Category:
Hindfoot; Ankle; Ankle Arthritis; Midfoot/Forefoot
Introduction/Purpose:
Markers used for diagnosis and severity grading are well studied in patients with Progressive Collapsing Foot ...Deformity (PCFD). Medial facet subluxation (MFS) in weight-bearing computerized tomography (WBCT) has been established as an early indicator of peritalar subluxation (PTS). When the disease affects the ankle leading to a valgus talar tilt (class E), structures distal to this topography may behave differently, trying to compensate for proximal deformity. The aim of this study is to assess predictors of deformity in PCFD patients with and without valgus of the ankle. Our hypothesis is that MFS cannot be used in Class E patients as an accurate marker for the evaluation and staging of PCFD.
Methods:
In this IRB-approved retrospective case-control study, we analyzed WBCT imaging of 21 consecutive patients with PCFD with valgus of the ankle and 64 controls (flexible PCFD without ankle involvement). MFS (defined by the percentage of uncoverage), middle facet incongruence angle, middle cuneiform-to-floor distance, forefoot arch angle, talonavicular uncoverage angle, hindfoot moment arm (HMA), Foot and Ankle Offset (FAO), and talar tilt angle (TTA) were obtained and compared between groups using one-way ANOVA. A multivariate regression analysis was performed to evaluate which of the measurements influenced the alignment. A partition prediction model was constructed to assess how the variables contributed to the deformity. P values <0.05 indicated statistical significance.
Results:
Differences between groups were found for MFS, HMA, FAO, and TTA, with a lower mean value of MFS in PCFD patients with valgus of the ankle. An inverse relation between MFS and TTA was found, which was demonstrated by an increase in the talar tilt and a decrease in middle facet uncoverage. FAO values were affected by MFS in the control group (R2: 0.25) but not in the ankle valgus group (R2: 0.001), which was influenced mainly by the TTA (R2: 0.53). Additionally, a FAO value higher than 12.14 was found to be a strong predictor of deformity at the ankle.
Conclusion:
Medial facet subluxation was lower in patients with PCFD and valgus of the ankle (Class E), which demonstrates that MFS is a weak predictor of deformity severity. Therefore, this suggests that talar tilt angle and Foot and Ankle Offset should be used as disease markers in this group of patients. Furthermore, a FAO value above 12.14 may be an indicator of ankle involvement in PCFD patients.
Category:
Ankle; Sports; Trauma
Introduction/Purpose:
Numerous radiographic studies examining Weber B fibular fractures demonstrate no change in tibiotalar contact area until the deltoid ligament is ...disrupted. In contrast, more recent studies using weight-bearing CT scan (WBCT) and 3D volume analysis suggest that medial clear space (MCS) volume can in fact increase in the setting of a Weber B fibular fracture even if initial radiographs are reassuring, possibly due to a loss of fibular buttress. This study aims to evaluate the ability of WBCT to quantify the impact of isolated Weber B fractures on MCS volume (3D), as well as understand the implication of increasing fibular displacement among patients with symmetric MCS distance (1D) on initial radiographs.
Methods:
The study group included 18 patients with unilateral Weber B ankle fractures who underwent preoperative bilateral foot and ankle WBCT. The control group consisted of 60 patients without ankle injury who underwent similar imaging.
Measurements on WBCT images included: 1) MCS distance, 2) syndesmotic area, 3) anterior, middle, and posterior distal tibiofibular distance, 4) fibular rotation, 5) distance from fibular tip to plafond, and 6) fibular fracture displacement. Additionally, volumetric measurements included: 1) MCS volume 2) syndesmotic joint volume from the tibial plafond extending to 3cm and 5 cm proximally, and 3) lateral clear space volume were calculated. Area under the receiver operating characteristic (ROC) curve analysis and Delong test were used, and optimal cutoff values to distinguish between stable and unstable Weber B fractures without syndesmotic instability and MCS widening were determined using Youden's J statistic.
