Abstracts

Kofoed H, Lundberg-Jensen A. Ankle arthroplasty

in patients younger and older than 50 years: a

prospective series with long-term follow-up. Foot

Ankle Int 1999; 20: 501]506.

The introduction of a three-component ankle arthro-

plasty with a polythene meniscus has lead to

renewed optimism regarding the use of total ankle

replacement. Originally, Hakon Kofoed used a two-

component device from 1981 to 1985. A three-

component was then introduced. Since 1990 this

prothesis has been changed from a cemented one to

an uncemented prosthesis with a hydroxyapatite

coating.

Koefed and Lundberg-Jensen have compared

patients over the age of 50 with patients under the

age of 50 in follow-up. They present a survivorship

analysis of 100 patients, 13 of whom died during the

period between 1981 and 1996. They point out that

none of these deaths was in any way due to the use

of an ankle prosthesis.

The authors could find no difference in follow-up

between patients with rheumatoid arthritis and

osteoarthritis. Neither was there any significant

difference in the survival rates between the two

different age groups studied. The younger patients

tended to have stiffer feet, and for this reason had a

low mobility score. Out of 30 patients under the age

of 50, four required arthrodesis or revision. Out of

the older patients over the age of 50, eight patients

out of 70 required arthrodesis or revision.

In general, the results seem remarkably good. The

authors do not discuss reasons for changing to a

three-component uncemented device. In fact, their

results for the two-component cemented prosthesis

appear remarkably good. They are able to conclude

that an ankle prosthesis is a safe and lasting

treatment for patients, whether they are under or

over the age of 50 years. Certainly the survivorship

figures they present bear comparison with total joint

replacements of hip or knee.

Maffulli N, Binfield PM, Moore D et al. Surgical

decompression of chronic central core lesions of the

Achilles tendon. Am J Sports Med 1999; 27: 749]752.

Degenerative change in the Achilles tendon is

especially troublesome for the older professional

footballer and for athletes. It seems likely that

mucoid degeneration frequently occurs in the

Achilles tendon but may not cause a problem unless

the patient is involved in running. In this series the

diagnosis was usually confirmed by MRI scan or

ultrasound scan, although the exact details are not

given for every patient.

The authors recount different methods of con-

servative treatment given for their patients prior to

surgery. Over a period of 9 years they operated on

207 patients with Achilles tendonopathy. They were

able to identify four patients who had had symp-

toms for more than 24 months prior to surgery. In a

previous series they had pointed out that percuta-

neous longitudinal tenotomy was successful in 70%

of athletes. The duration of the symptoms in these

patients was on an average of 12.8 months. Follow-

ing this procedure performed under local anaes-

thetic, 70% were able to return to high sporting

levels.

The results for patients with chronic Achilles

tendon pain were much less satisfactory. In this

series the operation had been performed under a

general anaesthetic and involved 3]5 tenotomies

into the Achilles tendon with excision of areas of

necrosis or muconoid degeneration.

It could be argued that the more extensive surgical

procedure in the chronic patients might have been

more successful if these patients had had a simple

tenotomy under a local anaesthetic with no tourni-

quet. Perhaps this gives rise to better healing than

excision of the muconoid lesion. The authors,

however, suggest that in the chronic patients that

the healing potential of the affected tendon had been

exhausted.

Foot and Ankle Surgery 2000 6: 139]141

# 2000 Blackwell Science Ltd 139

The poor results suggest that more radical surgery

might be needed in this group of patients, possibly

transfer of flexor hallucis longus to the Achilles

tendon, as suggested by Hansen, Klaue and others.

The loss of push-off from the big toe makes this a

controversial procedure for the professional athlete.

The authors suggest that prospective trials of

surgery for chronic Achilles tendon pain will be

helpful. This is difficult to undertake, as these

patients are often referred late to the surgeon.

Perhaps the increasing use of MRI and ultrasound

scans will be helpful, but these investigations are not

always clinically relevant. This remains a difficult

problem, to which there is no simple solution.

T. SMITH

Rochwarger A, Curvale G, Groulier P. Application

of bone graft to the medial side of the first metatarsal

head in the treatment of hallux valgus. J Bone Joint

Surg 19??; 81A: 1730]1735

Hallux varus is uncommon as a primary disorder

and almost always follows surgery for hallux valgus.

