Shockwave Therapy Effective for Treating Heel Pain

FOOT AND ANKLE
ORTHOPEDICS TODAY July 1, 2010

Shock wave therapy effective for chronic heel pain in randomized, prospective trial
Visual Analog Scale pain scores at 12 months post-treatment dropped 7.5 points from baseline and those patients reported no major adverse events.

Investigators for a multicenter study found that extracorporeal shock wave therapy safely and effectively reduced recalcitrant chronic plantar heel pain, according to findings from their randomized placebo-controlled trial.

“The focused extracorporeal shock wave therapy (ESWT) as applied in this study shows statistically and clinically relevant results with a much better outcome in the active group,” compared to the control group, Ludger Gerdesmeyer, MD, of Kiel, Germany, said at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

In the ESWT study group, “We have found no relevant side effects,” Gerdesmeyer said. The data he presented have been submitted to the U.S. Food and Drug Administration for possible clearance of the Duolith SD1 (Storz Medical) used in the study for this indication.

The 250-patient study was conducted at European and U.S. centers. Investigators enrolled patients from each center with chronic plantar heel pain of greater than 5 on the Visual Analog Scale (VAS) that did not respond to conservative care.
Focused ESWT

After a wash-out period, patients were randomized to either the active or control group. The active group received 0.25 mJ/mm2 ESWT, 4 Hz frequency, with the device focused on the site of heel pain without the aid of any radiography. Patients in the control group underwent a sham treatment where the ESWT device was deactivated but used identically.

Patients underwent three treatments each. Their results were assessed at 3 months and 12 months following their last treatment using the VAS pain scores as the main outcome measure. Results of the Roles and Maudsley patient self-assessment score and the SF-36 score served as secondary outcomes.

At 3 months, baseline composite VAS scores of 8.3 decreased to 2.7 points after ESWT in the active group and decreased to 5.3 points in the control group. In the ESWT group, VAS scores further decreased after 12 months to 0.8 points.
Less pain

“In the active group we have 69% of the patients [having] more than 60% pain reduction compared to baseline,” Gerdesmeyer said. By comparison, sham treatment was associated with more than 60% pain reduction in 34% of control patients, he said.

Differences between the baseline and follow-up secondary outcomes also favored the active group.

No major adverse events occurred related to ESWT treatment. Some patients treated with ESWT, however, reported device-related events including slight pain or discomfort during and after treatment and minor local swelling or redness.

“It was interesting to see that placebo patients getting just a sham treatment also reported pain during treatment,” Gerdesmeyer added. — by Susan M. Rapp

Reference:

* Gerdesmeyer L, Gollwitzer HW, Saxena A, et al. Focused shock wave therapy in chronic plantar heel pain: A randomized placebo controlled trial. #706. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.

Ludger Gerdesmeyer, MD, can be reached in the Department of Orthopedics and Traumatology, Klinikum Recht der Isar, Technical University Munich, Insmaniger Str. 22, Munich, Germany; 49-89-41402271; e-mail: gerdesmeyer@aol.com.

Perspective

Carol C. Frey, MD
Carol C. Frey

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

Foot Woes Keeping Him on His Toes

Podiatrist Lowell Weil Sr. had to travel to Papua New Guinea to find people without any foot problems.

"I went there to look at their feet because there'd been a paper written that showed that none of them had bunions. In fact, they have big toes that go out in the other direction," he said, noting the natives never wore shoes. "I had to see it for myself and I did. I took hundreds of pictures of the natives sticking their feet out."

Dr. Lowell Weil Sr. in an office at the Weil Foot and Ankle Institute in Des Plaines. Weil is a long-time Glenview resident and is known as the pioneer of shockwave treatment for heel pain.
(Allison Williams/Staff Photographer)

That solidified for Weil that shoes are a big culprit in aggravating bunions, although not necessarily causing them.

Weil, medical director of the Weil Foot and Ankle Institute in Des Plaines, has seen a lot of bunions, flat feet and other painful conditions below the ankle in 45 years of practice.

His specialty is the front part of the foot, where he designed an operation to shorten a bone causing pain under the ball of the foot that a French orthopedic surgeon named for him.

"I was in France lecturing. Somebody asked me from the audience, 'What do you do for this condition?' and there was a blackboard back in those days and I drew a picture. The next thing I knew, I came back to America and a friend of mine, an orthopedic surgeon, said to me, 'What the hell is this Weil osteotomy?'"

Most recently, he and his son, Lowell Weil Jr. of Lake Forest, who's part of the practice, lectured to a Chicago audience about the results of a nine-year study that showed sonic shockwave therapy has been effective in treating plantar fasciitis, a common form of heel pain.

Weil Sr. is also an expert in the "Refrigerator stepped on me" condition -- a reference to the jokes he heard from teammates of former Chicago Bear William "Refrigerator" Perry during the 25 years he spent as the football team's podiatrist.

Weil grew up in Skokie, where his parents long ran Weil Women's Clothing in downtown Skokie.

He settled with his wife, Nancy, in Glenview 37 years ago, in a house once owned by former Illinois Governor Otto Kerner.

Weil served on the Glenview Village Board from 1986 to 1990. His wife was on the Glenview School District 34 Board from 1980 to 1987.

Now a grandparent of six, Weil balances work with time at their second home in Mexico and travel.

"It's fun to be able to help people and meet the kind of people we meet," he said. "I never thought I'd be able to lecture in 29 countries and travel everywhere. I thought I'd have a nice little practice in Des Plaines, Ill. but it turned into something more than that."

