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Grand rounds: Sports medicine
GRAND ROUNDS: Sports Medicine
MODERATOR (far left): AMOL SAXENA, DPM, FACFAS, Department of Sports Medicine, Palo Alto Medical Clinic, USA Track and Field Sports Medicine Executive Committee; PARTICIPANTS (from left to right): RICHARD T. BOUCHE, DPM, FACFAS, Executive Board Member, Virginia Mason Sports Medicine Center, Seattle WA, American Academy of Podiatric Sports Medicine; K. GORDON CAMPBELL, MD, Department of Sports Medicine, Palo Alto Medical Clinic, Team Orthopedist, Stanford University, San Francisco Giants Baseball Team; ROBERT E. LEACH, MD, Editor, American Journal of Sports Medicine, Professor, Department of Orthopedics, Boston University School of Medicine; JOHN E. MCNERNEY, DPM, FACFAS, Diplomate, American Board of Podiatric Surgery, Team Podiatrist, New York Giants Football Club, New Jersey Nets Basketball Team; LOWELL SCOTT WElL, DPM, FACFAS, Team Podiatrist, White Sox Baseball, Podiatry Consultant, Chicago Bulls, Team Podiatrist, Chicago Bears Football Club.
DR. SAXENA: Gentlemen, I wanted to impart to our readership some of the techniques and trends of surgery on athletes. Often, the parameters we are taught hold true for the average patient, but not for the sports medicine patient. Some things we do differently for sports medicine patients. What are some of your basic parameters and pearls? DR. WElL: I try to reserve surgery on athletes until the end of their participating season. Often, we are faced with various conditions that we know must have surgical repair, and we are able to compensate (using various devices and treatment programs) to palliate the athlete until the season has been completed. The standard methodologies as far as surgery goes, essentially do not change for athletes compared with the normal patient. The only differences may lie in the postoperative physical therapy and the use of bone stimulators. We are more intense with physical therapy (with more frequency), but for athletes making a livingfrom sports, cost may not be an issue. That is why bone stimulators are often used, although there is no known study to show that bone heals faster in a routine osteotomy or fracture of the foot. Every opportunity is made to get the athletes better. DR. BOUCHE: Concerning surgery on athletes, our goal is two-fold: perform the best procedure indicated for the specific problem and return the athletes to their desired activity as quickly as possible without comproThe Journal of Foot and Ankle Surgery 1067-2516196/3506-0595$3.0010 Copyright © 1996 by the American College of Foot and Ankle Surgeons
mising the result. To accomplish these goals, it is important to use the most up-to-date technology that is relatively accepted and ideally, scientifically tested. The media, many times, create a false picture to the public about "new technologies" that are not accepted and are untested, making it difficult for us, as physicians, to live up to the patient's unrealistic expectations. New technologies must be approached openly, but with caution! Athletes contemplating surgery must realize common and uncommon complications that could occur as their surgical result may affect their ability to perform in the future. Surgery in the athlete must always be carefully considered, especially as it applies to their specific sport. Though there are certain situations that may require immediate surgery (i.e., displaced fractures, ruptured tendons, etc.), most surgery for more chronic problems should only be considered after an adequate trial of reasonable conservative treatment has been attempted and the athletes cannot function to their desired level of activity.
DR. McNERNEY: I try to break down the procedures into categories, class I being minimally invasive (nails, warts, soft tissue lesions, and hammertoes) that heal rapidly. These may be able to be performed in season. For class II (mild HAV, lesser metatarsal surgery, neuromas) that take 4 to 8 weeks, and class III (HAV with osteotomy, accessory ossicles) which take 6 to 8 weeks or longer to heal, I try conservative treatment for a significant period. If the athlete is hindered from performing sports (after trying orthoses, physical therVOLUME 35, NUMBER 6, 1996
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apy, etc.) then I recommend surgery. For Jones' and navicular fractures, I may recommend surgery for athletes more quickly and often use bone stimulators.
