Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.     

Complications of forefoot and midfoot fractures

Complications of the forefoot and midfoot are not as common as injuries to the hindfoot. The problem areas that the author will focus on with these injuries will be open injuries, unstable fractures, slow or poor healing fractures, and neurovascular injuries. The author also will discuss the toes, metatarsals, tarsometatarsal, cuneiforms, and talonavicular areas. Because the forefoot and midfoot must support as much as four times the body weight, alterations caused by injury to the weightbearing surface can have significant consequences. Treatment rationale to maintain a sound weightbearing plantar surface will be discussed. Each region will be highlighted with respect to the complications that can occur. Anatomic alignment with stable fixation and good soft tissue coverage in an appropriate rehabilitation program are the principles that should be followed and discussed.     

Minimally invasive surgery and percutaneous surgery of the hindfoot and midfoot

Minimally invasive surgery (MIS) and percutaneous (PC) surgery recently spread as a new technique in operative forefoot correction, and by extension in hindfoot and midfoot. Numerous procedures were described, and a race for MIS and PC has started. However, performing surgery with small incisions should not be an end in itself. Biomechanical and anatomical concerns must be taken into account and shall not be sacrificed for cosmetic reasons. For the most common hindfoot and midfoot pathologies, we discuss what we consider the surgical necessities and then describe the MIS and/or PC procedure we choose, according to these fundamentals.     

Assessment of plantar pressure in forefoot relief shoes of different designs

BACKGROUND: After reconstructive forefoot surgery, patients require complete or partial forefoot relief, which can be obtained with a variety of shoe designs. The aim of this study was to evaluate the effectiveness of two different types of forefoot-relief shoes frequently used after surgery, especially their safety against unintentional forefoot load. METHODS: Ten healthy volunteers were asked to perform five trials on a treadmill at self-selected speeds. In the first trial, mean peak pressure values in mass-produced shoes and insoles were evaluated and considered as 100%. Two different shoe designs (short heel-short sole, ii: short heel-complete sole) were compared in two trials each with appropriate and inappropriate use (attempting to put weight on the forefoot) gait pattern. Plantar pressure values were obtained using the Pedar cable system (Novel Inc., Munich, Germany). For analysis, pedobarographic pictures were subdivided into midfoot (31% to 60% of the total insole length) and forefoot (61% to 100% of the total insole length). ANOVA was used for statistical analysis, and p values less than 0.01 were considered significant. RESULTS: With the short-soled shoe, forefoot and midfoot relief was 100% in both compliant and in noncompliant use. With wearing a complete sole, compliant use led to a significant reduction (p < 0.01) of mean peak pressure under the forefoot (34 +/- 13% remaining) and midfoot (47 +/- 13% remaining). Noncompliant use of the complete-sole shoe produced mean peak pressure values significantly higher (p < 0.01) than normal gait in mass produced shoes under the forefoot, but not under the midfoot. CONCLUSIONS: Forefoot-relief shoes are effective in reducing both mean and peak plantar pressures. Shoes with a nonsupported midfoot and forefoot may be safer with inappropriate use than shoes with a complete sole. The kind of forefoot shoe should be carefully chosen to regulate weightbearing after reconstructive forefoot surgery.     

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.     

Treatment of residual clubfoot deformity--the "bean-shaped" foot--by opening wedge medial cuneiform osteotomy and closing wedge cuboid osteotomy. Clinical review and cadaver correlations

Six patients (seven feet) previously treated surgically for clubfoot had a "bean-shaped" foot. Opening wedge medial cuneiform and closing wedge cuboid osteotomies were done, resulting in good resolution of the prominent midfoot supination and forefoot adductus without significant soft tissue dissection and invasion of growing areas in the foot. Cadaver reproductions show that the cuboid closing wedge is responsible for the change in the midfoot, whereas the cuboid and cuneiform osteotomies both contribute to the change in the forefoot.     

Soft-tissue and osseous techniques to balance forefoot and midfoot amputations

Soft-tissue and osseous balancing of forefoot and midfoot amputations is imperative to provide the patient with a stable, durable, and functional residual foot. This article discusses reproducible methods for balancing transmetatarsal and Lisfranc amputations in high-risk patients, with detailed explanations of the recommended surgical techniques. In addition to performing the appropriate procedures for the individual patient, careful attention to the perioperative management of this patient population, with a multidisciplinary approach, is mandatory for long-term success.     

