Background:
In progressive collapsing foot deformity (PCFD), an internal and plantar rotation of the talus relative to the calcaneus may result in painful peritalar subluxation. Medial soft tissue ...procedures (eg, spring ligament repair) aim to correct the talar position via the navicular bone if bony correction alone is not sufficient. The effect of the medial soft tissue reconstruction on the talar reposition remains unclear. We hypothesized that a subtalar talocalcaneal ligament reconstruction might be favorable in PCFD to correct talar internal malposition directly. This pilot study aims to evaluate the anatomical feasibility and kinematic behavior of a subtalar ligament reconstruction in PCFD.
Methods:
Three-dimensional surface model from 10 healthy ankles were produced. A total of 1089 different potential ligament courses were evaluated in a standardized manner. A motion of inversion/eversion and talar internal/external in relation to the calcaneus were simulated and the ligament strain, expressed as a positive length variation, for each ligament was analyzed. The optimal combination for the ligament reconstruction with increased length in internal rotation of the talus, isometric kinematic behavior in inversion/eversion, and extraarticular insertion on talus and calcaneus was selected.
Results:
A laterodistal orientation of the talar insertion point in respect to the subtalar joint axis and laterodistal deviation of the calcaneal insertion point presents the highest ligament lengthening in internal talar rotation (+0.56 mm 3.8% of total length) and presented a near-isometric performance in inversion/eversion (+0.01 to −0.01 mm 0.1% of total length).
Conclusion:
This kinematic model shows that a ligament reconstruction in the subtalar space presents a pattern of length variation that may stabilize the internal talar rotation without impeding the physiological subtalar motion.
Clinical Relevance:
This study investigates the optimal location, feasibility, and kinematic behavior of a ligament reconstruction that could help stabilize peritalar subluxation in progressive collapsing foot deformity.
Graphical Abstract
This is a visual representation of the abstract.
Background:
Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of ...morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability.
Methods:
Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years.
Results:
Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001).
Conclusion:
A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure.
Level of Evidence:
Level IV, retrospective cohort study.
Graphical Abstract
This is a visual representation of the abstract.
Background: Acquired adult flatfoot deformity (AAFD) results in a loss of the medial longitudinal arch of the foot and dysfunction of the posteromedial soft tissues. Hintermann osteotomy (H-O) is ...often used to treat stage II AAFD. The procedure is challenging because of variations in the subtalar facets and limited intraoperative visibility. We aimed to assess the impact of augmented reality (AR) guidance on surgical accuracy and the facet violation rate. Methods: Sixty AR-guided and 60 conventional osteotomies were performed on foot bone models. For AR osteotomies, the ideal osteotomy plane was uploaded to a Microsoft HoloLens 1 headset and carried out in strict accordance with the superimposed holographic plane. The conventional osteotomies were performed relying solely on the anatomy of the calcaneal lateral column. The rate and severity of facet joint violation was measured, as well as accuracy of entry and exit points. The results were compared across AR-guided and conventional osteotomies, and between experienced and inexperienced surgeons. Results: Experienced surgeons showed significantly greater accuracy for the osteotomy entry point using AR, with the mean deviation of 1.6 ± 0.9 mm (95% CI 1.26, 1.93) compared to 2.3 ± 1.3 mm (95% CI 1.87, 2.79) in the conventional method ( P = .035). The inexperienced had improved accuracy, although not statistically significant ( P = .064), with the mean deviation of 2.0 ± 1.5 mm (95% CI 1.47, 2.55) using AR compared with 2.7 ± 1.6 mm (95% CI 2.18, 3.32) in the conventional method. AR helped the experienced surgeons avoid full violation of the posterior facet ( P = .011). Inexperienced surgeons had a higher rate of middle and posterior facet injury with both methods ( P = .005 and .021). Conclusion: Application of AR guidance during H-O was associated with improved accuracy for experienced surgeons, demonstrated by a better accuracy of the osteotomy entry point. More crucially, AR guidance prevented full violation of the posterior facet in the experienced group. Further research is needed to address limitations and test this technology on cadaver feet. Ultimately, the use of AR in surgery has the potential to improve patient and surgeon safety while minimizing radiation exposure. Clinical Relevance: Subtalar facet injury during lateral column lengthening osteotomy represents a real problem in clinical orthopaedic practice. Because of limited intraoperative visibility and variable anatomy, it is hard to resolve this issue with conventional means. This study suggests the potential of augmented reality to improve the osteotomy accuracy.
