Forefoot Surgery Research Articles

Blockade of the sciatic nerve in the popliteal fossa

In this article we reviewed different approaches to the sciatic nerve in the popliteal fossa. Alone or associated with the internal saphenous nerve block, it is an easy, reliable, long lasting block with a low percentage of complications. It is indicated for anesthesia and/or analgesia in forefoot, ankle and foot surgeries. Knowledge of the principles of nerve stimulation and anatomic characteristics of the sciatic nerve are needed for its successful implementation. Success of the block is mainly determined by eliciting inversion or combined inversion/plantar flexion at 0.3-0.5 mA/0.1 msec and by injecting 35 to 45 ml of the selected local anesthetic.

Auswirkungen von Vorfußentlastungsschuhen auf die plantare Druckverteilung

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). 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. 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. 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.

Assessment of Plantar Pressure in Forefoot Relief Shoes of Different Designs

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. 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. 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. 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.

A rare reason for prolonged pain and disability after forefoot surgery

We report diagnosis and adaequate surgical therapy a rare case of prolonged postoperative pain and swelling after fore-foot surgery caused by a chondroma of the neck of the talus. Resection and bone grafting resulted in a asymtomatic patient 42 weeks after surgery.

Informed consent – a contemporary myth?

In the absence of consent from the patient, in theory, every surgical procedure could be considered a criminal offence. Until recently, the patient’s consent was considered to have been implicitly granted as long as he or she presented at the appointed date for an elective surgical procedure. This

Peripheral Foot Blockade Versus Popliteal Fossa Nerve Block: A Prospective Randomized Trial in 51 Patients

The majority of foot and ankle operations are performed on an outpatient basis and often under some form of regional anesthesia. In this prospective, randomized study of 51 patients undergoing elective unilateral forefoot procedures, we compared 2 different anesthetic techniques: the peripheral foot blockade and the popliteal sciatic nerve block. Variables assessed included the quality of surgical anesthesia, postoperative analgesia, and the incidence of postoperative complications. The anesthesia was classified as effective if it was the sole anesthetic technique for the forefoot surgery. We found successful results in both groups: 92% in the foot block group and 96% in the popliteal block group. Analysis of time required to perform the anesthetic procedure showed a significant difference between the 2 groups, with foot block being considerably faster (14.3 minutes vs 19.2 minutes for popliteal block) (P = .0078). Foot block patients demonstrated 10.96 hours of analgesia, whereas popliteal block patients exhibited 14.32 hours (P = .132). With a mean follow-up of 5.7 months, we did not find anesthesia-related complications in any of the patients. Both techniques showed a high level of safety and efficacy, with no significant difference detected between them. Our patients showed a high rate of satisfaction with both procedures (96% for foot block patients and 96.1% for popliteal block patients) and reported a good discharge disposition. These data show that both procedures are safe and effective anesthetic techniques and well suited to forefoot ambulatory surgery.

Low-cost pain infusion catheter for the control of postoperative pain in ambulatory foot surgery

The authors report the use of a low-cost method of providing prolonged patient controlled anesthesia at the surgical site following elective forefoot surgery performed in ambulatory surgical settings. In this series of 54 patients there were no postoperative complications and 95.92% of patients believed the device helped to control their post-operative pain.

Bilateral ankle blocks: A prospective audit

There are significant advantages to the practice of bilateral ankle block. However, clinicians are reluctant to employ this technique due to concerns over reliability, local anaesthetic longevity and toxicity, surgical efficiency, and patient comfort. Sixty-six patients undergoing bilateral ankle blocks during mid- and forefoot surgery were audited to determine success rate, local anaesthetic safety and efficacy, and patient acceptance. Intravenous sedation was administered both during insertion of ankle blocks and intraoperatively, as requested by the patient and as deemed necessary by the anaesthetist. The choice of local anaesthesia was either a 50/50 mixture of lignocaine 1.5% plain and ropivacaine 7.5 mg/mL, ropivacaine 7.5 mg/mL alone or ropivacaine 7.5 mg/mL and clonidine 1 microg/kg. A total of 89% of patients had a successful bilateral ankle block. Ropivacaine and clonidine combination, ropivacaine, and ropivacaine and lignocaine combination provided a mean length of action of 17 h, 14 h and 8 h, respectively. No adverse local anaesthetic events were reported. Sixty-one per cent of patients remembered intraoperative events; only one patient would choose not to have the procedure performed again under ankle blocks. The present audit demonstrates that bilateral ankle blocks are a safe and efficient technique. With appropriate doses of sedative drugs both during insertion of the ankle block and surgery, patients remain comfortable.

