2 Bilateral presentation of violaceous plaques.

The patient’s symptoms were then thought to be inflammatory versus infectious in etiology. Erythema nodosum was made as the presumptive diagnosis secondary to the patient’s clinical presentation, elevation of ESR and CRP, history of ulcerative colitis, and lack of response to antibiotics. He was prescribed a Medrol dose pack. Following the start of methylprednisolone, the patient reported that overnight his swelling, ecchymosis, and erythema improved significantly. His ESR decreased from 90 to 32. The patient was discharged home and encouraged to keep his legs elevated and to continue the Medrol dose pack and Keflex.

Discussion

Erythema nodosum is a form of panniculitis, inflammation of subcutaneous fat tissue. Most cases occur between the ages of 20 and 45 and are 3 to 6 times more common in women than men [6]. EN is a delayed-hypersensitivity reaction and is thought to result from the formation of immune complexes and their deposition in venules of the subcutaneous fat. Histopathologically, neutrophilic inflammatory infiltrate involving the septa of the subcutaneous tissue has been noted along with a fourfold higher percentage of reactive oxygen intermediates produced by activated neutrophils.  Clinically, EN usually presents suddenly with symmetrical, tender, erythematous, warm, nodules and raised plaques commonly located on the anterior lower extremities. The nodules range from 1-5 cm, but can confluence in plaques. At first, the nodules are erythematous and raised. As EN progresses, the nodules become flat and violaceous then will exhibit a yellow green appearance. The nodules and plaques do not ulcerate and heal without atrophy and scarring. Flu-like symptoms such as fever, fatigue, malaise, and arthralgias are sometimes associated. The eruption usually lasts 3-6 weeks [7]. Treatment options for EN are aspirin, NSAIDs, potassium iodide, steroids, and colchicine [8]. 

Erythema nodosum is the most common dermatological manifestation presenting in patients with ulcerative colitis. Patients with irritable bowel disease present with multiple extra-intestinal manifestations with skin being the most common organ affected. The pathogenesis between IBD and extra-intestinal manifestations are hypothesized to result from the abnormal T-cell response ongoing in IBD disrupting the intestinal homeostasis triggering chronic inflammation and excessive secretion of cytokines resulting in further immune dysregulation in other parts of the body [7]. 

Erythema nodosum usually parallels with the intestinal disease and resolves with treatment of the underlying IBD. EN rarely precedes the onset of IBD or rarely occurs during quiescent phases of IBD [3]. Our patient showed no evidence of an ulcerative colitis flare or underlying infection due to the lack of clinical response to the multiple antibiotics given and negative blood cultures. He continuously denied abdominal pain and change in bowel habits. Therefore, the presentation of what we think is EN presented in the unlikely presentation of either preceding an upcoming UC flare or during a quiescent stage. 

One of the limitations in this case is a biopsy was not performed, which is the only way to make a definitive diagnosis of EN. The presumptive diagnosis of EN was primarily made on clinical presentation of firm, erythematous, tender, warm, nodules and plaques on the patient’s anterior shins, ankles, and feet. Also, the patient’s history of ulcerative colitis, the lack of response to antibiotics, and the rapid response and relief of symptoms following the administration of methylprednisolone. It is also important to mention some other possible diagnoses such as Behcet’s, acute urticaria, erysipelas, erythema induratum, and superficial thrombophlebitis since a biopsy was not performed [8]. 

