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:
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:
Ankle; Trauma
Introduction/Purpose:
Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported ...“normal” values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the “lateral tibial line” (LTL).
Methods:
The relationship of the LTL to the superolateral talus was assessed and characterized on ninety-nine standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. Additionally, the inter-observer reliability of the LTL measurement, determined by three reviewers, was recorded and compared to medial clear space measurements.
Results:
The median value for the lateral tibial line was -0.50 mm with an interquartile range of -1.4mm - 0.0mm. The LTL was within 1mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or was at most 1mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good inter-observer reliability (0.764, 95% CI: 0.670-0.834), similar to the measurement of MCS (0.742, 95% CI: 0.539-0.846).
Conclusion:
The LTL is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. It uncommonly fell more than 1 mm medial to the superolateral talus. In other words, it was uncommon for the talus to shift lateral to this line, as might be seen with displaced ankle fractures. These findings will hopefully serve as a standard for future studies evaluating the role of the LTL in assessing lateral displacement and stability of isolated fibula fractures.
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 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:
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.
Background:
The open modified Broström anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. Despite recent increases in publications regarding ...arthroscopic repair of the anterior talofibular ligament (ATFL) for treatment of chronic ankle instability, research is lacking that compares the functional outcomes between arthroscopic repair and open repair procedures for chronic ankle instability.
Purpose:
To compare function and activity level after arthroscopic repair versus open repair of the ATFL in patients with lateral ankle instability.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
All patients who underwent arthroscopic or open surgical Broström repair of the ATFL between January 2012 and August 2014 were invited to participate in this study. All of the patients had consented for arthroscopic repair if feasible. In cases in which arthroscopic repair was impossible, the open modified Broström procedure was performed after arthroscopy. Patients accepted a systematic rehabilitation program postoperatively. American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score were used to evaluate ankle function preoperatively and at a minimum follow-up of 2 years. Magnetic resonance imaging (MRI) was performed to evaluate the signal to noise ratio (SNR) of the repaired ATFL.
Results:
A total of 60 patients were included in this study. They were assigned to 1 of 2 groups according to their surgical procedure: 23 patients underwent arthroscopic repair (arthroscopic group) and 37 patients underwent open repair (open group). No patient in either group had ankle instability at follow-up postoperatively. After surgery, the AOFAS score (P < .001), KAFS (P < .001), and Tegner activity score (P < .001) increased significantly in both groups. However, no significant difference was found in AOFAS score (93.3 ± 8.9 vs 92.4 ± 8.6; P = .7), KAFS (90.3 ± 12.5 vs 89.4 ± 10.6; P = .75), and Tegner score (5 ± 2 vs 5 ± 2; P = .61) between the arthroscopic group and the open group, respectively. As well, no significant difference was found in the mean SNR value of ATFL between the arthroscopic group and the open group (9.1 ± 2.7 vs 8.8 ± 2.3; P = .39, respectively).
Conclusion:
When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. Arthroscopic ATFL repair, as a minimally invasive technique, provided favorable outcomes.
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.
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