A clinical longitudinal evaluation of pre-fabricated, semi-rigid foot orthoses prescribed to improve foot function

BackgroundCustom-made foot orthoses whilst effective can be expensive and time-consuming to manufacture making ready made devices an attractive option. This study, with follow up after 12 months provides longitudinal data not frequently available.ObjectivesLongitudinal evaluation of the efficacy of a slim, ready made, 3/4th length semi-rigid foot orthosis.MethodData was collected from 21 participants at baseline, at 4 weeks and via postal questionnaire after 12 months. Powerstep orthoses (Cuxson-Gerrard &; Co Ltd., Oldbury, UK) were given to participants with the therapeutic aim of resolving or reducing their lower limb symptoms.ResultsParticipants reported an initial marked decrease in foot pain, found the orthoses fitted in footwear readily, had a sense of increased foot stability and a significant improvement in comfort (p < 0.0001). Some increase in pain levels reported after 4-weeks (p = 0.01), was accompanied by an equally significant increase in mobility (p = 0.01) which triangulated closely against diary records. After a mean of 15.1 months, 73% of participants still found the orthoses beneficial.ConclusionParticipants found ready made orthoses enhanced sense of stability and generally reduced symptoms over a period of at least 1 year.     

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.ResultsThe mean postoperative [TCH] [70.3 ± 1.9 mm] was statistically better than the preoperative value [64.7 ± 2.2 mm] [p < 0.001]. There was a statistically significant decrease in [HVA] [p < 0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p < 0.001].ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.     

Computer-assisted surgery (CAS) based correction of posttraumatic ankle and hindfoot deformities—Preliminary results

The first clinical experiences with a computer assisted surgery based (CAS) guided correction arthrodeses at ankle, hindfoot and midfoot were evaluated.MethodsTime spent, accuracy, surgeons’ rating (Visual Analogue Scale [VAS], 0–10 points) were analyzed. The accuracy was assessed by ISO-C 3D (Siremobile™, Siemens, Germany).Results10 patients were included (ankle, n = 3; subtalar joint, n = 6; ankle and subtalar joint, n = 2; Lisfranc joint, n = 1). Time needed for preparation was 500 s (400–900). The correction process took 45 s (30–60). All angles/translations were achieved as planned before surgery (≤ ±1°/±1 mm). The ratings of the three involved surgeons were: feasibility, 9.5 (9–10); accuracy 9.8 (9.5–10); clinical benefit 9 (8–10).ConclusionsCAS guided correction of posttraumatic deformities of the ankle and hindfoot region provides very high accuracy and a fast correction process. The significance of the introduced method may be high in those cases, because the improved accuracy may lead to an improved clinical outcome.     

Effectiveness of subtalar arthroereisis with endorthesis for pediatric flexible flat foot: a retrospective cross-sectional study with final follow up at skeletal maturity

BackgroundPediatric flexible flatfoot is sometimes asymptomatic but it can rarely cause physical impairment, pain, and difficulty walking. We evaluated the radiographic effectiveness of intervention of subtalar arthroereisis with endorthesis for pediatric flexible flatfoot with final follow-up at skeletal maturity.MethodsThis is a retrospective cross-sectional study. 56 consecutive patients (112 feet) who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot (mean age at final follow-up 15.5 ± 1.2 years, 39.3% female) were enrolled. All the radiographic studies were performed in the hospital. Radiographs (standard weight-bearing radiographs of the foot with anteroposterior and lateral view) were used to measure lateral talocalcaneal angle (LTC), calcaneal pitch angle (CP), Meary’s angle (MA), anteroposterior talonavicular angle (APTN), talonavicular uncoverage percent (TNU). Minimum follow-up was 18 months. Measures were assessed pre-operatively and at the final follow-up. Clinical and functional parameters were assessed at the final follow-up.ResultsChildren who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot exhibited a statistically significant improvement in all radiographic measurement parameters at the last follow-up at skeletal maturity (all, p < 0.004). Mean follow-up was 40.1 ± 23.6 months. Clinical parameters were not correlated with the foot radiographic parameters at follow up period.ConclusionsOur results suggest that endorthesis in pediatric flexible flatfoot was effective for improving radiographic parameters at skeletal maturity. The amount of the morphologic correction at the end of the skeletal growth should be expected mainly for lateral tarso-metatarsal alignment and talo-navicular congruency (MA, APTN, TNU).Level of evidenceLevel III, retrospective study.     