DR. CAMPBELL: I feel that surgery should be done only if delaying the operation will have a lasting detrimental effect, or if the athlete cannot perform his or her role. We try to move from rigid immobilization as soon as possible to removable braces. Aerobic (hyperbaric) oxygen chambers and bone stimulation have only anecdotal backing. However, early partial weightbearing or protective motion has been shown to decrease healing time and speed rehabilitation. DR. SAXENA: Getting into specifics now, how do you treat hallux rigidus and hallux abducto valgus, and which procedures do you use? DR. McNERNEY: Most of the hallucial conditions can be treated and controlled conservatively. I will perform surgery only if the condition is significantly painful or progressive. In younger athletes with hallux rigidus, I may perform an Austin" or Waterman/Reverdin.' In Stage II and III hallux rigidus, I prefer cheilectomies, and I use this procedure mostly to buy time. In older athletes, I'll do a Keller (with capsular interposition) or a hinged SILASTIC implant. For bunions, I do an Austin with two Orthosorb'' pins using the traditional 60° wing. For base wedge osteotomes (1M angle greater than 15°), I prefer not to use screws for three reasons. First, more bone needs to be resected; second, screws are needed to fixate the osteotomy properly; and finally, a second surgery is often needed to remove the screws. I use 28-gauge monofilament wire crossing four cortices with either a K-wire or Orthosorb pin interpositioned. According to McGlamry (1), this fixation is nearly as stable as two screws, and allows early ambulation. DR. BOUCHE: In correcting hallux rigidus and hallux valgus deformities with osteotomies, I try to exclusively use screw fixation as it affords early joint mobilization 1 Jones fracture is a fracture of the fifth metatarsal at the junction of the base (metaphysis) and the shaft (diaphysis). 2 Austin osteotomy is a medially based, through and through, Chevron-shaped osteotomy in the distal metaphyseal portion of the first metatarsal head. The apex of the osteotomy is in the center of the metatarsal head and the capital fragment is transposed laterally to reduce the medial prominence, intermetatarsal angle, and realign the articular surface. 3 Waterman Reverdin osteotomy is an "L"-shaped osteotomy ofthe metatarsal head with a short arm superior to the sesamoids and a long arm parallel to the articular surface of the first metatarsal head. The osteotomy is performed through and through, and the capital fragment is fixated plantarflexed, with the plantar articular cartilage positioned more dorsally. 4 Dow Coming, Arlington, Tennessee. S Orthosorb, Johnson & Johnson Orthopedics, Inc., New Brunswick, NJ.
596
because of the rigid fixation achieved. As a rule, we do not use casts, but prefer removable splints and walkers to allow early physical therapy, therefore preventing "cast disease" (muscle atrophy, bone demineralization, joint stiffness). I use a variety of procedures to address hallux rigidus depending on the level and severity of deformity. Commonly, though for grades 11/111, I will use a ReverdinGreen" type of osteotomy of the distal first metatarsal with screw fixation combined with cheilectomy. The goal of this procedure is to decompress the first metatarsophalangeal joint (MTJ) by shortening and possibly plantarflexing the capital fragment. After this procedure, the patient is nonweightbearing in a removable splint with crutch ambulation for a 4-week period, though they begin range of motion (ROM) exercises of the first MTJ the first week. The patient progresses to a walking boot for 2 additional weeks, and then into athletic shoes. For grade IV hallux rigidus, I prefer first MTP arthrodesis. For HAV deformities, I again perform a variety of procedures based on level of deformity. Commonly for severe bunion deformity I will perform a base wedge osteotomy or a Lapidus7 procedure in addition to a bunion procedure distally. Postoperatively, I will keep these patients nonweightbearing with removable splint (for early ROM) and crutches for 6 weeks followed by 2 weeks in a walking boot. Though these patients are not ambulating early, their involved joints are being aggressively "mobilized" (i.e., active ROM) and their level of function at 8 to 10 weeks postoperatively, I feel, is better than those patients who walk immediately or after a few weeks postoperatively.
DR. WElL: I tend to perform my shortening/decompression osteotomies in younger patients with earlier stages of hallux rigidus (the patients need to be nonweightbearing for 6 weeks or to use an IPOS8 shoe). For grades II and III, I prefer the Valenti" arthroplasty. I find that many of the osteotomes performed for hallux rigidus look great on x-ray, but patients still have pain. For this reason, I feel the Valenti works better. One may think this a joint-destructive/burning bridges procedure, but it can be revised into a fusion or implant arthro6 Reverdin-Green osteotomy is a distal "L" shaped osteotomy in the first metatarsal head that incorporates a medial wedge which is removed. The lateral cortex is preserved when the osteotomy is reduced. The laterally maladapted joint space is realigned medially. 7 Lapidus procedure is a joint resection/fusion of the first metatarsal-cuneiform articulation to provide stability of the medial column, maintain plantarflexion of the first metatarsal, and in certain cases reduce the intermetatarsal angle. sIPOS of North America, Inc., Niagara Falls, New York. 9 Valenti technique is a wedge-shaped joint resection of the first metatarsophalangeal joint such that the dorsal aspect of the articular surfaces are removed, preserving the plantar articulation.
