Foot and Ankle in 2016 – The Big Questions!

Vol 1 | Issue 1 |  July – Dec 2016 | Page 42-44 | Abhishek Kini

Authors: Abhishek Kini [1].

[1] Foot and ankle reconstructive surgeon, Sportsmed Mumbai., India.

Address of Correspondence
Dr.Abhishek Kini,
Foot and ankle reconstructive surgeon,
Sportsmed Mumbai. , India

Some of the major questions in surgery have never been answered. While the push for evidence-based medicine is clearly a strong and well reasoned one for some interventions, perhaps the answer is self-evident – in the same way that parachutes will never be subjected to a randomized controlled trial, neither will chest drains for tension pneumothoraces. Somewhere beneath these self-evident truisms, however, lie accepted interventions (such as TKA and ACL reconstruction) that don’t always stand up to evaluation in a randomized control trial setting. In an era where nanotechnology is touching our lives and the Tata nano is hitting our roads, the “nano” or minimally invasive surgery (MIS) is coming in vogue.

Does MIS have a role in ankle fixation?
Minimally invasive surgery (MIS) has a number of potential clinical, cosmetic (and even financial) advantages – on paper at least! The majority of readers will remember the fashion for mini-hip, followed
by ‘mini-knee’, so given the lack of advantage these passing surgical fads have shown (and some have even been discredited due to higher complication rates), it is with some trepidation that we should approach this paper from Taipei, a retrospective comparative series of mini versus open reduction and internal fixation
for unstable ankle fractures [1]. The authors make a reasonable comment that in the face of higher infection rates and compromised soft tissues, there is perhaps an argument for minimally invasive surgery. The surgical teams undertook a retrospective study of 71 patients, all with 44-B type fractures. Whilst there is no argument that MIS is more complicated than the open approach, there is still very much debate about the relative benefits of each approach. MIS is not as easy to perform as open surgery – there is a learning curve, and special equipment is needed. The authors report essentially no differences in any of the outcome measures other than lower wound complication rates in the MIS group. This paper certainly supports the concept of MIS surgery in ankle fractures to reduce complication rates, however, in the face of other, better studies (such as the randomised controlled trials from Edinburgh reporting the fibular nail), a prospective randomised controlled trial would really be needed here to prove any kind of superiority. One of the most common procedures done in adult foot and ankle reconstruction in our setting is a subtalar fusion, the gold standard procedure for varying reasons from primary inflammatory arthritis to secondary post traumatic arthrosis. The pendulum has significantly shifted towards MIS by arthroscopic assisted subtalar fusion, especially in minimally deformed hindfoot, but the debate persists on.

One screw a screw too few..?
Achieving a stable fixation during arthrodesis is the key to reducing complications including metal-work fatigue and nonunion. The compression screw has long been the most reliable fixation in arthrodesis, although there are a variety of screw configurations around, all of which have their
potential advantages
in either surgical
access, achieving
compression or
stability. Researchers from Western Michigan University undertook a
biomechanical study
using a surrogate
bone model of the
subtalar joint [2]. They
tested three potential constructs – a single posterior screw, two minimally divergent posterior screws, and a highly divergent screw construct. The stability of the constructs was tested using a servo-hydrolic testing apparatus. As perhaps could be predicted, the two divergent screws offered significantly higher torsional stability over either of the other constructs. While this in itself is not surprising, it is important to add a slight note of caution: divergent screws by their nature do not increase the compression with the addition of the second screw and, as such, care should be taken in placement of the initial screw specifically to ensure that as much compression as possible is achieved prior to placement of the second screw, to ensure effective fusion. The Achilles tendon has brought the downfall of mighty warriors in battlefield as well as it brings agony and downfall of mighty surgeons (warriors) in their operation theatres (battlefield). This Trojan war on Achilles tendon is fought on.

