Dr. Amol Saxena, DPM
Palo Alto Foundation
Medical Group
Dept. of Sports Medicine
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Sports Medicine Grand Rounds. Vol 6, 1996 Journal of Foot and Ankle Surgery.
Moderator:
Amol Saxena, D.P.M., F.A.C.F.A.S
Department of Sports Medicine,
Palo Alto Medical Clinic
U.S.A. Track and Field Sports Medicine Executive Committee
Panel:
Richard T. Bouche, D.P.M., F.A.C.F.A.S.
Virginia Mason Sports Medicine Center
Seattle, WA.
Executive Board Member
American Academy of Podiatric Sports Medicine
K. Gordon Campbell, M.D.
Department of Sports Medicine,
Palo Alto Medical Clinic
Team Orthopedist,
Stanford University
San Francisco Giants Baseball Team
Robert E. Leach, M.D.
Editor, American Journal of Sports Medicine
Professor, Department of Orthopedics,
Boston University School of Medicine
John E. McNerney, D.P.M., D.A.B.P.S.
Team Podiatrist,
New York Giants Football Club
New Jersey Nets Basketball Team
Lowell Scott Weil, D.P.M., F.A.C.F.A.S.
Team Podiatrist, White Sox Baseball
Podiatry Consultant, Chicago Bulls
Team Podiatrist, Chicago Bears Football Club
Dr. Saxena: Gentlemen, I wanted to impart to our readership some of the techniques and trends of surgery on athletes. Often the parameters we are taught hold true for the average patient but not for the sports medicine patient. Some things we do differently for sports medicine patients. What are some of your basic parameters and pearls?
Dr. Weil: I try to reserve surgery on athletes until the end of their participating season. Often we are faced with various conditions that we know must have surgical repair, and we are able to compensate (using various devices and treatment programs) to palliate the athlete until the season has completed. The standard methodologies as far as surgery goes, essentially does not change for athletes compared to the normal patient. The only differences may lie in the postoperative physical therapy and the use of bone stimulators. We are more intense with physical therapy (with more frequency), but for athletes making a living from sports, cost may not be an issue. That is why bone stimulators are often used although there is no known study to show that bone heals faster in a routine osteotomy or fracture of the foot. Every opportunity is made to get the athletes better.
Dr. Saxena: Dr. Bouche?
Dr. Bouche: Concerning surgery on athletes, our goal is twofold: perform the best procedure indicated for the specific problem and return the athlete to their desired activity as quickly as possible without compromising their result. To accomplish these goals it is important to use the most up-to-date technology that is relatively accepted and ideally, scientifically tested. The media, many times, creates a false picture to the public about "new technologies" that are not accepted and are untested making it difficult for us, a physician,s to live up to the patient's unrealistic expectations. New technologies must be approached openly but with caution!!!
Athletes contemplating surgery must realize common and uncommon complications that could occur as their surgical result may affect their ability to perform in the future. Surgery in the athlete must always be carefully considered especially as it applies to their specific sport. Though there are certain situations that may require immediate surgery (i.e., displaced fractures, ruptured tendons, etc.) most surgery for more chronic problems should only be considered after an adequate trial of reasonable conservative treatment has been attempted and the athlete cannot function to their desired level of activity.
Dr. McNerney: I try to break down the procedures into categories, Class I being minimally invasive (nails, warts, soft tissue lesions and hammertoes) that heal rapidly. These may be able to be performed in season. For Class II (mild HAV, lesser metatarsal surgery, neuromas) that take four to eight weeks, and Class III (HAV with osteotomy, accessory ossicles) which take six to eight weeks or longer to heal, I try conservative treatment for a significant period of time. If the athlete is hindered from performing sports (after trying orthoses, physical therapy, etc.) then I recommend surgery. For Jones and navicular fractures, I may recommend surgery for athletes more quickly and often use bone stimulators.
