Low tibial osteotomy for varus-type osteoarthritis of the ankle

Supramalleolar Osteotomy vs Arthrodesis for the Treatment of Takakura 3B Ankle Osteoarthritis

BACKGROUND

To compare the clinical/functional outcomes of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) for the treatment of modified Takakura stage 3B ankle osteoarthritis.

METHODS

Outcomes of 28 SMOT patients and 30 AA patients were reviewed at an average of 50 and 51 months, respectively. The baseline characteristics of the 2 groups were similar. The preoperative tibial articular surface angle and talar tilt angle in the SMOT group were 82.6 and 10 degrees and in the AA group, 83.9 and 9.1 degrees, respectively. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, 12-item Short-Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores, range of motion (ROM), radiologic parameters, and complications were compared.

RESULTS

The AOFAS, VAS, and SF-12 MCS and PCS scores improved significantly postoperatively in both groups (P < .001). The VAS and SF-12 PCS scores indicate marginally better improvement in the AA group (P < .05). The patient satisfaction value (P = .028) and the possibility of repeated surgery value (P = .012) were also significantly higher in the AA group. The early (P = .905) and late (P = .181) complications did not significantly differ between the 2 groups. The reoperation rate was significantly higher in the SMOT group (P = .038).

CONCLUSION

Both SMOT and AA showed improvements in function, pain, alignment, and quality of life after surgery. Patients in the AA group reported better pain relief, had a lower reoperation rate, and better hindfoot alignment during a short- to mid-term follow-up time.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Supramalleolar Osteotomy for Ankle Varus Deformity Alters Subtalar Joint Alignment

BACKGROUND

Although correction of ankle and hindfoot deformity after supramalleolar osteotomy has been investigated extensively, the specific effect on the subtalar joint alignment remains elusive. This can be attributed to the limitations of 2-dimensional measurements, which impede an exact quantification of the 3-dimensional subtalar joint alignment. Therefore, we determined both the ankle, hindfoot, and subtalar joint alignment before and after supramalleolar osteotomy using autogenerated 3-dimensional measurements based on weightbearing CT imaging.

METHODS

Twenty-nine patients with a mean age of 50.4±10.6 years were retrospectively analyzed in a pre-post study design using weightbearing CT. Inclusion criteria were correction of ankle varus deformity by an opening wedge (n = 22) or dome osteotomy (n = 7). Exclusion criteria consisted of an additional inframalleolar arthrodesis or osteotomy. Corresponding 3-dimensional bone models were reconstructed to compute following autogenerated measurements of the ankle- and hindfoot alignment: tibial anterior surface (TAS), tibiotalar surface (TTS), talar tilt (TT) angle, hindfoot angle (HA). In addition, the talocalcaneal angle (TCA) in the axial (TCA_ax), sagittal (TCA_sag), and coronal (TCA_cor) plane were measured to assess the subtalar joint alignment.

RESULTS

The preoperative radiographic parameters of the ankle joint alignment (TAS=88±4 degrees, TTS=82±7 degrees, TT=5.8±4.9 degrees) improved significantly relative to their postoperative equivalents (TAS = 93±5 degrees, TTS = 88±7 degrees, TT=4.2±4.5 degrees; P < .05). The following radiographic parameters of the hindfoot and subtalar joint alignment improved significantly from preoperatively (8.7±8.9 degrees, TCA_ax = 41±10 degrees, TCA_sag = 48±10 degrees) to postoperatively (HA=4.5±8.6 degrees, TCA_ax = 38±9 degrees, TCA_sag = 44±11 degrees; P < .05). No significant differences could be detected in the coronal plane alignment of the subtalar joint (TCA_cor) pre- compared to postoperatively (P > .05).

CONCLUSION

This study quantified the 3-dimensional ankle, hindfoot, and subtalar joint alignment after a solitary supramalleolar osteotomy. We found alterations in the subtalar joint alignment, which occurred by 2 to 3 degrees in each anatomic plane. However, before recommendations can be given related to inframalleolar procedures in conjunction to supramalleolar osteotomies, further studies on the variation of subtalar joint alignment change are needed.

