Category:
Other; Ankle Arthritis; Hindfoot; Midfoot/Forefoot
Introduction/Purpose:
Allograft is routinely used to enhance bone healing in foot and ankle surgery. One allograft in particular employs ...viable cells and bone scaffolding in a gel base. There is little evidence that compares how this material effects rate of fusion (ROF) and time to fusion (TTF) when compared to autograft in routine forefoot, midfoot, and hindfoot fusions. Our study investigates the use of a viable cellular allograft and its effect on these two variables in a population of patients undergoing fusions in the foot and ankle.
Methods:
A retrospective review was conducted over a five-year span of patients undergoing fusions in the foot and ankle where the cellular allograft was used. We compared the ROF and TTF between the following three graft groups: cellular allograft alone, autograft alone, and combined allograft + autograft. Data was retrieved from the patients' electronic medical record and TTF was recorded as the time, in days, it took for a solid radiographic fusion to form. Secondary variables collected included etiology of disease (post-traumatic, inflammatory, or diabetic arthropathy) and also analyzed for effect on ROF and TTF.
Results:
Two hundred and twenty-five patients underwent a fusion in the foot or ankle over a five-year period. Autograft alone was used in 101 patients, the cellular allograft alone was used in 88 patients, and a combination of autograft and the cellular allograft was used in 36 patients. Each group were similar in their comorbid conditions and demographics. The ROF of the autograft only group was 88% (89/101), compared to the cellular allograft group's ROF of 89% (78/88), and the combination graft group's ROF of 75% (27/36). The average TTF between each group varied slightly, with the cellular allograft group fusing the fastest at 86, followed by the autograft alone group at 97 days, and the combined group at 112 days.
Conclusion:
Our study investigated the use of a viable cellular allograft and its effect on ROF and TTF compared to autograft alone and autograft combined with said cellular allograft. We found no significant difference in ROF between autograft alone and the cellular allograft alone but did find a significant difference in ROF for the combined group resulting in lower rate of fusion. Additionally, use of the cellular allograft resulted in fastest time to fusion compared to autograft alone or a combination of the graft types.
Category:
Ankle; Trauma
Introduction/Purpose:
The use of intraoperative three-dimensional fluoroscopy to evaluate syndesmotic and articular reduction in ankle fractures is a relatively new tool ...demonstrating usefulness in the literature. It has been described that it can detect up to 32.7% of intraoperative malreduction. The objective of this prospective study is to observe if surgeons, when performing operative treatment in ankle fractures with three- dimensional fluoroscopy assistance, modify the syndesmotic reduction and/or fixation. The definitive syndesmotic reduction was assessed with bilateral ankle CT-scan postoperatively.
Methods:
Sixteen patients with ankle fracture and syndesmotic instability were analyzed. After malleolar and syndesmotic fixation, intraoperative three-dimensional fluoroscopy was performed. The surgeon then analyzed cross-sectional images to evaluate the reduction of the fracture and syndesmosis. In this scenario, the surgeon decided whether to make any changes in the reduction of the syndesmosis or in the configuration of the fixation strategy. Postoperative bilateral computed tomography was carried out to corroborate in detail if there was any syndesmotic malreduction.
Results:
Sixteen patients were included in this study (10 men) with a mean age of 40 years (range 25-60 years). 62% were supination-external rotation fractures according to Lauge-Hansen classification. Of all the patients evaluated, only 4 underwent any modification after performing intraoperative three-dimensional fluoroscopy. From the previous group, in 3 patients (19% of the total) there was a change in syndesmal reduction and in only one there was a change of any element of osteosynthesis. When evaluating syndesmal reduction with postoperative bilateral CT, there were 6 patients in the total group who presented syndesmal malreduction. In patients in whom a modification to syndesmal reduction was made, it persisted in 2 of the 3 cases.
Conclusion:
In our series, the use of intraoperative three-dimensional fluoroscopy did not motivate most surgeons to make changes in syndesmotic reduction, unlike other previously published studies. Even despite making changes in syndesmotic reduction, the percentage of patients who persists with poor reduction is considerable. In this study, the percentage of poor syndesmotic reductions was 32.7%. Despite being a figure that is within what is expected according to the literature, we consider that it is high even using intraoperative fluoroscopy as support.