-- Lynne Stiefel

Originally published August 10, 2010 in Glenview Announcements

Study Shows ESWT an Effective Non-Surgical Alternative

The doctors of the Weil Foot & Ankle Institute have studied, published on and utilized Extracorporeal Shock Wave Therapy (ESWT) for years to treat patients with heel pain and other painful conditions of the foot and ankle. The studies commented on below are another confirmation that ESWT can be an effective non-surgical alternative to treating pain. From Orthopedics Today:

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

IL Podiatrist Questions Heel Pain Study's Conclusions

Women who habitually wear high heels have shorter muscle fibers in their calves and thicker Achilles' tendons than those who walk in flat shoes, researchers say. The result? The heel lovers’ tendons stiffen and become harder to stretch, which could explain why walking hurts after kicking off the Jimmy Choos, according to a small study published in the Journal of Experimental Biology. The researchers found that wearing heels affected muscle fiber length--the high heel wearers' muscle fibers were 13 percent shorter than those who wore flat shoes. For some women, once the heels come off, the pain starts because the muscles can't stretch enough, the researchers said.

Wearing a variety of different types of shoes and stretching may help alleviate the pain, according to the study authors. But Chicago podiatrist Steve Weinberg, who was not involved with the study, questioned whether it's possible to stretch the Achilles tendon enough to make a clinical difference. "If women are going to wear high heels, they should be prudent—stand or walk in them for a short time,” said Weinberg, a podiatrist at the Weil Foot & Ankle Institute and the longtime chief podiatrist for the Chicago Marathon.

Source: Julie Deardorff, Chicago Tribune [7/16/10]

Patient Experience: Conservative Treatment for Stress Fracture

When stress fractures occur in the foot or foreleg, one course of action is to fit the patient with a walking boot which offloads pressure from the injury. A doctor and colleague of our Dr. Jeff Baker recently experienced this treatment protocol firsthand. Read about her experience with a walking boot here.

Efficacy of Outpatient Bilateral Simultaneous Hallux Valgus Surgery

Abstract

Bilateral simultaneous hallux valgus correction is traditionally performed as an inpatient procedure due to concerns regarding adequate postoperative analgesia and difficulty mobilizing. We prospectively evaluated 40 consecutive patients (80 feet) who underwent outpatient surgical correction of bilateral symptomatic hallux valgus. Patients underwent preoperative radiological and clinical assessment using pain and American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scores. Patients underwent preoperative counseling and were assessed for medical suitability for outpatient surgery. They were instructed to have responsible adult caregivers available for 24 hours postoperatively, easy access to after-hours emergency medical care, and access to a telephone. Procedures were performed under general anesthesia with local anesthetic ankle block.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff with an oral analgesia regimen. Cast immobilization was not used. Patients were reviewed at 6 weeks and 3 months postoperatively with repeated clinical and radiological assessment. All patients were discharged home and none required inpatient ward admission. Post-discharge, no patient presented to the emergency department or their general practitioner as a consequence of poor pain control. At final follow-up assessment, mean AOFAS hallux scores had improved from 58.1 (range, 29-80) to 89.0 (range, 47-100) (P<.001). The mean hallux valgus angle improved from 33.2° (range, 15°-53°) to 16.9° (range, 3°-39°) and the intermetatarsal angle had improved from 13.2° (range, 6°-23°) to 8.5° (range, 4°-15°) (P<.001). Eighty-five percent of patients reported that they would recommend outpatient surgery. Bilateral hallux valgus surgery can be performed safely as an outpatient procedure in selected patients with acceptable levels of patient satisfaction.

An increasing number of orthopedic surgeries are now performed as outpatient procedures.^1,2 The clinical and economic benefits of outpatient surgery extend to the patient and the health care provider. Hospital stays are shorter, patients are able to recover in their own home environment, surgery cancellations due to inpatient bed shortages are unlikely, and the risks of hospital-acquired infection are reduced.^1,2

Published results of unilateral hallux valgus correction as an outpatient procedure indicate that it can be undertaken safely with a high degree of patient satisfaction.^3,4 However, hallux valgus has been reported to affect both feet in as many as 84% of cases.^5,6 As such, surgical correction of bilateral, symptomatic hallux valgus normally involves an inpatient admission due to concerns regarding postoperative pain control, or alternatively, 2 separate outpatient procedures. Performing this surgery as an inpatient procedure means that the institution cannot make use of the potential benefits of the outpatient surgery unit. Similarly, performing staged unilateral surgical corrections has social and economic implications for patients, as they must effectively recover from 2 separate surgical procedures.

This article reports the outcomes of bilateral corrective surgery for hallux valgus in a selected patient population.

Materials and Methods

Forty consecutive patients (80 feet) who presented to the outpatient surgery unit at our institution for surgical correction of bilateral hallux valgus were prospectively evaluated. Suitable patients were selected from those attending a specialist foot and ankle service with bilateral symptomatic hallux valgus.

Patient suitability was determined by assessing their medical and social circumstances. Clinical assessment for medical suitability for outpatient surgery was undertaken by a specialist nurse/anesthesiologist. Individuals who were American Society of Anesthesiologists (ASA) grades 1 and 2 were deemed suitable, along with those who were grade 3, providing their disease was well controlled. A body mass index (BMI) of ≤35 was also required. Each patient was counseled about the social and medical implications of having the procedure performed as an outpatient and was provided with an information sheet. In addition to being considered medically suitable for outpatient surgery, patients were instructed that they must have a responsible adult caregiver available for a minimum of 24 hours postoperatively, easy access to after-hours emergency medical care, and immediate access to a private telephone (Table 1).

Patients underwent preoperative clinical scoring using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scoring system in addition to radiological assessment by dorsoplantar, oblique, and lateral weight-bearing radiographs of the feet (Figure 1). Preoperative pain scores were also recorded.

Figure 1: Preoperative radiographs of a patient with bilateral hallux valgus and varus deformity of the fifth metatarsophalyngeal joints.