Formula: see text
Axial plane alignment of the talar component in total ankle arthroplasty is poorly understood and remains a major issue, especially since malpositioning results in increased peak pressure and ...rotational torque. Further profound knowledge regarding individual anatomy of the talus and its relation to proximal and distal osseous structures is therefore needed. Therefore, three‐dimensional (3D) surface models of 50 lower extremities were generated using computed tomography data of patients without ankle osteoarthritis. The talus neck torsion was measured using a novel 3D measurement method. Then, tibial torsion and subtalar joint axis orientation were measured and correlated to the talus neck torsion. Moreover, a 2D measurement method of the talus neck torsion was developed. A statistically significant correlation was found between external tibia torsion and medial talus neck torsion, as well as talus neck axis and subtalar joint axis in the transversal and frontal plane. The novel defined 3D measurement methods indicated excellent inter‐rater and intra‐rater reliability. The 2D measurement method of the talus neck torsion was in good agreement with the 3D method. The results showed that the rotational profiles of the tibia, talus, and adjacent joints are interconnected, which should be considered in total ankle replacement (TAR). Clinical relevance: This study improves the overall understanding of the talar anatomy, as well as its relationship to adjacent osseous structures. The novel 2D measurement method of the talus neck torsion might improve talar component positioning in the axial plane corresponding to the patient's individual anatomy, and therefore improve the survival rate of TAR.
If tibiofibular syndesmotic injury is undetected, chronic instability may lead to persistent pain and osteoarthritis. So far, no reliable diagnostic method has been available. The primary objectives ...of this study were to determine whether defined lesions of the syndesmosis can be correlated with specific tibiofibular joint displacements caused by external rotational torque and to compare the performance of bilateral external torque computed tomography (BET-CT) and arthroscopy. Secondary objectives included an evaluation of the reliability of CT measurements and the suitability of the healthy contralateral ankle as a reference.
Seven pairs of healthy, cadaveric lower legs were tested and assigned to 2 groups: (1) supination-external rotation (SER) and (2) pronation-external rotation (PER). In the intact state and after each surgical step, an ankle arthroscopy and 3 CT scans were performed. During the scans, the specimens were placed in an external torque device with 2.5, 5.0, and 7.5 Nm of torque applied.
The arthroscopic and CT parameters showed significant correlations in all pairwise comparisons. The receiver operating characteristic (ROC) curve analyses yielded the best prediction of syndesmotic instability with the anterior tibiofibular distance on CT, with a sensitivity of 84.1% and a specificity of 95.2% (area under the curve AUC, 94.8%; 95% confidence interval CI, 0.916 to 0.979; p < 0.0001) and with the middle tibiofibular distance on arthroscopy, with a sensitivity of 76.2% and specificity of 92.3% (AUC, 91.2%; 95% CI, 0.837 to 0.987; p < 0.0001). Higher torque amounts increased the rate of true-positive results.
BET-CT reliably detects experimental syndesmotic rotational instability, compared with the healthy side, with greater sensitivity and similar specificity compared with the arthroscopic lateral hook test. Translation of these experimental findings to clinical practice remains to be established.
Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Background:
Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I ...arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort.
Methods:
All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a “Virtual Tegner activity score” (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI).
Results:
Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group.
Conclusion:
In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years’ follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus.
Level of Evidence:
Level III, a case-control study.
Background:
Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon ...is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet.
Methods:
Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests.
Results:
Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees).
Conclusion:
Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint.
Level of Evidence:
Level IV, prospective case series.
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