Category:
Ankle; Sports; Other
Introduction/Purpose:
The isokinetic test has been used diffusely as a way to evaluate the functional results after the rehabilitation of musculoskeletal injuries. In ...the ankle, in particular, most studies are related to lateral ligament injuries and Achilles tendon's injuries. However, different protocols are used and a lack of normative values is observed in the literature. The aim of this work is to perform a global isokinetic evaluation on healthy ankles in order to propose reference values for future patients.
Methods:
We evaluated 100 participants (200 ankles) using the Biodex 3 System for the eversion, inversion, dorsiflexion and plantar flexion movements of the ankle. The sample consisted of individuals aged 20-60 years, with an active life and practice of recreational physical activity (non-athlete) and without previous injuries. Five repetitions for strength (N / m) and work (J) at a speed of 30o / sec and 10 repetitions for power (W) at a speed of 120o / sec were performed in our protocol. Agonist / antagonist ratio and the Muscle Deficiency Index, which globally assesses the balance between the sides for each movement, were also evaluated, as well as the demographic variables. Different statistical analyzes were performed for each parameter.
Results:
The mean age was 38.5 years and BMI 25.8 (CI 2.7 and 0.8 respectively) in 69 men and 31 women. In 78% of participants, the dominant ankle was the right one. The non-dominant side was consistently stronger (higher peak torque) in all movements (p<0.001 - Wilcoxon Test). The mean values obtained for force in each movement were 29.9N/m for eversion, 34.8N/m (CI 1.6) for inversion, 48.6N/m (2.0) for dorsiflexion and 140.2 N/m for plantar flexion. Such parameters for men and women were also obtained (p<0.001) and there was no correlation between age or BMI with the maximum torque (N/m) through Spearman's Correlation. The ratio of eversors / inverters was 88.8% (CI 3.1) and that of dorsiflexors / plantar flexors was 36.1% (1.3). Limb symmetry Index were >= 90% between sides in all four moviments (91,99% for eversion, 98,57% for inversion, 96,96% for dorsiflexion and 94,72% for plantarflexion).
Conclusion:
The non-dominant side was stronger in this evaluation of the two hundred healthy ankles. However, this difference was within the expected range for the limb symmetry index and for the MDI, showing that limb dominance is not relevant for the isokinetic assessment of the ankle. In the studied sample, the demographic variables (except gender) did not show any correlation with the evaluated parameters, especially with the maximum torque. Normative values of torque forces and agonist/antagonist balances were proposed. The results have implications for rehabilitation protocols and criteria for returning to sports.
Category:
Ankle
Introduction/Purpose:
The indications for total ankle arthroplasty (TAA) have greatly expanded over the past decade. This rapid growth has been made possible with evidence-based ...medicine. Patient-reported outcomes (PROs) have been the primary outcome measure in many of these studies. To evaluate the quality of the evidence underlying expanded indications for TAA, we must first understand what PROs have been used in the evaluation of outcomes of TAA.
Methods:
The goal of this study was to conduct a systematic review of the literature from 2010 to 2021 capturing all studies of TAA to determine what PRO instruments were used, and what facets of TAA practice were studied. Studies reporting on outcomes and PROs following a TAA procedure were selected to review from the PubMed database between January 2010 and July 2021. Results from one hundred sixty-three studies were reviewed and pooled for analysis for this study.
Results:
After the evaluation of one hundred sixty-three studies, twenty-four separate PRO measures were identified in the literature. The PROs that were most reported in the literature from 2010 to 2021 were American Orthopedic Foot and Ankle Score (AOFAS) (49.1%), 36-Item Short Form Survey (SF-36) (40.5%), visual analog scale - pain (VAS) (35.6%), Ankle Osteoarthritis Scale (AOS) Questionnaire (17.8%), and Short Musculoskeletal Function Assessment (SMFA) (14.7%). The independent variables in these studies included a wide range of modifiable and unmodifiable patient factors such as age (27 studies), BMI (23 studies), smoking (8 studies), and preoperative coronal plane deformity (5 studies). A significant portion of the studies (41%) advocating for expanded indications did so based on the failure to find a difference in groups.