All patients were admitted to a dedicated outpatient surgery ward on the day of the intended procedure. All procedures were performed under general anesthesia with local anesthetic ankle block for postoperative analgesia using the maximal individual dose of levobupivicaine (2 mg/kg). Surgeries were performed using pneumatic tourniquets with exsanguination using an Eshmarch bandage. Both feet were draped simultaneously. A number of surgical procedures have been described to correct the deformity of the first ray in hallux valgus, and several authors have published treatment algorithms to simplify the surgical management of this condition.^5,7-15 As such, the surgical procedure depended on a number of factors, including the degree of radiological deformity (hallux valgus and intermetatarsal angles) and the presence or absence of tarsometatarsal joint instability, first metatarsophalyngeal arthritis, and hallux valgus interphalangeus. Patients who required treatment of fixed lesser toe deformities in addition to the bilateral first ray deformity were not considered suitable for bilateral outpatient correction.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff. Each patient was discharged with a standardized oral analgesia regimen (altered if potential drug allergies or interactions were reported), which included diclofenac sodium 50 mg three times daily, acetaminophen 1000 mg 4 times a day, and dihydrocodeine 30 mg to be taken as necessary for 10 days. Each patient was given an information sheet and was advised to contact the orthopedic unit, the after-hours emergency medical service, or the hospital emergency department immediately if any postoperative complications occurred. Patients were reviewed 10 days postoperatively in a nurse-led foot clinic for wound inspection, suture removal, and reduction of dressings. Cast immobilization was not used, and all patients were instructed to bear weight with the heel only for the first 6 weeks postoperatively.

Patients were subsequently reviewed at routine outpatient clinics 6 weeks and 3 months postoperatively. At 3-month follow-up, radiographs were taken as previously described to document the radiological outcome of surgery (Figure 2). Clinical evaluation was repeated using AOFAS hallux scores and pain scores.

Figure 2: Postoperative radiographs after correction with bilateral chevron/akin osteotomies and osteotomies of both fifth metatarsals performed as outpatient procedures.

Statistical analysis was performed using SPSS 13.0 software (SPSS Inc, Chicago, Illinois). Comparison of postoperative outcome scores was performed using the Mann-Whitney test.

Results

All 40 patients (80 feet) successfully underwent bilateral corrective surgery. The mean age of the study population was 45 years (range, 17-69 years; SD ±15.9). Thirty-nine (97.5%) of the 40 patients in the study group were women. The surgical procedures performed and the indications are listed in Table 2.

All patients were discharged home successfully from the outpatient surgery unit, and no patient had to be transferred to the inpatient ward prior to discharge.

One patient (2.5%) presented to her general practitioner in the perioperative period with a superficial wound infection, which was successfully treated with a course of oral antibiotics.

Clinical and radiological outcomes were documented at a mean follow-up of 3.2 months (range, 1.4-4.6 months), and a statistically significant improvement was noted in both of these outcome measures (P<.001; Table 3).

Patients were also surveyed to determine whether they would undergo the procedure again or recommend it to a friend based on their recent experience. Eighty-five percent of patients (34 of 40) reported that they would do so, and 15% (6 of 40) reported that they would in retrospect have preferred the procedure to be undertaken as an inpatient with an overnight stay. Reasons cited for this included postoperative pain (2), difficulties with mobilizing at home (2), and a desire to recover in an inpatient ward-based environment despite adequate analgesia (2).

A number of postoperative complications were recorded, including 1 postoperative superficial infection; 1 case of persisting metatarsalgia; 1 case of persistent pain due to prominent metalwork, which required removal; and 1 deformity recurrence requiring revision surgery. One patient suffered a traumatic fracture of the first metatarsal after tripping while walking after the original osteotomy had successfully healed. No symptoms were reported preinjury, and the fracture healed with conservative management. No further surgery was indicated or performed. All osteotomies and fusions progressed to radiological union.

Discussion

Dedicated outpatient surgery units are more resource efficient and allow a surgical department to release inpatient beds for more major cases.^1,2 Advances in anesthetic techniques have resulted in an increasing number of procedures being offered as outpatient surgeries.¹ Several studies have reported favorable outcomes after unilateral hallux valgus correction as a outpatient procedure.^3,4,6 However, hallux valgus is frequently a bilateral condition, and performing staged unilateral surgical corrections has social and economic implications to patients, as they must recover from 2 separate surgical procedures. A single procedure is associated with increased operating time, increased postoperative pain, and difficulty mobilizing.¹⁶

When a surgical procedure is offered on an outpatient basis, it is essential to ensure that a number of caveats are met. The procedure must be suitable for such a setting, the risk of early postoperative complications (from surgery and anesthetic) should be minimized, and admission to an inpatient ward postoperatively should be unlikely. We have demonstrated that bilateral hallux valgus correction adequately satisfies these criteria. In addition, objective measures of clinical and radiological outcomes were highly satisfactory, and patient satisfaction was similar to that reported for unilateral outpatient hallux valgus surgery.^3,4

To avoid readmission, it is essential that the home circumstances of any patient considered for bilateral outpatient surgery are carefully considered. If a patient does not meet our criteria for domestic support, an inpatient admission is offered. In addition, it is essential that a patient is properly informed of the potential problems that may arise in the early postoperative period and that the patient should be suitably motivated to undergo such surgery.

The provision of adequate postoperative analgesia is also fundamental to the success of this procedure, and the effective use of nerve blocks to achieve this is a key factor in extending the indications of outpatient surgery to bilateral hallux valgus corrective surgery. The safety and efficacy of peripheral nerve blocks in foot and ankle surgery have been well established, and levobupivicaine is a safe, effective local anesthetic agent able to provide analgesia for up to 10 hours postoperatively.^17,18 As such, no patient in this study required increased analgesia above the oral agents prescribed on discharge from the outpatient surgery unit.