The symptomatic adult flatfoot: Is there a relationship between severity and degree of pre-existing arthritis in the foot and ankle?

BackgroundThe acquired adult flatfoot deformity (AFFD) is a potentially debilitating foot condition with a prevalence thought to be between 3 %–10 %. To the authors’ best knowledge, no association has been described between severity of AFFD and degree of pre-existing ankle or foot arthritis. The degree and pattern of preexisting ipsilateral arthritis of the foot and ankle was investigated in those with symptomatic AFFD presenting to hospital.MethodsRetrospective observational study between May 2015 and May 2018, of patients who presented to our tertiary clinic with symptomatic AFFD. Radiographs of one hundred and forty-eight (n = 148) patients were reviewed, excluding those with charcot arthropathy, previous trauma or coalition. The primary outcome measure was severity of OA in the ankle, subtalar, talonavicular and calcaneocuboid joints. Secondary outcome was severity of radiographic planovalgus deformity. The independant variables used were age and severity of planovalgus deformity as measured by the Meary angle, calcaneal pitch and medial cuneiform-fifth metatarsal height. A linear regression model was carried out on the outcomes.ResultsMedian age was 60.0 years (IQR 22). There were 56 males to 92 females, with 75 left sided deformities observed and 73 right sided. With increasing severity of planovalgus measurements, there was no significant association observed in severity of arthritis in the ankle joint (p = 0.766), subtalar joint (p = 0.090), talonavicular joint (p = 0.256) and calcaneocuboid joint (p = 0.091). With increasing age, there was significance observed in degree of ankle arthritis, subtalar, talonavicular and calcaneocuboid joints (p = 0.001). There was no significant correlation observed with age for the angular break of Meary’s line (p = 0.73), calcaneal pitch (0.262) and medial cuneiform-fifth metatarsal height (p = 0.937).ConclusionThis observational study shows no significant association between severity of radiographic planovalgus deformity and pre-existing arthritis of the ankle, hindfoot and midtarsal joints.     

The translation,cultural adaptation and psychometric evaluation of the Manchester Foot Pain and Disability Index in Persian-speaking Iranians with foot disorder

BackgroundFoot pain has a significantly detrimental effect on mobility, function and health status. Researchers have developed a number of measurement tools to assess foot health and its impact on the quality of life. This study was conducted to translate the original English Manchester Foot Pain and Disability Index (MFPDI) into Persian and to examine the psychometric properties of the Persian version.MethodsA total of 206 patients with a range of foot disorders filled out the Persian version of the MFPDI and the Short-Form 36 Health Survey (SF-36). The Persian version of the MFPDI was re-completed by the participants at an interval of five to seven days. The analyses performed included internal consistency, test-retest reliability, construct validity, and floor and ceiling effect analysis.ResultsThe Persian MFPDI had a good internal consistency (Cronbach’s α ≥ 0.70) and test-retest reliability (ICC = 0.84). The construct validity of the Persian MFPDI was demonstrated to be acceptable as a result of its significantly strong negative correlations with the SF-36.ConclusionThe results of this study showed that the Persian version of the MFPDI is a valid and reliable measure to assess foot-related disability.     

Short-term and mid-term outcome of total ankle replacement in haemophilic patients

BackgroundAnkle arthropathy is very frequent in haemophilic patients. Prostheses are valuable alternatives to arthrodesis in non-haemophilic patients. We report the experience of a single centre in France on the use of prostheses in haemophilic patients.MethodsRetrospective study of 21 patients with haemarthropathy who underwent ankle arthroplasty (32 ankles), with additional surgery, if needed, from July 2002 to September 2009 (mean follow-up 4.4 ± 1.7 years). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot scale was used to evaluate pain, function, ankle mobility and alignment.ResultsThe overall AOFAS score improved from 40.2 ± 19.4 (pre-surgery) to 85.3 ± 11.4 (post-surgery). The function score increased from 23.6 ± 7.7 to 35.9 ± 6.7 and dorsiflexion from 0.3° ± 5.0° to 10.3° ± 4.4°. Two patients underwent further ankle arthrodesis. On X-ray, both tibial and talar components were stable and correctly placed in all ankles. Alignment was good.ConclusionAnkle arthroplasty is a promising alternative to arthrodesis in haemophilic patients.     