Dr. Campbell: I feel that surgery should be done only if delaying the operation will have a lasting detrimental effect, or if the athlete cannot perform his or her role. We try to move from rigid immobilization as soon as possible to removable braces. Aerobic (hyperbaric) oxygen chambers and bone stimulation have only anecdotal backing. However, early partial weight bearing or protective motion has been shown to decrease healing time and speed rehab.
Dr. Saxena: Getting into specifics now, how do you treat hallux rigidus and hallux abductovalgus and which procedures do you use?
Dr. McNerney: Most of the above hallucial conditions can be treated and controlled conservatively. I will perform surgery only if the condition is significantly painful or progressive. In younger athletes with hallux rigidus I may perform an Austin or Waterman/Reverdin. In Stage II and III hallux rigidus I prefer cheilectomies, and I use this procedure mostly to buy time. In older athletes I'll do a Keller (with capsular interposition) or a hinged silastic implant. For bunions I do an Austin with two orthosorb pins using the traditional 60 degree wing. For base wedge osteotomes (IM angle greater than 15 degrees), I prefer not to use screws for three reasons. First, more bone needs to be resected, two, screws are needed to fixate the osteotomy properly, and finally, a second surgery is often needed to remove the screws. I use 28-gauge monofilament wire crossing four cortices with either a k-wire or orthosorb pin interpositioned. According to McGlamry, this fixation is nearly as stable as two screws, and allows early ambulation.
Dr. Bouche: In correcting hallux rigidus and hallux valgus deformities with osteotomies, I try to exclusively use screw fixation as it affords early joint mobilization because of the rigid fixation achieved. As a rule, we do not use casts but prefer removable splints and walkers to allow early physical therapy therefore preventing "cast disease". I use a variety of procedures to address hallux rigidus depending on the level and severity of deformity. Commonly though for grades 2/3, I will use a Reverdin-Green type of osteotomy of the distal first metatarsal with screw fixation combined with cheilectomy. The goal of this procedure is to decompress the first MTP by shortening and possibly plantarflexing the capital fragment. After this procedure, the patient is non-weight bearing in a removable splint with crutch ambulation for a four week period though they begin ROM exercises of the first MTP the first week. The patient progresses to a walking boot for two additional weeks then into athletic shoes. For grade 4 hallux rigidus, I prefer first MTP arthrodesis. For HAV deformities, I again perform a variety of procedures based on level of deformity. Commonly for severe bunion deformity I will perform a base wedge osteotomy or a Lapidus procedure in addition to a bunion procedure distally. Post-operatively, I will keep these patients non-weight bearing with removable splint (for early ROM) and crutches for 6 weeks followed by 2 weeks in a walking boot.Though these patients are not ambulating early their involved joints are being aggressively "mobilized" and their level of function at 8-10 weeks post-operatively, I feel, is better than those patients who walk immediately or after a few weeks post-operatively.
Dr. Weil: I tend to perform my shortening/decompression osteotomes in younger patients with earlier stages of hallux rigidus (the patients need to be non-weight bearing for six weeks or to use an Ipos shoe). For Grades II and III, I prefer the Valenti arthroplasty. I find that many of the osteotomes performed for hallux rigidus look great on x-ray but patients still have pain. For this reason, I feel the Valenti works better. One may think this a joint destructive/burning bridges procedure, but it can be revised into a fusion or implant arthroplasty. The advantage is with the Valenti is that athletes can get back to sports around four weeks.For younger athletes with Grade IV hallux rigidus, I prefer joint fusions. A British soccer player at age 34 had a cheilectomy only to have the symptoms reoccur. I performed a first MPJ fusion and he played one more year in the World Cup after that surgery. For HAV procedures, I try to reserve this for when the athlete has finished their career unless as mentioned previously, they cannot perform to their level. I perform bunionectomies on ballerinas that have gotten back to ballet. I often do a combined Scarf osteotomy with a phalanx osteotomy. It usually takes them 10 to 12 weeks to get back to activity, and this is aided by physical therapy including early range of motion started at one week post-op. These patients can get full range of motion back.
