Background:
Ankle arthritis leads to an elevated joint line compared to the nonarthritic ankle, as measured by the “joint line height ratio” (JLHR). Previous work has shown that the JLHR may remain ...elevated after total ankle arthroplasty (TAA). However, the clinical impact of this has yet to be determined. This study assessed the correlation between postoperative JLHR, post-TAA range of motion (ROM), and 1-year Patient-Reported Outcome Measurement Information System (PROMIS) scores.
Methods:
A retrospective review of 150 patients who underwent primary TAA was performed. Preoperative and postoperative JLHR, as well as postoperative dorsiflexion, plantarflexion, and total ROM, was calculated on weightbearing radiographs at a minimum of 1-year follow-up. Correlation between JLHR, post-TAA ROM, and 1-year PROMIS scores was investigated using Pearson correlation and multiple linear regression models. Interobserver reliability for the JLHR was also calculated.
Results:
Interobserver reliability for the JLHR was excellent (r = 0.98). Mean (SD) JLHR changed from 1.66 (0.45) to 1.55 (0.26) after TAA (P < .001), indicating that the joint line was lowered after TAA. An elevated joint line was correlated with decreased post-TAA dorsiflexion (r = −0.26, P < .001), total ROM (r = −0.18, P = .025), and worse 1-year PROMIS physical function (r = −0.22, P = .046), pain intensity (r = 0.22, P = .042), and pain interference (r = 0.29, P = .007). There was no correlation between the JLHR and post-TAA plantarflexion (r = −0.025, P = .76). Regression analysis identified a 0.5-degree reduction in post-TAA dorsiflexion with each 0.1-unit increase in JLHR (Coeff. = −5.13, P = .005).
Conclusion:
In this patient cohort, we found that an elevated joint line modestly correlated with decreased postoperative dorsiflexion, total ROM, and worse 1-year PROMIS scores. These data suggest that effort likely should be made toward restoring the native joint line at the time of TAA. In addition, future studies investigating the clinical outcomes after TAA may consider including a measure of joint line height, such as the JLHR, because we found it was associated with patient-reported outcomes.
Level of Evidence:
Level III, retrospective review of prospectively collected data.
Category:
Trauma; Ankle
Introduction/Purpose:
In surgery for ankle fractures with tibiofibular diastasis, it is important to vertically grasp the distal tibiofibular joint. However, it is difficult ...to do that because the tibiofibular joint surface is not under direct vision. Center-center method (CC) is an intraoperative fluoroscopic technique to determine the position of the syndesmotic clamp. CC has been reported to reduce the risk of syndesmotic malreduction, but It is unclear whether the axis by CC (CC axis) coincides with the axis perpendicular to the distal tibiofibular joint (trans-syndesmosis axis: TS axis). Therefore, the present study aims to 1) measure the difference between the CC axis and TS axis, and 2) compare the measured values when CC is performed at different distances from the ankle joint surface.
Methods:
The subjects were 150 patients who underwent CT scans for ankle joint disease and lower extremity trauma. CC is a method in which the ankle joint is rotated, and the midpoint of the anteroposterior margin of the tibia and fibula is superimposed by fluoroscopy. In the present study, CC was performed using Digitally reconstructed radiography (DRR) created from a CT image. At the ankle joint surface (0mm), CC axis and TS axis were projected onto the CT axis linked with DRR. The angle between the axes was measured (inter-axes angle). Also, the distance of the intersection of these axes through the medial cortex of the tibia was measured (inter-axes distance). It was also performed at 10mm and 20mm proximal to the ankle joint surface. One-way repeated measures analysis of variance and the post hoc Bonferroni tests were used to compare the measured values' difference according to the articular surface's height.
Results:
Overall, the TS axis was externally rotated relative to the CC axis, with a mean inter-axes angle of 8.5±6.8degrees. The inter-axes angle of 0mm, 10mm, and 20mm were 1.9±4.0degrees, 10±5.3degrees, and 13±5.1degrees, respectively (p < 0.001). Also, the intersection point of the TS axis with the medial tibial cortex was anterior to the intersection of the CC axis, with an inter-axes distance of 7.7±6.3mm overall. The inter-axes distance of 0mm, 10mm, and 20mm were 2.0±4.2mm, 9.0±4.9mm, and 11.3±5.2mm, respectively (p < 0.001). Both the inter-axes angle and the inter-axes distance were larger when the CC method was performed higher to the tibial plafond (P < .001), with the post hoc tests showing significant differences among all heights.
