Highlights of the Eighteenth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Traverse City, Michigan, 12–14 July 2002

Foot and Ankle Surgery 9 (2003) 67–76 www.elsevier.com/locate/fas

Special report

Highlights of the Eighteenth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Traverse City, Michigan, 12 –14 July 2002q E. Trepman, L.D. Lutter, C.L. Saltzman American Orthopaedic Foot and Ankle Society, Seattle, WA, USA

1. Introduction The Eighteenth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 12 – 14 July 2002 at the Grand Traverse Resort in Traverse City, Michigan. There were 348 registrants in attendance, including 26 individuals from 11 countries outside the United States.

2. Clinical symposia I.

Diabetic foot surgery. Exostectomy in the deformed diabetic foot is indicated for a bony prominence that causes an ulcer that does not respond to non-operative treatment [1]. In the diabetic ankle and hindfoot, muscle balancing may include a gastrocnemius recession, peroneus longus lengthening, or transfer of the extensor digitorum longus to the midfoot [2]. External fixation for ankle arthrodesis in the diabetic patient may include placement of frame components at the tibia, calcaneus, and forefoot that allow access to the soft tissues [3]. Arthrodesis of the Charcot hindfoot or midfoot is indicated for a deformity that cannot be braced, unstable deformity, recurrent ulceration, or persistent osteomyelitis, and may include a closing wedge osteotomy and plantar plate fixation [4]. Forefoot amputation options include ray resection and transmetatarsal amputation, and gastrocsoleus lengthening may decrease the risk of late ulceration caused by an equinus contracture [5].

q Publication does not constitute endorsement of content or validation of conclusions. Comparisons should be made with caution because statistical significance might not have been noted in the abstracts published in the conference program. Correspondence: Jessica Lutter, Managing Editor, Foot & Ankle International, 265 Brimhall Street, St. Paul, MN, 55105, USA.

doi:10.1016/S1268-7731(03)00013-4

II.

New sports techniques. Posterior ankle arthroscopy may be indicated for posterior ankle impingement, flexor hallucis longus tenosynovitis, painful os trigonum, posterior osteochondral lesion, and subtalar joint problems [6]. In securing a tendon transfer in a bony tunnel, such as with lateral ankle ligament reconstruction, a bioabsorbable interference screw may provide rigid fixation of the tendon graft to the bone [7]. Arthroscopic thermal capsular shrinkage with postoperative immobilization may be successful in achieving lateral ankle stability in patients with instability [8]. Evaluation of the hallux metatarsophalangeal (MP) hyperextension injury (‘turf toe’) may demonstrate laxity with dorsal drawer, proximal position of the sesamoids, or diastasis of a bipartite sesamoid; the goals of treatment include restoration of anatomy with either immobilization or surgery [9]. III. Practice development. Although fulfilling, professional life is demanding and insatiable; finding a balance of professional and personal priorities may be achieved by creating a ‘professional firewall’ to protect against allencompassing work activities [10]. In group practice, prudent selection of an associate includes assessment of the candidate’s goals and references; dissolving a professional relationship requires documentation, legal advice, and professional etiquette [11]. Hiring and maintaining good employees may be facilitated with attention to the interview process, background checks, teamwork and staff morale, the work environment, physician behavior, and conflict resolution [12]. A solo practice may afford greater control of overhead, staffing, and personal time, and may be facilitated by outsourcing and sharing costly services [13]. A decision to move to a new practice should follow a careful evaluation of the current and new practice situations, referral patterns, career time-frame, and advantages and disadvantages of the move [14].

