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.
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; 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
Introduction/Purpose:
Markers of diagnosis and severity 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 indicator of peritalar subluxation and an earlier detector of the disease. When the disease affects the ankle leading to a valgus talar tilt (class E), structures distal to this topography may behavior differently, trying to compensate 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 could not be used in class E patients as an accurate value for estimation and staging of PCFD.
Methods:
In this IRB-approved retrospective case-control study we analyzed WBCT acquisitions of 21 consecutive patients with PCFD presenting valgus of the ankle and 64 controls (flexible PCFD with no ankle involvement). MFS (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 Offstet (FAO) and talar tilt angle (TTA) were obtained and compared between groups using oneway ANOVA. A multivariate regression analysis was performed to evaluate which of the measurements influenced the alignment. A partition prediction model was also constructed to find how the variables contributed to the deformity and its aspects. Statistical significancy was set in p values <0.05.
Results:
We found differences among groups only for MFS, HMA, FAO and TTA, with a lower mean value of MFS in patients with valgus of the ankle. An inverse relation between MFS and TTA was obtained in this group, demonstrated by increase in the talar tilt and decrease in middle facet uncoverage. MFS affected FAO values in the control group (R2: 0.25) but not in the ankle valgus group (R2: 0.001), being that this last one was influenced mainly by the TTA (R2: 0.53). A FAO value higher than 12.14 was found to be a strong predictor of deformity at the ankle.
Conclusion:
MFS was lower in patients with PCFD and valgus of the ankle, demonstrated as a weak predictor of deformity severity. In this group of patients (class E), talar tilt angle and Foot and Ankle Offset should be used as disease markers. A FAO value above 12.14 must be appreciated as a possible sign of ankle involvement in PCFD patients.
Category:
Ankle; Sports
Introduction/Purpose:
The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare ...and evaluate chronic ankle instability treatment strategies in the military population.
Methods:
Electronic databases were systematically searched for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports.
Results:
Eight studies met inclusion criteria and represented 695 military service members-625 males (89.9%) and 70 females (10.1%). The four treatment strategies included were Broström-related procedures, modified Watson-Jones procedure, Colville's technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of subjective satisfactory outcomes ranged from 80 to 94.7%, and the percentage of objective satisfactory outcomes ranged from 72 to 100%. The range for Broström-related procedures was 73.2% (objective) to 94.7% (subjective). The modified Watson-Jones procedure had a subjective satisfactory outcome of 80% and objective satisfactory outcome of 72%. Colville's technique had an objective satisfactory outcome of 100%. No satisfaction outcome was available for the study utilizing the anatomic lateral ligament reconstruction with semitendinosus tendon allograft. Mean American Orthopaedic Foot & Ankle Society (AOFAS) scores, anterior drawer displacement, talar tilt, and visual analogue scale (VAS) scores were also reported.
Conclusion:
This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville's technique is another promising option for this patient population, but would require future studies to fully support this claim.
Category:
Ankle Arthritis; Hindfoot
Introduction/Purpose:
Dome shaped supramalleolar osteotomies are a well-established treatment option for correcting ankle deformity. However, the procedure remains ...technically demanding and is limited by a two-dimensional (2-D) radiographic planning of a three-dimensional (3-D) deformity. Therefore, we implemented a weight-bearing CT-scan (WBCT) to plan a 3-D deformity correction using patient specific guides.
Methods:
A 3-D guided dome shaped supramalleolar osteotomy was performed to correct ankle varus deformity in a cohort of 5 patients with a mean age of 53,8 years (range: 47-58). WBCT images were obtained to generate 3-D models, which enabled a deformity correction using patient specific guides. These technical steps are outlined and associated with a retrospective analysis of the clinical outcome using the EFAS score, Foot and Ankle Outcome Score (FAOS) and Visual Analog Pain scale (VAS).
Radiographic assessment was performed using the tibial anterior surface angle (TAS), tibiotalar angle (TTS), talar-tilt angle (TTA), hindfoot angle (HA), tibial lateral surface angle (TLS) and tibial rotation angle (TRA).
Results:
The mean follow-up was 40,8 months (range 8-65) and all patients showed improvements in the EFAS score, FAOS and VAS (p < 0.05). A 3-month postoperative WBCT confirmed healing of the osteotomy site and radiographic improvement of the TAS, TTS and HA (p<0.05), but the TTA and TRA did not change significantly (p>0.05).
Conclusion:
Dome shaped supramalleolar osteotomies using 3-D printed guides designed on WBCT, are a valuable option in correcting ankle varus deformity and mitigates the technical drawbacks of free-hand osteotomies.
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 30° / sec and 10 repetitions for power (W) at a speed of 120° / 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). The non-dominant side was consistently stronger (higher peak torque) in all movements (p <0.001 -). The mean values obtained for force in each movement were 29.9N / m (CI 1.4) for eversion, 34.8N / m (CI 1.6) for inversion, 48.6N / m (2.0) for dorsiflexion and 140.2 N / m (CI 6.1) for plantar flexion. There was no correlation between age or BMI with the maximum torque (N / m). The ratio of eversors / inverters was 88.8% (CI 3.1) and that of dorsiflexors / plantar flexors was 36.1% (1.3). The Muscle Deficiency Index showed a balance between the sides for each movement (p 0.062), with an average global difference of less than 10% between them (eversion 8.66 CI 3.17, inversion 4.2 3, 48, dorsiflexion 3.41 3.04 and plantar flexion 5.18 2.51.
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:
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.
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:
Ankle; Sports
Introduction/Purpose:
Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. The purpose of this study is to determine if there is a ...degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability.
Methods:
A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with MRI and operative findings.
Results:
A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (p=0.008 for tendonitis and p= 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (p=0.043).
Conclusion:
Stress radiographs may assist the surgeon in clinical decision making.
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