Foot and Ankle
Evidence Update
April 2018
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Introduction Welcome to this month’s Foot and Ankle Evidence Update, bringing you the latest evidence-based publications relevant to foot and ankle surgery. Foot and Ankle Evidence Updates are produced by the
Orthopaedics and Trauma Group at the University of Nottingham as a service to the foot and ankle surgery community, with support from the University of Nottingham and Nottingham
University Hospitals NHS Trust. Foot and Ankle Evidence Updates feature new systematic reviews and guidelines found by comprehensive, systematic searches of
PubMed and
NICE Evidence search, which are carried out each month. The Updates are compiled by Dr Douglas Grindlay and Professor Brigitte Scammell. An archive of the Updates is available on the
list home page. The title of each item provides a link to the abstract in PubMed. If the paper is open-access
(indicated in brown text towards the bottom of the PubMed record)
or you have an institutional subscription to the journal concerned, you can access it by clicking on the full text link at the top right of the PubMed record. It is important to appraise the quality of systematic reviews before applying to your practice—we recommend the
AMSTAR 2 tool, which is very quick and easy to use. See also this open-access article:
Research Techniques Made Simple: Assessing Risk of Bias in Systematic Reviews. Do please forward this e-mail to other colleagues who might be interested and encourage them to sign up. To join (or leave) this list, please visit the registration page on the JISCmail web site: https://www.jiscmail.ac.uk/FOOT-AND-ANKLE-EVIDENCE-UPDATES Alternatively, you can e-mail
[log in to unmask] to ask to be signed up. Systematic reviews & evidence summaries Foot and ankle surgery in general [S2-Guideline: Pediatric Flat Foot]. Hell AK, Döderlein L, Eberhardt O, Hösl M, von Kalle T, Mecher F, Simon A, Stinus H, Wilken B, Wirth T. Z Orthop Unfall. 2018 Apr 9. doi: 10.1055/s-0044-101066. [Epub ahead of print]
German. This guideline (in German with English summary) summarises the diagnosis, aetiology, risk factors and management of pediatric flat foot. Systematic reviews & evidence summaries Foot and ankle surgery in general None found this month. Foot and ankle
conditions Lin MT, Chiang CF, Wu CH, Hsu HH, Tu YK. Arthroscopy. 2018 Apr 20. pii: S0749-8063(18)30075-6. doi: 10.1016/j.arthro.2018.01.030. [Epub ahead of print] “RESULTS: Seven RCTs were enrolled in meta-analysis. The ABP [autologous blood-derived products] injection and placebo revealed equal effectiveness in VISA-A [Victorian Institute of Sports Assessment-Achilles]
score improvement at 4 to 6 weeks (short term, WMD 2.29, 95% confidence interval [CI]: -1.69, 6.27), 12 weeks (medium term, WMD 2.63, 95% CI: -1.72, 6.98), 24 weeks (long term, WMD 4.61, 95% CI: -1.25, 10.47), and 48 weeks (very long term, WMD 4.16, 95% CI:
-6.82, 15.14). In meta-regression, there was no association between change in VISA-A score and duration of symptoms at 4 to 6 weeks (short term), 12 weeks (medium term), and 24 weeks (long term). CONCLUSIONS: This meta-analysis revealed that ABP injection was not more effective than placebo (sham injection, no injection, or physiotherapy alone) in Achilles tendinopathy and that no association
was found between therapeutic effects and duration of symptoms.” Fraser JJ, Corbett R, Donner C, Hertel J. J Man Manip Ther. 2018 May;26(2):55-65. doi: 10.1080/10669817.2017.1322736. Epub 2017 May 3. “Results: Seven RCTs were selected that employed MT [manual therapy] as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater
improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5-21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7-3.0) from 4 weeks to 6 months when compared to interventions
such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES [Cohen's d effect sizes] calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions. Discussion: MT is clearly associated with improved function and may be associated with pain reduction in PF [plantar fasciitis] patients. It is recommended that clinicians consider use of both
joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF.” Physical impairments in adults with ankle osteoarthritis: A systematic review and meta-analysis. Al-Mahrouqi MM, MacDonald DA, Vicenzino B, Smith MD. J Orthop Sports Phys Ther. 2018 Apr 7:1-43. doi: 10.2519/jospt.2018.7569. [Epub ahead of print] “Results: Eight of 4565 identified studies (563 participants) satisfied the inclusion criteria and three studies were included in meta-analyses. All studies evaluated a range of end stage OA
[osteoarthritis] impairments, and exhibited poor reporting of missing data, assessor blinding and measurement validity. Meta-analyses revealed large impairments of sagittal plane motion and torque. Evidence from single studies indicated large deficits of frontal
plane motion and torque, talar translation and rotation on arthrometry, balance and electromyography of ankle joint muscles. There were also abnormal bony alignments and greater fatty infiltrate in all calf muscle compartments. Conclusion: Meta-analysis indicated large impairments in dorsiflexion and plantarflexion motion and torque in participants with ankle OA. However, there were limitation in the quality of the
studies, and only a few studies could be included in meta-analysis. Individual studies also suggested other possible impairments in ankle OA requiring further research.” Yammine K, Assi C. Surg Radiol Anat. 2018 Apr 26. doi: 10.1007/s00276-018-2013-5. [Epub ahead of print] “Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel
missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA)
to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A
total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular
involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be
higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential
injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.” None found this month. None found this month. Li Y, Wei Q, Gou W, He C. Clin Rehabil. 2018 Apr 1:269215518766642. doi: 10.1177/0269215518766642. [Epub ahead of print] “RESULTS: A total of 13 studies ( n = 572) met the inclusion criteria. A meta-analysis demonstrated a significant effect of mirror therapy on walking speed (mean difference (MD) 0.1 m/s, 95%
confidence interval (CI): 0.08 to 0.12, P < 0.00001), balance function (standard mean difference (SMD) 0.66, 95% CI: 0.43 to 0.88, P < 0.00001), lower limb motor recovery (SMD 0.83, 95% CI: 0.62 to 1.05, P < 0.00001) and passive range of motion of ankle dorsiflexion
(MD 2.07°, 95% CI: 082 to 3.32, P = 0.001), without improving mobility (SMD 0.43, 95% CI: -0.12 to 0.98, P = 0.12) or spasticity of ankle muscles (MD -0.14, 95% CI: -0.43 to 0.15, P = 0.35). CONCLUSION: The systematic review demonstrates that the use of mirror therapy in addition to some form of rehabilitation appears promising for some areas of lower limb function, but there is
not enough evidence yet to suggest when and how to approach this therapy.” Fraser JJ, Corbett R, Donner C, Hertel J. J Man Manip Ther. 2018 May;26(2):55-65. doi: 10.1080/10669817.2017.1322736. Epub 2017 May 3. See above under
Foot and ankle conditions None found this month. Anaesthesia & analgesia None found this month. None found this month. The provision of a link to an item in this e-mail shall not be taken as an endorsement of any kind. Whilst reasonable efforts have been made to ensure the accuracy of the information in this
newsletter, we cannot guarantee its correctness or completeness. We welcome all feedback and suggestions for improvement—please e-mail Douglas Grindlay,
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Dr Douglas Grindlay
Information Specialist
Orthopaedics and Trauma Group
School of Medicine
University of Nottingham
Queen’s Medical Centre
Nottingham, NG7 2UH
+44 (0) 115 8231113 | nottingham.ac.uk
www.nottingham.ac.uk/research/groups/orthopaedicsandtrauma
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