Dr. Saxena: Let's talk about a relatively nonsurgical problem - plantar fasciitis.
Dr. Leach: I try very hard to treat all patients nonoperatively. People eventually get well although some not as quickly as they or I would like. I recommend a Tuli's heel cup, stretching, nonsteroidal anti-inflammatories (only sometimes) and fashioning an insert with a felt wedge medially to support the plantar fascia. I am much less excited about injecting steroids than some of my colleagues, although I do it every once in a while. Surgery, which I have done on several professional basketball players and top level runners, is recommended when the athlete is so frustrated that they cannot tolerate any more nonoperative treatment nor do what they have to do. I am sure most of them have had symptoms for more than six months. I release the plantar fascia from the os calcis and debride any of the degenerated areas of the fascia. In my article I published, it consisted of 19 cases but this is over a long period of time.
Dr. Campbell: I recommend shoes with a supportive shank and heel padding; patients often progress to a custom orthotic. If this along with stretching and phonophoresis fail, then I will inject with steroid. If symptoms interfere with athletic activity and is six months or longer in duration, then surgery could be undertaken. Postoperative mobilization, stretching with weight bearing tolerance usually allows them to return to sports in six weeks.
Dr. Bouche: For plantar fasciitis in resistant cases, I consider an open surgical procedure performing a fascial release and spur excision (if present). I feel strongly that the incisional approach for plantar fasciitis is an important limiting factor in obtaining a desired surgical result. My incisional approach is different but quite effective, avoiding important vital structures, staying consistent with the skin lines and allowing adequate exposure. The incision is medial-plantar and placed anterior to the calcaneal tuberosity being oblique medially and transverse plantarly. After surgery, the involved foot is maintained in a neutral dorsiflexed position and patients are kept non-weight bearing for four weeks followed by two to four weeks in a walking boot.
Dr. Weil: I do a percutaneous plantar fasciotomy, cutting the medial one-third to one-half of the fascia. I have only had to operate on 3 out of 100 professional athletes for this problem. Most patients can get back around eight weeks. I try to treat all the patients conservatively for at least six months. Plantar fasciitis does seem to be on the rise. In my 20 year career of treating professional athletes, I have seen more cases in the past 3 years than in the previous 17 years. This may be attributed to the athletes getting bigger, heavier, and faster.
Dr. Saxena: How about ankle instability and ligament reconstruction? What are your preferred techniques?
Dr. Weil: I prefer the Brostrom-Gould procedure because it maintains normal range of motion. I have had good results on 330 pound linemen and 90 pound ballerinas. I use soft tissue anchors (anywhere from one to three) and have them weight bear to tolerance in a below-the-knee cast or removable cast-boot up to five weeks post-op. They get back to full athletic activities in 10 to 12 weeks. We never do a primary ligament repair on professional athletes in a first time ankle sprain.
Dr. Saxena: Interesting, because one of the classically reappearing American Board of Podiatric Surgery questions deals with a 19-year-old baseball player that sustained a Grade III lateral ankle sprain, and the correct answer is to perform a primary repair.
Dr. McNerney: I don't remember when was the last time I heard of a professional athlete undergoing primary lateral ankle ligament repair. My experience shows that 95 percent of the Grade I, II, and III lateral ankle sprains can be effectively managed with conservative care. When indicated, I use a peroneus brevis tenodesis through the fibula and haven't noticed any stiffness, as long as a therapy is started rapidly.
Dr. Bouche: For ankle instability, I differentiate one or two ligament insufficiency. For one ligament insufficiency (ATF), I perform a Brostrom-type procedure. For two ligament insufficiency (ATF and CF), I use a modified Chrisman-Snook procedure combined with a Brostrom procedure. Subtalar instability, if present, is also addressed with this procedure. Post-operatively, patients are non-weight bearing in a splint on crutches for one month followed by a walking boot for two to four additional weeks. Patients do not begin formal therapy until the third week and at two weeks when ankle ROM is initiated by the patient, ankle plantarflexion is limited to 15 degrees to avoid undue tension on the ATF. After a full rehab program and patients return to sports, they ar instructed to wear an ankle brace for "position sense" purposes and an appropriate shoe (preferably high top) for four to six months.