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Growth of a new practice may be facilitated by public and professional lectures, involvement in community projects, and availability to the media [15]. Negotiation with medical insurance carriers may be optimized by market analysis, contract review, and evaluation of practice strengths and weaknesses [16]. Ancillary services may improve service, access to care, and practice revenue; a potential opportunity should be studied to evaluate feasibility, local market issues, and legal aspects [17]. Abiding by sound financial principles and avoiding costly errors may be helpful in achieving financial and personal goals [18]. Second opinions, consultations, referrals, and transfers of care may require specific documentation, and ethical practice includes keeping the best interest of the patient as the guiding principle [19]. The medical record is a legal document, and testimony may be facilitated by preparedness, due diligence, and careful consideration of the posed question [20]. IV. Ankle arthritis. Ankle joint distraction with an Ilizarov external fixator may reduce pain and increase motion in osteoarthritic ankles [21]. Ankle arthrodesis is durable and may provide pain relief in approximately 90% of patients with ankle arthritis [22]. Total ankle arthroplasty with the Agilityw ankle prosthesis requires syndesmosis fusion, attention to alignment, marked bone resection, talar cortical bone retention, and a major ‘learning curve’ [23]. Mobile bearings in total ankle arthroplasty have potential design advantages (ease of ligament tensioning, ease of exchange, good polyethylene–metal congruency) and disadvantages (subluxation, dislocation, two-sided wear, and bony ingrowth that may limit motion) [24]. Treatment options for failed total ankle arthroplasty include bracing, resection arthroplasty, revision arthroplasty, arthrodesis, and amputation [25]. V. Debate—calcaneal fractures: open versus closed treatment. Risk factors for a poor prognosis after surgical treatment of a calcaneal fracture may include a negative preoperative Bo¨hler’s angle, patient age . 50 years, smoking, heavy labor occupation, and worker’s compensation claim [26]. Open reduction and internal fixation includes reduction of the articular surfaces and the tuberosity, and may improve the potential for normal footwear and function [27]. VI. International symposium: To fuse or not to fuse? Foot function includes shock absorption, support, and propulsion [28]. Biomechanical issues in the treatment of foot and ankle disorders include stability, the windlass effect, the metatarsal break, and deformity malalignment [28]. Soft tissue options for treatment of posterior tibial tendon (PTT) dysfunction include anterior transfer of the PTT, plication of the talonavicular capsule, flexor digitorum longus tendon transfer, tibialis anterior transfer, spring ligament reconstruction, and Achilles tendon lengthening [29].

Bony procedures for acquired flatfoot deformity include medial calcaneal osteotomy and lateral column lengthening [30]. Treatment of the planovalgus foot with associated forefoot supination deformity may include a plantarflexion metatarsal osteotomy or tarsometatarsal arthrodesis [31]. Management of cavovarus foot deformity may include a combination of soft tissue and bony procedures including plantar fascia release, Achilles tendon lengthening, claw toe correction, first metatarsal osteotomy, calcaneal osteotomy, and triple arthrodesis [32].

3. Scientific sessions 3.1. Ankle A.

B.

C.

D.

E.

Tibiotalocalcaneal arthrodesis. In 134 tibiotalocalcaneal fusions done for concomitant ankle and subtalar arthropathy, 22 (16%) cases had removal of the intramedullary nail (most frequently for infection) at an average of 18 months after arthrodesis [33]. In 18 (82%) of the 22 cases of nail removal, average AOFAS score was 62 points, 15 (83%) feet were plantigrade, 11 (61%) feet had radiographic union, and 12 (67%) feet required no assistive devices for ambulation [33]. Ankle osteoarthritis. Gait analysis in seven patients with unilateral ankle osteoarthritis and 14 normal control subjects showed that arthritis patients walked at a lower cadence and had a longer duration of the gait cycle and stance phase [34]. Arthritis patients had significantly less hindfoot motion and abnormal ground reaction forces compared with normal subjects [34]. Extended ankle and pantalar arthrodesis. In 11 extended ankle (tibiotalar and subtalar) arthrodeses done with compression screw techniques, union was achieved in 8 (73%) cases after primary or revision surgery, and average AOFAS score was 41 points [35]. In 18 pantalar fusions, union was achieved in 13 (72%) cases after primary or revision surgery, and average AOFAS score was 29 points [35]. Total ankle arthroplasty. In nine fresh frozen cadaver specimens implanted with the Agilityw total ankle prosthesis and loaded to 720 N in neutral position, average contact pressure was 5.6 MPa, contact area was 0.8 cm2, and peak pressure was 21 MPa [36]. Contact pressures varied inversely with component size [36]. Tibiotalar arthrodesis. Eight patients (mean age, 55 years) with talar body osteonecrosis underwent modified Blair tibiotalar arthrodesis [37]. Follow-up evaluation at an average of 30 months after surgery showed solid union in all patients (two after a repeat procedure for delayed union), and mean AOFAS score was 67 points [37].

