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A Closer Look At The Connection Between End-Stage Ankle Arthritis And Hallux Rigidus

In a recent study published in the Journal of Foot and Ankle Surgery (JFAS), researchers found that 72.9 percent of patients with end-stage ankle arthritis have concomitant hallux rigidus. 

Previous reports showed that adults exhibit a 17 percent incidence of radiographically-identified foot arthritis overall, with 25 percent of these cases being specific to the first MPJ. Accordingly, the authors of the JFAS study aimed to study the relationship between end-stage ankle arthritis and hallux rigidus in a total of 870 feet. They found that increased age was associated with a higher incidence of hallux limitus but found no statistically significant relationship to sex, ankle arthritis etiology or body mass index (BMI). 

Mark Prissel, DPM, FACFAS and Robert Joseph DPM, PhD, FACFAS both point out that the severity of a patient’s osteoarthritis (OA) symptoms does not always correlate with the radiographically-evident progression of disease. 

“Some patients may suffer from mild symptoms despite advanced radiographic signs of joint degeneration. However, this study supports specific inquiry of great toe dysfunction in patients evaluated and treated for OA of the ankle, and may facilitate earlier intervention of OA of the great toe,” suggests Dr. Joseph. 

Dr. Prissel emphasizes the importance of a thorough exam, including overall foot posture, limb alignment and forefoot structure. John Grady, DPM, FASPS, FACPM concurs. He says one should assess the entire foot when evaluating the arthritic ankle as there may be a negative impact on more distal joints due to poor biomechanics. Conversely, Dr. Grady explains that altered biomechanics of an arthritic first MPJ may contribute to degenerative changes more proximally in the ankle. Dr. Grady also says one must consider the role of non-traumatic causes of arthritis in the development of both first MPJ and ankle arthritis. 

“Just as we evaluate the relationship of the foot to the ground, to the tibia and the rest of the extremity when we evaluate a candidate for ankle replacement, the mechanics of the function of the foot and certainly the first MPJ are important components of how we’re going to address deformity of the ankle,” maintains Dr. Grady, the Chair of the Podiatric Section of the Department of Orthopedics at Advocate Christ Medical Center and Advocate Children’s Hospital in Oak Lawn, Ill. 

Dr. Joseph agrees that the condition of one joint can certainly affect another, which surgeons must take into account when planning a joint-sparing versus a joint-destructive procedure. 

What is the most optimal surgical approach to address end-stage ankle arthritis and concomitant hallux rigidus? Dr. Prissel says he would reserve treatment of both in the same setting for cases involving severe symptoms at the first MPJ as well as a rectus and stable alignment of the medial column. 

“The first MPJ will theoretically take on less mechanical stress with improved range of motion and function after the ankle replacement,” says Dr. Prissel, a fellowship-trained foot and ankle surgeon in Dublin, Ohio. “Conversely, if the medial column is unstable (e.g. Stage IV posterior tibial tendon dysfunction with associated hallux rigidus), one might consider a staged approach with correction of the foot first and then performing the ankle replacement three to six months later.” 

Dr. Grady feels the ideal approach to concomitant end-stage ankle arthritis and hallux rigidus (with failed conservative care) would be achieving ideal range of motion in both joints through surgical management. This could include total ankle replacement and arthroplasty of the first MPJ, although he notes a personal preference for non-implant first MPJ arthroplasty. Dr. Grady recognizes that one or both joints may warrant arthrodesis, but notes this is less ideal due to the resultant stress this will cause to other joints. 

Study Reveals More Than Tenfold Risk Of Amputation Since COVID-19 

By Jennifer Spector, DPM, FACFAS, Senior Editor

New data continues to emerge regarding the increasing rate of lower extremity amputations since the beginning of the COVID-19 pandemic. A new study published by the Journal of the American Podiatric Medical Association (JAPMA) noted a 10.8 times higher risk of any level of amputation in an eight-month time frame in 2020 in comparison to a similar time frame in 2019. 

In their retrospective review involving 270 inpatients with diabetic foot problems at a level one trauma center, the authors found a 12.5 times higher risk of that amputation being a below-knee amputation or higher. Researchers also noted a higher incidence of severe infections and emergent-level cases during the pandemic. 