References

  1. Schwartz RA, Nervi SJ. Erythema Nodosum: A Sign of Systemic Disease American Family Physician. 2007; 75(5): 695-700. 
  2. Kroshinksy D. Erythema nodosum. In: UpToDate, Callen J (Ed), UpToDate, Waltham, MA (Accessed on October 31, 2018)
  3. Peppercorn MA, Cheifetz AS. Dermatologic and ocular manifestations of inflammatory bowel disease. In: UpToDate, Rutgeerts P (Ed), UpToDate, Waltham, MA (Accessed on October 31, 2018)
  4. Ulcerative Colitis. American Society of Colon and Rectal Surgeons website https://www.fascrs.org/patients/disease-condition/ulcerative-colitis Accessed November 1, 2018
  5. Peppercorn MA, Kane SV. Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. In: UpToDate, Rutgeets P (Ed), UpToDate, Waltham, MA (Accessed on October 31, 2018)
  6. Oakley A. Erythema nodosum. DermNet NZ website https://www.dermnetnz.org/topics/erythema-nodosum/. 1997. Accessed October 31, 2018
  7. Requena L, Requena C. Erythema nodosum. Dermatology Online Journal. 2002, 8(1):4.
  8. Erythema Nodosum- Differential Diagnosis and Treatment. Lecturio. website https://www.lecturio.com/magazine/erythema-nodosum/ Updated July 2, 2018. Accessed on November 19, 2018.

Papillary endothelial hyperplasia (Masson’s lesion) of the toe: A case report

by Nicholas Thompson DPM, C.Ped1*, Michael Casteel DPM2, Lawrence DiDomenico DPM, FACFAS

The Foot and Ankle Online Journal 12 (4): 3

A unique case of papillary endothelial hyperplasia (Masson’s Lesion) detected on the fifth toe is presented. Angiosarcomas may initially present with similar pathologic features, so early identification of a suspicious vascular lesion is paramount in determining if aggressive treatment is necessary.

Keywords: Masson’s lesion, tumor, papillary endothelial hyperplasia, angiosarcoma

ISSN 1941-6806
doi: 10.3827/faoj.2018.1204.0003

1 – Resident at East Liverpool City Hospital, East Liverpool, OH
2 – The Villages Health, The Villages, FL
3 – Director of Reconstructive Rearfoot and Ankle Surgical Fellowship and Residency Training, East Liverpool City Hospital, East Liverpool, OH
* – Corresponding author: NTYoungstown@gmail.com


Papillary endothelial hyperplasia was first described as a neoplasm by Pierre Masson in 1923, which he called a ‘hemangioendotheliome vegetant intravasculaire’ [1]. Masson’s tumor, lesion, or hemangioma represents a proliferation to the cells of the endothelium into the lumen of the vessel leading to a subsequent obstruction. Several vascular pathologies have been linked to the development of intravascular papillary endothelial hyperplasias, such pyogenic granulomas, lymphangiomas, and hemangiomas [2,3,4]. Multiple reports of these lesions occurring in internal organs exist; such as the liver, kidney, and brain [5,6,7]. They have been reported in similar musculoskeletal sources such as the finger, ankle, and dorsum of the foot, with no prior documented descriptions occurring in the digits of the foot [8,9,10]. These lesions have been found to occur nearly twice as often in females and are typically small, measuring 0.2-2.0cm in diameter, with sharp demarcation and slight cutaneous elevation [11].

The diagnosis cannot be made by clinical evaluation alone, and requires histological evaluation to rule out neoplastic qualities such as invasive growth past the vessel walls. 

Case Report

A 75-year-old Caucasian female reported to clinic with complaints of “aching pain” in her right foot, fifth digit, for 6 months duration. She denied smoking or drinking alcohol and her medical history was significant for hypertension, hyperlipidemia, and gastro-esophageal reflux disease. The patient had no history of recent trauma to the foot or clotting disorders. On clinical examination, a small (0.4×0.4cm) hemorrhagic blister with cyanotic discoloration was noted to the medial aspect of the right fifth toe. Initially perceived as a simple friction blister, the lesion was lanced with a #27-gauge needle with several small droplets of blood expressed. The patient was instructed to follow-up should the pain persist for a biopsy of the lesion. 

Figure 1 Lesion at second appointment, prior to biopsy, with centralized eschar from drainage attempt on prior visit. 