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3.2. Fusion A.

B.

C.

D.

Ankle arthrodesis. In 26 patients with post-traumatic or idiopathic ankle arthritis who were treated with ankle arthrodesis, 77% of patients were satisfied with the clinical outcome [38]. Clinical results were rated as excellent or good in 46% of patients (AOFAS score), and gait analysis showed differences in cadence, stride length, and hindfoot motion compared with 27 control subjects [38]. Ankle and hindfoot arthrodesis: bone graft substitute. In 63 patients who had ankle, hindfoot, or tibiotalocalcaneal arthrodesis, demineralized bone matrix (Grafton putty in 37 [59%] patients and Orthoblast in 26 [41%] patients) was placed at the fusion site [39]. Non-union occurred in five (14%) patients treated with Grafton and two (8%) patients treated with Orthoblast (difference not significant) [39]. Reconstruction: bone graft substitute. In 31 procedures (filling of bone defects, fracture treatment, and arthrodesis) that included the use of artificial bone graft substitutes, success was achieved after one operation in 28 (90%) cases and two operations in three (10%) cases [40]. Advantages of bone graft substitutes included the avoidance of donor site morbidity and cost savings of $901 per case [40]. Ankle and subtalar joints: posterior surgical approach. A posterior surgical approach to the ankle and subtalar joints was described that included a straight posterior midline incision and division of the Achilles tendon [41]. In 20 consecutive patients who had reconstructive surgery with this approach, complications included one (5%) superficial wound eschar and one (5%) deep infection, but there were otherwise no wound healing problems [41].

C.

D.

E.

B.

Fifth metatarsal tuberosity fracture. In 10 pairs of cadaver feet, a simulated base of fifth metatarsal tuberosity fracture was made with a saw and fixed with either a 4.0 mm cannulated lag screw perpendicular to the fracture or a 4.5 mm cannulated intramedullary screw [42]. Load-to-failure testing in distraction showed that fixation with the lag screw was significantly stronger than intramedullary screw fixation [42]. Fifth metatarsal fracture. In 25 proximal diaphyseal fifth metatarsal (Jones) fractures (24 patients) treated with a tapered, variable-pitch bone screw (all 25 fractures) and bone graft (21 [84%] fractures), union was achieved in all fractures at an average of eight weeks [43]. Complications included screw malposition in one (4%) fracture and one (4%) stress fracture at the distal tibial bone graft donor site [43].

Ankle fracture and instability. In 70 ankle fractures evaluated with plain radiographs and magnetic resonance imaging (MRI) scans, there was no correlation between tibiofibular clear space (AP or mortise views) or tibiofibular overlap (AP view) and tears of the anterior inferior tibiofibular ligament, posterior tibiofibular ligament, or interosseous membrane (MRI) [44]. However, the medial clear space (mortise view) correlated significantly with deltoid ligament tear (MRI) [44]. Posteromedial talar facet fracture. In five cases of posteromedial talar facet fracture treated at a trauma center, all five (100%) fractures were associated with a medial subtalar joint dislocation [45]. Three (60%) fractures were not initially diagnosed with plain radiography, but were subsequently identified with computerized tomography (CT) [45]. Chopart fracture-dislocation. In 110 Chopart joint injuries (100 patients, 10 bilateral; mean age, 32 years), the diagnosis consisted of Chopart fracturedislocation in 60 (55%) injuries, Chopart joint pure dislocation in 28 (25%) injuries, and combined Chopart and Lisfranc fracture-dislocation in 22 (20%) injuries [46]. Initial open reduction was associated with better functional outcome scores at follow-up evaluation (average, nine years) than closed reduction for Chopart or combined Chopart and Lisfranc fracture-dislocations but not for pure Chopart dislocations [46].

3.4. Forefoot A.

3.3. Trauma A.

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B.

C.

D.