Acceptability of Ankle Tourniquet Use in Midfoot and Forefoot Surgery: Audit of 1000 Cases

While use of a thigh tourniquet with general anesthesia is widely accepted, use of an ankle tourniquet in the awake patient is more controversial. In particular, it is not clear how long patients tolerate this device or what the consequences are of intraoperative tourniquet pain. A prospective audit was done of 1000 patients undergoing midfoot and forefoot surgery using an ankle block. We examined the intraoperative problems associated with the use of an ankle tourniquet, particularly the role and consequences of intraoperative tourniquet pain. Risk factors for tourniquet pain were statistically examined, and patient acceptance was gauged through followup questions. With correct application and the option of sedation, 3.1% of patients complained of tourniquet pain. In 0.4% of patients tourniquet pain necessitated a conversion to general anesthesia. A significant association was found between tourniquet pain and both age and tourniquet time. We found that for patients younger than 70 years of age, the tourniquet can be applied comfortably for up to 30 minutes in over 97%. For each 11 minutes beyond this, another 1% of patients reported tourniquet pain. However, patients 70 years or older had an average 3.5 times increase in tourniquet pain. In this age group the tourniquet can be applied comfortably for up to 30 min in 91%. For each 3.2 minutes beyond this, another 1% reported tourniquet pain. When questioned, 97.2% of our patients reported that they would have surgery again with an ankle tourniquet. Our audit shows that with correct application and the option of sedation the ankle tourniquet is well tolerated by most patients. However, clinicians need to be mindful that patients 70 years of age or older are at greater risk of tourniquet pain and that in all patients the risk of tourniquet pain gradually increases when application times exceed 30 min.

Nerve blocks in foot and ankle surgery

A prospective study was conducted to evaluate the efficacy of nerve blocks for postoperative pain relief following foot and ankle surgery. The study included all patients who underwent foot and ankle surgery over a period of three months. Sciatic/popliteal nerve blocks were administered for hindfoot surgery and ankle blocks for forefoot surgery. Postoperative pain was assessed using visual analog scales and a record was kept of analgesic requirements. Ninety three percent of the patients were satisfied with the pain control and recorded low pain scores and sixty percent of these patients had good pain relief at an average of eighteen hours, without the need for any additional analgesics.

Treatment of recurrence of symptoms after excision of an interdigital neuroma

During a six-year period (January 1996 to January 2002), we re-explored 60 interspaces (49 patients, 49 feet) for recurrence or persistent symptoms after one or more previous procedures for excision of an interdigital neuroma. Ten patients underwent concomitant excision of a primary neuroma from an adjacent interspace, and 19 underwent concomitant forefoot surgery. The mean follow-up was 39.7 months (6 to 79). Evaluation included review of records and radiographs, clinical assessment, and a questionnaire regarding satisfaction, pain, restriction of footwear and activity. In total, 15 patients (30.7%) were completely satisfied, 13 (26.5%) were satisfied with minor reservations, ten (20.4%) were satisfied with major reservations and 11 (22.4%) were dissatisfied with the outcome. Of the 49 patients, 28 (57.2%) had no or mild pain, 29 (59.2%) had moderate or severe restriction of footwear and eight (16.3%) had moderate restriction of activity. Intra-operative findings, simultaneous surgery to adjacent interspaces, concomitant forefoot surgery and previous re-explorations did not significantly influence the outcome. Persistent or recurrent symptoms after transection of a nerve present a challenging problem for both the surgeon and patient. It is essential that there is a thorough pre-operative discussion with the patient, providing the rates of failure and the increased likelihood of restriction of footwear and activity after revision surgery.

Poor analgesic effect of instilling local anaesthetic during surgery for hallux valgus: A randomised, double blind trial

We studied the effect on postoperative pain of instilling, rather than injecting, long acting local anaesthetic into the wound during forefoot surgery. In a double blind, randomised, prospective study of 34 women undergoing Mitchell’s osteotomy for hallux valgus, we instilled either isotonic saline or bupivacaine solution into the operation wound before closure. Patients kept a diary regarding postoperative pain and use of analgesic tablets. We found a statistically significant moderate reduction in pain in the bupivacaine group for the first postoperative 8 hours ( P=0.01), but could not find evidence of less pain after this time, less maximum pain, or less use of analgesics throughout the whole of the postoperative period. We conclude that the effect of simply instilling bupivacaine before closure of the wound after operation for hallux valgus is very slight and therefore probably not worthwhile.

The use of a local anesthetic foot block in patients undergoing outpatient bony forefoot surgery: A prospective randomized controlled trial

Foot blocks are known to prolong postoperative pain relief. Consequently, their use has been extended to patients having outpatient surgery, despite little evidence to show improved patient satisfaction. Indeed, patients having outpatient surgery actually may be less satisfied because they will first experience pain at home on the first postoperative night, which may be more severe than anticipated. In this prospective, randomized, blinded study, 42 patients having unilateral outpatient bony forefoot surgery were assigned randomly to either having the surgery under general anesthesia alone or under general anesthesia with supplementary foot block (0.5% bupivicaine). All patients were assessed at home by telephone interview on the first and second postoperative day. There was a significantly longer time to first perceived pain in the foot block group compared with the control group, but no difference in the number of postoperative analgesic tablets consumed, no difference in pain score on the first night, first postoperative or second postoperative day, or any difference in the overall patient satisfaction scores at 2 days. The authors conclude that a local foot block, although prolonging the time to first perceived pain, does not improve patient satisfaction and is not detrimental when used as analgesia in the outpatient setting. (The Journal of Foot & Ankle Surgery 42(1):24–29, 2003)