Results:
Among patients with unilateral Weber B ankle fractures, all WBCT measurements showed no side-to-side difference in any parameter, except MCS volume (p-values <0.001). When compared to the uninjured side, fibular displacement up to 2cm and up to 4cm increased lateral MCS volume by 37.1% (0.23cm3) and 51.8% (0.3cm3), respectively. Based on ROC analysis and Youden's J statistic, the optimal threshold for differentiating stable from an unstable Weber B fracture was 2.3 mm of displacement (AUC 0.81; sensitivity 77.8%; specificity 80%). The control group showed no difference in any of the measurements between the two sides.
Conclusion:
When using WBCT, 3D MCS volume increases significantly with Weber B fibular fractures, even if 1D distance measurements at the medial clear space are reassuring. This is especially true with fibular displacement greater than 2.3mm and may have an important role in the management of SER II ankle fractures.
Category:
Ankle
Introduction/Purpose:
Autologous osteochondral transplantation (AOT) is a replacement strategy used to treat osteochondral lesions of the talus (OLT), typically reserved for the ...treatment of lesions of larger sizes, highly cystic lesions, or in patients who have failed previous treatment. The purpose of this study was to evaluate the long-term (>8 years) clinical and radiographic outcomes of AOT for the treatment of OLT in the form of a retrospective case series.
Methods:
Patients who underwent AOT between 2006 and 2008 were evaluated. Functional outcomes were assessed pre- and post-operatively using the Foot and Ankle Outcome Score (FAOS), and Short-Form-12 (SF-12) general health questionnaire. The most recent post-operative MRI was evaluated with the modified Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score.
Results:
Twenty-eight patients who underwent AOT were included and evaluated at a mean follow-up of 122.9 months. The mean FAOS pain subscale improved from 52.7 to 82.9 and the mean SF-12 improved from 30.3 to 58.3 at final follow-up (both, p < 0.01). The mean FAOS pain subscale then decreased to 77.6 at final follow-up, but this decrease was not statistically significant (p=0.293). At the final follow-up, the mean FAOS subscale scores of symptoms, pain, daily activities, sports activities, and quality of life were 66.6, 77.6, 86.0, 60.4, and 53.6, respectively. The mean VAS score was 2.2 at a final follow-up. The mean MOCART score was 83.8 with a mean MRI follow-up of 82.8 months. Ten patients (35.7%) had additional surgery, with the most common procedure being arthroscopic anterior ankle debridement. One patient failed AOT and developed osteoarthritis of the ankle requiring a total ankle replacement.
Conclusion:
AOT appears to be an effective treatment for OLT with good long-term clinical and radiographic outcomes. Secondary procedures were typically minor and the overall clinical failure rate was low.
Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be ...thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.
Category:
Ankle; Trauma
Introduction/Purpose:
Ankle fractures are the most common fractures of the lower extremity. In spite of that, there is still no consensus regarding the best way to approach ...posterior malleolus (PM) fractures. The aim of this study is to compare the degree of PM exposure, tension of the flap containing the medial neurovascular bundle (NVB) and distance between the surgical incision and the NVB using three different posteromedial ankle approaches.
Methods:
Three different posteromedial approaches were compared: direct medial (DM) modified posteromedial (MPM) and posterior paramedian (PPM). Each approach was performed four times using a standardized technique. With a digital tensiometer, the minimal tension of the flap containing the NVB that allowed proper exposure of the PM was measured. In a second stage, an axial cut 1cm proximal to the tibiotalar joint was performed in nine frozen pieces and PM exposure degree and distance between the incision and the NVB was measured.
Results:
The median minimal tension was DM: 14,78 N, MPM: 8N and PPM: 5,75N. The median distance between the incision and the NVB was DM: 17mm, MPM: 6mm and PPM: 28mm. The median degree of exposure was DM: 51%, MPM: 58% and PPM: 72%.