THE JOURNAL OF FOOT AND ANKLE SURGERY
plasty. The advantage with the Valenti is that athletes can get back to sports at around 4 weeks. For younger athletes with grade IV hallux rigidus, I prefer joint fusions. A British soccer player at age 34 had a cheilectomy, only to have the symptoms reoccur. I performed a first MPJ fusion, and he played 1 more year in the World Cup after that surgery. For HAV procedures, I try to reserve this for when the athlete has finished their career unless, as mentioned previously, they cannot perform to their level. I perform bunionectomies on ballerinas that have gotten back to ballet. I often do a combined Scarf''" osteotomy with a phalanx osteotomy. It usually takes them 10 to 12 weeks to get back to activity, and this is aided by physical therapy including early range of motion started at 1 week postoperative. These patients can get full range of motion back. DR. SAXENA: Let's talk about a relatively nonsurgical problem-plantar fasciitis. DR. LEACH: I try very hard to treat all patients nonoperatively. People eventually get well although some not as quickly as they or I would like. I recommend a Tuli'sll heel cup, stretching, nonsteroidal anti-inflammatories (only sometimes) and fashioning an insert with a felt wedge medially to support the plantar fascia. I am much less excited about injecting steroids than some of my colleagues, although I do it every once in a while. Surgery, which I have done on several professional basketball players and top level runners, is recommended when athletes are so frustrated that they cannot tolerate any more nonoperative treatment nor do what they have to do. I am sure most of them have had symptoms for more than 6 months. I release the plantar fascia from the os calcis and debride any of the degenerated areas of the fascia. In my article I published, consisted of 19 cases, but this is over a long period. (Schepsis, A, Leach, R., Gorzycha, J. Plantar Fasciitis: Etiology, Treatment Surgical Results and Review of the Literature. Clin. Orthop. 266:185-196, 1991.) DR. CAMPBELL: I recommend shoes with a supportive shank and heel padding. Patients often progress to a custom orthotic. If this along with stretching and phonophoresis fail, then I will inject with steroid. If symptoms interfere with athletic activity and are 6 months or longer in duration, then surgery could be undertaken. 10 Scarf osteotomy/Z-bunionectomy is a "Z"-shaped osteotomy (in the sagittal plane) of the first metatarsal shaft that is performed by beveling, grooving, or halving the bone, repositioning the two pieces, and then fixating, usually via compression screws. 11 Tuli's Heel cup: International Comfort Products, San Marcos, California.
Postoperative mobilization, and stretching (deep tissue massage, calf and arch stretching), with weightbearing tolerance usually allows them to return to sports in 6 weeks. DR. BOUCHE: For plantar fasciitis in resistant cases, I consider an open surgical procedure performing a fascial release and spur excision (if present). I feel strongly that the incisional approach for plantar fasciitis is an important limiting factor in obtaining a desired surgical result. My incisional approach is different, but quite effective, avoiding important structures, staying consistent with the skin lines and allowing adequate exposure. The incision is medial-plantar and placed anterior to the calcaneal tuberosity being oblique medially and transverse plantarly. After surgery, the involved foot is maintained in a neutral dorsiflexed position and patients are kept nonweightbearing for 4 weeks, followed by 2 to 4 weeks in a walking boot. DR. WElL: I do a percutaneous plantar fasciotomy, cutting the medial one-third to one-half of the fascia. I have only had to operate on 3 out of 100 professional athletes for this problem. Most patients can get back around 8 weeks. I try to treat all the patients conservatively for at least 6 months. Plantar fasciitis does seem to be on the rise. In my 20-year career of treating professional athletes, I have seen more cases in the past 3 years than in the previous 17 years. This may be attributed to the athletes getting bigger, heavier, and faster. DR. SAXENA: How about ankle instability and ligament reconstruction? What are your preferred techniques? DR. WElL: I prefer the Brostrom-Gould'< procedure because it maintains normal range of motion. I have had good results on 330-pound linemen and 90-pound ballerinas. I use soft tissue anchors (anywhere from one to three) and have them bear weight to tolerance in a below-the-knee cast or removable-cast boot up to 5 weeks postoperative. They get back to full athletic activities in 10 to 12 weeks. We never do a primary ligament repair on professional athletes in a first-time ankle sprain.
12 Brostrom-Gould procedure is delayed primary repair of anterior talofibular (ATF) and calcaneofibular (CFL) ligaments (originally described by Brostrom). Gould modified this to include reefing of the inferior extensor retinaculum onto the anterolateral fibula to augment the repair.