Performing bilateral hallux valgus surgery may in theory increase the risk of certain postoperative complications, such as loss of fixation and deep venous thrombosis; however, no such problems were identified in this patient cohort.

Conclusion

Bilateral hallux valgus surgery can be performed safely on an outpatient basis in selected patients with acceptable levels of patient satisfaction. To our knowledge, this has not been previously reported in the literature.

References

1. Department of Health. Day surgery: operational guide: waiting, booking and choice. London, England: Department of Health; August 2002.
2. Aylin P, Williams S, Jarman B, Bottle A. Trends in day surgery rates. BMJ. 2005; 331(7520):803.
3. Bhargava A, Rai P, Shrivastava RK. Adult day case hallux valgus surgery—a safe and viable option. Ambulatory Surgery. 2003; 10(3):151-154.
4. Tibrewal SB, Foss MV. Is day surgery for Wilson’s osteotomy safe? J Bone Joint Surg Br. 1991; 73(2):340.
5. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007; 28(7):759-777.
6. Thomas S, Barrington R. Hallux valgus. Current Orthopaedics. 2003; 17(4):299-307.
7. Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000; 5(3):525-558.
8. Borton DC, Stephens MM. Basal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br. 1994; 76(2):204-209.
9. Coughlin MJ, Saltzman CL, Nunley JA II. Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int. 2002; 23(1):68-74.
10. Coull R, Stephens MM. Operative decision making in hallux valgus. Current Orthopaedics. 2002; 16(3):180-186.
11. Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int. 2007; 28(6):748-758.
12. Johnson KA, Cofield RH, Morrey BF. Chevron osteotomy for hallux valgus. Clin Orthop Relat Res. 1979; (142):44-47.
13. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop Relat Res. 1960; (16):119-135.
14. Mitchell CL, Fleming JL, Allen R, Glenney C, Sanford GA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958; 40(1):41-58.
15. Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005; 87(8):1038-1045.
16. Lin JS, Bustillo J. Surgical treatment of hallux valgus: a review. Curr Opin Orthop. 2007; 18(1):112-117.
17. Dhukaram V, Kumar CS. Nerve blocks in foot and ankle surgery. Foot Ankle Surg. 2004; 10(1):1-3.
18. Gottschalk A, Burmeister MA, Radtke P, et al. Continuous wound infiltration with ropivacaine reduces pain and analgesic requirement after shoulder surgery. Anesth Analg. 2003; 97(4):1086-1091.

Authors

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay are from the Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom.

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay have no relevant financial relationships to disclose.

Correspondence should be addressed to: Graeme Holt, FRCS(Tr&Orth), Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, United Kingdom (graemeholt@btinternet.com).

doi: 10.3928/01477447-20100429-09

Study of Microfracture of the Ankle

The recent article in the publication Foot and Ankle International has shown excellent results with microfracture of the ankle in a wonderful study.

This research mirrors what arthroscopic ankle specialists Dr. Jeffrey Baker and myself have seen with our patients.

Lowell Weil, Jr., DPM, MBA, FACFAS
Fellowship Director, Weil Foot & Ankle Institute
Team Podiatrist, Chicago White Sox



Second-Look Arthroscopic Findings and Clinical Outcomes After Microfracture for Osteochondral Lesions of the Talus

Keun-Bae Lee, MD, PhD†‡*,
Long-Bin Bai, MD†‡,
Taek-Rim Yoon, MD, PhD†‡,
Sung-Taek Jung, MD, PhD† and
Jong-Keun Seon, MD†
+ Author Affiliations
† Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Korea
‡ The Brain Korea 21 Project, Center for Biomedical Human Resources at Chonnam National University, Gwangju, Korea
*Address correspondence to Keun Bae Lee, MD, PhD, Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 8 Hakdong, Donggu, Gwangju, 501-757, Korea (e-mail: kbleeos@chonnam.ac.kr).

Abstract

Background Arthroscopic microfracture is frequently used to repair osteochondral lesions of the talus. However, despite the popularity of this technique, no study has been conducted on cartilage repair after microfracture by second-look arthroscopy.

Purpose The purpose of the present study was to evaluate cartilage repair in osteochondral lesions of the talus by second-look arthroscopy and to compare arthroscopic findings with clinical outcomes 12 months postoperatively.
Study Design Case series; Level of evidence, 4.

Methods Second-look arthroscopies were performed in 20 ankles of 19 patients at 12 months postoperatively. Arthroscopic findings were classified using the Ferkel and Cheng staging system, and cartilage repair was assessed using the International Cartilage Repair System (ICRS). Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale.

Results According to the Ferkel and Cheng staging at second-look arthroscopy, 7 of the 20 ankles (35%) showed incomplete healing (stage D). In terms of ICRS overall repair grades, 8 ankles (40%) were abnormal (grade III). Mean AOFAS scores for Ferkel and Cheng stages A to C (n = 13) and stage D (n = 7) were 88.5 and 82.0 points, and those for ICRS repair grades I and II (n = 12) and grade III (n = 8) were 88.7 and 82.5, respectively. Good correlations were found between AOFAS scores and Ferkel and Cheng stages and ICRS grades. Overall, 90% of ankles achieved an excellent or good AOFAS score of over 80 points.

Conclusion Second-look arthroscopic findings at 12 months postoperatively after microfracture for osteochondral lesions of the talus revealed that 40% of lesions were incompletely healed. Nevertheless, the majority of patients achieved a good clinical outcome. Furthermore, postoperative clinical scores were found to be correlated with ICRS repair grades.