Conclusion:
The PPM approach achieved the highest degree of PM exposure, with the lowest tension applied to the NVB and allowing the greatest distance between the incision and the NBV. Thus, we believe it should be considered the approach of choice for large fractures compromising the posteromedial and posterolateral aspect of the PM.
Category:
Other
Introduction/Purpose:
Ganglion cysts are a well documented phenomena occurring in a variety of joints. They are described as a tumour like lesion filled with mucopolysaccharides. The ...majority occur in the hand and wrist (88%) with a small yet significant minority occurring in the foot and ankle (11%). Currently, there is a lack of high-quality literature regarding the management of ganglia in the foot and ankle region. Therefore this scoping review aims to systematically map and summarise current evidence regarding the management of ganglia of the foot and ankle, whilst identifying areas for further research.
Methods:
This scoping review follows the methodology outlined by Arksey and O'Malley, Levac, the Joanna Briggs Institute and PRISMA framework.. A detailed search strategy was used to identify relevant articles using free text terms such as 'foot' 'ankle' 'ganglion' 'ganglia' 'ganglionic cyst'. This was carried out in four electronic databases; PubMed, EMBASE, CINAHL and Ovid MEDLINE. A stage two-stage independent screening process based and title and/or abstract then full-text was carried our by two reviewers. The a-priori selection criteria included all primary research (observational studies and randomised control trials) whilst excluding (case reports, letters to editors, editorials, commentaries and review articles). Studies that did not separate the treatment of foot and ankle tumours from ganglia were excluded. The MINORS criteria were used to assess methodological quality of included studies.
Results:
In total, 2286 unique articles were initially identified, from which 11 met the criteria for inclusion. A variety of conservative and surgical treatment strategies were reported. The use of surgical excision was reported in all 11 studies, ten of which via an open surgical approach, with only one study using an endoscopic approach. The use of conservative treatments, involving aspiration and/or steroid injection, were reported in only 5 studies. As for the recurrence rate, 7 studies reported a rate of 5.7% - 65.7%, with an overall pooled recurrence rate of 30.6%. Pooled recurrence rates showed that surgical excisions were associated with a lower recurrence rate than conservative treatments. Complications other than occurrence were described in 6 studies. Only 3 studies performed an analysis of outcomes based on the location or site of origin of ganglia.
Conclusion:
The current literature regarding the treatment of foot and ankle ganglia is of a low-quality, as the articles included in this scoping review are level III or IV cohort or case series design. The literature alludes to the idea that a surgical approach provides greater efficacy than a conservative approach. There is also limited evidence to suggest that factors such as the origin or location of ganglia may affect treatment outcomes. Alternative approaches utilised in the treatment of wrist ganglia are yet to be investigated. Further research is required before more definitive conclusions into any such associations may be drawn.
Category:
Ankle; Sports
Introduction/Purpose:
Reliable landmarks of ankle syndesmosis change in various position is important for managing ankle injury. The purpose of our study was to investigate ...and compare radiographic landmarks of normal ankle in various positions.
Methods:
The study involved both ankle radiographs of 30 subjects (15 males, 15 females) without clinical or radiographic abnormality. Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO) were measured on anteroposterior (AP) and mortise radiographs in non-standing (NS) and standing (S) neutral and dorsiflexion 10 (DF10) and 20 degrees (DF20). The radiographic measurements were used to calculate means, standard deviations, and intra- and interobserver reliabilities, and compare TFCS and TFO in various positions and genders.
Results:
On the AP view, the mean TFCS in NS, S, DF10, and DF20 positions were 4.00+-0.97, 4.00+-0.83, 4.35+-0.95, and 4.45+-0.89 and the mean TFO on the same positions were 6.58+-2.27, 4.27+-1.90, 3.44+-1.96, and 2.38+-1.91. On the mortise view, the mean TFCS in NS, DF10, and DF20 positions were 3.62+-0.88, 4.08+-0.86, and 3.88+-0.97 and the mean TFO on the same positions were 3.57+-2.13, 2.31+-1.77, and 3.57+-2.14. The reliabilities in all positions except TFCS on some positions were excellent. No measurement was significantly different between females and males except TFO in NS on mortise view (p=0.006) and DF10 on AP view (p=0.032).
