Background
Several operative techniques exist for Achilles tendinopathy. The purpose of our study was to compare the clinical and functional outcomes of flexor hallucis longus (FHL) transfer and V-Y ...advancement for the treatment of chronic insertional Achilles tendinopathy.
Methods
Retrospective chart review from 2010 to 2016 of patients that underwent FHL transfer or V-Y advancement for chronic insertional Achilles tendinopathy. Outcome measures were compared for these two procedures.
Results
In total, 46 patients (49 ankles) with a mean age of 55.0 (range 33–73) years. Mean follow-up time 44.7 +/− 25.5 months. FHL group had 21 patients (21 ankles) with 89% satisfaction, 14% complication rate, final VAS of 0.4, final VISA-A of 89.1, subjective strength improvement following surgery of 78%, and 94% would recommend the procedure. V-Y group had 25 patients (28 ankles) with 74% subjective satisfaction, 21% complication rate, final VAS of 1.4, final VISA-A of 78.4, subjective strength improvement following surgery of 67%, and 84% would recommend the procedure. There was no significant difference in any of the results rates between the two groups (
p
> .05).
Conclusion
V-Y advancement is comparable to FHL transfer for the operative management of insertional Achilles tendinopathy. Though our results trend towards less satisfactory results following V-Y advancement, we found high satisfaction rates with similar functional outcomes and complication rates in both operative groups. We suggest considering V-Y advancement as a viable option for the primary treatment of chronic insertional Achilles tendinopathy in patients who may not be an ideal candidate for FHL transfer.
To evaluate the reliability of ankle syndesmotic measurements and their changes during active motion using four-dimensional computed tomography (4DCT) examination in asymptomatic ankles.
4DCT was ...performed on both ankles of patients with signs and symptoms of unilateral ankle instability. Ankles from the asymptomatic side of 10 consecutive patients were included in this analysis. Five ankle syndesmotic measurements were adopted from the available literature and performed by two fellowship-trained foot and ankle surgeons: (1) syndesmotic anterior distance (SAD); (2) syndesmotic posterior distance (SPD); (3) syndesmotic translation (ST); (4) syndesmotic tibiofibular angle (STFA); and (5) ankle tibiofibular angle (ATFA). A Monte Carlo simulation was also performed to obtain exact p-values with 99% confidence intervals.
Excellent interobserver reliability was observed among the two readers for four out of five measurements (intra-class correlation coefficients ICC: 0.767–0.995, p<0.001–0.020). The ICC values for SAD were not statistically significant (ICC=0.548 and 0.569 for dorsi and plantarflexion respectively, p=0.1). Among the five measurements, only ST measurements had significant changes during active motion (median interquartile range for change: –0.70 mm –1.6–0.10; p=0.012). Of the above measurements, only the ST measurements demonstrated a negative linear association with the tibiocalcaneal angle during active motion (beta=–2.5, p=0.04).
Reliable quantitative kinematic assessment of ankle syndesmosis can be performed using 4DCT examination. Syndesmotic measurements remain unchanged during ankle motion except for the syndesmotic translation, which tends to decrease during plantar flexion.
•Kinematic assessment of ankle syndesmosis using 4D CT examination is feasible.•Syndesmotic measurements could be obtained during ankle motion with excellent inter-observer reliability.•Syndesmotic translation decreases during plantar flexion, but the remaining measurements remain unchanged during ankle motion.
Purpose
A medializing calcaneal osteotomy (MCO) is a surgical procedure frequently performed to correct an adult acquired flatfoot (AAFD) deformity. However, most studies are limited to a 2D analysis ...of 3D deformity. Therefore, the aim is to perform a 3D assessment of the hind- and midfoot alignment using a weightbearing CT (WBCT) preoperatively as well as postoperatively.
Methods
Eighteen patients with a mean age of 49.4 years (range 18–67) were prospectively included in a pre–post-study design. A MCO was performed and a WBCT was obtained pre- and postoperative. Images were converted into 3D models to compute linear and angular measurements, respectively, in millimeters (mm) and degrees (°), based on previously reported landmarks of the hind- and midfoot alignment. A regression analysis was performed between the displacement of a MCO and the obtained postoperative correction.
Results
The mean 3D hindfoot angle improved significantly preoperative compared to postoperative (
p
< 0.001). This appeared according to a linear relation with the amount of medial translation in a MCO (
R
2
= 0.84,
p
< 0.001). The axes of the tibia showed significant coronal as well as axial changes (
p
< 0.05). Analysis of the midfoot showed significant changes in the navicular height and rotation as well as the Méary angle (
p
< 0.05). Additionally, a linear trend between the midfoot measurements and amount of medial translation in a MCO was observed, but not significant (
p
> 0.05).