Background:
Ankle arthrodesis has historically been the standard of care for end-stage ankle arthritis; however, total ankle arthroplasty (TAA) is considered a reliable alternative. Our objective was ...to compare 3-dimensional foot and ankle kinetics and kinematics and determine the ankle power that is generated during level walking and stair ascent between TAA and ankle arthrodesis patients.
Methods:
Ten patients who underwent TAA with a modern fixed-bearing ankle prosthesis and 10 patients who previously underwent ankle arthrodesis were recruited. Patients were matched for age, sex, body mass index, time from surgery, and preoperative diagnosis. A minimum of 2-year follow-up was required. Patients completed instrumented 3D motion analysis while walking over level ground and during stair ascent. Between-group differences were assessed with a 2-tailed Mann-Whitney exact test for 2 independent samples.
Results:
Sagittal ankle range of motion (ROM) was significantly higher in the TAA group (21.1 vs 14.7 degrees, P = .003) during level walking. In addition, forefoot-tibia motion (25.3±5.9 degrees vs 18.6±5.1 degrees, P = .015) and hindfoot-tibia motion (15.4±3.2 degrees vs 12.2±2.5 degrees, P = .022) were significantly greater in the TAA group. During stair ascent, sagittal ankle ROM (25 vs 17.1 degrees, P = .026), forefoot-tibia motion (27.6 vs 19.6 degrees, P = .017), and hindfoot-tibia motion (16.8 vs 12 degrees, P = .012) was greater.
Conclusion:
There were significant differences during level walking and stair ascent between patients with TAA and ankle arthrodesis. TAA patients generated greater peak plantarflexion power and sagittal motion within the foot and ankle compared to patients with an ankle arthrodesis. Further investigation should continue to assess biomechanical differences in the foot and ankle during additional activities of daily living.
Level of Evidence:
Level III, comparative study.
Diagnosis and treatment of tibiofibular syndesmosis lesions Tourné, Yves; Molinier, François; Andrieu, Michael ...
Orthopaedics & traumatology, surgery & research,
December 2019, 2019-12-00, 20191201, Letnik:
105, Številka:
8
Journal Article
Recenzirano
Odprti dostop
The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Syndesmosis lesions are quite frequent in ankle trauma. This is a key ...element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. The lesions are often overlooked due to diagnostic difficulties, but collision sport with strong contact is the main culprit. Diagnosis, whether in the acute or the chronic phase, is founded on an association of clinical and paraclinical signs. Cross-sectional imaging such as MRI is fundamental to confirming clinical suspicion. Absence of tibiofibular diastasis no longer rules out the diagnosis. Stress CT and the introduction of weight-bearing CT are promising future diagnostic tools. Exhaustive osteo-ligamentous ankle assessment is necessary, as syndesmosis lesions may be just one component in more complex rotational instability. Therapeutically, arthroscopy and new fixation techniques, such as suture buttons, are opening up new perspectives, especially for chronic lesions (>6months). The present anatomic, epidemiological, diagnostic and therapeutic review does not preclude further clinical studies of rotational ankle instability with its strong risk of osteoarthritis.
Background:
We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by ...which approach.
Methods:
The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond.
Results:
In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury.
Conclusion:
The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries.
Level of Evidence:
Level III, retrospective comparative series.
In advanced stages of ankle osteoarthritis (OA), ankle arthrodesis (AA) or total ankle arthroplasty (TAR) may be necessary. Our purpose is to compare AA and total ankle replacement for the surgical ...management of end stage ankle OA.
We conducted a literature search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the terms 'ankle' in combination with 'OA', 'arthrodesis', 'arthroplasty', 'joint fusion', 'joint replacement'. Studies where treatment was exclusively total ankle replacement or AA were excluded. Treatment characteristics and outcome parameters (overall postoperative outcome and complication rate) were reviewed.
When counseling patients who are considering their options with regard to ankle arthritis treatment, surgeons should determine on an individual basis which procedure is more suitable.
TAR has become an accepted treatment for end-stage OA, but revision rates for TAR are significant higher than for AA (odds ratio 2.28 95% confidence interval CI, 1.63-3.19; P < 0.0001).
The results of TAA are gradually improving, but the procedure cannot yet be recommended for the routine management of ankle OA.
Although there is some evidence to support TAR to conserve ankle motion and offer improved function and decreased pain with high satisfaction rates, revision rates for TAR are significantly higher than revision rates for AA. Proper patient selection should be better addressed in future studies for successful treatment of end-stage ankle OA.
Systematic review, level III.