She returned in one month with complaints of residual discomfort, at which time the digit was anesthetized and a 4mm punch biopsy was utilized to extract the lesion in toto. The specimen was sent for histopathology in formalin. The patient tolerated the procedure well, with the biopsy site allowed to heal by secondary intention. The patient performed her own daily dressing changes with triple antibiotic ointment and a band-aid until closed, and no additional treatment was performed following the pathology report of a benign Masson’s Lesion. At two months after the procedure, the patient was feeling well with no signs of recurrence. 

Figure 2 Cross-section with associated hyperplasia of endothelial wall into the venous lumen.

Pathologic Examination

Gross description of the specimen was described; “1 punch biopsy of skin measuring 0.4 x 0.4 x 0.3cm and 1 piece of red-brown tissue measuring 0.4 x 0.3 x 0.1cm.” The pathology report diagnosed the biopsied tissue as a “Dilated vein with thrombus and papillary endothelial hyperplasia (Masson’s Lesion).” The report also noted, “No staining of lesional nuclei is present with an immunohistochemical marker for HHV-8,” indicating that the lesion was not a Kaposi’s sarcoma-associated herpes virus [12]. 

Discussion

Masson’s lesions are formed in a process of vascular hyperplasia. It is induced by thrombosis and inflammation, which is considered a reactive process of endothelial cells. Thrombus formation is a pathologic process routinely associated with this occurrence, as was the case in this patient. The development of a thrombus that leads to this lesion can be linked to trauma. Not to be excluded is the consideration that the previous attempt at drainage of this sanguineous bulla, albeit with a 27 gauge needle, may have contributed in formation of this lesion. Not all Masson’s lesions show a clear contribution from vascular pathology or thrombus formation; however, multiple variables such as blood pressure and cholesterol can influence the vascular system, and thrombi may dislodge and disappear over time. 

In this case, there was no history of direct trauma to this patient’s toe. However, vascular pathology may have resulted with contribution of hypertension on the microvasculature as well as the constant inherent pressure occurring inter-digitally. 

Conclusion

While this lesion was ultimately benign in nature, the decision to biopsy and confirm diagnosis should always be pursued if any question for advanced disease process is suspected. Fortunately, this diagnosis allowed both the patient and physician piece of mind with no additional intervention necessary. This example of a digital Masson Lesion may provide the physician with an additional differential diagnosis for a suspicious vascular-cutaneous lesion of a toe. 

References

  1. Masson P. Hemangioendotheliome vegetant intravasculaire. Bull Soc Anat Paris 1923; 93: 517-23.
  2. Inalöz HS, Patel G, Knight AG. Recurrent intravascular papillary endothelial hyperplasia developing from a pyogenic granuloma. J Eur Acad Dermatol Venereol. 2001;15:156–8.
  3. Takayama A, Nakashima O, Kobayashi K, Kojiro M. Splenic lymphangioma with papillary endothelial proliferation: a case report and review of the literature. Pathol Int. 2003;53:483–488.
  4. Tanio S, Okamoto A, Majbauddin A, Sonoda M, Kodani I, Doi R, et al. Intravascular papillary endothelial hyperplasia associated with hemangioma of the mandible: a rare case report. J Oral Maxillofac Surg Med Pathol 2016;28:55–60.
  5. Hong SG, Cho HM, Chin HM, et al. Intravascular papillary endothelial hyperplasia (Masson’s hemangioma) of the liver: a new hepatic lesion. J Korean Med Sci. 2004;19(2):305–308. 
  6. Essid MA, Bouzouita A, Blel A, et al. Masson’s tumor of the kidney: a case report. J Med Case Rep. 2018;12(1):376. Published 2018 Dec 22. 
  7. Lesley WS, Kupsky WJ, Guthikonda M. Intravascular papillary endothelial hyperplasia arising within a posteroinferior cerebellar artery aneurysm : case report and review of the literature. Neurosurgery. 2000;47:961–965. discussion 966.
  8. Erol O, Ozcakar L, Uygur F, Kecik A, Ozkaya O. Intravascular papillary endothelial hyperplasia in the finger: not a premier diagnosis. J Cutan Pathol 34:806–807, 2007.
  9. Znati K, Daoudi A, Chbani L, et al. Intravascular papillary endothelial hyperplasia of the ankle: a case report. In Annales de chirurgie plastique et esthetique 2009;54(6), 600-602.
  10. Serin, M, Altinel D, Leblebici C, et al. Intravascular Papillary Endothelial Hyperplasia of the Foot. The Journal of Foot and Ankle Surgery, 2018;57(1), 188-190.
  11. Kuo TT, Sayers CP, Rosai J. Masson’s “vegetant intravascular hemangioendothelioma”: a lesion often mistaken for angiosarcoma. Study of seventeen cases located in the skin and soft tissues. Cancer, 38: 1227- 1236, 1976.
  12. Ablashi DV, Chatlynne LG, Whitman Jr J. Spectrum of Kaposi’s sarcoma-associated herpesvirus, or human herpesvirus 8, diseases. Clinical microbiology reviews. 2002;15(3), 439-464.