Dr. Leach: I feel that very few people need this done; however, these operations work exceedingly well and are perhaps the best ligament reconstructions I do on the body. I use a version of the Brostrom or a modified Chrisman-Snook. We used to cast them, but now we put them in some type of brace and allow immediate weight bearing. We limit inversion-eversion allowing dorsiflexion-plantar flexion and continue to brace for six to seven weeks. Strengthening of the invertors-evertors is initiated, and most people return to full activity at 12 to 14 weeks.
Dr. Campbell: I also find athletes are able to return to activity around 12 weeks; I do have them use a brace when they return to sports. I prefer to use a Brostrom when possible, casting it for two to three weeks, then have them use a boot for another three weeks. They then start their rehab.
Dr. Saxena: How about surgery for stress fractures of the navicular and the Jones fracture? It seems that we are treating these as the injury has progressed from a stress fracture to a true fracture.
Dr. McNerney: I like to use an intramedullary screw for the Jones fracture, especially if we see intramedullary sclerosis. I try to use as long a screw as possible. Conservative care can be used for both for both Jones and navicular stress fractures, but it takes a long time. I try to combine casting with bone stimulation, because it seems that both together work better than either alone. For navicular stress fractures, I cast the patient non-weight bearing for six to eight weeks, followed by another two to four weeks weight bearing in a cast, then aggressive therapy.
Dr. Bouche: Khan's study (Kahn KM, Fuller PJ, Bruncker PD, et al: Outcome of Conservative and Surgical Management of Navicular Stress Fractures in Athletes. American J Sports Med 20:657, 1992) on navicular stress fractures concluded that navicular stress fractures heal with six to eight weeks of non-weight-bearing whether acute or chronic. If the navicular stress fracture progresses to an overt fracture, ORIF with screw fixation should be considered. If navicular stress fractures are missed, overt fracture can result with subsequent TN joint arthritis ultimately requiring TN joint arthrodesis.
For Jones fractures, I also recommend non-weight-bearing for six to eight weeks as a conservative approach. Surgically, I generally fix displaced Jones fractures with a Steinman pin (5/64) obliquely oriented from posterior plantar to dorsal distal engaging both cortices (a screw is used as an alternative). The Steinman pin is easy to place and affords rigid immobilization as good if not better than an intramedullary screw, in my opinion. I find that guiding the screw down the medullary shaft of the fifth metatarsal may times distracts the fracture because of the lateral metatarsal bowing commonly found. Onlay bone grafting with ORIF should be used in delayed and nonunions.
Dr. Saxena: You have all mentioned that these injuries take a while to heal. What about refracture?
Dr. Campbell: That's why I prefer to ORIF both navicular and Jones stress fractures. The athletes can get back to athletic activities in two to three months. Refractures, delayed healing, etc. is the reason to operate on these. One little technique tip - in order to orient the screw for the Jones fracture properly is to take a rongeur and remove some of the base of the fifth metatarsal so you have a flat surface to guide your pin or screw. Otherwise, you have a heck of a time trying to get the screw placed properly.
Dr. Saxena: Yes, I have noticed in all the articles dealing with Jones fractures, the authors often show oblique radiographs; they rarely show AP views of the intramedullary screw placement unless the screw was bent. Maybe because it is hard to align it well. Any final comments on these two injuries, Dr. Weil?
Dr. Weil: I also recommend intramedullary ORIF for Jones fractures for high level and professional athletes, especially in football and basketball players because the chance of reinjury is so high. Every surgery does have its risks. True navicular stress fractures do well in six to eight weeks non-weight bearing followed by physical therapy and gradual return to activity. One of Chicago's most famous athletes had complete recovery with this regimen.
Dr. Saxena: Thank you.
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