Classic Papers in Foot and Ankle
Surgery: Introduction
Rajesh Kakwani and Malik Siddique
Foot and Ankle is such an upcoming and ever evolving
speciality. The selection criterion used for this chapter involved
choosing articles that have made a significant impact on the
way we manage foot and ankle disease, not just selecting arti-
cles based on the highest citation counts. We do not make any
claims that these are the only classic papers in this speciality.
The book in general is designed for general orthopaedic
review; hence only the articles which have made a landmark
change in the management of common cases were included.
The management of Achilles tendon ruptures, one of the
most common conditions encountered in day-to-day practice
is still very controversial. There have been numerous ran-
domised controlled trials and meta-analyses regarding the
management options conservative or operative with exactly
opposing results. One can find enough evidence to justify
ones own method of dealing with this condition. Most of the
studies included prolonged immobilisation of the ankle, but
there have been several publications regarding the benefit of
functional stimulus to healing tendons. Hence our rationale to
include the Canadian study which is the largest study to date
using functional rehabilitation for Achilles tendon ruptures.
Patient related outcome measures have been gaining
increasing importance in orthopaedics. Outcome measures
used for hip and knee arthroplasty are well established. The
American Orthopaedic Foot and Ankle society have develo-
ped a standard scoring system for foot and ankle conditions
the AOFAS score. Although the AOFAS score has not been
yet validated, it is still the most widely used system in foot
and ankle publications. It provides a basis on which various
modalities of management have been compared.
R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*)
Department of Orthopaedics, Northumbria NHS Trust,
Ashington, UK
e-mail: rajeshkakwani@gmail.com
M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD,
FRCS (Tr & Orth)
Department of Orthopaedics, Freeman Hospital,
Newcastle Upon Tyne, UK
e-mail: malik.siddique@nuth.nhs.uk
P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics,
DOI 10.1007/978-1-4471-5451-8_51, Springer-Verlag London 2014
51
The evolution of the surgical management of severe
claw toe deformities of the rheumatoid forefoot started
with Hoffmanns description in 1912. The importance of
re-positioning of the plantar fat pad under the residual
metatarsal heads and the maintenance of the metatarsal
parabola was highlighted by Fowler. Various modifications
of the two procedures have followed with variable results.
Although the management of the great toe has since shifted
towards fusion surgery, to give a stable medial ray, the man-
agement of claw toes still follows the same principles high-
lighted by Fowler.
The landmark article by Hawkins regarding talar neck
fractures has pioneered the understanding of management of
this complex injury. The article outlined the extent of
vascular insult to the talus as the group increases, and hence
the higher risk of avascular necrosis of the talus. The prog-
nostic value of his classification has stood the test of time.
The sensitivity of the Hawkins sign is around 100 %.
The other extremely controversial topic in this sub-
speciality is the management of calcaneal fractures. The
Buckley study has been one of the largest randomised con-
trolled trials on this topic. It highlights various prognostic
factors that help decision making for this injury. Although
further studies are needed to compare minimally invasive
techniques to non-operative management, this remains the
most widely quoted guidance for this severe injury.
Finally, last but not the least. The true classic demonstra-
tion of the gold standard surgical solution for chronic lateral
ligament instability of the ankle. In contrast to the previous
concept, that chronic ligament ruptures are not amenable to
repair, Brostrom proved that the direct repair of the lateral
ankle ligaments yield excellent result. The most commonly
used modification is the Gould modification of the Brostrom
repair. The tendinous reconstruction of the lateral ligaments
is nowadays used only as a revision procedure. The non-
anatomical reconstruction techniques have been associated
with a high incidence of sural nerve injury.
We hope that you will relish this nostalgic journey through
the memory lane of evidence based foot and ankle surgery.
211