A Randomised Control Trial for evaluating over-the-counter golf orthoses in alleviating pain in amateur golfers

BackgroundThere are few studies to evaluate the effectiveness of orthoses on foot function and pain whilst playing golf.ObjectivesThe study aimed to evaluate the capacity of three different types of orthoses to alleviate levels of pain, whilst playing golf.MethodOver a period of 3 months, 32 amateur golfers took part in a Randomised Control Trial which looked at a prefabricated over-the-counter golf orthosis against a placebo and a cushioning Poron insole using two validated tools—the Foot Health Status Questionnaire and the Foot Posture Index.ResultsOf the 27 golfers that completed the trial, the results showed that the use of orthoses whilst playing golf reduced the levels of pain experienced, with equally positive responses in the placebo group. Of statistical significance (where p > 0.05) was the improvement in foot posture of the right foot (p = 0.053), for those using the Golf Orthaheel. A visual analogue scale showed statistically significant pain reduction (p = 0.007) when using the Poron insole.The results from this trial suggest that orthoses may have an effect in reducing pain and improving foot posture by controlling pronatory movements in golfers.     

Simulated weight reduction using an anti-gravity treadmill – A pilot study of the impact of weight loss on foot and ankle arthritis

BackgroundDespite a paucity of evidence, obesity is frequently cited as an exacerbator of symptoms in foot and ankle arthritis. The aims of the current study were to determine whether simulated weight loss would improve symptoms in obese patients with foot and ankle arthritis.MethodsPatients walked on an “anti-gravity” treadmill allowing simulated weight reduction. Pain was recorded at baseline weight and then compared with pain at simulated normal BMI.ResultsSimulated reduction to BMI 25 caused a significant reduction in pain. Mean pain scores improved from baseline to BMI 25 by 32% (15.9 points, p = 0.04). Paired analysis showed a significant improvement in pain scores (p = 0.016) from BMI of 30 to 25.ConclusionSimulated weight loss from high to normal BMI improved arthritic symptoms. This could be used to power future studies to further investigate the effects of weight loss in foot and ankle patients.Level of evidence Level II – repeated measures cohort study.     

Improved functional outcome after early reduction in Bosworth fracture-dislocation

BackgroundBosworth described an unusual fracture-dislocation of the ankle with fixed posterior fracture-dislocation of the fibula. Previous epidemiological data on the prevalence and characteristics of patients with Bosworth ankle fractures have been limited. Bosworth fracture-dislocations are often missed in patients with ankle fractures. We investigated the outcomes of missed diagnosis and the prevalence of Bosworth fracture-dislocation in patients with ankle fractures.MethodsWe conducted a retrospective analysis of inpatients aged 15 years and older with an ankle fracture, who underwent surgery between 2007 and 2016 in 4 Korean hospitals. The patient demographics, risk factors, fracture characteristics, treatment data, outcomes, and complications were analyzed.ResultsWe reviewed 3405 hospital admissions for ankle fractures. During the study period, Bosworth fracture-dislocations were diagnosed in 51 cases. The prevalence of Bosworth fracture-dislocations (n = 51) was 1.62% among patients with ankle fractures who were enrolled in this study (n = 3140). Emergency surgery was performed within 24 h of injury in 36 cases (group A) and delayed surgery was performed in 15 cases (group B). The mean patient age at admission was 35.97 (standard deviation [SD], 1.643) years in group A and 34.33 (SD, 2.296) years in group B. Men were more commonly affected than women, with a 32:19 ratio. Most of the patients with Bosworth fracture-dislocations were young adults with high-energy trauma. The most frequent mechanism of trauma was falling down stairs (n = 27, 52.94%), followed by traffic accidents. Patient outcomes were significantly better in group A than in group B.ConclusionThe prevalence of Bosworth fracture-dislocations was higher than expected. If unrecognized, it can result in inappropriate treatment and permanent disability. With accurate diagnosis and prompt treatment, excellent results can usually be obtained.Level of clinical significance4.     