Efficacy evaluation and systematic review of supramalleolar osteotomy for treatment of varus-type ankle arthritis

BACKGROUND

The current surgical treatment plan for medium-term varus-type ankle arthritis is primarily supramalleolar osteotomy (SMOT), but the reliability of this procedure still lacks high-quality evidence-based medical studies, such as randomized controlled clinical trials and meta-analyses of comparative studies.

OBJECTIVE

The current study explored whether significant differences were present in the clinical effect, reoperation rate, complications, and failure rate of this type of surgery.

METHOD

Two researchers searched the relevant literature in seven databases, including PubMed, Cochrane Library, EMBASE, the China Biomedical Literature Database, the China Academic Journals Full-text Database, the Wanfang database, and the Weipu Chinese Science and Technology Journal Database. The retrieval time spanned the establishment of the specific database up to September 2020, and the literature was screened to determine their final inclusion in the study.

RESULTS AND CONCLUSIONS

A total of 20 studies were included, including one Chinese and 19 English language studies. The primary indicators included a definitive effect of SMOT on the treatment of medium-term varus-type ankle arthritis. Concerning secondary indicators, although the surgery effect was satisfactory, some patients may require follow-up surgery, which may be unsuccessful with complications. The study results showed that, based on existing literature reports, the effect of SMOT for varus-type ankle arthritis was a satisfactory surgical method with some clinical value for correcting the ankle force line and relieving or even reversing ankle arthritis. However, its risk of complications and failure rate were comparatively high and, accordingly, requires good preoperative planning and close communication with patients. Due to the limited sample size of this study, more data and longer follow-up times involving this type of surgery should be reviewed to confirm this conclusion.

Supramalleolar Lateral Opening-Wedge Osteotomy in Conjunction With Progressive Collapsing Foot Deformity Reconstruction for PCFD With Ankle Instability

BACKGROUND

Reconstruction of progressive collapsing foot deformity (PCFD) with ankle instability (PCFD class E) remains a substantial challenge to orthopaedic surgeons. We report the outcomes of PCFD class E treated by means of a relatively standard PCFD foot reconstruction approach with the addition of a supramalleolar lateral opening-wedge osteotomy.

METHODS

We conducted a retrospective study of 13 patients (15 ankles) who underwent this procedure for PCFD class E between 2010 and 2021. Mean follow-up time was 3.8 (range, 2-6.3) years. Clinical assessment was based on the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale as well as a Self-Administered Foot Evaluation Questionnaire (SAFE-Q). Radiographic assessments, including identification of the mechanical ankle joint axis point and a modified valgus Takakura-Tanaka osteoarthritis grade, were recorded.

RESULTS

The mean JSSF score improved significantly from 45.2 preoperatively to 83.9 postoperatively (P < .001). SAFE-Q scores at the final follow-up were 70.1 for the pain and pain-related subscale, 75.4 for the physical functioning and daily living subscale, 83.0 for the social functioning subscale, 74.4 for the shoe-related subscale, and 78.1 for the general health and well-being subscale. Radiographic measurements showed improvement in the tibiotalar tilt angle (average improvement: 5.4 degrees); orientation of the talus joint line relative to the ground (average improvement: 14.0 degrees); anteroposterior talus-first metatarsal angle (average improvement: 11.2 degrees), talonavicular coverage angle (average improvement: 21.6 degrees), and lateral talus-first metatarsal angle (average improvement: 17.0 degrees). Postoperatively, the mechanical ankle joint axis point moved medially for all patients and into the medial half of the ankle joint for 7 patients. The modified osteoarthritis stage improved postoperatively in most cases.