It is difficult to treat but fortunately rarely encoun-

tered, despite the large number of patients having

surgical correction of hallux valgus. A variety of

surgical procedures usually involving tendon trans-

fer or tenodesis have been described. In this paper

from Marseilles, France, the authors describe the use

of a bone graft to the medial aspect of the first

metatarsal head. Over a 20-year period 37 patients

had been treated for hallux varus. They were able to

review 30 patients and in all cases the deformity was

iatrogenic. Eight patients (10 feet) had been treated

by bone grafting to the first metatarsal head. The

authors pint out that hallux varus is often the result

of excessive resection of bone when a bunionectomy

is performed. Four patients (five feet) had been

treated by a McBride procedure, including phalan-

geal osteotomy. In the McBride procedure, the

adductor hallucis had been transferred to the first

metatarsal head. The operation required this to be

released and the tight structures on the medial side

of the first metatarso-phalangeal joint were also

released. A bone graft from the iliac crest was

screwed into place on the medial side of the first

metatarsal head and then milled into a satisfactory

shape. After the operation weight bearing was

avoided for 4]5 days. The authors note that most

of the patients had an excessively long first ray. The

intermetatarsal angle appeared well corrected by the

previous surgery. The degree of varus deformity

was an average of 188 (range 10]288). All the patients

had pain associated with hallux varus and there was

also clawing of the big toe before operation. Follow-

up was possible in all but two of the patients and

ranged from 2 years to 22 years. In general, the

results appear to have been very satisfactory,

although one patient was dissatisfied due to recur-

rent hallux valgus deformity. The authors stress that

the best strategy is prevention and that hallux valgus

should not be over-corrected in the primary opera-

tion. It is unwise to resect too much bone when a

bunionectomy is performed. Exostectomy per-

formed as part of the McBride procedure appears

to be particularly dangerous in this respect

Chao K-B, Lee C-H, Lin L-C. Surgery for

symptomatic Frieberg's disease. Acta Orthop Scand

1999; 70: 483]486

Georges Gauthier presented the results of a dorsal

closig wedge osteotomy for Freiberg's disease in

1973. Subsequently his results were published in

French in 1974 and in English in 1979. Although this

operation has been known for over 20 years, it is still

not widely performed. In the author's opinion this is

most unfortunate as this is a very successful

procedure for Freiberg's disease of the lesser

metatarsal bones. Smillie described five stages of

Freiberg's disease. Gauthier recommends that a

dorsal closing wedge osteotomy can be used for

stages II, III and IV. The technique allows the more

healthy plantar part of the metatarsal head to swing

round so that this articulartes with the articular

cartilage of the proximal phalanx. Gauthier recom-

mends using a simple wire suture. In this paper by

Chao and colleagues, a similar technique was

employed but using fixation with two closed pins.

The authors treated 13 patients who were followed

up for an average of 40 months (range

20]54 months). The patients were assessed using a

100-point lesser toe metatarsophalangeal]interpha-

langeal scale. On this basis, out of the 13 patients

140 ABSTRACTS

# 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 139]141

treated, four had an excellent result, seven had a

good result, one had a fair result and one had a poor

result. The authors comment that resection of the

metatarsal heads inevitably leads to transfer meta-

tarsalgia. In their series only one patient had a

transfer lesion, and this was associated with short-

ening of 3 mm. Like other authors, Chao and his

colleagues recommended that conservative treat-

ment should be used before surgery. However, the

outcome of surgery is usually better than the

outcome of conservative treatment. This series is of

particular interest, as in patients from Europe the

condition is usually four times more common in

women than in men. In this series, of the 13 patients

10 were men. Possibly there is some difference

between Chinese and European patients. In this

series from Taiwan, trauma appears to have been

important, as four patients had a history of injury

and six others gave a history of chronic repetitive

stress due to play sport or to army service.

Nicholson JD. Psychogenic equin-varus: the

importance of recognition and nonoperative

treatment. Foot Ankle Int 19??; 21: 31]37

Some years ago I was asked to review a teenage girl

who had been diagnosed as suffering from hyster-

ical paralysis and had a fixed equino-varus defor-

mity of both feet. Subsequent investigations revealed

that she had a tumour of the spinal cord. This

illustrates the diffuculty in making a diagnosis of

hysterical conversion reaction. The authors quote

Sigmund Freud himself who said that:

the lesion in hysteria must be entirely indepen-

dent of the anatomy of the nervous system, since

hysteria behaves in its paralyses and other

manifestations as if anatomy were non-existent,

or as if it had no knowledge of it.

Certainly, patients with hysterical paralysis of the

foot often show anaesthesia of stocking distribution

and lead to a suspicion of hysteria. Before this can be

diagnosed, organic causes such as diabetic periph-

eral neuropathy have to be excluded. A neurological

opinion may be wise in this type of case, although

dystonia is a particularly difficult problem for the

orthopaedic surgeon and for the neurologist. Dr

Nicholson presents three cases in which a young

woman developed pain in the foot associated with

equino-varus deformity. In one case the pain was

mild and there was no history of injury, but in all

three cases there was quite marked deformity which

disappeared when the patient was examined under

anaesthesia. It was noted that under the anaesthetic

one of the patients began to flail her legs around

using the hip flexors. It is suggested that it is unwise

to confront these patients with a diagnosis of

hysterical conversion. Perhaps a diagnosis of psy-

chogenic dystonia would seem more appropriate.

The diagnosis may be suspected by a history of

previous investigations, e.g. finding no cause for

other conditions, such as chest pain. It may be

advisable for treatment to consist of casting under

the anaesthetic and subsequent encouragement and

physical therapy. The authors point out that a

genuine contracture is very unlikely in this type of

patient. Reference to an earlier paper from 1989

suggests that only two patients out of 60 with

hysterical gait disorders developed contracture. It

will be interesting to know if any readers have

encountered a case of a patient who developed

contracture of the foot due to hysteria.

T. SMITH

ABSTRACTS 141

# 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 139]141