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DR. McNERNEY: I don't remember the last time I heard of a professional athlete undergoing primary lateral ankle ligament repair. My experience shows that 95% of the grade I, II, and III 13 lateral ankle sprains can be effectively managed with conservative care. When indicated, I use a peroneus brevis tenodesis through the fibula and haven't noticed any stiffness, as long as therapy is started rapidly. DR. BOUCHE: For ankle instability, I differentiate one- or two-ligament insufficiency. For one-ligament insufficiency [anterior talofibular (ATF»), I perform a Brostrom-type procedure. For two-ligament insufficiency [ATF and calcaneofibular (CF»), I use a modified Chrisman-Snook'" procedure combined with a Brostrom procedure. Subtalar instability, if present, is also addressed with this procedure. Postoperatively, patients are nonweightbearing in a splint on crutches for 1 month, followed by a walking boot for 2 to 4 additional weeks. Patients do not begin formal therapy until the third week and at 2 weeks when ankle ROM is initiated by the patient, ankle plantarflexion is limited to 15° to avoid undue tension on the ATF. After a full rehabilitation program and patients return to sports, they are instructed to wear an ankle brace for "position sense" purposes and an appropriate shoe (preferably high top) for 4 to 6 months. DR. LEACH: I feel that very few people need this done. However, these operations work exceedingly well and are perhaps the best ligament reconstructions I do on the body. I use a version of the Brostrom or a modified Chrisman-Snook. We used to cast them, but now we put them in some type of brace and allow immediate weightbearing. We limit inversion-eversion allowing dorsiflexion-plantar flexion and continue to brace for 6 to 7 weeks. Strengthening of the invertorsevertors is initiated, and most people return to full activity at 12 to 14 weeks. DR. CAMPBELL: I also find athletes are able to return to activity around 12 weeks; I do have them use a brace when they return to sports. I prefer to use a Brostrom when possible, casting it for 2 to 3 weeks, then
13 Grade I: mild sprain with stretching of ligament fibers with minimal swelling. Grade II: moderate sprain with partial tearing of the ligament fibers, greater edema, and decreased ability to bear weight. Grade III: severe sprain with complete tearing of ligament fibers, severe edema, ecchymosis, and inability to bear weight. 14 Chrisman-Snook procedure is lateral ligament reconstruction utilizing peroneus brevis tendon, often a hemisection, to reapproximate the course of both ATF and CFL. The ligament is routed from the base of the fifth metatarsal through a drill hole in the distal fibula into the lateral calcaneus.
598
have them use a boot for another 3 weeks. They then start their rehabilitation. DR. SAXENA: How about surgery for stress fractures of the navicular and the Jones fracture? It seems that we are treating these as the injury has progressed from a stress fracture to a true fracture. DR. McNERNEY: I like to use an intramedullary screw for the Jones fracture, especially if we see intramedullary sclerosis. I try to use as long a screw as possible. Conservative care can be used for both Jones and navicular stress fractures, but it takes a long time. I try to combine casting with bone stimulation, because it seems that both together work better than either alone. For navicular stress fractures, I cast the patient nonweightbearing for 6 to 8 weeks, followed by another 2 to 4 weeks weightbearing in a cast, then aggressive therapy. DR. BOUCHE: Khan's study on navicular stress fractures concluded that navicular stress fractures heal with 6 to 8 weeks of nonweightbearing whether acute or chronic. If the navicular stress fracture progresses to an overt fracture open reduction with internal fixation (ORIF) with screw fixation should be considered. If navicular stress fractures are missed, overt fracture can result with subsequent talonavicular (TN) joint arthritis ultimately requiring TN joint arthrodesis. For Jones fractures, I also recommend nonweightbearing for 6 to 8 weeks as a conservative approach. Surgically, I generally fix displaced Jones fractures with a Steinman pin (5/64) obliquely oriented from posterior plantar to dorsal distal engaging both cortices (a screw is used as an alternative). The Steinman pin is easy to place and affords rigid immobilization as good if not better than an intramedullary screw, in my opinion. I find that guiding the screw down the medullary shaft of the fifth metatarsal many times distracts the fracture because of the lateral metatarsal bowing commonly found. Onlay bone grafting with ORIF should be used in delayed and nonunions. DR. SAXENA: You have all mentioned that these injuries take a while to heal. What about refracture? DR. CAMPBELL: That's why I prefer to ORIF both navicular and Jones stress fractures. The athletes can get back to athletic activities in 2 to 3 months. Refractures, delayed healing, etc. are the reasons to operate on these. One little technique tip-in order to orient the screw for the Jones fracture properly, take a rongeur and remove some of the base of the fifth metatarsal so you have a flat surface to guide your pin or screw. Otherwise, you have a difficult time trying to get the screw placed properly.
THE JOURNAL OF FOOT AND ANKLE SURGERY
DR. SAXENA: Yes, I have noticed in all the articles dealing with Jones fractures, the authors often show oblique radiographs; they rarely show anteroposterior views of the intramedullary screw placement unless the screw was bent. Maybe because it is hard to align it well. Any final comments on these two injuries, Dr. Weil?
physical therapy and gradual return to activity. One of Chicago's most famous athletes had complete recovery with this regimen.
DR. WElL: I also recommend intramedullary ORIF for Jones fractures for high level and professional athletes, especially in football and basketball players because the chance of reinjury is so high. Every surgery does have its risks. True navicular stress fractures do well in 6 to 8 weeks of nonweightbearing, followed by
References
DR. SAXENA:
Thank you, gentlemen.
1. McGlamry, E. D. Comprehensive Textbook ofFoot Surgery, Williams & Wilkins, Co., Baltimore, MD, 1987. 2. Kahn, K M., Fuller, P. J., Bruncker, P. D. Outcome of conservative and surgical management of navicular stress fractures in athletes. Am. J. Sports Med. 20:657, 1992.
