Background:
The anatomy of the syndesmosis is variable, yet little is known on the correlation between differences in anatomy and syndesmosis reduction results. The aim of this study was to analyze ...the correlation between syndesmotic anatomy and the modes of syndesmotic malreduction.
Methods:
Bilateral postreduction ankle computed tomography (CT) scans of 72 patients treated for fractures with syndesmotic disruption were analyzed. Incisura depth, fibular engagement into the incisura, and incisura rotation were correlated with degree of syndesmotic malreduction in coronal and sagittal planes as well as rotational malreduction.
Results:
Clinically relevant malreduction in the coronal plane, sagittal plane, and rotation affected 8.3%, 27.8%, and 19.4% of syndesmoses, respectively. The syndesmoses with a deep incisura and the fibula not engaged into the tibial incisura were at risk of overcompression, anteverted incisuras at risk of anterior fibular translation, and retroverted incisuras at risk of posterior fibular translation.
Conclusions:
Certain morphologic configurations of the tibial incisura increased the risk of specific syndesmotic malreduction patterns.
Level of Evidence:
Level III, comparative study.
PURPOSETo investigate the joint-specific contributions to the total lower-extremity joint work during a prolonged fatiguing run.
METHODSRecreational long-distance runners (n = 13) and competitive ...long-distance runners (n = 12) performed a 10-km treadmill run with near-maximal effort. A three-dimensional motion capture system synchronized with a force-instrumented treadmill was used to calculate joint kinetics and kinematics of the lower extremity in the sagittal plane during the stance phase at 13 distance points over the 10-km run.
RESULTSA significant (P < 0.05) decrease of positive ankle joint work as well as an increase of positive knee and hip joint work was found. These findings were associated with a redistribution of the individual contributions to total lower-extremity work away from the ankle toward the knee and hip joint which was more distinctive in the recreational runner group than in the competitive runner group. This redistribution was accomplished by significant (P < 0.05) reductions of the external ground-reaction force lever arm and joint torque at the ankle and by the significant (P < 0.05) increase of the external ground-reaction force lever arm and joint torque at the knee and hip.
CONCLUSIONSThe redistribution of joint work from the ankle to more proximal joints might be a biomechanical mechanism that could partly explain the decreased running economy in a prolonged fatiguing run. This might be because muscle–tendon units crossing proximal joints are less equipped for energy storage and return compared with ankle plantar flexors and require greater muscle volume activation for a given force. To improve running performance, long-distance runners may benefit from an exercise-induced enhancement of ankle plantar flexor muscle–tendon unit capacities.
Background
Despite the appearance of new-generation, mobile-bearing, cementless prostheses, total ankle arthroplasty remains controversial. Among the criteria guiding the choice between arthrodesis ...and arthroplasty, the long-term survival and postoperative function are of critical importance. The mobile-bearing Salto prosthesis has been used in Europe since 1997, but only 2 to 5 years of followup data have been reported.
Questions/purposes
We analyzed the longer-term survivorship and causes of failures of the Salto prosthesis in a cohort of previously studied patients. We asked whether this prosthesis provided a functional ankle (AOFAS score) and durable radiographic fixation.
Patients and Methods
We retrospectively reviewed 96 prospectively followed patients with 98 prostheses implanted between 1997 and 2000. Of those, 85 patients (87 prostheses) had a minimum followup of 6.8 years (mean, 8.9 years; range, 6.8–11.1 years).
Results
The survival rate was 65% (95% CI, 50–80) with any reoperation of the ankle and 85% (95% CI, 75–95) with revision of a component as the end points. Six prostheses were removed for arthrodesis, and 18 ankles underwent reoperation without arthrodesis. We observed three main causes of reoperations: bone cysts (11 patients), fracture of the polyethylene (five patients), and unexplained pain (three patients). The mean AOFAS score was 79 ± 12 points. Radiographic subsidence was observed in three patients and bone cysts in eight patients.
Conclusions
Our data suggest a high rate of reoperations but only six revisions with arthrodesis with mid-term followup. We observed few patients with loosening and/or subsidence.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Purpose
This study aimed to measure the change in knee joint line obliquity (KJLO) and the changes in radiologic parameters of the ankle and hip joints after medial opening-wedge high tibial ...osteotomy (MOWHTO), and to evaluate the correlation and causal relationship between these parameters.
Methods
This study evaluated 109 patients who underwent MOWHTO between April 2015 and December 2021. Radiologic parameters, including KJLO, medial proximal tibial angle (MPTA), ankle joint line obliquity (AJLO), and hip abduction angle (HAA), were analysed before and 1 year after MOWHTO. Multiple linear regression analysis was used to identify independent variables that significantly affected the change in KJLO after MOWHTO. Receiver operating characteristic (ROC) analysis was used to evaluate the cutoff value for a change in KJLO that exceeded 5° postoperatively, and the predicting values of radiologic parameters.