Neurolysis, neurectomy, and grafting for chronic lower extremity pain following major rearfoot reconstruction

by Nathan Blanton1*, DPM, Phuoc Bui, DPM, Dominic Rizzo, DPM, FACFAS

The Foot and Ankle Online Journal 12 (4): 2

Chronic pain is something that any provider will see throughout their career, and it is very common following trauma and/or reconstructive surgery. Up until recently, there hasn’t seemed to be too many advances in treatment options for patients with chronic nerve pain, and who have had all other potential sources of pain ruled out. Unfortunately, a good number of patients either choose to deal with their pain day to day, or get passed onto pain clinics. Presented is a case report of a patient who had previous hindfoot reconstructive surgery and chronic lower extremity pain since surgery. The patient had diagnostic, in office, local anesthetic blocks applied around specific nerve courses. He reported improvement in his symptoms with these blocks. He then underwent surgical neurolysis and neurectomy of his superficial peroneal nerve and sural nerve, with significant subjective pain reduction post-operatively. 

Keywords: nerve decompression, neurolysis, neurectomy, nerve cap, nerve allograft

ISSN 1941-6806
doi: 10.3827/faoj.2018.1204.0002

1 – TriHealth Residency – Director of Research, American Microsurgical Orthoplastic Society Chairman, Cincinnati, Ohio
* – Corresponding author: nathan_blanton@trihealth.com


Pain following acute trauma or major reconstruction is prevalent. A 2008 study found that 62.7% of patients still complained of pain up to one year following trauma or injury. Seventy-three percent of patients with lower extremity trauma complained of continued ongoing pain up to 7 years following the incident [1].

Incidents of trauma, and equally traumatic major reconstructive surgery, are events that are common enough to the foot and ankle surgeon that the complications of such events cannot be ignored. Being able to handle these patients with efforts other than chronic pain medication is becoming equally important in our modern society. According to the CDC, in 2017 the number of overdose deaths involving opioids (including prescription and illegal opioids) was six times higher than it was in 1999 [2].  Opioid prescribing has quadrupled since 1999, and according to a 2016 study, most opioid related deaths involved prescribed medications such as oxycodone and hydrocodone [3]. 

Not only is chronic pain a threat to a patient’s quality of life, but there is data to suggest that it also has severe detrimental effects on the patient’s social and family environment, and well as on the health care services. Employing proper peripheral nerve surgical techniques may be beneficial to the patient, when other, more conservative methods have failed to reduce pain. Presented is a case review of one patient undergoing microscopic peripheral nerve surgery for the treatment of chronic lower extremity pain, following previous reconstructive rearfoot surgery.

Figure 1 The superficial peroneal nerve (SPN) emerging through the fascia to become superficial.

Figure 2 The nerve allograft sutured to the connector. 8-0 nylon suture was utilized; one on each side of the connector.