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MODERATOR (far left): AMOL SAXENA, DPM, FACFAS, Department of Sports Medicine, Palo Alto Medical Clinic, USA Track and Field Sports Medicine Executive Committee; PARTICIPANTS (from left to right): RICHARD T. BOUCHE, DPM, FACFAS, Executive Board Member, Virginia Mason Sports Medicine Center, Seattle WA, American Academy of Podiatric Sports Medicine; K. GORDON CAMPBELL, MD, Department of Sports Medicine, Palo Alto Medical Clinic, Team Orthopedist, Stanford University, San Francisco Giants Baseball Team; ROBERT E. LEACH, MD, Editor, American Journal of Sports Medicine, Professor, Department of Orthopedics, Boston University School of Medicine; JOHN E. MCNERNEY, DPM, FACFAS, Diplomate, American Board of Podiatric Surgery, Team Podiatrist, New York Giants Football Club, New Jersey Nets Basketball Team; LOWELL SCOTT WElL, DPM, FACFAS, Team Podiatrist, White Sox Baseball, Podiatry Consultant, Chicago Bulls, Team Podiatrist, Chicago Bears Football Club.
DR. SAXENA: Gentlemen, I wanted to impart to our readership some of the techniques and trends of surgery on athletes. Often, the parameters we are taught hold true for the average patient, but not for the sports medicine patient. Some things we do differently for sports medicine patients. What are some of your basic parameters and pearls? DR. WElL: I try to reserve surgery on athletes until the end of their participating season. Often, we are faced with various conditions that we know must have surgical repair, and we are able to compensate (using various devices and treatment programs) to palliate the athlete until the season has been completed. The standard methodologies as far as surgery goes, essentially do not change for athletes compared with the normal patient. The only differences may lie in the postoperative physical therapy and the use of bone stimulators. We are more intense with physical therapy (with more frequency), but for athletes making a livingfrom sports, cost may not be an issue. That is why bone stimulators are often used, although there is no known study to show that bone heals faster in a routine osteotomy or fracture of the foot. Every opportunity is made to get the athletes better. DR. BOUCHE: Concerning surgery on athletes, our goal is two-fold: perform the best procedure indicated for the specific problem and return the athletes to their desired activity as quickly as possible without comproThe Journal of Foot and Ankle Surgery 1067-2516196/3506-0595$3.0010 Copyright © 1996 by the American College of Foot and Ankle Surgeons
mising the result. To accomplish these goals, it is important to use the most up-to-date technology that is relatively accepted and ideally, scientifically tested. The media, many times, create a false picture to the public about "new technologies" that are not accepted and are untested, making it difficult for us, as physicians, to live up to the patient's unrealistic expectations. New technologies must be approached openly, but with caution! Athletes contemplating surgery must realize common and uncommon complications that could occur as their surgical result may affect their ability to perform in the future. Surgery in the athlete must always be carefully considered, especially as it applies to their specific sport. Though there are certain situations that may require immediate surgery (i.e., displaced fractures, ruptured tendons, etc.), most surgery for more chronic problems should only be considered after an adequate trial of reasonable conservative treatment has been attempted and the athletes cannot function to their desired level of activity.
DR. McNERNEY: I try to break down the procedures into categories, class I being minimally invasive (nails, warts, soft tissue lesions, and hammertoes) that heal rapidly. These may be able to be performed in season. For class II (mild HAV, lesser metatarsal surgery, neuromas) that take 4 to 8 weeks, and class III (HAV with osteotomy, accessory ossicles) which take 6 to 8 weeks or longer to heal, I try conservative treatment for a significant period. If the athlete is hindered from performing sports (after trying orthoses, physical therVOLUME 35, NUMBER 6, 1996
595
apy, etc.) then I recommend surgery. For Jones' and navicular fractures, I may recommend surgery for athletes more quickly and often use bone stimulators.