Cast versus early weight bearing following Achilles tendon repair ..
The treatment of the Achilles tendon continues to vex many trauma and foot and ankle surgeons. Not only is the decision to operate fraught with difficulty, but the choice of rehabilitation regime is far from clear. To make matters worse, although there are some short-term studies, there are no longer-term randomized controlled trials on which to base these decisions. Researchers in Finland report the ten-year outcomes of their randomized controlled trial comparing cast immobilization with a restricted motion brace allowing neutral plantar flexion and early weight bearing [3]. At a mean of 11 years following treatment, there were no differences in their primary outcome measure of the Leppilahti score at final follow-up (92.2 vs 93.6) and no differences in secondary outcomes including plantar flexion peak torques, or angular velocity measurements. Interestingly, there were differences in peak torque
and isokinetic strength which were maintained between one and 11 years compared with the contralateral side, however, it is arguable whether or not these differences are clinically significant, given the impressively normal functional scores. The same research team reports their study of 60 patients, all presenting with an acute Achilles tendon rupture managed over a three-year period [4]. At 14 years of follow-up, 55 patients were available for review. All patients were managed with a similar splinting protocol as their rehabilitation, with the only difference being that 28 patients received a simple end-to-end suture repair while 27 patients received a fascial flap-augmented repair. The research team reported myriad outcomes including the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey. The bottom line is that the end-to-end repair group performed better at final follow-up. There were no differences in re-rupture rates and the augmented group had poorer calf muscle deficit that persisted right through to final follow-up. Hence giving us clear indications for not augmenting our Achilles tendon repairs.  Another major controversy in foot is management is the naïve looking but grossly disabling Lisfranc’s injury. The question is whether to Primarily fuse or ORIF the second tarsometatarsal joint in the context of severe trauma?  The Lisfranc joint has been the cause of some head scratching over the past few years. Ever since the publication of a randomized controlled trial suggesting fusion was superior to fixation, this has become an ongoing debate. The anxiety for the operating surgeon, especially in treating younger, higher demand patients, is whether a primary fusion or ORIF. By definition, fusion limits the functional capability of the foot in the future, due to either loss of
the joint or the inherent shortening that always occurs. Hence there is general hesitance to fuse joints in the younger population and a tendency to try and preserve motion by joint reconstruction in the index surgery. A paper from Hospital for Special Surgery, New York, has some significant value in this perspective [5]. It does present the return to function data for a mixed group of purely ligamentous and mixed osseoligamentous injuries after primary fusion at index surgery. The study has a retrospective design and utilized patient reported activity level questionnaires, and concludes participation in sports as equivalent to pre-injury in 64% and reduced in 25% of patients. This was a mixed group of partial fusions, including single column or all three. The activities referred to included impact sports, and relied on patient declaration to record the premorbid activity levels. It is reasonable to advise patients contemplating a primary fusion that on average just over half of patients make a full return to sporting activity following this kind of surgery. There was a higher risk of metalwork removal in the ORIF group, although this is not surprising as many surgeons routinely remove metal- work inserted for ORIF but do not for a fusion. Clearly there is still some way to go to narrow the evidence gap in Lisfranc injuries, and we are still waiting for the ‘definitive study’ to inform practice. However, for the time being these functional data do reassure all involved in their care that these patients may be successfully treated with a fusion, and that the long-term results are not as bad as one might think. It appears that in spite of a single study favoring fusion, there is little in the way of evidence to support the suggestion that fusion outdoes ORIF and that for the moment at least, the two methods appear to be equivocal and ‘dealers choice’. Questions, are a linguistic expressions used to make a request for information. As we look forward to the dawn of 2017, the horizon will come up with newer questions which will paint / reflect on our sea of knowledge a better picture for better understanding and betterment of services of foot and ankle reconstruction.


1. Chiang CC, Tzeng YH, Lin CC, Huang CK, Chang MC. Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures. Foot Ankle Int. 2016 Jun;37(6):611-9.
2. Jastifer JR, Alrafeek S, Howard P, Gustafson PA, Coughlin MJ. Biomechanical Evaluation of Strength and Stiffness of Subtalar Joint Arthrodesis Screw Constructs. Foot Ankle Int. 2016 Apr;37(4):419-26.
3. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after Achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med. 2015 Sep;43(9):2302-9.
4. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14.
5. MacMahon A, Kim P, Levine DS, Burket J, Roberts MM et al. Return to Sports & Physical activities after Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients. Foot Ankle Int. 2016 Apr;37(4):355-62.

How to Cite this article: Kini  A. Foot and Ankle in 2016 – The Big Questions!. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):42-44.

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