Methods

The patient was a 45-year-old male with a history of trauma to the right lower leg and ankle. He is now multiple years removed from tibiotalocalcaneal (TTC) fusion (via a strict lateral approach), with hindfoot rigidity and compensatory discomfort in the midfoot.  

Figure 3 Allograft with nerve connector sutured to the proximal stump of the SPN.

Figure 4 The multiple branches of the sural nerve course.

He was also still having pain in the region of his previous TTC surgery. Imaging modalities confirmed that the structural integrity of the bone and fusion site were fine, with an arthrodesis of the ankle and subtalar joint appreciated. In the office setting, the patient underwent regional blocks of the superficial peroneal nerve (SPN) and the sural nerve (SN), with subjective improvement in pain of more than 75%. The blocks were performed in the lower 1/3rd of the leg. Due to this improvement, and the chronicity of his pain, neurolytic and neurectomy procedures were decided upon for the SPN and SN. 

The patient was cleared for surgery by his primary care physician. Once in the operating room, he was placed on the table in the supine position with a bump placed under his right hip. After anesthesia was obtained, the left shoulder was tilted down some in order to better visualize the anterolateral and posterolateral lower leg. An anterolateral leg incision was created approximately 10 cm proximal to the ankle joint line. This incision was approximately 5 cm in length and it was further and carefully carried down to the level of the fascia. At approximately 10 cm to the ankle joint, the SPN was located piercing through the fascia where it becomes superficial (Figure 1). The SPN was carefully dissected away from surrounding soft tissue.  At a level just distal to the SPN becoming superficial, a fresh 15 blade was used to transect the nerve completely and cleanly. Literature indicates that at this level, the SPN is entirely sensory with motor branches having come off much more proximal [4]. Meanwhile, on the back table, an Axoguard nerve connector (Axogen, Inc. Alachua, Fl) was half way placed around and covered one end of an Avance allogenic nerve graft (Axogen, Inc.). The nerve graft and connector were sutured together with 8-0 nylon, while using 2.5x loupe magnification (Figure 2). This connector/graft structure was brought over to the operating table, and the other end of the nerve connector was attached in similar fashion as before to the freshly severed end of the proximal SPN stump; again using 8-0 nylon (Figure 3). 

The nerve allograft was allowed to lie in the normal plane of the SPN. The distal stump of the SPN had axonal degeneration performed via the “double crush” technique, which is discussed later.

The original incision was continued distally, and posteriorly, another few centimeters in a “lazy S” configuration to reach the approximate anatomical location of the distal sural nerve (SN). The incision was carefully deepened until the SN came into view. At this level, we identified two branches of the SN (Figure 4). These branches were traced proximally a few centimeters until one main branch of the SN was identified. Once the main SN branch was identified, a fresh 15 blade was used to transect the nerve cleanly. Again, the distal nerve stumps underwent a “double crush” technique. The proximal nerve end was covered with another nerve connector, and held in place with 8-0 nylon. The distal end of the connector was capped with a vascular clip and the nerve was allowed to lie in its normal plane. Neither the SPN nor SN was buried into muscle or bone.

The surgical area was irrigated. The adipose layer and the skin were closed. The deep fascial layer was not re-approximated with suture. 20 mL of bupivacaine plain was injected around the surgical site and the patient was placed in a soft but compressive dressing.

Results

The patient has been followed for 12 months at the time of this writing. At his first postoperative visit week one, he relates that his subjective pain to lower leg and lateral ankle was already 50% better. At his most recent follow-up visit, he relates that his musculoskeletal pain overall is significantly reduced by about 70%. In some areas of the leg and ankle, he feels his pain is reduced by up to 90%. He does not relate having any irregular sensitivities or paresthesias. Most of his relief is located around the distal lateral leg, lateral foot and ankle, with some elements of the dorsolateral foot. Overall, he relates that he is very happy and pleased with his progress. He states that he has actually been much more physically active in light of the denervation procedure.