Dr. Jeff Baker Nominated for Man of the Year by the Leukemia & Lymphoma Society

Dear Friends and Colleagues,

I am a person who believes in giving back and this year I wanted to do something big. Today I launch my campaign for the Man & Woman of the Year, a fundraising effort of the Leukemia and Lymphoma Society. The mission, to cure blood cancer and improve life for patients and their families.

I have built a connection to The Leukemia & Lymphoma Society over the past several years due to my friendship with Mike Odisho. His father passed away from Leukemia in 1998. Mike has given his heart and soul to this cause over the years and I was honored when as member of the Man & Woman of the Year nominating committee, he nominated me.

I am excited to announce that my challenge to raise $10,000 for the Leukemia & Lymphoma Society. My campaign starts today and lasts for the next 10 weeks. The money I raise will help find cures for blood cancers and improve the quality of life for patients and their families. I am viewing this challenge as way to honor all who have been affected by cancer. Given their struggles, it is the least I can do.
Why LLS? Because it’s the world’s largest voluntary health organization dedicated to fighting blood cancer and I want to help fight cancer. The Man & Woman of the Year campaign is in its tenth year and maintains an exceptional cost/income ratio – over 86 cents of each dollar nationally directly funds the mission.

I’m also participating in honor of the Girl of the Year, Rachel Williams. Rachel is a 6- year-old who has recently finished two and a half years of chemotherapy, spinal taps, and bone marrow testing. She is now in a “wait and see period” to find out if the treatments worked. Rachel loves to participate in cheerleading, horseback riding, gymnastics, and school. Meeting Rachel and hearing her story really affected me. Her mom spoke of how this journey started, fatigue and weakness initally diagnosed as mono. Rachel is a sparkplug of hope and determination. Meeting and talking with her was an experience I will never forget. She was so full of life, something we all take for granted everyday. I want to help make sure all children affected by blood cancer are able to have a happy, healthy and fun-filled childhood. I hope you can help me with that vision.

Here is how the Man & Woman of the Year campaign works: I am a candidate. You “vote” for me by donating to my campaign. If I receive the most votes (dollars), I will be named the 2010 Man of the Year. You will then see my picture on taxi rooftop ads in Chicago. If you are really generous I may become the national winner and be featured in USA Today.

There are a variety of ways in which you can contribute to my campaign, and to cures for cancer. Any donations will be a great help towards the mission. Here are some options:

¨ Donate online at http://il.mwoy.llsevent.org/jbaker. You will be directed to a secure site to make your donation.
¨ Attend my future fundraising events. Information on these events will be available soon.
¨ Send a check, made payable to The Leukemia & Lymphoma Society. Be sure to put my name in the memo line and send to LLS at 651 W. Washington Blvd., Suite 400 Chicago, IL 60661
¨ Corporate sponsorship
¨ Send my website to your friends; http://il.mwoy.llsevent.org/jbaker.
¨ Donate an item for my silent auction (time shares, sports tickets, airline miles)

Remember, 86% of each donation raised nationally will directly fund the mission of The Leukemia & Lymphoma Society. Thank you so much for your support of me and The Leukemia & Lymphoma Society.

Jeff Baker, DPM, FACFAS

ESWT for the Treatment of Plantar Fasciitis: A Nine-Year Follow-Up

ESWT for the Treatment of Plantar Fasciitis: A Nine-Year Follow-Up

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM

Anthony Borrelli, DPM, Wendy Benton-Weil, DPM

WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

Extracorporeal Shockwave Therapy (ESWT) is a well-accepted treatment alternative, world wide, for the treatment of chronic and recalcitrant tendonopathies and plantar fasciitis. Early and mid-term study results indicate success with a variety of orthopedic disorders, including plantar fasciitis. While several short-term studies support ESWT for the treatment of plantar faciitis1,2, there are only a few mid-term studies that have evaluated the benefit of ESWT on function and pain five years post-treatment. These studies demonstrate favorable results including improved function and pain .3,4

Objective

To determine the long term benefit (9 years) and safety of ESWT on patient reported measures of function, pain, patient satisfaction, and level of improvement and time necessary to resume regular activities. Safety measures evaluated whether there was any history of long-term weakness, lateral column pain, or plantar fascial rupture that could be attributed to the ESWT intervention.

Methods

Study Design

The number of patients with plantar fasciitis treated with ESWT in 2001-2002 was identified using retrospective chart review (N=197).

Data Collection

A 10-item paper pencil retrospective survey was mailed to each patient and was used to document level of function, pain, patient satisfaction, level of improvement, time necessary to resume regular activities, and complications.

Statistical Analysis

Descriptive statistics were used to examine the distribution for all key variables. For categorical variables (i.e., level of satisfaction, level of function, and etc..), frequency counts were calculated. For continuous variables (i.e., level of improvement, level of pain), measures of central tendency and dispersion were calculated. Additional analyses included cross tabulation and correlations of key variables to further understand the data. SAS version 9.1 was used for all analyses.

Results

Of the 197 patients identified for inclusion in the study, 75 patients returned the survey (38.1%).

SATISFACTION

65 patients (87.84%) reported moderate to high satisfaction with ESWT.
Of those patients, 58 reported high satisfaction. For those patients, the percentage of improvement in heel pain was 96.4% (SD=6.16) with an average pain rating of 0.77 (SD=1.10) after the procedure.

ACTIVITY

Of the 63 patients (87.50%) able to return to regular activities after ESWT, the amount of time was 3.44 weeks and average pain rating after the procedure was 1.21.

PAIN

There was a significant negative correlation between percentage of improvement in heel pain and average pain rating after the procedure (r=-0.801, p < 0.001).