DR. CAMPBELL: I feel that surgery should be done only if delaying the operation will have a lasting detrimental effect, or if the athlete cannot perform his or her role. We try to move from rigid immobilization as soon as possible to removable braces. Aerobic (hyperbaric) oxygen chambers and bone stimulation have only anecdotal backing. However, early partial weightbearing or protective motion has been shown to decrease healing time and speed rehabilitation. DR. SAXENA: Getting into specifics now, how do you treat hallux rigidus and hallux abducto valgus, and which procedures do you use? DR. McNERNEY: Most of the hallucial conditions can be treated and controlled conservatively. I will perform surgery only if the condition is significantly painful or progressive. In younger athletes with hallux rigidus, I may perform an Austin" or Waterman/Reverdin.' In Stage II and III hallux rigidus, I prefer cheilectomies, and I use this procedure mostly to buy time. In older athletes, I'll do a Keller (with capsular interposition) or a hinged SILASTIC implant. For bunions, I do an Austin with two Orthosorb'' pins using the traditional 60° wing. For base wedge osteotomes (1M angle greater than 15°), I prefer not to use screws for three reasons. First, more bone needs to be resected; second, screws are needed to fixate the osteotomy properly; and finally, a second surgery is often needed to remove the screws. I use 28-gauge monofilament wire crossing four cortices with either a K-wire or Orthosorb pin interpositioned. According to McGlamry (1), this fixation is nearly as stable as two screws, and allows early ambulation. DR. BOUCHE: In correcting hallux rigidus and hallux valgus deformities with osteotomies, I try to exclusively use screw fixation as it affords early joint mobilization 1 Jones fracture is a fracture of the fifth metatarsal at the junction of the base (metaphysis) and the shaft (diaphysis). 2 Austin osteotomy is a medially based, through and through, Chevron-shaped osteotomy in the distal metaphyseal portion of the first metatarsal head. The apex of the osteotomy is in the center of the metatarsal head and the capital fragment is transposed laterally to reduce the medial prominence, intermetatarsal angle, and realign the articular surface. 3 Waterman Reverdin osteotomy is an "L"-shaped osteotomy ofthe metatarsal head with a short arm superior to the sesamoids and a long arm parallel to the articular surface of the first metatarsal head. The osteotomy is performed through and through, and the capital fragment is fixated plantarflexed, with the plantar articular cartilage positioned more dorsally. 4 Dow Coming, Arlington, Tennessee. S Orthosorb, Johnson & Johnson Orthopedics, Inc., New Brunswick, NJ.
596
because of the rigid fixation achieved. As a rule, we do not use casts, but prefer removable splints and walkers to allow early physical therapy, therefore preventing "cast disease" (muscle atrophy, bone demineralization, joint stiffness). I use a variety of procedures to address hallux rigidus depending on the level and severity of deformity. Commonly, though for grades 11/111, I will use a ReverdinGreen" type of osteotomy of the distal first metatarsal with screw fixation combined with cheilectomy. The goal of this procedure is to decompress the first metatarsophalangeal joint (MTJ) by shortening and possibly plantarflexing the capital fragment. After this procedure, the patient is nonweightbearing in a removable splint with crutch ambulation for a 4-week period, though they begin range of motion (ROM) exercises of the first MTJ the first week. The patient progresses to a walking boot for 2 additional weeks, and then into athletic shoes. For grade IV hallux rigidus, I prefer first MTP arthrodesis. For HAV deformities, I again perform a variety of procedures based on level of deformity. Commonly for severe bunion deformity I will perform a base wedge osteotomy or a Lapidus7 procedure in addition to a bunion procedure distally. Postoperatively, I will keep these patients nonweightbearing with removable splint (for early ROM) and crutches for 6 weeks followed by 2 weeks in a walking boot. Though these patients are not ambulating early, their involved joints are being aggressively "mobilized" (i.e., active ROM) and their level of function at 8 to 10 weeks postoperatively, I feel, is better than those patients who walk immediately or after a few weeks postoperatively.
DR. WElL: I tend to perform my shortening/decompression osteotomies in younger patients with earlier stages of hallux rigidus (the patients need to be nonweightbearing for 6 weeks or to use an IPOS8 shoe). For grades II and III, I prefer the Valenti" arthroplasty. I find that many of the osteotomes performed for hallux rigidus look great on x-ray, but patients still have pain. For this reason, I feel the Valenti works better. One may think this a joint-destructive/burning bridges procedure, but it can be revised into a fusion or implant arthro6 Reverdin-Green osteotomy is a distal "L" shaped osteotomy in the first metatarsal head that incorporates a medial wedge which is removed. The lateral cortex is preserved when the osteotomy is reduced. The laterally maladapted joint space is realigned medially. 7 Lapidus procedure is a joint resection/fusion of the first metatarsal-cuneiform articulation to provide stability of the medial column, maintain plantarflexion of the first metatarsal, and in certain cases reduce the intermetatarsal angle. sIPOS of North America, Inc., Niagara Falls, New York. 9 Valenti technique is a wedge-shaped joint resection of the first metatarsophalangeal joint such that the dorsal aspect of the articular surfaces are removed, preserving the plantar articulation.