Ergebnisse einer Umfrage zur fußchirurgischen Operationsaktivität an orthopädischen Kliniken und Hauptabteilungen in Deutschland

Summary Nationwide collecting evaluations for the foot surgical operation activity on orthopaedic clinics and departments in Germany are not available up to now. For extraction of a survey, we carried out this inquiry at German clinics and orthopaedic departments under two aspects: how great is the annual feet surgical operation appearing on orthopaedic clinics at all and which functional techniques come in case of specific – typical – clinical pictures to application? The data are based on own information of the clinics and offer a good survey of foot surgical activities at orthopaedic handles in Germany. At the most houses one carries out in 75% of cases forefoot surgery and in 25% of the cases, rearfoot surgery. The ambulant foot surgery is no emphasis at German clinics, the pedobarography is no means of routine diagnostic. The information confirms the variety of the functional therapy in treatment of classical forefoot surgical questions. Very obviously the well criticized resectionarthroplasty is still noticed as a good therapeutic option in all clinical pictures despite of the heaviness of forefoot malposition.

The arterial supply of the lesser metatarsal heads: a vascular injection study in human cadavers.

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.

Complications after surgery of the hallux.

The great toe is affected by many congenital and acquired conditions including arthritis, hallux valgus, and hallux rigidus and disease of the hallucal sesamoids. Many surgical procedures have been described for the treatment of these conditions. With the increased popularity of forefoot surgery comes the potential for complications even when the surgery is done meticulously by an experienced surgeon under well-planned conditions. When a complication occurs, it can present difficult and challenging problems. It is, therefore, important to recognize a complication early so it may be analyzed and treated successfully. When recognized, a plan should be developed to identify, quantify, control, and resolve the problem. The current review defines some common complications and treatment options. Several problems may exist at the same time. A solution addressing all aspects of the problem must be designed so as not to augment the presenting complications. Salvage operations and long-term treatment are included to provide a perspective on treatment of residual deformity. It is important to realize that there often are several solutions to a difficult problem. Many factors influence the surgeon's choice and implementation of a solution, but the ultimate outcome always depends on a well thought out plan.

Complete vs. selective ankle block anaesthesia for forefoot surgery with ankle tourniquet

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Local and Regional Anaesthesia

Significance of post-operative fever in diabetics with forefoot surgery for osteomyelitis

Significance of post-operative fever in diabetics with forefoot surgery for osteomyelitis

A double-blind study of the effect on hemostasis of nabumetone (Relafen ®) compared to placebo

A double-blind, placebo-controlled clinical trial comparing the effect on hemostasis of nabumetone (Relafen) to placebo in patients who were about to undergo forefoot surgery was performed. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are reported to inhibit platelet cyclooxygenase activity, resulting in altered platelet function and thus potentially enhanced bleeding. Nabumetone has been reported to have no effect on platelet aggregation and bleeding time in normal volunteers and in patients who have undergone knee arthroscopy. After fulfilling the inclusion criteria and after a 1-week washout period (acetaminophen controlled), 15 patients were enrolled in the nabumetone group and 15 patients were randomized in the placebo group. Hemostatic parameters [prothrombin time (PT), partial thromboplastin time (PTT), and Ivy bleeding time (IBT)] were assessed at baseline, visit 2, visit 3, and final visit. No meaningful differences were observed between treatment groups in any of the measured hemostatic parameters. No significant adverse events were reported. There was no significant change from baseline for PT, PTT, and IBT in the nabumetone group (PT, p < .06; PTT, p < .64; IBT, p < .17) versus the placebo group (PT, p < .61; PTT, p < .63; IBT, p < .25). The lack of bleeding diathesis and significant prolongation of PT, PTT, or IBT in this study suggests that nabumetone in dosages up to 1000 mg/day can be administered safely in the immediate preoperative period to patients undergoing forefoot surgery.

Ankle block for forefoot surgery: patient choice and efficacy

One hundred consecutive patients made an informed preoperative choice for elective forefoot surgery between general anaesthetic (GA) and ankle block (AB). Fourteen patients requested GA, 57 AB and 29 were ambivalent, but chose to proceed with AB and sedation anaesthesia after further explanation. The ambivalent group had a higher level of preoperative concerns ( P < 0.03) and required more intraoperative sedation, but were equally satisfied at review. AB patients had longer postoperative pain relief and fewer required strong analgesia on both the day of operation and the next day ( P < 0.05). One AB patient required unplanned conversion to GA for tourniquet pain. With adequate preoperative counselling and additional sedation anaesthesia, if required, there is a high voluntary acceptance of ankle block and good subjective outcome for forefoot surgery.