CONCLUSION

In this select and relatively small group of patients who had a supramalleolar lateral opening-wedge osteotomy combined with PCFD reconstruction, we measured general improvement in JSSF scores and radiographic variables. Long-term durability of the procedure remains unknown. This procedure may be an option for preserving the ankle joint in treatment of PCFD class E with osteoarthritis of the ankle.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Evaluation of the hindfoot alignment before and after total knee arthroplasty

BACKGROUND

Open wedge high tibial osteotomy (OWHTO) and total knee arthroplasty (TKA) alter the ankle joint line obliquity (AJLO) to be more horizontal relative to the ground and aligns the valgus subtalar joint (SJ) neutrally. A previous study of the hindfoot alignment angle (HAA) showed that lower limb alignment after OWHTO becomes under-corrected because of abnormal compensation by the SJ. However, because TKA can exclude effects of femorotibial joint instability, analysis of a post-TKA cohort enables a more accurate evaluation of SJ compensation than analysis of a post-OWHTO cohort. In the present study, we performed radiographic evaluations before and after TKA to analyze SJ compensation.

METHODS

Lower limb and hindfoot alignment were measured on plain radiographs in 46 patients (48 knees) who underwent TKA in our department. The patients were divided into Group A (postoperative AJLO within ±1°) and Group B (postoperative AJLO greater than ±1°), and various parameters were compared between the groups. The preoperative HAA that resulted in an abnormal postoperative AJLO was investigated.

RESULTS

Group A had a significantly smaller preoperative HAA (p = 0.03) and postoperative HAA (p < 0.01) than Group B. Differences in the preoperative HAA between the two groups showed a cut-off value of 9.06°.

CONCLUSION

Patients with an HAA of more than 9.06° are likely to have abnormal hindfoot compensation.

Evaluation of postoperative orientation of the knee and ankle joint after open wedge high tibial osteotomy

Background

Cases with varus knee osteoarthritis (OA) often present concomitant ankle joint deformity and poor tibial plafond inclination (TPI) in the coronal plane. Although changes to the TPI with respect to the ground after open wedge high tibial osteotomy (OWHTO) have been described, reports on the relationship between the correction angle and severity of knee joint line obliquity (KJLO) are scarce. This study aimed to examine the correlation between the correction angle after OWHTO and the change in knee and ankle inclination with respect to the floor.

Methods

Between January 2016 and December 2019, 39 knees in 39 patients (mean age, 58.3 ± 9.7 years; male, 14 knees; female, 25 knees) underwent OWHTO for varus knee OA. The mean duration of follow up was 30.1 ± 9.8 months. Radiological severity of OA was evaluated for those with Kellgren-Lawrence grade 1-3. Preoperative and 1-year postoperative radiographs were used to examine the postoperative femorotibial angle, hip-knee angle, KJLO, TPI, talar tilt (TT), position of weight bearing line of the tibial plateau width (WBL ratio; %), and the relationship between the pre-to postoperative changes in each measured value and intraoperative correction angle. The relationship between the pre-to postoperative changes in each measured value and intraoperative correction angle were evaluated. Clinical evaluations were conducted before and 2 years after OWHTO using the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale of pain.

Results

The mean pre-to post-operative changes were 3.2 ± 2.2 for KJLO and 3.1 ± 2.5 for TPI, both demonstrating significant differences as well as significant correlations with the correction angle. The knee joint demonstrated postoperative changes in the valgus direction and none in the varus direction with respect to the floor in all cases. Furthermore, the sum of changes to the KJLO and TPI showed a positive correlation that approximates the change in the correction angle. The mean pre- and postoperative 2-year KOOS subscale of pain were 50.2 ± 10.2 and 82.3 ± 9.1. There were no correlations between preoperative TPI, pre-to postoperative change in TPI, and 2-year postoperative of KOOS subscale of pain.

Conclusion

For those who underwent OWHTO for varus OA, the knee joint changed from a preoperative varus malalignment to mild valgus malalignment, and the ankle joint tended to improve from a preoperative valgus malalignment to the postoperative neutral alignment with respect to the floor. Although a positive correlation was found in which the correction angle approximates the sum of changes to the KJLO and TPI, no significant difference was found between changes in KJLO and TPI nor in the ratio between the correction angle and changes in each measured value.