Conclusion:
The most commonly used PROs for TAA were AOFAS, SF-36, and VAS. The AOFAS score which had been the most commonly used PRO in 2009, is still today despite the determination in 2011 that it is not valid and there is a substantial risk for bias. Newer, validated PRO instruments, such as PROMIS, have not yet attained significant implementation in studies of TAA. The vast majority of the evidence supporting the expanded indications for TAA has come from studies with negative results. Caution should be exercised in interpreting these results and their study implications.
Category:
Ankle Arthritis; Ankle
Introduction/Purpose:
Tendinopathy of the flexor hallucis longus is a common condition that occurs with considerable frequency, but in some specific situations, due ...to a content (tendon)/continent (retomalleolar groove) conflict, could manifest a scenario in which the tendon suffers entrapment during its entry to the tunnel and clinically represented as hallux saltans
Methods:
We present a case report of a young active patient without any of the conditions or etiological agents previously described in the literature that could explain the cause of this rare condition. After failing conservative treatment, we performed arthroscopic release of the tendon and the fibrous tunnel, achieving direct visualization and minimal soft tissue injury
Results:
At 6 months, the patient resumed sports and activity of daily living without any type of sequelae.
Conclusion:
Hallux saltans is a rare condition mostly idiopathic in its origin. After conservative measures fail, surgical management is an option, which consists of resecting FHL enlargement to its original width and freeing the fibro-osseous tunnel in the back of the talus in order to solve the space conflict during its normal gliding. An arthroscopic approach is optimal as it allows a good visualization without harming soft tissues and allowing a quicker recovery.
Category:
Midfoot/Forefoot; Basic Sciences/Biologics; Hindfoot
Introduction/Purpose:
The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible ...classes that describe different deformity components. Each class is defined by clinical and radiographic findings. These components are ostensibly independent from one another during evaluation and treatment. However, PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high.
Methods:
In this IRB-approved retrospective case-control study, we assessed 32 feet diagnosed with PCFD and 28 controls matched on gender, BMI and age. All measurements were performed using weight-bearing CT (WBCT) scans and completed by two foot and ankle surgeons. The classes and their associated radiographic measurements were defined as follows: Class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by the talus-first metatarsal (Meary) angle, class D (peritalar subluxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. Data were checked for multicollinearity with the Belsley-Kuh-Welsch technique. Heteroskedasticity and normality of residuals were assessed respectively by the Breusch-Pagan test and the Shapiro-Wilk test. A p-value <0.05 was considered significant.
Results:
After removing confounding variables, each class was separately evaluated. In Class A, Meary was positively correlated (rs=0.46; p=0.009) with HMA, explaining 21% of changes in this angle (R2=0.21). Class B evaluation showed that MFU was correlated with TNCA (rs=0.76; p=0.001), explaining 63% of TNCA variations (R2=0.63). In Class C, HMA (rs=0.71; p=0.001) and MFU (rs =0.75; p=0.001) were correlated to Meary's angle and both measures explained 58% of changes in this angle (R2=0.58).
When assessing Class D, TNCA (rs =0.76; p=0.001) and Meary (rs=0.75; p=0.001) correlated with MFU and were responsible for 63% of variations on this angle. Finally, Class E deformity, determined by TTA, was not correlated with any other measurement.
Conclusion:
This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were found to be influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features. Further, these results support the concept that a specific component correction may impact other misalignments, decreasing the necessity for adjuvant procedures. This could have a direct effect in clinical practice, changing how providers assess PCFD and plan treatments.
Category:
Hindfoot; Ankle; Other
Introduction/Purpose:
Equinovarus foot deformities typically present with equinus contractures, hindfoot varus, dorsiflexion of the medial midfoot, and adduction ...deformities of the forefoot. Whether of neurologic or muscular origin, all forms result muscular imbalance. Flexor hallucis longus (FHL) transfer to peroneus brevis (PB) is indicated when both peroneal muscles are in unrepairable condition to restore active eversion. However, in cases of muscle paralysis where the PB is still in continuity, we recommend a novel technique where FHL is tenodesed proximal to the peroneal retinaculum within the leg to avoid the additional morbidity associated with more distal fixation or tenodesis.
