Abstract
The European Foot and Ankle Society meeting in Stockholm was attended by over 250 delegates from 33 countries including Bosnia and Herzegovina. The meeting was organized as a series of symposia with instructional lectures followed by oral presentations on related topics.
BIOMECHANICS
Instructional lectures were given by Peter Cavanagh (USA), Anthony Huson (Netherlands) and Benno Nigg (Canada). Professor Nigg presented research on the influence of orthoses on the mechanics of the foot and possible implications for athletic performance.
There were two papers from Baltimore, USA, regarding the use of immediate or early postoperative pros-theses for below-knee amputation. In a cadaver study 1 strain gauges were applied across the wounds following suture of skin after a transtibial amputation. The results comparing static with cyclic loads and with different load levels suggested that there was insufficient movement at the suture line to cause wound dehiscence. The same authors 2 compared a group of amputees fitted with an immediate postoperative prosthesis with a group treated with dressings and no prosthesis. The former group did better in terms of having fewer falls, fewer complications, fewer revisions and being fitted with a definitive prosthesis sooner.
RSscan pressure measuring insoles were used to investigate in-shoe pressures in a group of diabetic patients with peripheral neuropathy but no important foot deformity.
The effect of an insole depended on the design characteristic of the patients' shoe. A rocker-bottom shoe was very effective in reducing the pressure beneath the heel and the central metatarsal heads by between 35% and 65%. 3
A further study of plantar pressure was made in nor-mal feet, using the EMED-SF system. 4 This confirmed the work of previous authors in showing that there is no transverse arch in the forefoot and the highest pressures are beneath the second and third metatarsal heads. The same group from Ankara, Turkey had investigated heel pain using the EMED-SF system and measuring the thickness of the heel pad radiologically in loaded and unloaded feet. There was no significant difference between the group of patients with heel pain and a matched control group. 5
The van Nes rotationplasty is a rare surgical procedure, first described by Borggreve. This procedure was performed on cadaver lower limbs and pressure-sensitive Fuji film inserted into the ankle joint to measure mechanical parameters when loading was applied. It was found that the load was applied more posteriorly to the talus and over a smaller contact. The role of a prosthesis in changing the load requires further investigation. 6
Motion analysis has been used to investigate patients with posterior tibial tendon dysfunction. 7 Significant differences in the four lower-limb segments investigated were noted. For example the hindfoot showed increased valgus, plantar flexion and internal rotation.
A biomechanical study of patients with severe calcaneal fractures compared 13 patients treated surgically with 11 patients treated by elevation and a subsequent cast. Force and pressure data showed little difference between the two groups. The biomechanical outcomes were not influenced by either calcaneal height or by the range of subtalar movement. 8
Harris and Beath mats were used to study foot morphology in 4,320 Greek children. 9 In the younger children there was a tendency to cavus or flat feet. Comparison of different age groups showed that the feet tended to a more normal pattern from the age of 6 years to 18 years. However 7% of children had persistent cavus or flat feet at skeletal maturity.