Coronal plane Calcaneal-Talar Orientation in Varus Ankle Osteoarthritis

BACKGROUND

We do not yet fully understand how the subtalar joint position is related to the varus osteoarthritic ankle joint. The purposes of this study were (1) to investigate the coronal orientation of the calcaneus relative to the talus according to the ankle osteoarthritis stage, talar tilt (TT), and (2) to determine if there is TT threshold at which apparent subtalar compensation begins to fade.

METHODS

We retrospectively reviewed 132 ankles that underwent weightbearing computed tomography (WBCT) for varus ankle osteoarthritis. The TT, subtalar inclination angle (SIA), and calcaneal inclination angle (CIA) were measured using WBCT. Ankles were divided into 5 groups according to Takakura stage and 2 groups according to the apparent compensation status of the subtalar joint and compared the index of the inclination of the subtalar joint relative to the ankle (SIA) or the index of the inclination of the calcaneus relative to the ankle (CIA). Additionally, we explored the relationship between SIA or CIA and the TT.

RESULTS

Apparent subtalar compensation (SIA and CIA) was significantly lower in Takakura stages 3b and 4. The SIA and CIA significantly differed according to the apparent compensation status (P < .001 and P = .030, respectively). The CIA of the noncompensated group varied widely, whereas the SIA was relatively constant. Furthermore, TT was greater than 9.5, which indicated a high probability of a noncompensated heel (sensitivity, 92.6%; specificity, 89.7%).

CONCLUSION

The position of the calcaneus appears compensatory with coronal plane orientation in varus ankle osteoarthritis when the TT is ≤9.5 degrees.

LEVEL OF EVIDENCE

Level IV, case series.

Plain Radiographs Underestimate Varus Deformity of the Tibial Plafond

Understanding plain radiograph in association with 3-dimensional (3D) morphology of the ankle is essential for treatment about varus ankle osteoarthritis (OA). The aims of this study were to investigate whether the alignment of the tibial plafond as determined on plain radiograph reflected the alignment of the tibial plafond on computed tomography (CT) in varus ankle OA and whether the alignment of the tibial plafond changed as the OA progressed. The 3D CT and plain radiographs from 101 ankles with varus ankle OA were analyzed and compared with 40 ankles in control group. The tibial plafond was assessed in the coronal and sagittal planes using 3D CT. The medial angle between the vertical line and the tibial plafond was measured on 3 different coronal plane CT images which was anterior, middle and posterior area of the tibial plafond. The medial distal tibial angle on plain radiograph reflected the posterior area of the tibial plafond on CT. The amount of varus angulation on CT was larger in anterior and middle area of the tibial plafond than the posterior area. There was a difference in the degree of varus of the tibial plafond between control group and OA patients; however, there was no difference among patients in different stages of varus ankle OA. Weightbearing plain radiographs underestimate the varus deformity in anterior and middle area of the tibial plafond and there is no significant difference in deformity of the tibial plafond among patients in different stages of varus ankle OA.

Outcomes of oblique supramalleolar osteotomy without fibular osteotomy for congruent- and incongruent-type medial ankle arthritis

BACKGROUND

Although high talar tilt and ankle mortise incongruence are risk factors for supramalleolar osteotomy (SMO), no study on lateral talofibular joint congruence exists. We aimed to evaluate the outcomes of oblique SMO without fibular osteotomy for medial ankle arthritis and compare them according to the lateral talofibular joint congruity.

METHODS

Forty-eight ankles were retrospectively reviewed and divided according to preoperative talofibular joint congruity (congruent, 22 [45.8%] vs. incongruent, 26 [54.2%]).

RESULTS

The mean VAS score, AOFAS score, and modified Takakura stage were significantly improved. No significant differences were noted in clinical outcomes, but the mean postoperative tibiotalar angle and difference between the upper and lower talofibular gaps were significantly different in both groups (p = 0.004 and p = 0.009, respectively). The mean Takakura stage at 1 and 2 years after surgery was higher in the incongruent group (p = 0.013, p = 0.012).

CONCLUSION

This procedure was effective against early- to mid-stage medial ankle arthritis. Radiographic arthritic grade changed according to the talofibular joint congruity.