Conclusion:
The TS axis was externally rotated to the CC axis and positioned slightly anteriorly. Also, the inter-axes angle and distance were larger when the CC method was performed higher to the tibial plafond. If the surgeon aimed to clamp the syndesmosis along the TS axis, the CC method should be applied closer to the ankle joint surface, and the medial tip of the forceps be placed slightly anterior to the point determined by the CC axis.
Category:
Ankle Arthritis; Ankle
Introduction/Purpose:
The aim of the study was to assess 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate ...(AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach.
Methods:
In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue- Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2- year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.
Results:
One hundred and twenty-nine patients with 136 chondral lesions were included in in the study. The chondral lesions were located as follows (n (%)), medial talar shoulder only, 62 (46); lateral talar shoulder only, 42 (31); medial and lateral talar shoulder, 7 (10); tibia, 18 (13). The average for lesion size was 1.8 cm2, for VAS FA 45.7 and for EFAS Score 9.8. 2FU/5FU was completed in 105 (81%)/104(81%) patients with 112/111 previous chondral lesions. VAS FA improved to 79.8/84.2 and EFAS Score to 20.3/21.5 (2FU/5FU). No parameter significantly differed 2FU and 5FU.
Conclusion:
AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores at 2FU/5FU. 2FU and 5FU did not differ.
Category:
Ankle; Trauma
Introduction/Purpose:
The controversy surrounding the indications for fixation of posterior malleolar fractures remains unresolved, particularly in cases of middle-sized ...fragments that make up between 10-25% of the joint surface. Although several studies have been conducted, the evidence to support the need for fixation of such fragments is limited, with a lack of level 1 evidence.
This study aimed to assess patients with ankle fractures involving middle-sized posterior fragments and compare those who received posterior malleolus fixation to those who did not. The hypothesis was that fixation of middle-sized (10-25%) posterior malleolar fractures would result in superior functional and radiological outcomes in the short to mid-term follow-up.
Methods:
A prospective randomized-controlled study was conducted to assess the effects of posterior malleolus fixation in patients with acute rotational ankle fractures involving a middle-sized fragment. Eligible patients were included and randomly allocated into two groups, Group 1 receiving open reduction and internal fixation without posterior malleolus fixation, and Group 2 receiving the same procedure with posterior malleolus fixation, following informed consent. Prior to the study, a power analysis was conducted, indicating that a minimum of 16 patients in each group would be necessary to achieve 80% power and a 5% significance level. The randomization was conducted using an even/odd numbers technique, resulting in 20 patients in each group. Patient clinical and functional status was evaluated annually postoperatively, utilizing the VAS pain scale, AOFAS and SMFA scales. Radiological evaluations were conducted through direct radiographs, utilizing articular step-off evaluation and the Kellgren Lawrence osteoarthritis grading system.
Results:
The groups were comparable in terms of age, BMI, gender, and fracture type distribution. There were no significant differences in average follow-up times, posterior malleolus size, or height values. However, articular step-off greater than 1mm was more common in Group 1 (p=0.04).
Despite slightly better functional outcomes in Group 2, there were no significant differences between the two groups in terms of VAS pain, AOFAS, or SMFA scores (functional, bothersome, and total). However, there was a trend towards significance in the SMFA Function score difference (p=0.07).
Multivariate analysis showed that Haraguchi type 1 fractures had better functional outcomes in only the SMFA Bothersome parameter (p=0.03). Patients with articular step-off greater than 1 mm had significantly worse outcomes in all SMFA and AOFAS parameters (p < 0.05).
Conclusion:
In patients with closed rotational ankle fractures involving medium-sized (10-25%) posterior fragments, there was no significant improvement in functional or radiological outcomes with posterior fragment fixation at short to mid-term follow-up. Patients without posterior fixation were more likely to have articular step-off greater than 1 mm, which was associated with poorer functional outcomes. Despite similar outcomes in both groups, posterior fragment fixation may decrease the incidence of articular step-off and contribute to improved functional outcomes.
Category:
Midfoot/Forefoot; Hindfoot
Introduction/Purpose:
The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. 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:
We retrospectively assessed weight-bearing computed tomography (WBCT) measurements of 32 feet with PCFD diagnosis. 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 Meary’s 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. A p-value < 0.05 was considered significant.