The use of ‘off-the-shelf’ foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

BackgroundFoot pain in patients diagnosed with early rheumatoid arthritis is common.ObjectivesTo investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis.MethodsThirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured.ResultsThere was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p < 0.05) and clinically significant reductions in pain levels were also noted.ConclusionPatients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.     

Biering-Sorensen test scores in coal miners

ObjectivesBiering-Sorensen test is an isometric back endurance test. Biering-Sorensen test scores have varied in different cultural and occupational groups. The aims of this study were to collect normative data on Biering-Sorensen holding times, to determine the discriminative ability of the Biering-Sorensen test in Turkish coal miners, and to examine the association between Biering-Sorensen test result and functional disability.MethodsOne hundred and fifty male coal miners participated in this study. Trunk extensor muscle strength was measured using the Biering-Sorensen test. Oswestry disability index was used to measure the functional disability level of low back pain.ResultsThe mean Biering-Sorensen holding time for the total subject group was 107.3 ± 22.5 s. The mean time of Biering-Sorensen test of the subjects with and without low back pain were 99.9 ± 19.8 and 128.6 ± 15.2 s, respectively. The difference between the subjects with and without low back pain was statistically significant (p < 0.001). There was a statistically significant negative correlation between Oswestry functional disability score and Biering-Sorensen holding time (r = ?0.824, p < 0.001).ConclusionsTurkish coal miners have low mean back extensor endurance holding times. Biering-Sorensen test had a good discriminative ability in our study group. Trunk muscle strength has a significant effect on the disability level of low back pain. Thus trunk muscle endurance training exercise therapy may be effective for the reduction of disability in patients with low back pain.     

Impact of the rotational position of the hindfoot on measurements assessing the integrity of the distal tibio-fibular syndesmosis

BackgroundApproximately 20% of patients with ankle fractures demonstrate evidence of syndesmotic injuries. As intra-operative measurements have high specifity but low sensitivity for identifying injuries to the distal tibio-fibular syndesmosis, numerous measurements have been developed to assess pre-operative syndesmosis integrity. Several factors affecting measurements on conventional radiographs and computed tomography (CT) images have been identified. The influence of the rotational position of the hindfoot during imaging, however, remains unclear.MethodsTwenty (20) healthy volunteers (mean age 49, standard deviation [SD] 7.5, range 40–66 years) underwent a weightbearing cone beam CT scan. From this dataset, digitally reconstructed radiographs (DRRs) and axial CT images of the hindfoot were reconstructed. For each image, an antero-posterior view (defined as a plane perpendicular to the longitudinal axis of the second metatarsal) was reconstructed. Then, internal and external rotation of the hindfoot was simulated in 10° increments (maximum rotation of 30°). The tibio-fibular clear space (TFCS), tibio-fibular overlap (TFO), and medial clear space (MCS) were measured on each reconstructed DRR and axial CT image.ResultsInternal rotation of the hindfoot substantially impacted inter-observer agreement for TFCS measurements on DRRs. Intra- und inter-observer agreement of measurements (MCS, TFCS, TFO) on axial CT images was minimally affected by hindfoot rotation. Hindfoot rotation highly impacted on absolute values of each measurement. As little as 10° of internal or external rotation significantly (P < 0.05) impacted MCS and TFO measurements (DRRs and axial CT images). External rotation increased, while internal rotation decreased, MCS and TFO measurements. TFCS measurements performed on DRRs did not significantly differ for 10° (P = 0.0931) and 20° (P = 0.486) of external rotation or for 10° of internal (P = 0.33) rotation.DiscussionThe rotational position of the hindfoot during imaging has a major impact on MCS, TFCS, and TFO measurements when using DRRs and axial CT images. To avoid misinterpretation of measurements, the position of the hindfoot during imaging must be standardized.ConclusionsDRRs and axial CT images require reliable reconstructions to allow accurate assessment of the TFCS, TFO, and MCS.     

