Is The Open Modified Brostrom Procedure Superior To An Arthroscopic Approach?

Although data showed that each intervention studied for lateral ankle instability showed positive results, the open modified Brostrom procedure may yield better outcomes than an arthroscopic approach after one year. This study was recognized as the first-place oral abstract presentation at this year’s American Podiatric Medical Association National conference. The authors evaluated 84 consecutive patients that underwent either an open modified Brostrom procedure (n=14) or an arthroscopic modified Brostrom procedure (n=70) over more than a six-year period. Average age was 48.4 ± 14.4 yrs, body mass index (BMI) was 31.1 ± 6.2 kg/m² and follow-up was 12.1 ± 6.15 months. Ninety-three percent of patients studied also had concomitant procedures at the time of their modified Brostrom intervention.

Both groups exhibited significant improvement from preoperative baseline Foot and Ankle Outcomes Scores (FAOS) at final follow-up. However, those that underwent the open procedure reported better scores in three out of five domains: pain; symptoms; and quality of life, compared to the arthroscopic cohort.

The authors note that ankle sprains are a common injury that can lead to long-standing pain and disability. Traditionally, most consider an open Brostrom procedure the gold standard when directly repairing lateral ankle ligaments. However, developments in instrumentation led to the availability of an arthroscopic version of this procedure. This study aimed to evaluate differences in outcomes between the groups. Since all patients in the study experienced improvement in FAOS scores, the authors feel this strongly supports treating lateral ankle instability. However, they note that their data suggests that the open modified Brostrom procedure may be preferrable based on the reported outcomes.

Erin Klein, DPM, MS, an author on the study, stresses that ankle sprains can lead to long-term problems if not treated assertively (bracing, orthotics, physical therapy with a full kinetic chain exam and associated treatment) when they occur.

“Instability of the ankle joint can cause pain and disability. Stabilizing the ankle (by surgical means as in this study) decreases pain and dysfunction,” she says. “Also, be confident that the open procedure, based on this data, does a fine job stabilizing the ankle and the scores suggest that this might be the better procedure.”

Dr. Klein, Associate Director of Research at the Weil Foot and Ankle Institute, says she initially expected the arthroscopic procedure to prove superior in their study.

“There are so many minimally invasive techniques right now with aggressive media and advertising campaigns,” she adds. “Media and advertising would lead one to believe that these less invasive procedures are better. I’m not sure that they are always better, as the data in this study supports.”

As she notes in her practice that patients with ankle instability seem to also have hip weakness, Dr. Klein says she would like to learn more through future research about the connection between the hip muscles/stabilizers (i.e. gluteus medius) and the ankle/hindfoot complex of joints.

Overall, Dr. Klein encourages surgeons to continue stabilizing lateral ankles when indicated, as this could make a significant difference for patients’ comfort, function and quality of life.

Does Surgical Place Of Service Have An Impact On Forefoot Amputations?

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent poster presented at the American Podiatric Medical Association National conference found no differences in short-term adverse outcomes when performing partial forefoot amputations on an outpatient versus inpatient basis. The authors queried the 2018 American College of Surgeons (ACS) NSQIP database, choosing subjects with CPT code 28805 and full surgical closure (326 inpatient and 72 outpatient). They then evaluated the primary outcome measures for frequency and statistical comparison.

“Based on our results, we did not find a significant difference in terms of superficial site infection, deep incisional infection, or wound disruption,” says Sara Mateen, DPM, one of the authors on the study. “There was also no significant difference with respect to unplanned reoperations or hospital admissions. The results of our investigation may have clinical significance when considering hospital admissions, timing of partial foot amputations prior to revascularization, lower extremity soft tissue loss, and length of hospital stay. Although we encourage critical readers to review the study design and of course appreciate the limitations of the publication, we do feel that this data may help providers decide on outpatient surgery if indicated. This in the long term can help decrease hospital admission costs, length of stay, and overall patient satisfaction.”

Dr. Mateen, Chief Resident at the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia, shares that although they expected to identify selection bias among the cohorts, they found relatively few demographic and clinical differences between the two groups.

Overall, she shares that the authors hope that the information provided in this poster will lead to future investigations, specifically looking at clinical scenarios as it relates to hospital admission criteria in the setting of lower extremity soft tissue loss, length of hospital admission, timing to partial foot amputation after revascularization, and economics of limb preservation.

Study Finds No Anatomic Relationship Between Renal Disease And Charcot Location

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent poster at the American Podiatric Medical Association National Conference presented a level III, matched cohort retrospective analysis that compared patients with diabetic Charcot disease both with and without renal disease. Due to a known direct relationship between the skeletal system and renal disease, the poster authors shared that the purpose of the study was “to explore the anatomic relationship between bones and joints of the foot and ankle to determine if renal compromise indeed changes, influences, or has predilection for at risk areas of the lower extremity in Charcot neuroarthropathy.”

The authors evaluated 105 patients, 55 each with and without renal disease, based on glomerular filtration rate less than 60 mL per minute. Among the combined cohort, the most-involved area of Charcot neuroarthropathy was the midfoot complex. On average, the study found that patients typically had more than one bone or joint involvement, but that the presence or absence of renal disease did not show any significant correlation with any particular Charcot-affected bone or joint in the foot or ankle.

Jonathan D. Furmanek, DPM, lead study author, says that multiple comorbidities, such as renal disease, among patients with Charcot neuroarthropathy is of concern for those undergoing realignment arthrodesis.

“Bone density and thus strength is determined by a delicate balance between bone formation and degradation,” he explains. “Calcium, phosphorus, and vitamin D levels play a critical role in this homeostasis. Changes in calcium, phosphorus, and vitamin D homeostasis often occur early in renal disease, and if left untreated can lead to metabolic bone disease, with potential effects on surgical outcomes in this cohort.”

Although the cohort demonstrated no significant osseous or joint predilection among varying levels of renal disease, Dr. Furmanek points out that one could interpret these results as meaning that any level of renal disease will have an effect on bone homeostasis, however the level of renal disease does not reflect the amount of osseous involvement or joint predilection.

“We believe that there is a metabolic process at play in this cohort and this may be a causative factor for sub-satisfactory outcomes, however, to date this process is not clearly defined,” says Dr. Furmanek, a third-year resident at MedStar Health Podiatric Surgery Residency in Washington D.C. “We advocate for metabolic work-up and optimization for patients with any level of renal disease undergoing Charcot realignment arthrodesis.”