Tarsal Coalition
Good results were reported following excision of talocalcaneal bars in eight young people. All but one returned to sport and four achieved full subtalar movement. 10
Hallux Valgus and Hallux Rigidus
Scarf osteotomy has become a popular technique for hallux valgus deformity but no long-term follow-up studies are available. Two experienced Swiss surgeons reported the complication rate for their first 100 cases. There were 28 complications with 10 patients complaining of persistent valgus deformity; this appeared to be associated with using a transarticular approach for the lateral soft-tissue release of the first metatarsophalangeal joint. Other complications included osteonecrosis of the first metatarsal head, pseudarthrosis, fracture of the first metatarsal, soft-tissue necrosis and reflex sympathetic dystrophy. Seven patients had a stiff first metatarsophalangeal joint. An overlong screw was a problem in only one case. 11
A different group from Switzerland found that only three of 73 patients treated by Scarf osteotomy would not have the same procedure again. 12 A low incidence of complications was also reported in another series of 111 Scarf osteotomies; in this paper it was concluded that fixation with one Barouk screw was just as good as using two screws for the osteotomy. 13
A long-term review of Mitchell osteotomy for hallux valgus showed a high incidence of rotational deformity, involving eight of 60 feet. Metatarsalgia was also a problem, affecting 21 of 600 feet. 14
Capsular interposition arthroplasty was compared with Keller's procedure for patients with severe hallux rigidus. Although 20 of 30 feet were classified as excel-lent by the patient, there was no difference in clinical outcome compared with the Keller's group. Twenty-three percent of the patients in the capsular interposition group showed radiological evidence of avascular necrosis of the first metatarsal head but this did not relate to the clinical outcome. 15
In a study of the Austin chevron osteotomy for hallux valgus, three types of fixation were compared. Internal fixation with cannulated compression screws was better than fixation with K-wires. The worst results were obtained with biodegradable screws. 16 Chevron osteotomy allowed correction of moderate degrees of hallux valgus but could be combined with the fibrous cerclage of Lelièvre to allow correction of hallux valgus when the intermetatarsal angle was greater than 15°. 17
A study of lateral release of the first metatarsophalangeal joint showed that this could be performed through a medial arthrotomy using the medial incision for a first metatarsal osteotomy. The authors advised a shortening osteotomy of the first metatarsal in cases where the first metatarsophalangeal joint was subluxated. 18
In another prospective surgical study of hallux valgus, comparison was made of two groups of patients treated by proximal crescentic osteotomy of the first metatarsal. In one group the apex of the osteotomy was proximal, in the other group the apex was distal. There appeared to be no great difference in the results of the two groups, except that in the apex distal group there was a lower incidence of complications and there was a better radiological improvement in sesamoid subluxation. 19
A study of proximal chevron osteotomy of the first metatarsal combined with Akin osteotomy of the proximal phalanx showed this to be an effective procedure for moderate or severe hallux valgus. The average intermetatarsal angle improved from 15.6° to 3.8° but only 52% of patients regarded the result of surgery as excellent. 20
Another variation of first metatarsal osteotomy for hallux valgus was described from North America. This involved a basal osteotomy with a plantar shelf in combination with a McBride procedure. In 24 patients treat-ed by this technique the intermetatarsal angle was reduced from an average of 17° to 6°. In this group of patients with severe deformity there was one failure of correction, one patient had delayed union and one developed RSD. 21
A replacement arthroplasty of the first metatarsophalangeal joint was described (Bioaction Implant). Of 52 patients treated for hallux rigidus 45 were said to have a good result after follow-up averaging four years. An improved range of movement was obtained with an average of 42° extension and 17° flexion at the first metatarsophalangeal joint following surgery. 22 A French group 23 reported good results from a different type of arthroplasty (Sixtine prosthesis). This gave good results in 34 of 42 cases on long-term follow-up and was indicated for Grade II hallux rigidus.
The Youngswick modification of the Austin chevron osteotomy was described originally as treatment for metatarsus primus elevatus. A retrospective series of 50 patients was presented in which the indication was mild to moderate hallux valgus. After an average follow-up of 38 months, 40 patients were satisfied with the outcome. Five patients had transfer metatarsalgia and three had a bad result requiring conversion to a Keller type of arthroplasty. 24
Does the pronated foot predispose to the development of hallux valgus? A group from Japan investigated-ed various angles measured on standing radiographs of feet in normal volunteers with those of patients with hallux valgus. In the latter group they found that the most significantly decreased angle was that of the naviculo-cuneiform joint. 25
