Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Distal tibial osteotomies for the treatment of foot and ankle disorders

Distal tibial osteotomy is an effective treatment for a variety of pediatric and adult foot and ankle disorders. Exposure osteotomies provide access to the tibiotalar joint for such problems as talar body fractures and osteochondral lesions of the talus. The channel osteotomy provides improved access to posterior talar dome lesions, especially for the use of osteochondral autograft. Although technically demanding, the supramalleolar osteotomy can benefit many patients, including patients with residual clubfoot deformity, primary and secondary osteoarthritis, malunion, and physeal arrest.

Classification and treatment of plantar fibromatosis

A retrospective study of 18 patients (23 feet) with plantar fibromatosis who required surgical excision between January, 1991, and June, 1998, was performed. Subtotal plantar fasciectomy was performed to remove the tumor with a wide disease-free margin. 16 patients (21 feet) were interviewed and 14 patients (19 feet) were examined with an average followup of 36 months. Two patients (2 feet) with less than 12 months followup were excluded. Both subjective and objective evaluations and pre- and postoperative x-rays were reviewed to assess the alignment of the bony arch. There were nine males and nine females, age 49 years, average, at the time of diagnosis. Sixty-seven percent of patients had bilateral disease, and 28% had associated Dupuytren's contracture. There were 18 primary and five recurrent tumors. An operative staging system, I to IV, for plantar fibromatosis is presented which incorporates the extent of plantar fascia involvement, the presence of skin adherence, and the depth of tumor extension. The stage of the tumor correlated well with postoperative wound healing, skin necrosis, and recurrence. In fifteen of 21 feet, the patients were satisfied without reservations, and in three of 21 feet, they were satisfied with reservations. In 18/21 (86%) feet, the patient reported he/she would have surgery done again. There were two recurrent tumors. One was reoperated and the patient was disease free twelve months postoperatively. The other recurrence was asymptomatic 40 months postoperatively and required no treatment. One patient required an excision of a postoperative cutaneous neuroma. Eleven of 21 feet (52%) experienced delayed healing and of which four required a split thickness skin graft. Ten of the eleven feet with delayed wound healing and all four cases requiring a skin graft had a stage ill or IV tumor. Pre- and postoperative weightbearing radiographs revealed a slight decrease in the calcaneal pitch angle, navicular height, and medial cuneiform height indicating a decrease in the height of the medial longitudinal arch.

Treatment of acquired adult planovalgus deformities with subtalar fusion

A retrospective review was conducted of isolated subtalar arthrodeses performed on 32 adults (34 fusions) between August 1990 and September 1993. Each fusion was performed using a single large cannulated lag screw through the talar neck. The American Orthopaedic Foot and Ankle Society standard clinical rating system for the ankle and hindfoot was used to assess outcome. Patients answered subjective questions based on the scale. Followup examination was done to evaluate clinically and radiographically each patient's foot and ankle according to the scale. Average patient age was 53 years (range, 27-80 years). Average followup was 30.8 months (range, 16-55 months). Twenty-four patients answered the subjective questions, and the average subjective score was 47 of a maximum 60 points (range, 9-60 points). Clinical data from 17 patients showed an average objective score of 30 of a maximum 34 points (range, 25-34 points). The average total score was 77 of a maximum 94 possible points (range, 34-94 points). Forty-two percent of the patients indicated a 100% improvement, 42% a 75% improvement, and 16% a 50% improvement. Eighty-three percent stated they definitely would have the procedure again. Results indicate that subtalar arthrodesis is an effective treatment for adult patients with pain and disability secondary to acquired planovalgus, posttraumatic, and inflammatory conditions of the hindfoot. In addition, the American Orthopaedic Foot and Ankle Society standard rating system of the ankle and hindfoot corresponds to clinical outcome.