First MP joint arthrodesis. In 10 pairs of cadaver feet, first MP joint arthrodesis was done with cup-and-cone joint surface preparation and fixation with either two crossed 4.0 mm partially-threaded cannulated cancellous screws or a single 6.5 mm partially-threaded intramedullary cancellous lag screw placed parallel to a 1.6 mm Kirschner wire [47]. Load-to-failure testing with a plantar to dorsal load showed that intramedullary fixation was stiffer and stronger than crossed screw fixation [47]. Second MP joint arthrodesis. In eight patients who were treated with second MP joint arthrodesis for severe crossover toe deformity, all patients were reported to have good or excellent results at an average of 13 months after surgery [48]. Hallux rigidus. Surgery (cheilectomy, membrane arthroplasty, arthrodesis, or Keller arthroplasty) was done in 34 feet (30 patients; average age, 61 years) for treatment of hallux rigidus [49]. For both primary (20 [59%] feet) and revision (14 [41%] feet) surgery, the hallux score increased by an average of 25 points [49]. Lesser toe deformity. In 266 toes (161 patients; average age, 66 years; 139 [86%] women), a transfer of the flexor digitorum longus tendon was done as part of

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surgical correction for flexible hammertoes, fixed hammertoes, mallet toes, and claw toes [50]. At an average of six years after surgery, 95% of the toes were rated as satisfactory by the patients [50]. Metatarsal osteotomy. In six fresh frozen loaded cadaver specimens, performance of a distal second metatarsal osteotomy caused a reduction in pressure measured under the second metatarsal head, both in simulated midstance and heel-rise positions [51]. Metatarsal osteotomy. In 69 patients with intractable metatarsalgia with or without intractable plantar keratosis, a solitary distal second, third, or fourth metatarsal osteotomy resulted in resolution of the original metatarsalgia in 66 (96%) patients at an average of eight years after surgery [52]. However, symptomatic transfer metatarsalgia was noted in six (9%) patients [52].

E.

3.6. New approaches A.

3.5. Midfoot and forefoot A.

B.

C.

D.

Clawed hallux. In eight fresh frozen loaded cadaver feet, the effects of overpulling the extrinsic tendons to the first ray were evaluated [53]. Overpulling the peroneus longus caused the greatest increase in plantar pressure under the first metatarsal head; overpulling the flexor hallucis longus caused the greatest increase in plantar pressure under the hallux and the greatest angular change in the interphalangeal joint; and overpulling the extensor hallucis longus caused the greatest angular change in the MP joint [53]. Interdigital clavus. Partial syndactylization (44 procedures in 41 patients) was done for painful interdigital clavus, including two cases in which revision of the syndactylization was done [54]. Follow-up evaluation at an average of four years after surgery showed that all patients would have the procedure done again, all patients returned to preoperative shoe wear, and there were no complaints of poor cosmesis [54]. Acquired flat foot. In 37 feet (23 patients; average age, 50 years) with dorsolateral peritalar subluxation, simulated weight bearing CT showed significantly greater degenerative changes in the subtalar, talonavicular, naviculocuneiform, calcaneocuboid, and first tarsometatarsal joints compared with a control group of six feet (five healthy subjects; average age, 36 years) [55]. The degenerative changes were usually not visible on plain radiographs [55]. In the study patients, medial column collapse occurred in the naviculocuneiform and talonavicular joints, and dorsal subluxation of the first tarsometatarsal joint was noted [55]. Midfoot arthritis. In 58 feet (58 patients; average age, 49 years) with post-traumatic (33 [57%] feet) and degenerative (25 [43%] feet) arthritis, treatment included various combinations of first, second, and third tarsometatarsal, intercuneiform, and naviculocuneiform arthrodesis [56]. Radiographic union was

noted in 48 (83%) feet at an average of 11 weeks after surgery, and 52 (90%) patients had symptomatic improvement [56]. Chondrosarcoma. In the Scottish Bone Tumour Registry, there were 10 cases of chondrosarcoma involving the bones of the foot [57]. In the affected patients (age range, 17 – 83 years), progressively painful swelling was usually noted on presentation, and radiography usually showed bone expansion, cortical destruction, and soft tissue extension [57]. At an average of seven years after presentation, one (10%) patient had local recurrence after limited local surgery and one (10%) patient had died of metastatic disease [57].

B.

C.

D.