Metatarsalgia
Metatarsal lengthening using a callotasis technique was described by a group from Italy. This was done in 15 cases of brachymetatarsia but with a high incidence of complications, including stiffness of the toe joints, delayed union and subluxation of the metatarsophalangeal joint. 26
Metatarsal neck osteotomy was described by a minimally invasive technique which involved drilling with a Kirschner wire under X-ray control. This technique was used in 15 patients mostly with peripheral neuropathy. Elevation of the metatarsal head by a few millimeters allowed healing of neuropathic ulcers. 27
Two groups of patients with Morton's neuroma were followed for 31 months in 30 patients treated by a plan-tar incision and for 41 months for 41 patients treated by excising the neuroma through a dorsal incision. Both approaches were equally successful. 28
The Physically Strained Foot
Cricket is not widely played in Europe or North America but remains popular in countries formerly in the British Empire. The ball cannot be thrown but has to be bowled with a straight arm whilst running; this unnatural action forces the ankle into plantar flexion. The physiotherapist of the South African Cricket Team reported that posterior talar impingement syndrome was common in fast bowlers. Of 23 fast bowlers eight had developed this problem and five came to surgery. This involved removal of the os trigonum or the enlarged posterior process of the talus and gave good results. 29
Barefoot pedobarographs were performed in normal female subjects before and after wearing shoes with two different heel heights. After a day wearing high heels there was increased pressure beneath the metatarsal heads, especially the fifth metatarsal head. This was a transient effect with plantar pressure measurements returning to normal the following day. 30
A group from Israel investigated ankle strains in 103 members of the Border Police. A high incidence (58.5%) reported ankle strains in the group not fitted with an over-the-shoe brace. In the group fitted with this brace (Aircast jump brace) the incidence was 18%. This study was made during an advanced commando course during which 19 braces broke. 31
Ankle Joint
Arthroscopic treatment of anterior ankle impingement by removal of osteophytes is now an established procedure. A study of 62 patients from Holland showed that good results were maintained over an average follow-up of 6.5 years. In Grade 0 patients with subchondral sclerosis and no osteophytes, arthroscopic synovestomy was performed with good results and these 10 patients remained in Group 0. Of the Grade 1 patients, 67% had recurrence of osteophytes radiologically but this did not correlate with the level of pain. After long-term follow-up (range five to eight years) 53% were satisfied with the result of surgery compared with 50% satisfied after two-year follow-up (32). The same group of surgeons investigated 110 patients with persistent pain lasting for more than six months after an ankle sprain, not responding to conservative treatment. All patients had plain X-ray films, CT scan, MRI scan, isotope bone scan and arthroscopy of the ankle. Twenty-nine patients had osteochondritis dissecans (OCD) of the talus and two OCD of the tibia. Arthroscopy was the most accurate investigation and MRI the next best with a sensitivity of 0.71 and a specificity of 0.96. 33
Eight patients with OCD of the talus had been treated by autologous chondrocyte transplantation. The average surface area of the defect was 3.3 square cm. Follow-up after one year included arthroscopy of the ankle. Biopsy of the treated area showed good results in terms of production of type II collagen and proteoglycan. 34
The indications for osteochondral grafting in patients with OCD of the talus are not clear. A study of 11 patients with relatively large defects reported good short-term results with arthroscopy after three to five months showing satisfactory healing. Review at between one and three years showed that all patients had less pain than before the operation. 35 The same group from Japan studied 12 patients with idiopathic avascular necrosis (AVN) of the talus and 34 patients with AVN secondary to fracture of the talus. MRI scanning was a very sensitive method for the diagnosis of AVN following fracture but in idiopathic cases the diagnosis was not made until the patient had severe pain and marked changes on MRI. It was noted that arthrodesis had been performed in eight of the idiopathic group and 11 of the post-traumatic group but the results were not good. 36
Double arthrodesis (subtalar and talonavicular joints) had been performed on 150 patients with stiff valgus feet with a variety of causes. This was done by a medial approach to correct the valgus deformity. It was noted that there was no need to fuse the calcaneocuboid joint which showed good tolerance after a follow-up of up to 10 years. 37
Injury of the Foot and Ankle