Optimising use of the mini C-arm in foot and ankle surgery

BackgroundThe mini C-arm reduces exposure to ionising radiation compared to the conventional C-arm. Optimising radiation exposure is not only desirable, but also a legal requirement and protocols should be in place to achieve this.MethodsSince 2004, all elective foot surgery requiring intraoperative imaging was performed using the mini C-arm. Screening times and radiation doses were recorded for each procedure.ResultsFollowing a learning curve, the screening times stabilised around the median value for the individual procedures. For subtalar or triple arthrodesis this was less than 60 s, for ankle arthrodesis, less than 90 s, for hindfoot arthrodesis using a nail, less than 100 s and for joint injections less than 12 s.ConclusionScreening time can be used as an audit tool to measure optimum use of the mini C-arm. A protocol is presented including an audit form for every operation where the mini C-arm is used. Radiation protection issues are addressed.     

Vitamin D levels in 577 consecutive elective foot & ankle surgery patients

BackgroundVitamin D deficiency is a global concern impacting upon large communities and certain disease populations. It can adversely affect the outcome of orthopaedic operations. We aimed to perform an audit of the Vitamin D status of patients in two centres in the United Kingdom undergoing elective foot and ankle surgery.MethodsSerum 25-hydroxyvitamin-D (vitamin D) levels were obtained prospectively in 577 consecutive elective patients undergoing elective foot and ankle surgery between October 2014 and March 2017 (29 months). Variables including age, gender, ethnicity, location, season, month and procedure type were recorded.Results577 patients were included over the study period. 62.0% were female. Mean age was 53.2 (median 54.5, range 16.7–86.6). 300 patients were treated in Northampton and 277 in Leicester. The serum 25-hydroxyvitamin-D levels for the patient group were normally distributed. The mean was 52.3 nmol/L (SD 28.0; range 7.5–175) and the median 47.5 nmol/L. 21.7% were grossly deficient, 31.9% deficient, 28.9% insufficient and 17.5% within normal range. Age, gender and procedure type did not statistically affect vitamin D levels (p = 0.5, t-test). Ethnicity, location and Winter season did affect Vitamin D levels (p < 0.05). August was the most significant month with levels significantly higher than January, February, March, April, June, November and December (p < 0.05, one-way ANOVA).ConclusionsOnly 1 in 5.7 patients had a normal Vitamin D level and 1 in 4.6 were grossly deficient. Ethnicity and patient location significantly affected Vitamin D results. Summer months were noted to demonstrate significantly the highest levels and August the highest. We did not find that age or gender affected Vitamin D levels in our cohort.     

Can foot orthoses impose different gait features based on geometrical design in healthy subjects? A systematic review and meta-analysis

ObjectiveFoot orthoses (FOs) are popular treatment to alleviate several abnormalities of lower extremity. FO designs might alter lower extremity biomechanics differently, but the association is not yet known. This review aimed to evaluate how different FO designs, namely FO with medial posting, lateral posting, arch support, or arch & heel support, change lower limb kinematics and kinetics during walking.Literature surveyElectronic database search were conducted from inception to March 2019, and 25 papers passed the inclusion criteria. Two independent reviewers checked the quality using a modified Downs and Black checklist (73.7 ± 5.5%) and a biomechanical quality checklist (71.4 ± 17.1%). Effect sizes for differences between with- and without- FO walking were calculated, and meta-analysis was performed whenever at least two studies reported the same variable.ResultsMedial posting reduced peak ankle eversion moment. Lateral posting brought about higher peak ankle dorsiflexion and peak ankle eversion for kinematics, as well as higher peak ankle abduction moment, lower peak knee adduction moment, and higher peak mediolateral ground reaction force (GRF) for kinetics. FOs with either arch support or arch & heel support tended to decrease vertical ground reaction force, but it was not significant.ConclusionThe findings of this review reveal that medial or lateral posting work efficiently to change foot and knee kinematics and kinetics. However, the impact force is just slightly decreased by arch-supported and heel supported FOs. Due to the small number of available studies, and heterogeneity in meta-analysis findings, further research with more standardized biomechanical approach are required.     