THE JOURNAL OF FOOT AND ANKLE SURGERY
plasty. The advantage with the Valenti is that athletes can get back to sports at around 4 weeks. For younger athletes with grade IV hallux rigidus, I prefer joint fusions. A British soccer player at age 34 had a cheilectomy, only to have the symptoms reoccur. I performed a first MPJ fusion, and he played 1 more year in the World Cup after that surgery. For HAV procedures, I try to reserve this for when the athlete has finished their career unless, as mentioned previously, they cannot perform to their level. I perform bunionectomies on ballerinas that have gotten back to ballet. I often do a combined Scarf''" osteotomy with a phalanx osteotomy. It usually takes them 10 to 12 weeks to get back to activity, and this is aided by physical therapy including early range of motion started at 1 week postoperative. These patients can get full range of motion back. DR. SAXENA: Let's talk about a relatively nonsurgical problem-plantar fasciitis. DR. LEACH: I try very hard to treat all patients nonoperatively. People eventually get well although some not as quickly as they or I would like. I recommend a Tuli'sll heel cup, stretching, nonsteroidal anti-inflammatories (only sometimes) and fashioning an insert with a felt wedge medially to support the plantar fascia. I am much less excited about injecting steroids than some of my colleagues, although I do it every once in a while. Surgery, which I have done on several professional basketball players and top level runners, is recommended when athletes are so frustrated that they cannot tolerate any more nonoperative treatment nor do what they have to do. I am sure most of them have had symptoms for more than 6 months. I release the plantar fascia from the os calcis and debride any of the degenerated areas of the fascia. In my article I published, consisted of 19 cases, but this is over a long period. (Schepsis, A, Leach, R., Gorzycha, J. Plantar Fasciitis: Etiology, Treatment Surgical Results and Review of the Literature. Clin. Orthop. 266:185-196, 1991.) DR. CAMPBELL: I recommend shoes with a supportive shank and heel padding. Patients often progress to a custom orthotic. If this along with stretching and phonophoresis fail, then I will inject with steroid. If symptoms interfere with athletic activity and are 6 months or longer in duration, then surgery could be undertaken. 10 Scarf osteotomy/Z-bunionectomy is a "Z"-shaped osteotomy (in the sagittal plane) of the first metatarsal shaft that is performed by beveling, grooving, or halving the bone, repositioning the two pieces, and then fixating, usually via compression screws. 11 Tuli's Heel cup: International Comfort Products, San Marcos, California.
Postoperative mobilization, and stretching (deep tissue massage, calf and arch stretching), with weightbearing tolerance usually allows them to return to sports in 6 weeks. DR. BOUCHE: For plantar fasciitis in resistant cases, I consider an open surgical procedure performing a fascial release and spur excision (if present). I feel strongly that the incisional approach for plantar fasciitis is an important limiting factor in obtaining a desired surgical result. My incisional approach is different, but quite effective, avoiding important structures, staying consistent with the skin lines and allowing adequate exposure. The incision is medial-plantar and placed anterior to the calcaneal tuberosity being oblique medially and transverse plantarly. After surgery, the involved foot is maintained in a neutral dorsiflexed position and patients are kept nonweightbearing for 4 weeks, followed by 2 to 4 weeks in a walking boot. DR. WElL: I do a percutaneous plantar fasciotomy, cutting the medial one-third to one-half of the fascia. I have only had to operate on 3 out of 100 professional athletes for this problem. Most patients can get back around 8 weeks. I try to treat all the patients conservatively for at least 6 months. Plantar fasciitis does seem to be on the rise. In my 20-year career of treating professional athletes, I have seen more cases in the past 3 years than in the previous 17 years. This may be attributed to the athletes getting bigger, heavier, and faster. DR. SAXENA: How about ankle instability and ligament reconstruction? What are your preferred techniques? DR. WElL: I prefer the Brostrom-Gould'< procedure because it maintains normal range of motion. I have had good results on 330-pound linemen and 90-pound ballerinas. I use soft tissue anchors (anywhere from one to three) and have them bear weight to tolerance in a below-the-knee cast or removable-cast boot up to 5 weeks postoperative. They get back to full athletic activities in 10 to 12 weeks. We never do a primary ligament repair on professional athletes in a first-time ankle sprain.
12 Brostrom-Gould procedure is delayed primary repair of anterior talofibular (ATF) and calcaneofibular (CFL) ligaments (originally described by Brostrom). Gould modified this to include reefing of the inferior extensor retinaculum onto the anterolateral fibula to augment the repair.
