Foot and Ankle

Evidence Update

April 2018

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.

Contents

Guidelines

Systematic reviews & evidence summaries

Foot and ankle surgery in general

Foot and ankle conditions

Trauma

Paediatric

Diabetic foot

Physical therapies

Orthotics and prosthetics

Anaesthesia & analgesia

Basic science

Notes

Guidelines

[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.

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Systematic reviews & evidence summaries

Foot and ankle surgery in general

None found this month.

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Foot and ankle conditions

Meta-analysis comparing autologous blood-derived products (including platelet-rich plasma) injection versus placebo in patients with Achilles tendinopathy.

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.”

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review.

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.”

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Trauma

Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies.

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.”

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Paediatric

None found this month.

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Diabetic foot

None found this month.

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Physical therapies

Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials.

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.”

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review.

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

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Orthotics and prosthetics

None found this month.

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Anaesthesia & analgesia

None found this month.

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Basic science

None found this month.

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Notes

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, [log in to unmask]

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