evidence in foot and ankle surgery
TRANSCRIPT
Evidence in Foot and Ankle Surgery
Evidence in Foot and Ankle SurgeryDr Hitesh GopalanExpert Advisor, www.orthoevidence.comEditor, Orthopaedic Principleswww.orthopaedicprinciples.com
Advanced Clinical Evidence
Evidence in Foot and AnkleFoot and Ankle International(AOFAS)Foot and Ankle Surgery(British and European Society)JBJS- AmJBJS- British
Level 1 and level 2: 10%
Ankle Sprains
Grade 3 Ankle sprain:SurgeryVs No-Surgery
Pihlajamki et al.. JBJS A-201051 Finnish men
Grade 3 acute lateral ligament injuries
Intervention: Surgical repair followed by plaster cast for 6 weeks
Comparison: Functional rehab with aircast ankle brace
Level 1 RCT
14 years follow up
ResultsAll patients in both groups recovered to preinjury activity levelsRisk of reinjury: 1 out 15 in surgical group, 7/18 in non surgical groupOsteoarthritis: 4/15 in surgical group and 0/18 in non surgical group
Questions whether surgical treatment is necessary for grade 3 lateral ligament injuriesACE Score: 6/10
Plyometric training in Ankle SprainsIsmail MM 2010Population: 22 athletes with grade 1-2 inversion injuryIntervention: Plyometric trainingComparison: Resistive TrainingLevel 2 Randomised TrialTime: baseline and 6 weeks
Plyometric TrainingPeak torque of ankle evertors and invertors were sameOverall functional performance better in plyometric group
Plyometric training is good for acute injuries and may prove to be superior to resistance training in ankle injuries
ACE SCORE: 6/10
Sterility in Foot and Ankle Surgery
Preoperative foot bath
Ng AB , 2009Population: 44 patients, elective foot and ankle surgeryIntervention: Chlorhexidine+ I2 with foot bathComparison: I2 without foot bathOutcome: Bacterial culture taken prior, intra-op and post-op
Preoperative swabs: 100 % colonisationIntraop swab: 16 % colonisation in foot bath, 96% in comparisonPost op swab: no significant difference
Preoperative foot bath reduced intraoperative bacterial load
ACE SCORE: 6.5/10
Iodine Vs ChlorhexidineCheng K 2009 50 patients Forefoot preparationIntervention: Iodine +/- isopropyl alcoholComparison: Chlorhexidine +/- isopropyl alcoholOutcome: Swabs after applying solutionEqual resultsScrubbing does not prove to be advantageous
ACE Score: 7.5/10
Toes: Cover or notGoucher NR et al..2007Population: 40 patients ankle and foot surgeryIntervention: Surgery with toes coveredComparison: Not coveredOutcome: Cultures+ve cultures for 2 patients in both groups, but no signs of postoperative infectionNo difference when toes covered/uncovered
ACE Score: 6/10
Tendoachilles Rupture
Acute Tendoachilles tearsJiang et al..Int Orthop 2012
Analysis of 10 RCTs that compare surgical Vs Nonsurgical interventionCritical Appraisal: Modified Jaddad ScaleSoftware: RevMan 5.1 software894 patients
Surgical Vs NonsurgicalRe rupture: 4.3 Vs 9.71Complications: 26.6 Vs 7.91Early return to work in the operated group
Functional outcome could not be assessed
ACE: 10/10
Achilles Tendon Repair: Augment or not?Pajala A , 2009 60 patients Intervention: Augmented Repair with gasctrocnemius fascia flapComparison: Non augmented repairOutcome: Clinical measurements, Lepilahti score, isokinetic calf muscle performance testsFollow up: 12 monthsNo Significant differences
Achilles Tendinosis
Skin Derived FibroblastsObaid H et al..2012 32 patientsSkin derived fibroblasts suspended in autologous plasma: InterventionCompared with local anaesthesia aloneOutcomes: VISA and VAS scoresMean Visa scores improved from 34 to 75 in 6 month periodMaybe indicated in refractory cases
Ankle OA
Hyaluronic Acid in ankle OADeGroot H et al.. 65 patientsIntervention: noncross linked LMW HAComparison: Normal salineOutcome: AOFAS scores, AOS, VASFollow up: 12 weeksNo significant differencesHA not recommended for treating ankle OA