Lower extremity amputation. In 19 patients (average age, 64 years), including 14 (74%) patients with diabetes, amputation (transtibial or knee disarticulation) for gangrene or infection was followed by application of a prefabricated immediate postoperative prosthesis in the operating room [58]. Four (21%) patients were excluded because of death, ischemic wound failure, or cardiac complications; the other 15 (79%) patients began partial weight bearing on the first postoperative day and were fitted with a custom prosthetic limb at an average of eight weeks after surgery [58]. Two (13%) of the 15 patients had minor skin loss secondary to shear, but this resolved with local care [58]. Tourniquet pressure. Limb occlusion pressure, defined as the tourniquet cuff pressure required to occlude arterial flow, was determined in 40 patients having foot and ankle surgery under general anaesthesia [59]. A wide, contoured tourniquet cuff used in 20 patients resulted in lower limb occlusion and cuff pressures than a 4 in. cuff used in 20 patients (average limb occlusion pressure: wide cuff, 140 ^ 30 mm Hg; 4 in. cuff, 180 ^ 30 mm Hg) (average cuff pressure: wide cuff, 190 ^ 40 mm Hg; 4 in. cuff, 240 ^ 40 mm Hg) [59]. Plantar fasciitis. In 150 patients with chronic unilateral plantar fasciitis, active treatment with extracorporeal shock wave therapy (a single, 20 min session; 1300 mJ/mm2) was compared with sham treatment (no shock wave penetration) [60]. At three months after treatment, a visual analog score showed a 56% success rate in the active treatment group and a 45% success rate in the sham treatment group [60]. Transtibial amputation. In 12 patients (average age, 43 years) who had primary or revision transtibial amputation with a distal bone bridge synostosis, union of the bridge was achieved in 11 (92%) patients at an average of 11 weeks after surgery [61]. Six (50%) patients required screw removal [61].

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3.7. Diabetes A.

B.

C.

D.

E.

Charcot foot and ulceration: external fixation. In 77 feet (77 patients; average age, 57 years; mean duration of diabetes, 18 years) with chronic ulceration (average duration, 12 months) and Charcot arthropathy, treatment included debridement, osteotomy, and stabilization with a fine wire ring external fixator for an average of 90 days [62]. Follow-up evaluation at a mean of 20 months after surgery showed that no patients had recurrence of ulceration at the prior site, and 3 (4%) patients had below knee amputation [62]. Diabetes: ankle stiffness. In 25 diabetic and 29 nondiabetic adults, measurement of passive plantarflexion and dorsiflexion at a rate of 40 cycles per minute showed that the diabetic ankles were stiffer at maximum plantarflexion and dorsiflexion than non-diabetic ankles [63]. Diabetic ankles absorbed more energy during cyclic motion than non-diabetic ankles [63]. Total contact cast. In 70 patients with severe peripheral neuropathy, a total of 398 total contact casts (average: six casts per patient, eight days per cast) were used to treat neuropathic ulcers (271 [68%] casts) or Charcot arthropathy (200 [50%] casts) [64]. Complications consisted of de novo ulceration with 22 (6%) casts; all new ulcers healed within three weeks except for one ulcer that resulted in a toe amputation [64]. Charcot joints: midfoot. In 12 patients with complex midfoot Charcot deformity, surgical reconstruction included bony resection or osteotomy and compression arthrodesis with long, large-diameter intramedullary screw fixation [65]. Bony union was achieved in 10 (83%) patients at an average of five months after surgery, and all patients returned to functional ambulatory status within seven months [65]. Ulceration: Achilles tendon lengthening. In 55 patients with neuropathic plantar ulcers, treatment consisted of total contact casting (TCC) alone in 31 (56%) patients or tendo-Achilles lengthening (TAL) with six weeks of immobilization in 24 (44%) patients [66]. There was no difference in frequency of wounds healed (TCC, 28 of 31 [90%] wounds; TAL, 22 of 24 [92%] wounds) or average time to healing (TCC, 40 ^ 30 days; TAL, 40 ^ 10 days) between the two treatments, but frequency of recurrent plantar ulcer within six months was much lower for the TAL group (TCC, 15 of 25 [60%] patients; TAL, 3 of 21 [14%] patients; P , 0.005) [66]. Average forefoot plantar peak pressure during barefoot walking was reduced six weeks after TAL ð50 ^ 30ÞN/cm2 but returned to the pre-treatment value ð90 ^ 20ÞN/cm2 within six