Methods:
Surgical intervention first involved a posterolateral approach to the ankle and an Achilles tendon Z-lengthening to fix her equinus contracture. The ankle and subtalar joint capsules were contracted requiring release. Flexor digitorum longus (FDL) and FHL were tenotomized, which immediately corrected her claw toes. Since the tendon had already been released, we were able to deliver the FHL tendon into the posterolateral leg wound. The peroneal fascia and sheath were opened proximal to the superior peroneal retinaculum to prevent tendon subluxation. PB was identified by confirming that it produced foot eversion and by visualizing the peroneus longus (PL). The tension of PB was confirmed by observing that it did not cause tension at PL insertion on the plantar 1st ray. FHL was then transferred to the PB utilizing a Pulvertaft weave technique with the tendon appropriately tensioned in mid eversion in the middle of the Blix curve (Figure 1).
Results:
After FHL transfer, the patient was immediately allowed to weight bear as tolerated in a short leg cast. This was due to her deconditioned state to limit atrophy and the effects of prolonged recumbency in this medically fragile young woman. The patient ultimately was casted for 10 weeks total as she was unable to tolerate a CAM boot or other orthotic due to the weight and problems with the fit. At 4 months follow up, her foot is corrected and she is able to stand in a neutral, plantigrade position. Using a new AFO, she can walk without issue. Her foot remains well balanced and plantigrade.
Conclusion:
This simple FHL transfer technique decreases morbidity since the transfer occurs within the leg, proximal to the superficial peroneal retinaculum (SPR). The transfer pulls on the paralyzed, but intact PB instead of routing the FHL to the 5th metatarsal base or PB stump. This technique is only recommended if PB is intact but non-functional. It should be noted that adequate tensioning is essential for a successful transfer. Benefits of this procedure include no cluttering under the SPR and no risk of scarring that region which can lead to decreased tendon excursion.
Category:
Trauma; Ankle
Introduction/Purpose:
The anterior distal tibial tubercle (Tillaux-Chaput tubercle) frequently fractures in the wake of malleolar fractures. It provides attachment to the ...anterior tibiofibular syndesmosis and may be considered a fourth or anterior malleolus (AM). In analogy to posterior malleolar fractures, AM fractures may extend into the tibial incisura and tibial plafond. We analyzed the pathoanatomy of AM fractures and associated injuries in ankle fractures in adults.
Methods:
Over a course of 9 years, 140 patients (average age 58.3 years) with 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with CT imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all 1,379 patients treated for malleolar fractures at our institution during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients aged less than 18 years were excluded as the frequent anterolateral distal tibial fractures along the physeal growth plate in adolescents are beyond the scope of this analysis. Fractures were classified according to the most frequent patterns and possible treatment options.
Results:
Of the 140 AM fractures, 52.9% were classified type 1 (extra-articular avulsion), 35.7% type 2 (incisura and plafond involvement), and 11.4% type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%, the medial malleolus in 67.1%, and the posterior malleolus in 69.3%. Isolated AM fractures were seen in only 6 cases (4.3%). The severity of AM fractures correlated negatively with that of posterior malleolar fractures (p<0.001). The proportion of pronation-abduction fractures increased and the proportion of supination external rotation fractures decreased with increasing severity of AM fractures (p=0.055). Fractures involving the AM had a prevalence of 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries (p<0.001). No supination-abduction fractures were seen with AM involvement. The interclass correlation coefficient for the proposed classification of AM fractures was 0.961 (95% CI 0.933-0.980) for interobserver agreement and 0.941 (95% CI 0.867-0.974) for intraobserver agreement.
Conclusion:
Knowledge of the 3D pathoanatomy of AM fractures and associated injuries may help with surgical planning. CT imaging should be employed generously in the assessment of complex ankle fractures, particularly with pronation injuries. In analogy to posterior malleolar fractures, fixation of displaced AM fractures potentially restores syndesmotic stability, congruity of the tibial incisura thus facilitating fibular reduction and joint congruity at the anterolateral tibial plafond. Proposed treatment options include transosseous suture for syndesmotic avulsions (type 1), screw fixation for fractures involving the incisura and plafond (type 2), and elevation of the impacted plafond with buttress plating for type 3 fractures.