Ian Barron, DPM, AACFAS, a senior author on the study, attributes the increased risk of amputation to delays in care. 

“Patients were limited during the initial stages of the pandemic. Whether it was through closures of primary care offices or a fear of contracting the virus, there were delays in receiving appropriate evaluation and care,” explains Dr. Barron, who is in private practice in Columbus and Dublin, Ohio. “This delay in treatment led to minor infections getting out of control and leading to amputation.” 

Dr. Barron notes that he sees a relative improvement in these care disruptions with more offices open or using telemedicine. However, the recent spike of new COVID-19 cases also contributes to a surge in patient fear and anxiety regarding seeking care or going to the hospital. 

“This fear of contracting the virus seems to force our high-risk patients’ decision to neglect their care to avoid risk of exposure,” notes Dr. Barron. 

Education for patients and hospital administrations regarding the staggering risk of amputation if a patient with diabetes delays care is the best action DPMs can take during this pandemic, according to Dr. Barron. This is in addition to the already concerning mortality rate associated with major diabetic amputations that makes timely and appropriate care crucial. 

“This study shows that although DPMs may not be directly on the front lines of treating COVID-19 patients, we have a major role in providing continued limb salvage for at-risk populations during the pandemic,” maintains Dr. Barron. “This role can prevent further burden on our already strained hospital systems and potentially save the limbs/lives of our patients with diabetes.” 

New ACFAS Consensus Statement Addresses Acute Achilles Tendon Pathology 

By Jennifer Spector, DPM, FACFAS, Senior Editor 

A new American College of Foot and Ankle Surgeons (ACFAS) consensus statement aims to address the changing landscape of the treatment of acute Achilles tendon pathology. 

A panel of five experts evaluated 13 statements regarding this complex condition and through a comprehensive evaluation deemed the statements “appropriate,” “neither appropriate or inappropriate,” or “inappropriate.” 

Maryellen Brucato, DPM, FACFAS, one of the authors of the consensus statement, shares a few particularly impactful findings from the panel’s investigation. One of the statements deemed “appropriate” states that physicians should implement early weightbearing and progressive physical therapy after surgical repair or at the start of non-operative treatment of Achilles pathology. 

“Long gone are the days of six to eight weeks non-weightbearing in a cast,” says Dr. Brucato, who is in private practice in Clifton, N.J. “Across the board, the evidence demonstrates unequivocally that outcomes significantly improve with early weightbearing and aggressive physical therapy, regardless of treatment choice.” 

Primary surgical repair is not the only option for acute Achilles rupture. In regard to the perception that surgical intervention is essential for these ruptures, the consensus panel deemed this statement to be “inappropriate.” 

“Historically, non-operative management of Achilles tendon ruptures was thought to carry a higher incidence of complications, including re-rupture as well as lower functional outcomes. However, after we reviewed the most recent literature with the highest level of evidence, the data showed equivalent long-term outcomes for non-operative versus operative treatment,” notes Dr. Brucato, who is board-certified in foot and ankle reconstructive surgery. “I found this to be most surprising especially because my training taught me that acute Achilles tendon ruptures need to be surgically fixed.” 

What about percutaneous versus open surgical repair of acute Achilles tendon ruptures? The panel found no real evidence showing a significant difference between these methods with respect to wound complications, infections, re-rupture or functional outcomes. 

“Theoretically, the percutaneous approach has smaller incisions, thus resulting in smaller wounds if they do, in fact, dehisce. Along that same vein, there was no statistically significant evidence showing augmentation of primary repair with allograft, autograft or xenograft improved functional outcomes,” points out Dr. Brucato. 

What then drives surgeon choice of how to approach a surgical repair or reconstruction of the Achilles tendon? 

“After our assessment of percutaneous repair as well as augmentation of the repair with some type of graft, I would submit that it is simply physician preference and perhaps industry-driven,” concedes Dr. Brucato. 

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By Jennifer Spector, DPM, FACFAS, Senior Editor
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