18 patients (24.3%) were able to discontinue comfort maintenance (i.e., stretching, icing and etc..) after ESWT. For those patients, percentage of improvement in heel pain was 95.8% (SD=7.72) with an average pain rating of 0.67 (SD=1.19) after the procedure. For the remaining 56 patients who continued maintenance, the percentage of improvement in heel pain was 79.7% (SD=32.60) with an average pain rating of 2.07 (SD=2.77).

FUNCTION

Of the 66 patients (91.67%) who reported better functioning after ESWT, the percentage of improvement in heel pain was 91.09% (SD=17.38)

COMPLICATIONS

There were no long-term complications such as continued lateral column pain, neuropraxia, nerve injury, or plantar fascial rupture reported.

Table 1. Descriptive Statistics
Domain	Outcome	N=74 Patients
Satisfaction	Level of satisfaction with ESWT n (%)	65 (87.84)
Pain	Average percent improvement in heel pain (0-100%; Mean ± SD) Average heel pain rating following ESWT (0-10; Mean ± SD)	83.61 ± 29.40 1.73 ± 2.55
Function	Level of functioning following ESWT n (%)	66 (91.67)
Activity	Ability to return to regular activities n (%) Average time (weeks) necessary to return to regular activities (Mean ± SD)	4.50 ± 12.74

Conclusions

ESWT has been shown to be highly effective in treating numerous musculoskeletal conditions, including chronic plantar fasciitis, in patients as early as three months following treatment. To date, there have been no studies evaluating these patients beyond five years.

We have evaluated a limited number of patients, retrospectively, who were an average of nine-years post-ESWT treatment of plantar fasciitis. Our early results have continued to be beneficial and satisfying to the great majority of patients responding to our request for evaluation.

This leads us to a conclusion that ESWT is equivalent to open surgery for the treatment of chronic plantar fasciitis, and that the results of this treatment appears to be void of some of the complications such as chronic lateral column pain and neuropraxia that are seen with surgical intervention.

In short and long-term studies, the clinical benefit of ESWT for plantar fasciitis across the dimensions of pain, function, patient satisfaction and activity has been consistently positive.

The results of this study combined with the results that have been reported in the world literature over the past five years are significant and greater in number than similar studies evaluating surgery for plantar fasciitis. The results seem to be equivalent, with faster recovery and no complications from ESWT.

It is our opinion that ESWT can no longer be considered as an investigational treatment and should be made compensable by insurance to the public at large.

We are aware of the limitation of this study because of the limited number of responses (75, 38.1%) drawn from our index number of (197)

References

1. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. Nov 2008;36(11):2100-9.
2. Lowell Scott Weil Jr. DPM, Thomas S. Roukis DPM, Lowell Scott Weil Sr. DPM, and Anthony H. Borrelli DPM, Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to plantar fasciotomy. Journal of Foot and Ankle Surgery. 41(3): 166-72.
3. Ogden, John A, MD, et al. Electrohydraulic High-Energy Shockwave Treatment for Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery (American) 86:2216- 2228 (2004)
4. Wang, Chin-Jeng, MD, et al. Long-Term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis. The American Journal of Sports Medicine. April 2006. 34: 592-596.
5. Benton-Weil, W, Weil, Jr, LS, Weil, Sr, LS, Borrelli AH, Percutaneous plantar fasciotomy, :a minimally invasive procedure for recalcitrant plantar fasciitis. J. Foot Ankle Surg. 37(4):269-272, 1998

View as Powerpoint

(847) 390-7666

Email : info@weil4feet.com

Website : www.weil4feet.com

Retrospective Comparison of Patients Undergoing Formal Physical Therapy Versus No Physical Therapy Following Bunion Correction

Retrospective Comparison of Patients Undergoing Formal Physical Therapy

Versus No Physical Therapy Following Bunion Correction

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM

Anthony Borrelli, DPM, Wendy Benton-Weil, DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

Physical therapy (PT), following bunion correction, is theorized to recover range of motion of the first metatarso-phalangeal joint (MTP). PT can also aid in decreasing the recovery period from hallux valgus surgery, which is particularly advantageous to the active patient.1 Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function.2

Few investigations include both subjective and objective measurements of the effectiveness of physical therapy treatments in reconstructive foot surgery, particularly following hallux valgus correction.

We hypothesize that patients receiving formal physical therapy will yield functional benefits and an improved return of 1st MTP range of motion, as well as an increased patient satisfaction as compared to those who did not receive a formal physical therapy program, post operatively. This study evaluates the effectiveness and differentiates whether a regimented course of physical therapy following bunion correction enhances the results of the surgical correction.

Methods

Study Design

Patients with a history of receiving Scarf bunionectomies by three surgeons at the Weil Foot & Ankle Institute were identified using retrospective chart review and (N=55) recruited to participate in this retrospective, post-operative follow-up study. All three surgeons used virtually the same technique in performing the Scarf Bunion Procedure.

Two of the surgeons used a standard, formal physical therapy program beginning at one week post-operative. The third surgeon did not use physical therapy post operatively.

Data Collection

Patients were administered five subjective instruments during their follow-up clinical office visit. Instruments were completed before any clinical assessment to avoid biasing patient’s responses. Several instruments include objective clinician rating, which were completed during the course of the office visit. Retrospective chart review was used to obtain pre-operative pain ratings as well as the number of post operative physical therapy sessions attended.

Instrumentation

1. The 8-item American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale: a patient-reported measure of pain combined with a clinician rating of function and alignment.
2. The 3-item AOFAS Hallux MPJ Scale: a patient-reported measure of pain and function.
3. The 10-item Weil Satisfaction Survey: a newly developed patient-reported measure of function, pain, patient satisfaction, level of improvement and time necessary to resume regular activities.
4. The 5-item American College of Foot and Ankle Surgery First Metatarsophalangeal Joint and First Ray: a patient-reported measure of pain, cosmesis, and functional capacities with clinician ratings of radiography and function.
5. The 23-item Foot Function Index: a patient-reported visual analog scale (VAS) of pain severity, activity difficulty, and limitation frequency.