Landmine injuries were described in 14 patients from Turkey. All patients had severe soft-tissue injury as well as complex calcaneal fractures and were treated by external fixation with a circular frame. The frame had to be maintained for between 82 and 175 days. It was advisable to delay further operative treatment of the calcaneus until soft-tissue healing had occurred. Eventually all patients were able to walk independently and nine had excellent or good results. 38
A study of 99 fractures of the talus showed that early reduction and stable osteosynthesis achieved the best results. A primary pantalar arthrodesis was performed in two patients and a secondary pantalar arthrodesis in five. The incidence of AVN in 11.3% and this depended on the type of fracture, the surgical approach and the type of fixation used. 39
In a series of 297 patients with calcaneal fractures there were six who were treated by primary subtalar arthrodesis. Five of these were of Sanders type IV, but the indication for this procedure was destruction of more than 50% of the articular cartilage of the posterior facet as shown on exploration. Good results were shown at an average follow-up of 4.9 years, but one patient developed arthritis of the talonavicular joint. 40 The same group from Germany analyzed the foot fractures of front seat occupants from 15,559 road traffic accidents. Fractures were mainly caused by deformation of the vehicle's foot compartment in head-on collisions. The incidence of severe injury had fallen during the 1990s due to improved car safety design. 41
A Japanese group had reviewed 25 patients with “subtle Lisfranc injuries,” defined as diastasis of the first and second metatarsals without a fracture on initial radiographs. In this group 10 patients were subsequently found to have a small bone fragment on tomography or CT scan. In eight patients the diastasis was reduced by primary fixation with a screw and in five patients a secondary local arthrodesis was performed. Surgical treatment gave good results in all these patients. 42
Two groups of patients with severe Lisfranc injuries were compared. Twelve patients had primary arthrodesis with compression screws inserted across the tarsometatarsal joints. In the other group 16 patients the joints were reduced and temporary K-wire fixation used for 12 weeks (ORIF group). In the arthrodesis group six patients had fusion of all five tarsometatarsal joints and this gave the worst results. In the six patients who had arthrodesis avoiding the fourth and fifth tarsometatarsal joints, the results were just as good as the ORIF group. 43
The cannulated Herbert/Whipple screw has been used for the internal fixation of fractures in the foot and ankle. A series of patients were treated by inserting such screws through small incisions. Generally good results were reported. The main indication was a Jones fracture of the fifth metatarsal (22 of 36 fractures). Good results were also reported for fractures of the talus, navicular and metatarsal bones, as well as a small number of patients with fractures of the lateral malleolus. 44
Pantalar fusion using an ACE humeral nail had been performed in 22 patients who had arthritis of both the ankle and subtalar joints. Union occurred in 20 patients. This was a good technique, although four patients had pain from the proximal locking screws and four had pain thought to arise from the proximal end of the nail. 45
Arthroscopy of the subtalar joint was used in eight patients needing internal fixation of a Sanders type II fracture of the calcaneus. Under direct vision the fragments were manipulated with a Steinmann pin and fixed percutaneously with 3.5-mm screws. Good early results were reported. 46
Outcome Measures
A review of 38 patients with arthritis of the tarsometatarsal joints secondary to a Lisfranc injury was made following total or partial arthrodesis. Using two different outcome scores, it was clear that the 17 patients with total arthrodesis of the tarsometatarsal joint had the worst results. Of the remaining patients those with a lateral partial fusion (six patients) did better than those with a medial partial fusion (15 patients). Complete fusion of the Lisfranc joint lead to severe functional disability. 47
The results of ankle arthrodesis are often said to be poor long-term. An average follow-up of 20 ankles in 18 patients showed good patient satisfaction, good movement in the other joints of the foot and relatively mild degenerative symptoms from these joints. The average AOFAS score for the hindfoot was 86.9 and 16 of the 18 patients said they would undergo the same treatment again. 48
The long-term results of the Grice-Green extra-articular subtalar fusion were assessed in 75 cases treated during childhood. After an average follow-up of 14.6 years, 19 had very good results, 35 good results, 10 moderate results and 11 bad results. All cases had severe pes planovalgus preoperatively but with a variety of underlying disease. The best results were in children with cerebral palsy and idiopathic foot deformity and the worst in spina bifida and in uncorrected talipes equiovarus. Complications such as graft resorption and arthritis in adjacent joints were relatively common. 49
A comparison of 13 different forefoot scores to evaluate hallux valgus surgery showed that there was little correlation between them. The authors concluded that the scores did not necessarily reflect the patient's aims, a pain-free great toe and the ability to wear conventional shoes. 50