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:
Hindfoot; Ankle; Ankle Arthritis; Sports
Introduction/Purpose:
Severe hindfoot valgus deformity has been reported as one of the main causes of sinus tarsi and subfibular impingement in ...patients with adult acquired foot deformity (AAFD). Chronic Impingement and overload of the talus and/or calcaneus on the articular surface of the distal fibula can potentially lead to distraction stresses on the distal tibiofibular syndesmosis (DTFS). However, to the authors knowledge, no direct assessment of DTFS widening in patients with AAFD has been reported in the literature. The purpose of this study was to evaluate the correlation between hindfoot alignment and DTFS widening using weightbearing computed tomography (WBCT) images, and to compare the results between AAFD patients and controls.
Methods:
In this case-control study, we included 97 patients who underwent WBCT examination, 63 AAFD patients and 34 controls, with no history of major ankle trauma or surgeries of the foot and ankle. Hindfoot alignment was assessed using Foot and Ankle Offset (FAO) and the widening of the DTFS was evaluated by measuring the syndesmotic area (mm2) on axial plane WBCT images, at a level 1cm proximal to the apex of the tibial plafond. Controls were defined as patients with no clinical AAFD and normal FAO values (from -0.6 to 5.2). FAO and DTFS area measurements were compared by paired T-tests and ANOVA. Correlation between variables was assessed by bivariate linear regression. A partition predictive model was used to define threshold values of FAO that would influence DTFS area measurements. P-values of less than 0.05 were considered significant.
Results:
AAFD patients demonstrated significantly increased mean values for DTFS area (90.0mm2; 95%CI, 84.3 to 95.7) when compared to controls (79.9 mm2; 95%CI 73.8 to 85.9), p=0.03. However, no significant direct linear correlation was found between FAO and DTFS area measurements (p=0.07) in the bivariate analysis. The partition predictive model demonstrated that two threshold values of FAO would significantly influence DTFS area (R2=0.14): when FAO was <7 the average DTFS area was 80.8mm2 (SD 17.8), when FAO was >7, the mean DTFS area was 92.7mm2 (SD 22.4). Interestingly, when assessing patients with more severe valgus (FAO>7), the DTFS area measurements were even higher when FAO values were in between 7 and 9.3 (average, 104.6mm2, SD 22.5), but decreased when FAO>9.3 (average, 88 mm2; SD 22.3).
Conclusion:
This is the first study to compare distal tibiofibular syndesmotic widening in patients with AAFD and controls. We found that AAFD patients had significant syndesmotic widening when compared to controls, with a difference of about 10 mm2 in the measured area. More than that, we found that AAFD patients with FAO in between 7 and 9.3 would demonstrate the largest amount of syndesmotic widening. However, no direct linear correlation was found between FAO and syndesmotic area measurements. Our findings suggest that increased hindfoot valgus deformity may have negative biomechanical impact on syndesmotic alignment, with increased stresses and resultant widening.
Category:
Ankle; Trauma
Introduction/Purpose:
It is controversial whether routine arthroscopy is beneficial at the time of ankle fracture fixation. This may be, in part, due to sparse information ...regarding the incidence of chondral injury in the setting of ankle fractures.The purpose of this study is to systematically review the incidence of chondral injures in patients with ankle fractures and to further characterize intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following an ankle fracture.
Methods:
The literature search was performed based on the PRISMA guidelines. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures were included. The incidence of intraarticular chondral lesions was recorded, as well as location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. All statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL, USA). Multiple comparisons were used to compare incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < 0.05 was considered statistically significant.
Results:
Fifteen studies with 1,355 ankle fractures were included. Of those ankles, 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Overall, 648 ankles had chondral lesions on the talus (47.8%), 207 ankles had lesions on the tibial plafond (15.3%), 165 has lesions of the lateral malleolus (12.2%), and 133 had lesions of the medial malleolus (9.8%). Weber C group had significantly higher incidence than Weber A group (p=0.015). Trimalleolar and isolated lateral malleolar fracture groups had significantly higher incidence of chondral injury than bimalleolar and isolated medial malleolar fracture groups (p<0.001). A significant difference was found in occurrence rate of chondral injury among Lauge-Hansen classification, with supination-adduction having the lowest incidence (p=0.001).
Conclusion:
Our study found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy, with more than half of all patients having a chondral lesion. Talar lesions were most common. This study may help direct greater attention to the Talus as a source of chondral injury particularly in higher grade fracture patterns.
PDF