Conclusion
This study demonstrates an effective 3D correction of an AAFD by a MCO according to a linear relationship. The concomitant formula can be used to perform a preoperative planning. The novelty is the comparative 3D weightbearing CT assessment of both the computed hind- and midfoot alignment after a medializing calcaneus osteotomy. This could improve accuracy of the currently performed preoperative planning in clinical practice.
•Sural nerve injury is reported from 0 to 18% in percutaneous ankle procedures.•Most studies do not account for all attempts made at wire positioning.•The mean number of guidewires needed to achieve ...an acceptable position was 2.34.•The sural bundle was either injured or in direct contact with the guidewires in 73% of the time.
The objective of this cadaveric study was to identify the number of attempts necessary for a perfect positioning of the ankle fusion home run screw and the neurovascular and tendinous structures at risk.
Eleven cadaveric limbs were used. Guidewires were percutaneously placed into the distal posterolateral aspect of the leg, under fluoroscopic guidance, with the ankle held in neutral position. Malpositioned guidewires were not removed and served as guidance for the following wires. The number of guidewires needed to achieve an acceptable positioning of the implant was noted. Neurovascular and tendinous injuries were assessed, and the shortest distance between the closest guidewire and the soft tissue structures was measured using a precision digital caliper.
Mean number of guidewires needed to achieve acceptable positioning of the implant was 2.34 (SD 0.81, range 2–4). The mean distances between the closest guide pin and the soft tissue structures of interest were: Achilles tendon 5.35 mm (SD 2.74 mm); peroneal tendons 9.65 mm (SD 5.19 mm); posteromedial neurovascular bundle 12.78 mm (SD 7.14 mm). The sural bundle was in contact with the guide pin in 5/11 specimens (45.5%) and impaled in 3/11 specimens (27.3%). The average distance from the sural nerve bundle was 3.58 mm (SD 2.16 mm).
The placement of percutaneous ankle fusion home run screws is technically demanding requiring multiple attempts for acceptable placement. Important tendinous and neurovascular structures are in close proximity to the guidewires. The sural bundle was either injured or in direct contact with the guide wire in approximately 73% of the cases. When using a home run screw, a mini-open approach is recommended.
Level V, cadaveric study.
•AAFD measurements with WBCT are reliable regardless of investigator experience.•We found overall substantial to perfect intra- and interobserver reliability.•Similar results for medical student, ...orthopedic resident, and orthopedic surgeon.
Our purpose was to assess the reliability of measurements of adult-acquired flatfoot deformity (AAFD) taken by investigators of different levels of clinical experience using weightbearing computed tomography (WBCT).
Nineteen AAFD patients underwent WBCT. Three investigators with different levels of clinical experience made AAFD measurements in axial, coronal, and sagittal planes. Intra- and interobserver reliability were assessed. Mean values for each measurement were compared between investigators.
After a training protocol, substantial to perfect intra- and interobserver reliability was observed for most measures, regardless of the investigator’s experience level. Significant differences between investigators were observed in 2 of 21 measured parameters: medial cuneiform–first metatarsal angle (P=0.003) and navicular–medial cuneiform angle (P=0.001).
AAFD radiographic measurements can be performed reliably by investigators with different levels of clinical experience using WBCT.
Level II, prospective comparative study.
SEMAC MRI of total ankle arthroplasty de Cesar Netto, C; Dein, E.J; Zhang, H ...
Foot and ankle surgery,
June 2016, Letnik:
22, Številka:
2
Journal Article
A medializing calcaneal osteotomy is frequently performed to correct adult-acquired flatfoot deformities, but there is lack of data on the associated three-dimensional variables defining the final ...correction. The aim of this study was to assess the correlation between the pre-operative hindfoot valgus deformity and calcaneal osteotomy angles and the post-operative calcaneal displacement.
Weight-bearing CT scans obtained pre- and post-operatively were retrospectively analyzed for sixteen patients. Corresponding three-dimensional bone models were used to measure valgus deformity pre- and post-operatively, inclination of the osteotomy and displacement of the calcaneus. Linear regression was conducted to assess the relationship between these measurements.
On average, the hindfoot valgus changed from 13.1° (±4.6) pre-operatively to 5.7° (±4.3) post-operatively. A mean inferior displacement of 3.2mm (±1.3) was observed along the osteotomy with a mean inclination of 54.6° (±5.6), 80.5° (±10.7), -13.7° (±15.7) in the axial, sagittal and coronal planes, respectively. A statistically significant positive relationship (p<.05, R
=0.6) was found between the pre-operative valgus, the axial osteotomy inclination, and the inferior displacement.
This study shows that the degree of pre-operative hindfoot valgus and the axial osteotomy angle are predictive factors for the amount of post-operative inferior displacement of the calcaneus. These findings demonstrate the added value of a computer-based pre-operative planning in clinical practice. Level of evidence II Prospective comparative study.