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months ð90 ^ 30ÞN/cm 2 of treatment (N ¼ 13 patients; P , 0.001) [66]. This study received the Roger Mann Award. Dorsal wounds: soft tissue reconstruction. Treatment of 44 dorsal foot wounds (diabetic, 26 [59%]; nondiabetic, 18 [41%]) consisted of serial debridement followed by reconstruction based on size and depth of wound (primary closure, secondary intention, skin graft, local flap, pedicled flap, or microvascular free flap) [67]. Complete healing occurred in 42 (95%) wounds by an average of 120 days after the first debridement, and two (5%) wounds required transtibial amputation [67].

3.8. Soft tissue and sport injury A.

B.

C.

D.

E.

Plantar fascia. In 38 feet with heel pain, preoperative MRI of the plantar fascia showed chronic tear in 30 (79%) feet and chronic inflammation in eight (21%) feet [68]. Postoperative MRI at 1 – 7 years after excision of the plantar fascia and calcaneal prominence showed good healing of the plantar fascia in 16 (42%) feet, a defect with inflammation in 13 (34%) feet, inflammation in seven (18%) feet, and a defect in two (6%) feet; clinical results were rated very good or good in 24 (63%) feet [68]. Achilles tendon rupture. Follow-up evaluation at an average of four years after non-operative treatment of Achilles tendon rupture (40 ruptured tendons in 37 patients; average age, 46 years; weight bearing cast for two months) showed that average AOFAS score was 96 points [69]. Thirty-two (86%) patients had returned to full, unrestricted activities, and two (5%) tendons reruptured [69]. Achilles tendon sleeve avulsion injury. Achilles tendon sleeve avulsion consisted of avulsion of the Achilles insertion as a continuous sleeve of soft tissue, without bony avulsion or tendon discontinuity [70]. Surgical repair of this injury (primary suture of the tendon to two drill holes in the calcaneus; excision of the Haglund prominence) in six patients (mean age, 51 years) gave clinical results similar to the opposite, noninjured side (average AOFAS score at an average of 17 months after repair: injured side, 94 ^ 9 points; noninjured side, 97 ^ 5 points); average strength testing results (mean, eight months after surgery) were similar for the injured and non-injured sides [70]. Chronic Achilles tendon rupture. In 18 chronic Achilles tendon ruptures or re-ruptures (18 patients; age range, 24 – 46 years), tendon reconstruction was done with an artificial ligament [71]. Follow-up evaluation at an average of 3.5 years after surgery showed that 14 (78%) patients had returned to the preinjury level of sport participation [71]. Achilles tendon healing. Mice deficient in Growth and Differentiation Factor 5 (GDF-5) had impairment of

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Achilles tendon healing after tenotomy and repair [72]. Compared with control mice, GDF-5-deficient mice had a delay in Achilles tendon healing of approximately one week, and biomechanical parameters (peak force to failure and stiffness of repair tissue) remained compromised after five weeks of healing [72]. Gastrocnemius recession. A modified Strayer gastrocnemius recession was done in 93 adults (average age, 47 years) for a broad variety of indications including forefoot overload conditions and Achilles tendinopathy [73]. Follow-up evaluation at an average of 13 months after surgery showed that 95% of patients were satisfied, 88% of patients had mild or no change in calf strength, and 90% of patients had improvement or no change in activities of daily living; however, 33% of patients reported a frequent limp [73].

E.

a load (259 N) applied to the peroneus brevis tendon caused more talonavicular eversion than a load (259 N) applied to the peroneus longus tendon (peroneus brevis, 2 ^ 48 eversion; peroneus longus, 0 ^ 58 inversion; P ¼ 0:009) [77]. Plantar fasciitis. A prospective randomized study of 82 patients with chronic proximal plantar fasciitis (duration . 9 months) was done to compare the efficacy of stretching programs for either the plantar fascia or Achilles tendon [78]. Follow-up evaluation after eight weeks of treatment showed significantly greater improvements in pain subscale scores of the Foot Function Index and in the Subject Relevant Outcome Survey in patients who did the plantar fascia stretching program [78].