Results
Multiple linear regression analysis showed that changes in MPTA, AJLO, and HAA (
β
= 0.440,
P
< 0.001;
β
= − 0.310,
P
< 0.001;
β
= 0.164,
P
= 0.035, respectively) were predictors of the change in KJLO after MOWHTO. ROC analysis showed that the threshold value for a change in KJLO which exceeded 5° postoperatively was 4.6° (66.7% sensitivity, 63.8% specificity,
P
= 0.025). Moreover, ROC curves for predicting a change in KJLO of > 4.6° showed that the AUC was significantly higher for the change in MPTA than that of the other two parameters (
P
= 0.011 for AJLO and
P
< 0.001 for HAA).
Conclusion
MOWHTO increases the KJLO by valgization of the proximal tibia and causes hip adduction and ankle valgization. The postoperative ankle valgization after MOWHTO could reduce the increase in KJLO, counteracting the effects of proximal tibial valgization and hip adduction. Therefore, the effects of the hip and ankle joints should be considered to achieve an optimal KJLO and satisfactory clinical outcomes after MOWHTO.
Level of study
Cohort study, IV.
Background
Although its FDA-approved applications are limited, the pro-osteogenic benefits of recombinant human BMP-2 (rhBMP-2) administration have been shown in off-label surgical applications. ...However, the effects of rhBMP-2 on ankle fusions are insufficiently addressed in the literature, which fails to include a case-control study of adequate sample size to evaluate the efficacy of rhBMP-2 treatment.
Questions/purposes
In this study we asked whether rhBMP-2 treatment (1) would increase the rate of successful ankle fusion in complex patients (patients with comorbidities associated with poor surgical healing) compared with a control group of patients undergoing ankle fusion who did not receive rhBMP-2; (2) would reduce total time wearing a frame when compared with the control group; (3) would result in a difference in the percentage of bone bridging between the group treated with rhBMP-2 and the control group, as determined by CT scans 3 months after surgery; and (4) would encounter an equal rate of complications different from untreated patients.
Methods
A retrospective chart study was performed on 82 patients who, because of a host of comorbidities associated with poor healing, required a complex ankle arthrodesis with the Ilizarov technique. The first 40 patients did not receive rhBMP-2, whereas the subsequent 42 patients received intraoperative rhBMP-2. Time wearing the frame was determined by chart review; decision to remove the frame was made by the surgeon based on quantitative bone bridging measured using a CT scan taken 3 months after fusion.
Results
Patients treated with rhBMP-2 were more likely to obtain fusion after the initial surgery (93% versus 53%, p < 0.001; OR, 11.76; 95% CI, 3.12–44.41), spent less total time wearing the frame (124 versus 161 days, p < 0.01), and showed more bone bridging on CT scans (48% versus 32%, p < 0.05). All patients with greater than 30% bone bridging observed on CT scans 3 months postoperatively achieved successful union without further intervention.
Conclusions
Our findings suggest that rhBMP-2 is a beneficial adjunct for selected groups of patients undergoing complex ankle arthrodesis. CT is a promising modality in the assessment of bone healing in ankle fusion. A proper randomized controlled trial remains necessary to fully describe the efficacy of rhBMP-2 in accelerating bone healing.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Background:
Osteochondral lesions of the talar dome (OLTs) involve the articular cartilage and subchondral bone. The subchondral bone plate (SBP) plays a crucial role in cartilage metabolism, and ...computed tomography (CT) can provide more precise information on subchondral bone. CT image prediction of the histological findings on OLT will be useful to determine the most appropriate therapeutic strategy.
Purpose:
To evaluate the unique features of the CT findings that relate to the condition of the articular cartilage in OLT.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Thirty ankles in 29 patients who had OLT with an osteochondral fragment were retrospectively reviewed. At surgery, the osteochondral fragment of 19 ankles could be preserved (preservation group) by fixation or drilling, and in the remaining 11 ankles, the osteochondral fragment was removed (excision group). Preoperative CT findings were compared between the 2 groups. Biopsies of the osteochondral fragment from 13 ankles were performed. The relationship between the CT and histological findings were evaluated.
Results:
The area of lesion in the preservation group was significantly larger than that in the excision group. The CT images of the lesion showed the rate of absorption of the SBP in the preservation group to be lower than that in the excision group. As for the lesion bed absorption, it was higher in the preservation group than in the excision group. All cases in the excision group showed bed sclerosis, compared with 42.1% in the preservation group. The specimens with disruption of the SBP exhibited cartilage degeneration and abundant chondrocyte cloning. OLT with absorption of the SBP on CT showed severe cartilage degeneration, while the remaining SBP on CT showed low-grade cartilage degeneration.