Statistical Analysis

Descriptive statistics were used to examine the distribution for all key variables. For categorical variables (i.e., level of satisfaction, level of function, and etc..), frequency counts were calculated. For continuous variables (i.e., level of improvement, level of pain), measures of central tendency and dispersion were calculated. Change in level of pain was assessed using a paired samples t-test. The sub-analyses by physical therapy participation was assessed using Independent Samples t-test. Additional analyses included cross tabulation and correlations of key variables to further understand the data. SAS version 9.1 was used for all analyses.

Overall Results

Patient Demographics

The study included 55 patients (79 feet; average age 57, range 16-78 years) with right (n=16), left (n=15), or bilateral (n=24) Scarf Bunionectomies. 44 patients (80.0%; 65 feet) participated in a formal, regimented physical therapy program and 11 (20%; 14 feet) were not given a post operative, PT program.

Patient Satisfaction

48 out of 55 patients (87.3%) were moderately to extremely satisfied with the results of the Scarf Bunionectomy procedure.

Function and Daily Activities

49 out of 55 patients (89.1%) were able to return to their routine daily activities at an average of 11.6 weeks (SD=10.2, range=1-48 weeks). 48 out of 55 patients (87.3%) reported similar or improved post-operative functioning. On the AOFAS Hallux MPJ, 89.4% of patients indicated “no limitations” in daily activities.

Pain

Patients reported a 87.1% (SD=21.8) improvement in pain post-operatively. There was a significant reduction in patient reported pain rating (t=6.280, df=30, p= < 0.0001). The average change in pain rating (0-10) was a 3.2 point decline (FIGURE 1: SD=2.9). Pre-operatively, patients reported an average pain score (0-10) of 5.3 (SD=2.3, range=2-10). Post-operatively, patients reported an average pain score (0-10) of 2.1 (SD=2.1, range 0-4). On the patient report AOFAS Hallux MPJ, 75% of patients indicated “none” to “mild, occasional” pain.

Physical Therapy Results

Results indicate that patients who participated in physical therapy reported significantly higher foot function and fewer activity limitations as measured by the Foot Function Index (see Table 1: Foot Function Index), than the patients who had no physical therapy program. These results were confirmed by the patient reported measure of functional capacity as well as the clinical (objective) rating of foot function on the ACFAS (SEE TABLE 1: ACFAS).

Dorsiflexion was categorically measured on the ACFAS as well as clinically rated during the office visit. For 65.0% of patients who participated in physical therapy, the range of motion was 60 degrees or greater (39 feet, mean=66.4, SD=20.2). Only 45.5% of patients who did not participate in physical therapy had a similar range of motion (5 feet, mean=60.7, SD=25.8).

Plantarflexion was categorically measured on the ACFAS. For 98.4% of patients who participated in physical therapy, the range of motion was 0 degrees or greater (63 feet). The same was true for 91.7% of patients who did not participate in physical therapy (11 feet).

Conclusions

The application of continuous passive motion to joints immediately after joint surgery stimulates the regeneration of articular tissue, eliminates adhesions, prevents joint stiffness, reduces pain, and is well tolerated by patients.³
Although the idea of post-operative physical therapy is supported and recommended by podiatric and orthopedic surgeons, the literature is weak in identifying the benefit of physical therapy after reconstructive bunion correction.

Patients who underwent regimented physical therapy post-Scarf Bunionectomies at the Weil Foot & Ankle Institute presented higher satisfaction rates, and scored better in the Foot Function Index and ACFAS total scores, versus those patients who did not complete physical therapy. These patients were also shown to function better and at a higher level of capacity with less limitation (TABLE 1). It is imperative to note that the correlation, while positive, between AOFAS and ACFAS scores is considered marginally moderate (r=0.409). Similarly, it was expected that the correlation between the Foot Function Index and ACFAS and AOFAS would be low, but the direction negative, given that one is patient-reported while the other two are clinically rated. This assumption was true for the ACFAS (r=-0.072); however, for the AOFAS, the correlation was positive (r=0.007). This indicates that the ACFAS may be more sensitive for discriminating between patient groups in observational studies.

Formal physical therapy following bunion correction yields favorable clinical and functional results, including an increased level of patient satisfaction, and is shown to provide continual long-term benefits after the post-operative course.

References

1. Saxena, A., O’Brien, T. Postoperative Physical Therapy for Podiatric Surgery. JAPMA. 1992, Aug. 8. 2(8): 417-23.
2. Deyle, Gail D., MPT et al. Effectiveness of Manual Physical Therapy and Exercise of the Knee:
   A Randomized, Controlled Trial. Annals of Internal Medicine. Vol. 132 (3), 1 Feb. 2000. 173-8.
3. The Podiatric Application of Continuous Passive Motion: A Preliminary Report. JAPMA
   Dec. 1991; 81(12): 631-7.

View as Powerpoint

(847) 390-7666

Email : info@weil4feet.com

Website : www.weil4feet.com

Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal Approach Plantar Plate Repair – A New Technique & Early Results

Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal

Approach Plantar Plate Repair – A New Technique & Early Results

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

The plantar plate is the principal sagittal plane stabilizer of the metatarsal-phalangeal joint (MTP) and any compromise to the integrity of the plate can lead to wearing and rupture of this joint. Plantar plate tears often contribute to metatarsalgia, leading to chronic instability, subluxations, and dislocations. A plantar plate rupture can be either acute, due to a hyperextension injury, or chronic in nature, secondary to chronic metatarsal overload. Primary repair of a plantar plate tear has been performed for years, although the etiology of a non-traumatic, isolated primary plantar plate injury has not been clearly understood.1,2,3 The traditional repair of the plate from a plantar approach is both difficult and does not address the underlying etiology of those cases caused by chronic pathology: an elongated or sub-located lesser metatarsal.