3.10. Trauma 3.9. Hindfoot A. A.

B.

C.

D.

Acquired flatfoot deformity. A survey of 52 academic foot and ankle surgeons about the surgical treatment of a 62 year old man with symptomatic type II acquired flatfoot deformity showed wide variation in current approaches [74]. Preferred surgical treatment included a bony procedure by 51 (98%) surgeons, preservation of the subtalar and talonavicular joints by 46 (88%) surgeons, medial calcaneal osteotomy by 40 (77%) surgeons, lateral column lengthening by 25 (48%) surgeons; preferred treatment included a soft tissue procedure by 50 (96%) surgeons, augmentation of the PTT by 49 (94%) surgeons, and spring ligament repair by 28 (54%) surgeons [74]. Talonavicular arthrodesis. In 11 patients (average age, 55 years) who had isolated talonavicular arthrodesis for stage II PTT dysfunction, follow-up evaluation (mean, 36 months) showed excellent or good results in four (36%) patients, mean AOFAS score of 52 points, nonunion in three (27%) patients, and subtalar arthritis in seven (64%) patients [75]. In four patients (average age, 45 years) who had isolated talonavicular arthrodesis for talonavicular arthritis, follow-up evaluation (mean, 41 months) showed excellent or good results in one (25%) patient, mean AOFAS score of 72 points, non-union in three (75%) patients, and subtalar arthritis in one (25%) patient [75]. PTT dysfunction. PTT dysfunction (stage II) was treated with tendon debridement, flexor digitorum longus tendon transfer to the navicular tuberosity, and medial calcaneal osteotomy in 11 patients (average age, 59 years; average weight, 80 kg) [76]. Gait analysis two weeks before and one year after surgery showed a postoperative increase in gait velocity, step length, and push-off power that was not significant, possibly because of the small sample size [76]. Peroneal tendons. In six fresh frozen cadaver specimens arranged in a simulated early heel rise position,

B.

C.

D.

E.

Ankle fracture. In 25 patients who had a displaced pronation, lateral rotation ankle fracture, CT showed a consistent external rotation deformity of the distal fibula fragment [79]. The talus remained congruently aligned with the lateral malleolar articular facet, but was externally rotated relative to the medial malleolus [79]. Calcaneal fracture. Retrospective review of 90 patients after calcaneal fracture showed that lesser toe deformities were present in 13 (14%) patients [80]. The lesser toe deformities were symptomatic in six (7%) of the 90 patients and were operated in three (3%) patients [80]. Calcaneal fracture. In 21 patients who were treated for a tongue-type calcaneal fracture with a minimallyinvasive method (Essex –Lopresti reduction maneuver and small fragment screw fixation), follow-up evaluation (average, 26 months after surgery) showed an average Foot Function Index score of 21 points [81]. In 26 patients treated with this method, average Bo¨hler’s angle was increased from 38 before surgery to 278 after union [81]. Calcaneal fracture. In 25 patients over the age of 65 years (average age, 70 years), 27 calcaneal fractures were treated with open reduction and internal fixation (26 fractures) or primary fusion (1 fracture) [82]. Follow-up evaluation (average, 37 months after treatment) showed that 26 (96%) fractures had healed with index treatment, 11 (25%) patients had developed post-traumatic arthritis, 12 complications had occurred in 12 (48%) patients, and average AOFAS score was 82 points [82]. Soft tissue reconstruction. Free tissue transfer using perforator flaps (flaps, based on perforating vessels, that transfer only skin and fascia while preserving the underlying muscle) was done in 10 patients for management of wounds that had resulted from trauma, surgery, or diabetes [83]. All flaps survived with no

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deep infection, and advantages over muscle flaps included diminished bulk, earlier shoe-fitting, and diminished donor-site morbidity [83]. 3.11. Talar lesions A.

B.

C.

D.