Category:
Midfoot/Forefoot; Other
Introduction/Purpose:
Lateral Column Lengthening (LCL), Medial Displacement Calcaneal Osteotomy (MDCO) and Cotton Osteotomy (CO) are considered the work-horse ...surgical procedures for Progressive Collapsing Foot Deformity (PCFD) correction. The amount of three-dimensional correction induced by each isolated procedure cannot be established in the clinical setting since procedures are frequently performed in combination based on deformity severity and surgeon's preference. Understanding the influence of each one of the procedures, as well as their magnitudes, in the overall 3D correction of the deformity would be extremely helpful in the surgical planning of PCFD. Therefore, our simulated weightbearing cadaveric study aimed to assess the amount of 3D correction induced by different magnitudes of isolated and combined LCL, MDCO, and CO procedures, using weightbearing CT (WBCT) imaging.
Methods:
In this cadaveric study 12 below-knee specimens with no deformity were used. They were mounted on a frame under 360N of axial load, while keeping conventional stance level tension to tendinous structures. Each group of four specimens underwent isolated and progressive magnitudes of MDCO (6, 10 and 14mm), LCL (6, 8 and 10mm) and CO (4, 8 and 12mm). Following isolated correction, the specimens were randomized into different amounts of combined correction, first with two procedures (only moderate correction; four specimens each combination) and then with three procedures (combined mild, moderate and large corrections; four specimens each). The 3D measurement Foot and Ankle Offset (FAO), representing the relative position between the center of the ankle joint and the weight bearing tripod of the foot, was calculated from WBCT datasets for each specimen in each one of the tested corrected conditions. Comparison between the different conditions was performed using Paired T-Test/Wilcoxon.
Results:
All isolated performed corrective procedures (MDCO, LCL and CO) significantly influenced FAO measurements (All p- values <0.05). When applied in isolation, every 1mm increase in MDCO, LCL and CO decreased FAO values by respectively 0.8%, 0.36%, and 0.29%, highlighting the importance of the heel position in the overall 3D position of the foot. Combination of two moderate-sized procedures decreased FAO values significantly (p<0.05) and more pronouncedly, with combination of MDCO and LCL decreasing FAO by an average of 7.2%, MDCO and CO by 6.2% and LCL and CO by 3.9%, with no significant differences between the three. As expected, combination of the three procedures lead to pronounced and significant decreased of FAO values by respectively 5.2%, 8.5% and 14.2% for mild, moderate, and large corrections. The combination of the three large sized corrections was significantly higher than mild and moderate corrections (p=0.002).
Conclusion:
In this cadaveric WBCT study we assessed the influence of different magnitudes of isolated and combined MDCO, LCL and CO in foot and ankle 3D alignment. We found that all isolated procedures significantly decreased FAO measurements, with every 1mm increase in MDCO, LCL and CO decreasing FAO by respectively 0.8%, 0.36%, and 0.29%. Combination of two procedures and three procedures also lead to significant and more pronounced alignment change. The data presented in this study can serve as baseline predictive values of foot alignment correction when planning the use of MDCO, LCL and CO for surgical treatment of PCFD.
Category:
Midfoot/Forefoot; Ankle; Hindfoot
Introduction/Purpose:
Progressive Collapsing Foot Deformity (PCFD) comprises five independent deformities represented by five classes: hindfoot valgus ...(class A), midfoot abduction (class B), forefoot varus (class C), peritalar subluxation (class D) and ankle valgus (class E). Conservative treatment includes the use of corrective insoles and orthotics. Longitudinal arch support inflatable ankle-foot orthoses (IAFO) help control pain in PCFD patients. But we have no knowledge about the ability of IAFOs to correct deformities in PCFD. The aim of this prospective case-controlled study was to assess the ability of longitudinal arch support IAFOs to correct 3D overall PCFD alignment as well as the five different PCFD classes independently. We hypothesized that IAFOs will correct PCFD 3D overall alignment as well as the five independent classes.