ACE: 8/10
Motion Distraction in ankle OASaltzman CL et al..201236 patients with ankle OA after anterior osteophyte removalIntervention: Distraction rods with hinges allowing joint motionComparison: Distraction rods without hingesOutcomes: AOS, PCS, SF-36Significant improvement in the joint motion groupACE: 7.5/10
Rh-PDGF for hindfoot fusionDi Giovanni 2011 20 patients requiring hindfoot fusionIntervention: rh-PDGF(Augment TM, Biomet)Compared with autologous bone graftOutcomes: Clinical and radiological parameters, AOFAS, FFI, SF-12, VAS77% union rate in the Augment synthetic groupSample size: smallNeeds large trialsACE: 6.5/10
Plantar Fasciitis
Shock waveWang CJ 2006 149 patientsIntervention: 1500 impulses of shock wave at 16kVComparison: NSAIDs, physical therapyOutcomes: 100 point scoring system, VAS
Follow up: 5- 6 years
Shock wave group: 69% excellent results, 13% good, 6.2 fair, 11% poor
Control: 0 excellent, 55% good, 36% fair, 9% poorNo systemic or local complications due to device
Shock wave is safe and effective in the long run
Autologous BloodLee TG, 2001 64 patientsIntervention: CorticosteroidComparison: Autologous BloodOutcomes: VAS, tenderness thresholdSignificant decrease in pain levels, but no differenceAutologous blood is a good alternative
Lisfranc injuriesLy TV 2006 41 patientsPrimary medial partial arthrodesis Vs primary ORIFAOFAS scores: 88 in arthrodesis group and 68.6 in ORIF groupPersistent pain in 5 patients in the ORIF group due to arthrosisPrimary arthrodesis was superior in ligamentous LisFranc injuries
Calcaneal Fractures
MetaanalysisNan Jiang 2012891 patientsSource: Published RCTs from pubmed, CochraneData Extraction: All RCTs involving displaced intraarticular fractures which compared surgical Vs nonoperative methods Revman 5.1 software
Surgical groupLess loss of calcaneal heightMore comfortable wearing shoesMore patients were able to return to preinjury level75/119 patients experienced residual pain77/338 developed complications
Non Surgical GroupSignificantly smaller Bohlers angleMore loss of calcaneal heightLess comfortable wearing shoes85/121 had residual pain53/328 developed complications
Calcaneal Intra-articular fracturesSurgical treatment may lead to better anatomical and functional outcome
Risk of complications
Anaesthesia
Intrarticular Lidocaine BlockBrian White, 200842 patients with ankle fracture dislocationsIntra-articular lidocaine block Vs SedationOutcomes: VASComparable pain scores, one failed reduction in sedation group Longer time to stabilisation in the sedation groupIntra-articular lidocaine should be offered to patients who are at risk for sedation
ACE score: 6/10
PRP for OCD TalusMei Dan- O 2012 32 patients with symptomatic OCD talusPRP: 3 injections over 4 week periodComparison: HA 3 injections over 2 week periodFollow up: 28 weeksOutcome: AHFS score, VAS, subjective function and disability
OCD Talus-PRPSignificant improvement in AHFS and VAS scores in the PRP group
PRP is safe and efficacious
RA forefoot
PLDLA for MTP joint SurgeryTiihonen R 2010 36 patients with refractory RAPLDLA MTP joint interposition arthroplastyCompared with conventional head resectionOutcomes: Functional assessment, VAS, AOFAS, gait ability and radiological assessmentFollow up: 3months and 12 monthsNo difference in scores
Hallux Valgus
Scarf Vs ChevronDeenik R 2007108 patientsScarf Vs ChevronOutcomes: AOFAS, hallux valgus scale, HV angle, IM angleFollow up: 27 months post surgery
Scarf Vs ChevronNo difference in outcomes
Complications were different:
Scarf: Type 1 CRPS -1 patient
Chevron: partial osteonecrosis of metatarsal head
Thank You