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. METHODS: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. RESULTS: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p相似文献   

Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Clinical and patient-reported outcomes following Low Intensity Pulsed Ultrasound (LIPUS,Exogen) for established post-traumatic and post-surgical nonunion in the foot and ankle

BackgroundBiophysical methods including Low Intensity Pulsed Ultrasound (LIPUS) are emerging as potential alternatives to revision surgery for treating established nonunions. We aim to prospectively review the clinical and patient-reported outcomes of patients treated with LIPUS following post-traumatic and post-surgical nonunions in the foot and ankle.MethodsForty-seven consecutive patients underwent Exogen treatment. Patient-reported outcome scores included MOXFQ, EQ-5D and VAS. Patients were divided in to 3 groups: fractures (A), hindfoot procedures (B) and midfoot/forefoot procedures (C).ResultsThirty-seven patients (78.7%) clinically united, 4 patients (8.5%) noticed no significant improvement but did not want further intervention and 6 patients (12.8%) underwent revision surgery. The mean duration of Exogen treatment was 6 months. Union rates of 93%, 67% and 78% were noted in the three groups. Significant improvement in functional outcomes and potential cost savings were observed.ConclusionsExogen for established nonunion in the foot and ankle is a safe, valuable and economically viable clinical option as an alternative to revision surgery. We observed better results in the fracture and midfoot/forefoot groups and relatively poorer results in the hindfoot fusion group.     

Pedal ectrodactyly: a case report with a new surgical management.

A case report is presented regarding a patient with type IV bilateral ectrodactyly treated with a double surgical approach: in forefoot to correct the malformation and in rearfoot to prevent secondary deformity of the subtalar joint. The forefoot was enlarged and in particular the second and third rays were absent. There was also a metatarsus primus varus with interphalangeal hallux abductus. The second cuneiform bone was removed with a wedge resection of the midfoot. The reduction in transverse diameter of the forefoot was obtained by cerclage of the first and fourth metatarsal bones. For hallux valgus, a percutaneous distal osteotomy of the proximal phalanx was performed. Several months after the forefoot correction, subtalar joint pronation was noted secondary to the altered forefoot mechanics and was treated with a subtalar Arthroereisis. The contralateral foot was addressed using similar techniques, except all procedures were done in a single surgical session. A favorable outcome for the patient 1 year and 6 months after surgery seems to justify this approach.     

A clinically applicable six-segmented foot model

We describe a multi‐segmented foot model comprising lower leg, rearfoot, midfoot, lateral forefoot, medial forefoot, and hallux for routine use in a clinical setting. The Ghent Foot Model describes the kinematic patterns of functional units of the foot, especially the midfoot, to investigate patient populations where midfoot deformation or dysfunction is an important feature, for example, rheumatoid arthritis patients. Data were obtained from surface markers by a 6 camera motion capture system at 500 Hz. Ten healthy subjects walked barefoot along a 12 m walkway at self‐selected speed. Joint angles (rearfoot to shank, midfoot to rearfoot, lateral and medial forefoot to midfoot, and hallux to medial forefoot) in the sagittal, frontal, and transverse plane are reported according to anatomically based reference frames. These angles were calculated and reported during the foot rollover phases in stance, detected by synchronized plantar pressure measurements. Repeated measurements of each subject revealed low intra‐subject variability, varying between 0.7° and 2.3° for the minimum values, between 0.5° and 2.1° for the maximum values, and between 0.8° and 5.8° for the ROM. The described movement patterns were repeatable and consistent with biomechanical and clinical knowledge. As such, the Ghent Foot model permits intersegment, in vivo motion measurement of the foot, which is crucial for both clinical and research applications. © 2011 Orthopaedic Research Society. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:655–661, 2012     

Influence of postoperative shoes on plantar pressure patterns

AIM: There are several different types of shoe devices in the postoperative treatment of forefoot surgery. They all have the aim to unload the operated region. Examples for forefoot surgery are hallux valgus operations or correction of claw toes. The aim of this study was to compare a special forefoot shoe (Darco's Ortho Wedge) with a lengthwise and crosswise prepared postoperative shoe (Darco's Medical Surgical). METHOD: Plantar pressure distribution measurements were used to evaluate the unloading effect of the shoe conditions. The pressure in a standard shoe (Nike's Air Triax) was measured for further comparison. RESULTS: The results demonstrate that all analyzed shoes relieve weight under the medial forefoot region. The lengthwise prepared Medical Surgical achieves the highest pressure reduction under the medial forefoot, but the midfoot and the lateral forefoot are subjected to significantly higher loads. The Ortho Wedge reduces the load under the toes and the forefoot and relieves the midfoot region. The pressure is redistributed under the hindfoot. The crosswise prepared Medical Surgical also relieves pressure under the forefoot but not to the same extent as the Ortho Wedge. CONCLUSION: In conclusion it can be stated that the Ortho Wedge shows the best results of the tested shoes for pressure relief and load transfer under the forefoot.     