Larger sagittal inter-screw distance/tibial width ratio reduces delayed union or non-union after arthroscopic ankle arthrodesis

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) has risks of complications, such as delayed union and non-union. The number and direction of the inserted screws have been reported as important factors affecting the time to union of AAA. However, the ratio of inter-screw distance (ISD) to tibial width (TW) in different planes has not been investigated. Therefore, we aimed to explore the effect of this ratio on bone union following AAA.

METHODS

We retrospectively enrolled 63 patients (64 ankles) undergoing AAA from 2013 to 2019. Then, their age, body mass index (BMI), sex, diabetes mellitus (DM) status, Takakura-Tanaka classification, number of screws and radiographic parameters were analysed.

RESULTS

The patients had a mean age of 70.3 (range, 45-91) years. Bone fusion was achieved in 57 ankles (89%) in a mean period of 3.3 (range, 2-6) postoperative months. There were four cases of delayed union and three of non-union. No significant differences in age, BMI, sex, DM, Takakura-Tanaka classification, and number of screws could be detected between the groups. However, the sagittal ISD/TW ratio was significantly larger in the union group than in the delayed/non-union group with a cut-off value of 57.0%.

CONCLUSION

Larger sagittal ISD/TW ratios result in reduced post-AAA delayed union or non-union. The surgeon should be aware that the anterior and posterior screw widths should be approximately 60% or more of the anteroposterior width of the tibia.

The L-shaped tunnel technique showed favourable outcomes similar to those of the Y-graft technique in anatomic lateral ankle ligament reconstruction

PURPOSE

To compare the mid- to long-term clinical and radiological outcomes of the confluent L-shaped tunnel technique with the Y-graft technique for anatomic lateral ankle ligament reconstruction.

METHODS

This retrospective study involved 41 patients who underwent lateral ankle ligament reconstruction between 2013 and 2018. Based on the tunnel direction and tendon fixation method at the fibula side, patients were divided into two groups, with 17 patients in the L-shaped tunnel group and 24 patients in the Y-graft group. The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner score, and Karlsson score were evaluated and compared preoperatively and at follow-up. Anterior talar translation and talar tilt at stress radiographs, postoperative sprain recurrence, range of motion (ROM) restriction, sensory disturbance, etc., were also collected and compared.

RESULTS

The mean follow-up times were 72 and 42 months for the L-shaped group and Y-graft group, respectively. The median VAS pain score, Tegner score, AOFAS score, Karlsson score significantly improved from a preoperative level in both groups (all with p < 0.01). No significant difference was found between the two groups regarding the changes from preoperatively to postoperatively except for the VAS pain score reduction (1.58 ± 1.58 in the L-shaped group vs. 2.53 ± 1.29 in the Y-graft group, p = 0.035). The incidence of flexion-extension ROM restriction (≥ 5°) was significantly higher in the Y-graft group (41.2%) than in the L-shaped group (12.5%) (p = 0.035).

CONCLUSIONS

Both the confluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability (CLAI) at mid- to long-term follow-up. The confluent L-shaped tunnel technique resulted in lower rates of flexion-extension ROM restriction, while the Y-graft technique showed better VAS pain reduction. This result could provide further evidence for the surgical treatment of CLAI.

LEVEL OF EVIDENCE

III.

Intra-articular opening wedge osteotomy for varus ankle arthritis with computer-assisted planning and patient-specific surgical guides: a retrospective case series

Background

Computer-assisted preoperative planning, combined with PSI has become an effective technique for treating complex limb deformities. The purpose of this study was to evaluate the efficacy and safety of the novel technique in corrective osteotomy for intra-articular varus ankle deformities associated with osteoarthritis and ankle instability.

Methods

Nineteen patients with intra-articular varus ankle arthritis were reviewed between April 2017 and June 2019, including ten men and nine women with a mean age of 58.3 ± 9.9 years (range, 38 to 76 years). All patients underwent intra-articular opening wedge osteotomy assisted by 3D virtual planning and PSI. Weight-bearing radiographs were used to assess the radiographic results, including TAS angle, TT angle, TMM angle, TC angle, TLS angle, opening-wedge angle, and wedge height. Functional outcomes were assessed by the AOFAS score, VAS score, and ROM of the ankle.