Conclusion:
Increase of TFCS and decrease of TFO on AP view reflects syndesmosis change from non-standing to DF20 on standing. Clinically, Effect of weight-bearing and reliability of TFO should be considered.
Category:
Ankle; Arthroscopy; Basic Sciences/Biologics
Introduction/Purpose:
The purpose of this study was to assess whether all significant structures in the ankle could be visualized and surgically ...reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage.
Methods:
A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh- frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed.
Results:
All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case, but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage.
Conclusion:
2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.
Category:
Ankle; Hindfoot; Other
Introduction/Purpose:
There is limited documentation of the results of the treatment of advanced progressive collapsing deformity with talar tilt. No article to our ...knowledge with pre-and post-operative ankle x-rays has more than eight patients and average follow up more than three years.
Methods:
This article presents the results of twenty consecutive patients with medium to long term follow up. All patients had deltoid reconstruction with tendon graft from the talus to the tibia and foot reconstruction to achieve a heel centered under the lower leg, a stable midfoot and a mild to moderately plantarflexed first metatarsal. Patients were followed an average 10.8 years (SD = 4.6, Range 4.6-17) and had standing pre-and post-operative radiographs along with FAOS and PROMIS scores. Radiographs were assessed for talar tilt preoperatively, early postoperatively and at final follow up. Data was analyzed with paired t-tests, Mann Whitney U test, fisher's exact test and univariable linear regression. All p-values are two-sided and statistical significance was evaluated at the 0.05 alpha level.
Results:
Two patients failed the procedure; one had an ankle fusion and the second infection eventually required a BKA. The remaining 18 patients were satisfied with their procedure, maintained significant improvement in outcome scores and talar tilt and required no other procedure on their ankle. The mean talar tilt preoperatively was 10.9 degrees (SD = 3.9) and at final follow up 4.2 degrees (SD = 2.8) (P<0.0001). Initial correction of the talar tilt as documented by early post-operative (mean early follow-up years = 2.2, SD = 1.9) with standing radiograph was maintained within 3 degrees in comparison to final radiographic follow up (Mean=0.56, 95%CI (-0.40, 1.51) P<0.0001).
Conclusion:
Combined deltoid and foot reconstruction, as described, has acceptable results in majority of patients at medium to long term follow up.
Category:
Arthroscopy; Sports
Introduction/Purpose:
The high prevalence of ankle sprains in the population produces a significant number of patients with lateral instability. Maintenance of this ...condition may lead to the progressive involvement of medial structures, causing a multidirectional rotational instability.
Methods:
This is a retrospective study with patients diagnosed with multidirectional instability, submitted to an ankle arthroscopy with medial (arthroscopic tensioning) and lateral repair (arthroscopic Bröstrom) between January 2018 and January 2020. All patients were evaluated for pain and function according to the VAS and the AOFAS Score at a mean of 14.8 months (5-27 months) in follow-up.
Results:
A total of 30 ankles (29 patients) were included in the study. AOFAS score increase from a 49.7 (CI 5.8) to a 91.9 (CI 2.4) mean (p=0.001) and was followed by significant improvement in the mean VAS (6.83; CI 0.37 to 0.95; CI 0.31). The majority of patients had associated procedures (53.3%) and a low complication rate was found (16.6%).
Conclusion:
Combined medial and lateral arthroscopic repair might be an effective and safe alternative in the treatment of multidirectional instability. Inclusion of the deltoid ligament complex and the low invasiveness of the arthroscopic technique can improve the clinical outcomes of these patients.
PDF