Discussion

Described here is a case of one patient with intractable lower leg and ankle pain following trauma with subsequent hindfoot reconstruction. The patient’s pain was subjectively improved with surgical intervention to the SN and SPN. This is an important subject matter for those patients with post-traumatic/surgical pain. A 2008 study indicated that nearly 63% of patients still have pain averaging 5.5 on a 10 point scale at one year following the trauma [1].

The concept of neurolysis of peripheral nerves received very little attention in the literature until 1970 [5]. In regards to the foot and ankle, a common and historically accepted treatment of peripheral neuromas was complete transaction of the nerve with possible implantation into surrounding tissue. This treatment does not address the terminal end of the nerve. More recent techniques for the management of neuromas have been developed over the past several years. The decision as to which technique may be best is often decided by how available the terminal nerve end is for reconstruction. These techniques include: centro-central connector assisted neurorrhaphy, nerve capping, nerve graft relocation, hollow tube reconstruction, “end-to-side” neurorrhaphy [6] and some others. The ones presented in this case are nerve capping and nerve graft relocation. Both of these techniques are passive in nature, in that we did not directly reconstruct the nerve end.

The nerve graft relocation technique, for the SPN, is designed to provide a runway for any regenerating nerve. The intent is for the allograft to become a less painful destination for the axons to grow into. The regenerating axons will work their way into the organized graft, which is size matched (in diameter) to the nerve of interest. The allograft nerve also will need to be several centimeters in length to allow for any axonal growth to dissipate. This technique allows for regeneration but does not necessarily restore function [6]. The hollow nerve connector keeps any regenerating axons in their path to the nerve allograft. Leaving a gap of a couple millimeters between the proximal nerve end and the allograft nerve end is recommended to prevent a “mushroom” effect of new axons directly up against the allograft, which could ultimately produce a new stump neuroma. Also of note, the allograft nerve end was not implanted into muscle or bone. It was left in line along the course of the SPN. In the lower third of the leg, there are more tendons than large muscle bellies, so it would be difficult to bury it effectively. But, the other thought is to limit motion of the nerve end as much as possible anyways, to prevent the likelihood of a stump neuroma reforming.

In regard to the SN, the nerve capping technique has been shown to have some promising results [7]. Again, the capping technique is passive and does not reconstruct the nerve, but rather reigns in the terminal end of the nerve [6]. As of now, there is not enough data to suggest one technique over another. More studies need to be done comparing the results of each technique. In this case, multiple methods were chosen. It is possible that if one procedure was performed at each nerve site, maybe the patient would have more or less pain resolution. However, for now this is difficult to determine. 

Passive techniques were decided upon for this patient, due to the location of his pain symptoms. Since the neurectomy for the SPN and SN were performed so low on the leg, it would have been difficult to reconstruct the nerve distally after resection of the neuromas. Any further distal, and the nerves become too thin and wispy to handle with care. Also, it becomes more difficult to suture the connector, or end cap, through just the epineurium, which is the recommended layer for peripheral nerve repair [8].

The “double axonal crush” technique is one that was described by Bridge, et al., 1994. The technique involves using two hemostats and placing them at the stump of the transected nerve, approximately 1 cm apart. The nerve is crushed when each hemostat is closed down to one “click” and held in that position for approximately 30-60 seconds.  This crush technique causes impairment of the fascicles of the axon, causing axonotmesis. From this, sensory function should be lost over time due to Wallerian degeneration [9,10].

In the procedure, the SPN and SN were strategically located and transected. First, it has been shown that the motor branches of the SPN have already separated off at a much more proximal level than where this procedure took place [4]. Also, it has been shown that in over 70% of patients, the SPN will pierce the crural fascia and become superficial at approximately 10-12 cm proximal to the ankle joint. At approximately 4.4 cm proximal to the ankle joint, the medial and intermediate dorsal cutaneous nerves (MDCN and IDCN) will divide the SPN. One must be careful however, because there can be instances where the MDCN and IDCN are separated much higher [11]. It is important to look out for this, and possibly identify both branches if necessary. 