Diagnostic imaging of trauma to the ankle and foot: IV. Fractures of the calcaneus

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle and foot. This review is divided into six parts. The previous presentations involved ankle fractures, ligamentous injuries, and trauma to the talus. Subsequent dialogues will consist of midfoot and forefoot injuries. Plain x-ray films, as well as sophisticated studies, will assist in recognizing these conditions.     

Diagnostic imaging of trauma to the ankle and foot: I. Fractures about the ankle

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle. The review is divided into six parts. The initial presentation deals with ankle fractures. Subsequent dialogues will consist of ligamentous injuries, trauma to the talus, calcaneal fractures, midfoot, and forefoot injuries. Plain x-ray film, as well as sophisticated studies, will assist in recognizing these conditions.     

Corrective midfoot osteotomies

Corrective midfoot osteotomies involve complete separation of the forefoot and hindfoot through the level of the midfoot, followed by uni-, bi-, or triplanar realignment and arthrodesis. This technique can be performed through various approaches; however, in the high-risk patient, percutaneous and minimum incision techniques are necessary to limit the potential of developing soft tissue injury. These master level techniques require extensive surgical experience and detailed knowledge of lower extremity biomechanics. The authors discuss preoperative clinical and radiographic evaluation, specific operative techniques used, and postoperative management for the high-risk patient undergoing corrective midfoot osteotomy.     

Plantar pressure analysis in cadaver feet after bony procedures commonly used in the treatment of stage II posterior tibial tendon insufficiency

BACKGROUND: Bony procedures play an essential role in the operative treatment of stage II posterior tibial tendon insufficiency and often substantially alter the loading characteristics of the foot. METHODS: Eight matched pairs of cadaver lower extremities were axially loaded onto a TekScan HR Mat. (TekScan, Inc., South Boston, MA) After intact testing, each specimen had a lateral column lengthening (either a calcaneocuboid distraction arthrodesis [CCDA] or Evans procedure), a medializing calcaneal osteotomy (MCO), and a plantarflexion (Cotton) osteotomy of the medial cuneiform. The measured plantar pressures were divided into three forefoot regions, two midfoot regions, and two hindfoot regions. For each region, average pressure, peak pressure, and contact area data were collected. RESULTS: Despite the fact that both lateral column lengthening procedures resulted in increased lateral forefoot pressures, no significant differences were noted between the CCDA and the Evans procedure. The addition of a MCO did not significantly alter the plantar pressures measured after the lateral column lengthening alone. Although the Cotton osteotomy resulted in increased average pressures within the medial forefoot, a compensatory significant decrease in lateral forefoot pressures was not observed. CONCLUSIONS: The present study demonstrated increased lateral forefoot pressures after a combined lateral column lengthening and MCO and does not support the idea that a Cotton osteotomy significantly reduces loading of the lateral forefoot. CLINICAL RELEVANCE: The incidence of lateral forefoot pain and fifth metatarsal stress fractures subsequent to either lateral column lengthening procedure may not significantly decline after a Cotton osteotomy.     

A comparison of two analytical techniques for detecting differences in regional vertical impulses due to plantar fasciitis

The vertical impulse distribution beneath the foot has been shown to be a useful objective method for evaluating gait and the efficacy of treatment programs. However, recent studies employing similar methods, but different analytical techniques, have reached divergent conclusions regarding the effect of plantar fasciitis on hindfoot, midfoot and forefoot impulses. The aim of the current study was to determine whether the impulse distribution beneath the hindfoot, midfoot and forefoot in subjects with, and without, plantar fasciitis was dependent on the analytic technique employed. A pressure platform was used to collect impulse estimates from 16 subjects with plantar fasciitis, and 16 control subjects, while walking at their preferred speed. The findings indicate that an impulse calculation incorporating the position of the center of pressure is more effective in detecting alterations in gait than the conventional method of estimating the impulse distribution beneath the foot. This study also demonstrates that subjects with plantar fasciitis possess modified gait patterns that are primarily manifest by a reduced hindfoot and an increased midfoot impulse, as defined by the pathway of the center of pressure.     

Open transmetatarsal amputation in the treatment of severe foot infections

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.     

Surgical correction of midfoot arthritis with and without deformity

The goals of midfoot reconstruction are to create a painless, functional, and plantigrade foot, which are generally accomplished with arthrodesis and realignment as indicated. The latter requires not only the correction of midfoot deformity when present, but also coexisting hindfoot and forefoot deformities. Once the initial decisions have been made regarding the need for realignment and which joints to include in the arthrodesis, the surgical plan needs to account for the approach, arthrodesis preparation, order of fixation, and choice of fixation.