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DR. McNERNEY: I don't remember the last time I heard of a professional athlete undergoing primary lateral ankle ligament repair. My experience shows that 95% of the grade I, II, and III 13 lateral ankle sprains can be effectively managed with conservative care. When indicated, I use a peroneus brevis tenodesis through the fibula and haven't noticed any stiffness, as long as therapy is started rapidly. DR. BOUCHE: For ankle instability, I differentiate one- or two-ligament insufficiency. For one-ligament insufficiency [anterior talofibular (ATF»), I perform a Brostrom-type procedure. For two-ligament insufficiency [ATF and calcaneofibular (CF»), I use a modified Chrisman-Snook'" procedure combined with a Brostrom procedure. Subtalar instability, if present, is also addressed with this procedure. Postoperatively, patients are nonweightbearing in a splint on crutches for 1 month, followed by a walking boot for 2 to 4 additional weeks. Patients do not begin formal therapy until the third week and at 2 weeks when ankle ROM is initiated by the patient, ankle plantarflexion is limited to 15° to avoid undue tension on the ATF. After a full rehabilitation program and patients return to sports, they are instructed to wear an ankle brace for "position sense" purposes and an appropriate shoe (preferably high top) for 4 to 6 months. DR. LEACH: I feel that very few people need this done. However, these operations work exceedingly well and are perhaps the best ligament reconstructions I do on the body. I use a version of the Brostrom or a modified Chrisman-Snook. We used to cast them, but now we put them in some type of brace and allow immediate weightbearing. We limit inversion-eversion allowing dorsiflexion-plantar flexion and continue to brace for 6 to 7 weeks. Strengthening of the invertorsevertors is initiated, and most people return to full activity at 12 to 14 weeks. DR. CAMPBELL: I also find athletes are able to return to activity around 12 weeks; I do have them use a brace when they return to sports. I prefer to use a Brostrom when possible, casting it for 2 to 3 weeks, then
13 Grade I: mild sprain with stretching of ligament fibers with minimal swelling. Grade II: moderate sprain with partial tearing of the ligament fibers, greater edema, and decreased ability to bear weight. Grade III: severe sprain with complete tearing of ligament fibers, severe edema, ecchymosis, and inability to bear weight. 14 Chrisman-Snook procedure is lateral ligament reconstruction utilizing peroneus brevis tendon, often a hemisection, to reapproximate the course of both ATF and CFL. The ligament is routed from the base of the fifth metatarsal through a drill hole in the distal fibula into the lateral calcaneus.
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have them use a boot for another 3 weeks. They then start their rehabilitation. DR. SAXENA: How about surgery for stress fractures of the navicular and the Jones fracture? It seems that we are treating these as the injury has progressed from a stress fracture to a true fracture. DR. McNERNEY: I like to use an intramedullary screw for the Jones fracture, especially if we see intramedullary sclerosis. I try to use as long a screw as possible. Conservative care can be used for both Jones and navicular stress fractures, but it takes a long time. I try to combine casting with bone stimulation, because it seems that both together work better than either alone. For navicular stress fractures, I cast the patient nonweightbearing for 6 to 8 weeks, followed by another 2 to 4 weeks weightbearing in a cast, then aggressive therapy. DR. BOUCHE: Khan's study on navicular stress fractures concluded that navicular stress fractures heal with 6 to 8 weeks of nonweightbearing whether acute or chronic. If the navicular stress fracture progresses to an overt fracture open reduction with internal fixation (ORIF) with screw fixation should be considered. If navicular stress fractures are missed, overt fracture can result with subsequent talonavicular (TN) joint arthritis ultimately requiring TN joint arthrodesis. For Jones fractures, I also recommend nonweightbearing for 6 to 8 weeks as a conservative approach. Surgically, I generally fix displaced Jones fractures with a Steinman pin (5/64) obliquely oriented from posterior plantar to dorsal distal engaging both cortices (a screw is used as an alternative). The Steinman pin is easy to place and affords rigid immobilization as good if not better than an intramedullary screw, in my opinion. I find that guiding the screw down the medullary shaft of the fifth metatarsal many times distracts the fracture because of the lateral metatarsal bowing commonly found. Onlay bone grafting with ORIF should be used in delayed and nonunions. DR. SAXENA: You have all mentioned that these injuries take a while to heal. What about refracture? DR. CAMPBELL: That's why I prefer to ORIF both navicular and Jones stress fractures. The athletes can get back to athletic activities in 2 to 3 months. Refractures, delayed healing, etc. are the reasons to operate on these. One little technique tip-in order to orient the screw for the Jones fracture properly, take a rongeur and remove some of the base of the fifth metatarsal so you have a flat surface to guide your pin or screw. Otherwise, you have a difficult time trying to get the screw placed properly.
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DR. SAXENA: Yes, I have noticed in all the articles dealing with Jones fractures, the authors often show oblique radiographs; they rarely show anteroposterior views of the intramedullary screw placement unless the screw was bent. Maybe because it is hard to align it well. Any final comments on these two injuries, Dr. Weil?
physical therapy and gradual return to activity. One of Chicago's most famous athletes had complete recovery with this regimen.
DR. WElL: I also recommend intramedullary ORIF for Jones fractures for high level and professional athletes, especially in football and basketball players because the chance of reinjury is so high. Every surgery does have its risks. True navicular stress fractures do well in 6 to 8 weeks of nonweightbearing, followed by
References
DR. SAXENA:
Thank you, gentlemen.
1. McGlamry, E. D. Comprehensive Textbook ofFoot Surgery, Williams & Wilkins, Co., Baltimore, MD, 1987. 2. Kahn, K M., Fuller, P. J., Bruncker, P. D. Outcome of conservative and surgical management of navicular stress fractures in athletes. Am. J. Sports Med. 20:657, 1992.
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