In regards to the SN, it was interesting to see multiple branches at this level. Historical variations have been described by Huelke in 1958. In his original paper, he dissected out the SN and its components on 198 limbs. From this he deduced eight different possible configurations for SN development. One of these variations involved the medial sural cutaneous nerve (MSCN) and lateral sural cutaneous nerve (LSCN) coursing distally and independently of one another. The MSCN continues onto the posterior heel, while the LSCN will continue on as the lateral dorsal cutaneous nerve of the foot.  Just proximal to the posterior ankle joint, there is a peroneal communicating nerve, connecting the MSCN and LSCN [12]. It is possible that in the case presented here, we found one cutaneous branch, the communicating branch, but not the other cutaneous branch. Unfortunately, as of now, there is no method, which we have found, to identify which SN variation a patient will have prior to surgery. Also, while in surgery, you want to minimize as much exploration and dissection as much as possible. A possible reason as to why this patient is still having some residual pain (although subjectively much less) is that the SN had another branch that was not located, cleanly transected, and capped. 

There are several limitations here. The first limitation being that this is only one case performed by one surgeon. A higher patient population would be better to see if these subjective results are reproducible. Also, there is no statistical analysis performed. If more patients are studied in the future, it would be beneficial to perform Visual Analog Scores pre-operatively, and at standardized time intervals post-operatively. Finally, the purpose of the surgical technique is to limit possible generation of stump neuromas. Post-operative EMG and NCV tests may be beneficial in that determination. More studies about these peripheral nerve techniques, and a comparison of the outcomes following each technique are needed. 

Conclusion

This was one case where a patient undergoing peripheral nerve surgery had subjective improvement in his chronic lower extremity pain. More research needs to be performed on the long term outcomes of these patients, as well as understanding if any one technique has better outcomes than the others. There seems to be an increased interest in microscopic nerve surgery in recent years. With this spike in interest, there should also hopefully be an increase in our understanding of chronic pain in the extremities and what we can do surgically to improve the quality of life for these patients.

References

  1. Rivara FP, Mackenzie EJ, Jurkovich GJ, Nathens AB, Wang J, Scharfstein DO. Prevalence of pain in patients 1 year after major trauma. Arch Surg. 2008;143(3):282-7.
  2. https://www.cdc.gov/drugoverdose/opioids/prescribed.html
  3. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths–United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-82.
  4. Ribak S, Fonseca JR, Tietzmann A, Gama SA, Hirata HH. The Anatomy and Morphology of the Superficial Peroneal Nerve. J Reconstr Microsurg. 2016;32(4):271-5.
  5. Brown HA. Internal neurolysis in the treatment of peripheral nerve injuries. Clin Neurosurg. 1970;17:99-110.
  6. Eberlin KR, Ducic I. Surgical Algorithm for Neuroma Management: A Changing Treatment Paradigm. Plast Reconstr Surg Glob Open. 2018;6(10):e1952.
  7. Yan H, Zhang F, Kolkin J, Wang C, Xia Z, Fan C. Mechanisms of nerve capping technique in prevention of painful neuroma formation. PLoS ONE. 2014;9(4):e93973.
  8. Griffin, M M, S H, Khan WS. Peripheral nerve injury: principles for repair and regeneration. Open Orthop J. 2014;8:199-203.
  9. Bridge PM, Ball DJ, Mackinnon SE, et al. Nerve crush injuries–a model for axonotmesis. Exp Neurol. 1994;127(2):284-90.
  10. Hoeft D, Spingola HD,  Rodriguez-Collazo E. Double Axonal Crush, Transection, and Implantation of Deep Peroneal Nerve for Intractable Pain. International Journal of Orthoplastic Surgery. 2(1)
  11. Blair JM, Botte MJ. Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin Orthop Relat Res. 1994;(305):229-38.
  12. Huelke DF. The origin of the peroneal communicating nerve in adult man. Anat Rec. 1958;132(1):81-92.