Conclusion:
This study shows the features of preoperative CT and histological findings in OLT with osteochondral fragments. The condition of the SBP affects the cartilage degeneration. CT findings provide important information for the determination of surgical treatment.
Ankle fusion is the primary treatment for advanced ankle arthritis. With the advancement of arthroscopy technology, ankle arthroscopy fusion has shown many advantages over traditional surgery. ...However, there are few related studies globally, and evidence-based medicine is needed to verify the reliability and feasibility of ankle arthroscopy fusion.
To compare the clinical efficacy and safety of arthroscopic ankle arthrodesis and open ankle arthrodesis.
We searched the databases of PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure CNKI, Wanfang Database, and VIP Database for published prospective or retrospective controlled studies of arthroscopic-assisted ankle fusion in the treatment of advanced ankle arthritis. The dates were limited from the construction of the library to June 30, 2019. Literature was included based on the principles and methods of evidence-based medicine. Literature retrieval, data extraction, and quality assessment were performed by 2 independent reviewers using the Cochrane 5.1 risk bias assessment tool. The methodological bias of the literature was evaluated, and a meta-analysis was using by RevMan 5.3 software.
A total of 18 studies and 1102 patients were included in the study, including 551 in the arthroscopic surgery group and 551 in the open surgery group. Arthroscopy-assisted surgery for advanced ankle arthritis was more effective than open surgery in terms of fusion rate (odd ratioOR = 3.32, 95% confidence intervalCI:2.16, 5.10), fusion time (mean differenceMD = -2.31, 95% CI:-4.63, -2.21), intraoperative blood loss (MD = -43.37, 95%CI: -48.49, -38.25), hospital stay (MD = -1.80, 95%CI: -2.28, -1.33), and visual analog scale score (MD = -1.75, 95%CI: -2.04, -1.46). In addition, rate of complications (OR = 0.33, 95%CI: 0.21, 0.52) was superior to open ankle fusion (P < .00001).
Arthroscopic ankle arthrodesis has more advantages than open ankle arthrodesis in improving the fusion rate and reducing complications, which is worthy of clinical application.
CRD42020195727.
The aim of this study was to investigate the effect of a posterior malleolar fragment (PMF), with < 25% ankle joint surface, on pressure distribution and joint-stability. There is still little ...scientific evidence available to advise on the size of PMF, which is essential to provide treatment. To date, studies show inconsistent results and recommendations for surgical treatment date from 1940.
A total of 12 cadaveric ankles were assigned to two study groups. A trimalleolar fracture was created, followed by open reduction and internal fixation. PMF was fixed in Group I, but not in Group II. Intra-articular pressure was measured and cyclic loading was performed.
Contact area decreased following each fracture, while anatomical fixation restored it nearly to its intact level. Contact pressure decreased significantly with fixation of the PMF. In plantarflexion, the centre of force shifted significantly posteriorly in Group II and anteriorly in Group I. Load to failure testing showed no difference between the groups.
Surgical reduction of a small PMF with less than 25% ankle joint surface improves pressure distribution but does not affect ankle joint stability. Cite this article:
2018;100-B:95-100.
Background:
Previous studies focusing on the effects of knee surgery on hindfoot alignment have suggested some degree of compensation between the knee and the hindfoot. However, these studies did not ...investigate a preoperative relationship in patients without end-stage knee osteoarthritis using 3-dimensional (3D) biometrics. The purpose of this study was to investigate the relationship between knee and hindfoot alignment using 3D weightbearing imaging.
Methods:
This retrospective comparative study included 95 lower limbs with weightbearing computed tomography and low-dose biplanar radiograph investigations. Cases with a history that may have caused a change in lower limb alignment were excluded. Hindfoot and knee alignments were measured using foot ankle offset (FAO) and hip-knee-ankle (HKA) angle, respectively. Patients were separated into 3 groups according to the knee deformity to investigate the distribution of FAO in each group.
Results:
The mean (SD) FAO was 2% (7%) for the knee varus group, 1% (6%) for the neutral knee group, and 4% (5%) for the valgus knee group (P = .12). Fifty-three percent of patients with knee valgus showed a pathological hindfoot valgus (P = .04). We found a positive but moderate correlation between hindfoot valgus and HKA (ρ = 0.53; P = .01). Female sex was associated with higher FAO (3% ± 4% vs 0.6% ± 6%; P = .009).
Conclusion:
This feasibility study suggests a new opportunity using 3D biometrics to understand the relationship between knee and hindfoot alignment and to highlight different patterns of combined deformities in further investigations.
Level of Evidence:
Level III, comparative study.
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