Results:
Class A showed a substantial positive correlation with class C (ρ=0.71; R2=0.576; p 0.001). Class B was substantially correlated with class D (ρ=0.74; R2=0.613; p 0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R2=0.576; p 0.001) and class D (ρ=0.75; R2=0.559; p 0.001). Class D showed a substantial positive correlation with class B and class C (ρ=0.74; R2=0.613; p 0.001), (ρ=0.75; R2=0.559; p 0.001) respectively. Class E did not show correlation with class B, C, or D (ρ=0.24; R2=0.074; p=0.059), (ρ=0.17; R2=0.071; p=0.179), and (ρ=0.22; R2=0.022; p=0.082) respectively. The average values of each class radiographic markers are listed in Figure 1.
Conclusion:
This study was able to find relations between components of PCFD deformity with exception of ankle valgus deformity (Class E). Measurements associated with each class were influenced by others, and in some instances, with pronounced strength such as between class A and C as well as between Class B and D. Surgical procedures to address certain class deformities could indirectly address other classes as well, which ultimately decreases surgical procedures numbers or complexity. 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.
Category:
Ankle; Sports
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 in 69 men and 31 women. In 78 participants, the dominant ankle was the right one. The non-dominant side was consistently stronger in all movements (p < 0.001). The mean values obtained for force in each movement were 29.9N/m for eversion, 34.8N/m for inversion, 48.6N/m 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 through Spearman's Correlation. The ratio of eversors/inverters was 88.8% and that of dorsiflexors/plantar flexors was 36.1%. The Muscle Deficiency Index showed a balance between the sides for each movement, with an average global difference of less than 10% between them.
Conclusion:
As far as we know, this is the largest isokinetic assessment of normal ankles ever performed. The sample, although not stratified, was considered homogeneous (coefficient of variation < 50%), which allows to propose several normative values for a non-athlete population in the isokinetic evaluation. It would be interesting to compare these data in the future with the functional results in patients after the treatment of certain injuries.
Category:
Trauma; Ankle
Introduction/Purpose:
Medial Malleolus Fractures (MMF) are frequently managed by orthopaedic surgeons and are one of the most treated fractures of the ankle. Many approaches ...to fixation are described in the literature. Currently, there is a lack of consensus on the number of screws used in fixation when attempting lag-screw fixation of MMF.
Aim:
To compare the outcomes of MMF with patients between fractures which have either undergone single-screw (SS) or dual-screw (DS) fixation.
Methods:
Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Analysis of their pre-operative, intra-operative and post-operative radiographs was performed to determine the initial type of injury and then surgical outcomes relating to non-union, malunion and whether revision surgery was required.
Results:
A total of 653 patients were identified across a 10-year period. There were 271 patients (41.50%) in the SS group and 382 patients in the DS group (58.50%). When comparing the outcomes of SS compared to DS, a non-union rate of 19.19% (52/271) was found in the SS group as compared to 18.85% (72/382) in the DS group. There was a malunion rate of 11.07% (30/271) in the SS group as compared to 3.93% (15/382) in the DS group, which was statistically significant (p <.001). On multi regression analysis, the other factors which gained significance for development of non-union was non fixation of syndesmosis (p= .039), ankle dislocation on arrival (p <.001) and non-restoration of fibular length (p <.001).
Conclusion:
Use of a single screw rather than double screw showed a significant increase in non-anatomical reduction but did not increase non-union or reoperation rate. Syndesmosis fixation has clear impact on the stresses on the medial malleolus and should have a low index of suspicion of injury and fixation.
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
Evidence in the literature suggests the negative effects of using High Heels (HH), becoming a challenge for clinicians and researchers since ...they are welcomed by women worldwide, mainly due to the subjective power of attractiveness given to them. Although some people blame HH as one of the causes of Hallux Valgus (HV), until now, there are no studies in the literature that effectively prove a cause-effect relationship between HH and HV. The objectives of this study are: (1) to analyze whether the increase in heel height can lead to HV and (2) to evaluate whether HV can increase in severity with increasing heels. We hypothesized that an increase in heel height could cause and increase the severity of HV deformity radiographically.
Methods:
Comparative cross-section4-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and with Body Mass Index 25.5 ± 2.0 m kg2) were recruited. HH shoes were designed for this study with three heights for each participant: 3, 6, and 9 cm. The inclusion criteria were: no regular wearing of heels. The exclusion criteria were: Hallux Valgus diagnosis and/or any orthopedic conditions that affect the Foot and Ankle joints.
Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), First-Metatarsal Phalangeal Angle, 1st-to-5th Intermetatarsal Angle, First Tarsometatarsal Angle (axial), Second tarsometatarsal angle (axial), Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle and, Foot Ankle Offset (FAO) were measurement using semiautomated software analysis.
Multiple comparisons were performed (Bonferroni's for normal distributions and Wilcoxon test for no normal distributions) when there was a main effect on an outcome (p < 0.05).
Results:
With the increase in HH, we noticed a progressive increase in HVA (p < 0.001), IMA (p < 0.001), First-Metatarsal Phalangeal Angle (p < 0.001), First Tarsometatarsal Angle (axial) (p < 0.001), and the Second tarsometatarsal angle (axial) (p < 0.001). The Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle, and Foot Ankle Offset (FAO) had hindfoot varus behavior. When we stratified the groups and compared them, we noticed that an increase of 3 cm in heels slightly increased HVA and IMA (p > 0.05). However, heel increases above 6 cm significantly increased HVA and IMA (p > 0.001). Based on Coughlin's classification, a 3 cm heel increase promoted a mild HV, and increases above 6 cm caused a moderate HV.
Conclusion:
Based on data from our study with patients without Hallux Valgus through analysis with WBCT versus High Heels, we conclude that increasing heel height can radiographically lead to Hallux Valgus deformity and progressively increase the severity. High heels above 6 cm can lead to radiographically moderate Hallux Valgus. These findings may be an essential step toward a better understanding the effects of increasing high heels on Hallux Valgus pathology. More studies are needed to support this data clinically.
Category:
Basic Sciences/Biologics; Ankle
Introduction/Purpose:
One of the most common procedures for treating end-stage osteoarthritis of the foot and ankle is arthrodesis 1. However, a significant ...complication with arthrodesis is the development of non-union. Thus, identification of adjuvants to enhance osteogenesis are paramount to fusion success. One possible molecule is the immunosuppressant FK506 (Tacrolimus). Previous research 2 demonstrated FK506 as a stand-alone small molecule capable of initiating osteogenesis and bone formation. The purpose of this study was to evaluate the osteogenic potential of FK506 alone and in combination with other bioactive factors to provide a foundation for future in vivo and clinical applications.
Methods:
Marrow-derived cells (MDCs) were isolated from juvenile bovine femoral condyles, to represent cells present at the ankle fusion site. MDCs (P1) were seeded at 50k cells per well (24-well plate). After 14 days, the wells were stained for calcium deposits using Alizarin Red S, and imaged with brightfield microscopy to visualize calcium deposits. Drug combinations of potentially osteogenic small molecules were tested (simvastatin, platelet derived growth factor PDGF, tamoxifen, triiodothyronine). The highest alizarin red absorbance values were used to choose the best drug combination. These combinations were further evaluated for gene expression by RT-qPCR Osteocalcin (OCN), Osteopontin (OPN), and Bone Sialoprotein (IBSP). To simulate a 3D osteogenic environment, cells were seeded into fibrin gels (to mimic the “fusion clot”), cultured for 14 days, and sectioned/stained with Alizarin red.
Results:
FK506 and PDGF produced the highest level of calcium staining compared to other bioactive factors, highlighted via heatmap of alizarin red absorbance values (Figure 1A). Compared to the control, FK506, PDGF, and the combination of both all resulted in enhanced alizarin red staining (Figure 1A/B). Overall, FK506 exhibited an increased expression across all genes. PDGF and the combination of FK506 and PDGF had a more varied expression within the genes queried (Figure 1C). Finally, in a fibrin gel system, variability was observed between gels of the same group. Displaying the best, middle, and worst sections give a comprehensive view of the explained variability. Across the sections, the FK506-PDGF combination showed the densest mineralization, highlighted by the dark maroon regions of the section (Figure 1D).
Conclusion:
This study confirms that FK506 demonstrates osteogenesis within marrow-derived cells (representative of a fusion site). The combination of FK506 to PDGF may enhance PDGF’s known healing potential within arthrodesis applications. This work provides the foundation for future clinical applications of FK506. Ongoing studies are focused on the effect of FK506, and potentially in combination with PDGF, in an rabbit ankle fusion model to evaluate efficacy and bone formation.
The authors thank the American Orthopaedic Foot and Ankle Society (AOFAS) and Emory Department of Orthopaedics for their support and funding.
References: 1 Park 2022. 2 Sangadala 2019
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