Osteochondral defect. In five matched cadaver talus and distal femur specimens, coronal (slice thickness, 1.5 mm) MRI and three dimensional reconstruction was done to evaluate topographic matching of six potential distal femoral donor sites with three medial talar recipient sites for osteochondral transplantation [84]. Better circumferential fits were demonstrated for transplantation to the posteromedial talar lesions than the middle –medial or anteromedial talar lesions, and the best surface contour restoration for all recipient sites was obtained from the superolateral femoral condylar donor site [84]. Osteochondral defect. In 12 ankles (12 patients; average age, 28 years), talar osteochondral defects were treated with autologous osteochondral graft from the lateral femoral condyle (11 cases) or talar head (one case) [85]. Evaluation at an average of two years after surgery showed that pain was alleviated in all patients and mean AOFAS score was improved (mean AOFAS score: preoperative, 62 points; follow-up, 90 points) [85]. Osteochondral defect. Nine adolescents (average age, 15 years) were treated for talar osteochondral defects (average duration of symptoms, 12 months) with arthroscopic examination, debridement, and drilling [86]. Evaluation at an average of 12 months after surgery showed that seven (78%) patients were free of pain and eight (89%) patients had no limitations of activity [86]. Osteochondral defect. MRI of 40 ankle fractures showed that 28 (70%) fractures had associated talar osteochondral defects [87]. Fracture mechanism included pronation with 15 (54%) talar defects and supination with 13 (46%) talar defects [87].

3.12. Sport injury: ligaments and tendons A.

B.

Ankle instability. Lateral ankle ligament reconstruction was done in 27 patients (mean age, 22 years) with a modified Brostrom procedure with suture anchors [88]. Evaluation at a mean of 14 months after surgery showed a good or excellent functional outcome in 25 (93%) patients, and only one (4%) patient underwent revision [88]. Subtalar instability. Six fresh frozen cadaver specimens were each loaded in six directions before and after section of the interosseous talocalcaneal ligament to determine load – displacement response [89]. The largest increase in neutral zone laxity consisted of a 76% increase in the anteromedial to

C.

D.

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posterolateral (300 – 1208) direction (reference axes: anterior, 08; lateral, 908; posterior, 1808; medial, 2708) [89]. This study received the J. Leonard Goldner Award. Lateral ankle instability. Imaging studies (MRI and CT scans) of 65 patients who had undergone lateral ankle ligament reconstruction for instability were compared to those of 65 control patients who did not have ankle instability [90]. Fibular position was more posterior in patients with instability, evidenced by the greater average axial malleolar index (AMI) in this group (average AMI: instability group, 178; control, 98; P , 0:001) [90]. Peroneal tendons. Anterior – posterior displacement of the talus in response to a 150 N load was evaluated in eight fresh frozen cadaver specimens in neutral position [91]. Average anterior displacement of the talus increased by 0.9 mm (15%) after release of the peroneal tendons, and by a total of 2.3 mm (34%) after both release of the peroneal tendons and section of the anterior talofibular ligament [91].

4. Conclusion The conference included several special presentations to honor past and present leaders of AOFAS and to expand global perspectives. Lew Schon reviewed the career of Melvin H. Jahss, who was one of the seven founding members of AOFAS, founding Editor-in-Chief of Foot & Ankle, and past president of AOFAS [92]. Outgoing president Pierce E. Scranton, Jr. was honored by a presentation from the Board of Directors for his efforts in establishing the AOFAS Outreach and Education Fund. Scranton publicly recognized the leading contributors to the Fund, and discussed the first overseas fellowship of AOFAS members to Vietnam [93]. Incoming president E. Greer Richardson reviewed the outstanding achievements of AOFAS and the efforts of the membership, concluding that “our Society is worthy of emulation” [94]. The role of AOFAS members in the world was further highlighted by an evening presentation about the AOFAS mission to Vietnam by Naomi Shields and a magnificent photographic presentation of landscapes, wildlife, and people by presidential guest speaker Roger Laurilla [95]. The summer meeting was a great success, thanks to the outstanding efforts of the AOFAS staff and generous educational grants from 38 corporate sponsors. The next meeting of the AOFAS will be on Specialty Day, February 8, 2003, at the meeting of the American Academy of Orthopaedic Surgeons in New Orleans, LA. The next summer meeting of the AOFAS will be held June 27 – 29, 2003 in Hilton Head, SC.

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