We present a new technique and early results that incorporate a Weil Metatarsal Osteotomy and primary repair of the plantar plate through a DORSAL approach. We have utilized this technique for over two years with promising early results. This unique surgical technique addresses and allows for correction of both the metatarsal deformity and plantar plate pathology through one, minimally invasive, surgical approach.

Surgical Technique

• A curvi-linear incision is made overlying the 2nd MTPJ exposing the metatarsal head and base of the proximal phalanx.
• A Weil metatarsal osteotomy is performed and the capital fragment is retrograded under the distal one third of the metatarsal, and is held in temporary position with a smooth .045 wire. This allows for exposure to the plantar plate and flexor tendon, when visible. The redundant dorsal bone surface is resected about 3-4 mm and smoothed to normal anatomical contour (FIG. 3).
• The plantar plate is visualized and noted to be torn (in this case) and/or attenuated (in other cases) at the insertion in the base of the proximal phalanx. The plantar plate is fully mobilized distally and freed of any residual attachments. (FIG. 4).
• Using the Smart Stitch System*, #2 Magnum wire is used to grab and fixate the plantar plate proximally with a mattress suture (FIG. 5, 6, 7).
• Two drill holes are then made with .062 threaded k-wires in the base of the proximal phalanx; one dorsal-medial to central and the other dorsal-lateral to central (FIG. 8). Using monofilament wire through the bone tunnels, the sutures securing the plantar plate are passed from the plantar to the dorsal surface of the base of the proximal phalanx.
• The temporary pin fixating the Weil osteotomy is removed and the 2nd metatarsal head is reduced, properly aligned to create corrected positioning and fixated with a 2.4mm threaded head screw or two .062 threaded k-wires (FIG. 9, 11).
• The suture on the dorsal surface of the proximal phalanx is now tied dorsally with the digit held in plantarflexion, and the 2nd MTP is reduced and stabilized
  (FIG. 10, 11, 12).

*Arthrocare Opus

Function and Daily Activities

11 out of 13 patients (84.6%) reported similar or improved post-operative functioning. All patients were able to return to their routine daily activities at an average of 14.7 weeks (SD=7.4, range=4-24 weeks).

Pain

Patients reported a 71.9% (SD=36.4) improvement in pain post-operatively. There was a significant reduction in patient report pain rating (t=6.824, df=13, p=< 0.0001). The average change in pain rating (0-10) was a 4.9 point decline (SD=2.7, range 2-8 reduction). Pre-operatively, patients reported an average pain score (0-10) of 6.7 (SD=1.7, range=2-9). Post-operatively, patients reported an average pain score (0-10) of 1.6 (SD=1.4, range 0-4).

Conclusions

Metatarsophalangeal joint instability/dislocation can be a very difficult problem for patients and surgeons. Until recently, repair of the plantar plate was limited to soft tissue correction without addressing the bony etiology of the deformity.

Through a dorsal approach, a Weil Osteotomy is performed and the plantar plate tear is visualized and primarily repaired, advanced, and strongly anchored into bone using a shoulder arthroscopy knotless system, addressing and correcting the true etiology of plantar plate pathology.

Despite the small sample size, this procedure has been shown to yield consistent and favorable early results across the domains of patient satisfaction, pain, function and daily activities, as well as ACFAS & AOFAS Scoring Scales

References

1. R.B. Johnston III, J. Smith and T. Daniels, The plantar plate of the lesser toes: an anatomical study in human cadavers, Foot Ankle Int 15 (1994), pp. 276–282.
2. Blitz, DPM, et al. Plantar Plate Repair of the Second Metatarsal Phalangeal Joint: Technique and Tips. Journal of Foot & Ankle Surgery. Vol. 43, Issue 4. 266-270.
3. Bouché DPM, FACFAS, Heit DPM, FACFAS Combined Plantar Plate and Hammertoe Repair with Flexor Digitorum Longus Tendon Transfer for Chronic, Severe, Saggital Plane Instability of the Lesser MPJ’s: Preliminary Observations. Journal of Foot & Ankle Surgery. Vol. 47, Issue 2, 2008. 125-37.

View as Powerpoint

(847) 390-7666

Email : info@weil4feet.com

Website : www.weil4feet.com

Treating a Fracture with Positive Results

I had surgery with Dr. Weil on November 16, 2009 to fix a bad fracture with tissue and nerve damage on my right foot. I already had surgery with another doctor a year before at Northwestern Hospital and my foot was becoming deformed and I was in a lot of pain. Well my surgery with Dr. Weil, Sr. was very successful and after 8 weeks I no longer have any doctor appointments. One thing I think made my surgery a success is I listened to him after each appointment. Dr. Weil stressed to me to keep weight off and always wear the boot when walking and use the machine called Vital Wrap to ice the foot. Well I wore the boot 24/7 except going to bed and taking a shower. Vital Wrap is wonderful for instant relief. Listening to the doctor and taking it seriously by not walking on the foot too soon made the difference. My post x-rays showed the healing and after sometime the swollen will go down. My only advice is to listen to the doctor, take his directions seriously and you will have success. Don't work out too early, it will come soon enough. The other note I would like to say is Dr. Weil is a specialist for feet, not hip replacements, knee replacements, etc. Also his stafff is the best I have ever seen and his nurse, Pam is such a huge asset for Dr. Weil.

Sue
Des Plaines, IL