Association between preoperative dynamic plantar pressures and clinical outcomes at 6 months after hallux valgus surgery

BackgroundThe influence of preoperative plantar pressures on clinical outcomes following hallux valgus surgery has not been yet established. This study aimed to assess the relationship between preoperative dynamic plantar pressure measurements and clinical outcomes following hallux valgus surgery.Material and methodsA prospective cohort study where patients attending the foot and ankle unit between 2016 and 2017, diagnosed of hallux valgus requesting surgical correction were recruited consecutively and preoperative plantar pressure were measured. At 6-months after surgery, the foot condition and foot pain were measured, through the American Orthopedic Foot and Ankle Society Score (AOFAS), and using Visual Analog Scale (VAS), respectively. A multivariate logistic model was used to estimate the magnitude of the associations between the explanatory variables and outcomes.Results114 patients were included in the study. Significant differences between patients with and without pain at 6-months after surgery were found in mean force on first toe, peak pressure on third and fourth metatarsal head, and maximum force on fourth and fifth metatarsal head (p < 0.05). The multivariate logistic model showed significant association between the preoperative peak pressure on fourth metatarsal head (OR:0.996, p = 0.003), walking (OR:7.430, p < 0.001), orthopedic shoe after surgery period (OR:0.754, p = 0.019) and preoperative AOFAS (OR:0.947, p = 0.006), and the appearance of pain at 6-months after surgery.ConclusionThe presence of pain at six months after surgery was significantly associated with the preoperative peak pressure under the fourth metatarsal head.     

Bone mass and anthropometry in patients with osteoarthritis of the foot and ankle

BackgroundPatients with hip and knee osteoarthritis (OA) have high bone mineral density (BMD) and high BMI. If the same accounts for patients with foot or ankle OA is unknown.MethodsWe measured BMD and femoral neck (FN) width by dual-energy X-ray absorptiometry in 42 women and 19 men with idiopathic OA in the foot or ankle, and in 99 women and 82 men as controls.ResultsWomen with OA had significant higher BMI than controls. Women with OA had higher BMI-adjusted BMD (p < 0.01) and smaller BMI-adjusted FN width (p < 0.01) than controls. Men with OA had higher BMI adjusted-BMD (p < 0.05) and smaller BMI-adjusted FN width (p < 0.01) than controls.ConclusionPatients with OA in the foot or ankle have higher BMD and smaller bone size than being expected by their BMI. This phenotype may provide unfavourable forces across the joint and is hypothetically important for development of OA.     

Extracorporeal shockwave therapy in the management of plantar fasciitis: A randomized controlled trial

BackgroundThis study aimed at estimating the extent to which a combination therapy of extracorporeal shockwave therapy (ESWT) with usual care (exercise and orthotic support) improve functional ability in the patient with plantar fasciitis when compared to usual care alone.MethodsParticipants with plantar fasciitis were randomly allocated into two groups: ESWT (n = 23), and control (n = 21). All participants received home exercise program with orthotic support. In addition, ESWT group received 2000 shock waves with 0.02 mJ/mm² for three sessions. Functional outcomes were measured by function subscale of American orthopedic foot and ankle society (AOFAS-F) score and 12 minutes walking test including walking speed, cadence. The scores were recorded at baseline, third week and third month after the treatment. Analysis was performed using repeated measures ANOVA, and an intention to treat approach using multiple imputations.ResultsResults showed that there was a significant improvement in AOFAS-F total score and walking speed over three months in both groups (p < 0.001, p = 0.04 respectively); improvements in AOFAS-F were particularly in activity limitation (p = 0.001), walking distance (p = 0.02) and walking surface (p = 0.02). Groups were comparable with each other for both walking speed and AOFAS-F in any assessment time (p > 0.05). However, groups performed differently in cadence where there was an increase in cadence in ESWT group whereas a decline in control at the third month (p = 0.07).ConclusionThe results revealed that ESWT did not have an additive benefit over usual care to improve foot function and walking performance in patient with plantar fasciitis over three months post-treatment.     

Is there a learning curve in foot and ankle surgery?

BackgroundPrevious studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome.Methods150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups.ResultsFunctional improvement was greater, approaching significance, in the second group (p = 0.0605). There was no difference for forefoot cases (p = 0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p = 0.0333).ConclusionsA learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.