Methods:
After IRB approval we enrolled 24 symptomatic flexible PCFD and 24 controls matched on age, sex, and BMI. Patients were scanned using Weight-Bearing CT with and without a longitudinal arch support IAFO. The Foot and Ankle Offset (FAO) was used to assess the 3D foot overall alignment. We measured the Hindfoot moment arm (HMA, Class A), the Talonavicular coverage angle (TNCA, Class B), the Meary's angle and the distance between the floor and the medial cuneiform (C1-floor) for the Class C and the middle facet uncoverage (MFunco, Class D). We did not have any Class E deformity in our PCFD cohort.
Data normality was assessed by Shapiro-Wilk test. Comparisons used normality based paired T-tests or paired-Wilcoxon tests. Hypothesizing that the IAFOs would be two times less efficient than the surgery (Day et al.) in correcting the FAO in PCFD, the requisite number of subjects was 24 per group.
Results:
Control measurements were all significantly different than unbraced PCFD measurements confirming our PCFD selection process. Comparing PCFD without and with IAFO via FAO did not show significant improvement (respectively 6.6+/- 3.7% vs 5.5+/-4.2%, p=0.101). The HMA (8.8+/-5.8 vs 8.1+/-5.8, p=0.66), the TNCA (24.2+/-10.6 vs 21.9+/-9.7, p=0.44) and the MFunco (37+/-12% vs 31+/-18%, p=0.17) did not show any significant improvement when applying the IAFOs. The Meary's angle (17.6+/-7.2 vs 10.8+/-7.3, p=0.002) and the C1-floor (17.2+/-3.3mm vs 24.1+/-5.3mm, p<0.001) were significantly improved by the IAFOs. The only measurements which was normalized when compare the PCFD to the control group after applying the IAFO was the C1-floor (24.1+/-5.3mm in PCFD with IAFO vs 25.7+/-5.4mm in controls, p=0.31)
Conclusion:
In this prospective case-control study, we found that longitudinal arch support IAFOs were less than half as effective as surgery in correcting overall 3D deformity in PCFD. Likewise, IAFOs were not efficient in correcting hindfoot valgus (Class A), midfoot abduction (Class B) and peritalar subluxation (Class D) in PCFD. On the other, IAFOs were effective in correcting forefoot varus and medial longitudinal arch collapse (Class C). This study provides relevant information to guide medical treatment and longitudinal arch support IAFO prescription in PCFD.
Category:
Ankle Arthritis
Introduction/Purpose:
There are limited studies on the outcomes of conversion to fusion following a failed ankle replacement. The primary aim of this NJR data linkage study ...is to determine the outcomes of conversion to fusion following a failed ankle replacement.
Methods:
A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as a further fusion procedure or amputation. Life tables and Kaplan Meier survival charts demonstrated survivorship. Cox proportional hazards regression models with the Breslow method used for ties were fitted to compare failure rates.
Results:
131 patients underwent conversion to fusion. The mean time from primary replacement was 33.8 months (range 1-100). The mean age was 63.3 (range 33-85), there were 73 males (55.7%). The mean BMI was 30.7 (SD 5.3) mean ASA was 2.0 and the mean Charlson co-morbidity score was 2.5. The most commonly revised implant was the Mobility in 45.0%, Zenith in 16.8% and Box in 11.5%.105 (80.2%) were as a single stage and 26 (19.8%) as a 2 stage procedure. The 1 year survivorship was 96.0% (95% CI 90.6%-98.3%), 2 year survivorship was 83.8% (95% CI 75.4%-89.5%) and 5 year survivorship was 72.4% (95% CI 62.0%-80.4%) A Cox regression model adjusting for individual factors did not find any risk factor significantly increased the risk of failure.
Conclusion:
Conversion to fusion following a failed ankle replacement has high rates of further surgery. Further prospective studies are required to determine risk factors for failure to improve outcomes for these patients.