Results

The average follow-up time was 32.2 ± 9.0 months (range, 22 to 47 months). The average union time was 4.4 ± 0.9 months (range, 3.0 to 6.5 months). The TAS angle significantly changed from 84.1 ± 4.6° preoperatively to 87.7 ± 3.1° at the 1-year follow-up and 86.2 ± 2.6° at the latest follow-up. Similarly, the TT angle, TMM angle and TC angle changed significantly at the 1-year follow-up compared with the preoperative assessment and remained stable until the last follow-up. However, the TLS was not corrected significantly. The postoperative obtained opening-wedge angle, and wedge height showed no significant change with preoperative planning. The overall complication rate was 15.8%. The mean VAS score improved from 5.3 ± 0.6 to 2.7 ± 0.7. The mean AOFAS score improved from 56.2 ± 7.6 to 80.6 ± 4.6. However, the ROM showed no significant change.

Conclusions

Accurate correction and satisfactory functional recovery were attained with computer-assisted planning and PSI in the corrective osteotomy of intra-articular varus ankle deformities.

Supplementary information

The online version contains supplementary material available at 10.1186/s12891-022-05437-z.

Joint-Preserving Surgery in Varus Ankle Osteoarthritis

Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.

Evaluation of Subtalar Joint’s Compensatory Function in Varus Ankle Osteoarthritis Using Globally Optimal Iterative Closest Points (Go-ICP)

Background:

A previous study on 2-dimensional evaluation of the subtalar joint functioning in varus ankle osteoarthritis concluded that varus deformity was compensated for by the subtalar joint during early stages but not in the advanced stages. Although compensatory function is expected both along the axial and coronal planes, compensatory function in all 3 dimensions (3D) remains unevaluated. This study evaluated the 3D-compensatory function of a varus subtalar joint using Globally Optimal Iterative Closest Points (Go-ICP), a 3D-shape registration algorithm, after 3D-bone shape reconstruction using computed tomography.

Methods:

This study included 22 ankles: 4 stage 2 ankles, 5 stage 3a ankles, 6 stage 3b ankles, and 4 stage 4 ankles, categorized according to the Takakura-Tanaka classification. As the control group, 3 ankles without prior ankle injuries and disorders and 4 stage 2 ankles were included. One control ankle was used as a reference. Relative values compared with the reference ankle were evaluated in each group using Go-ICP. Each axis was set so that dorsiflexion, valgus, and abduction were positive on the X axis, Y axis, and Z axis, respectively.

Results:

Rotation angles of the talus (Rotation T) and calcaneus (Rotation C) on the Y axis in the control and stage 3b were −7.6, −28, −2.1, and −13 degrees, respectively, indicating significant differences. Value of Rotation T-Rotation C (Rotation T-C) represents compensatory function of the subtalar joint. In all ankles, there was a correlation between Rotation T and Rotation T-C on the Y axis and Z axis (P < .01, r = 0.84; P < .01, r = −0.84, respectively). There was a correlation between Rotation T values on the on Y and Z axes (P = .01, r = 0.53).

Conclusion:

In varus ankle osteoarthritis, the talus had varus deformity with adduction. Compensatory function in the coronal plane persisted, even in the advanced stages; however, it was not sufficiently maintained in stage 3b. Furthermore, compensatory function in the axial plane was relatively sustained.

Level of Evidence:

Level III, retrospective comparative study.

Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis

PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.

Treatment of Early to Intermediate Stage Ankle Osteoarthritis With Nonosteotomy Approaches: Intermediate-Term Efficacy

This study aimed to investigate the intermediate-term efficacy of nonosteotomy approaches in the treatment of early to intermediate stage ankle osteoarthritis (OA). Forty-two patients received treatment for early to intermediate stage ankle osteoarthritis with nonosteotomy approaches were reviewed. The surgical satisfaction was evaluated at 1 year after surgery and the last follow-up period; the American Orthopaedic Foot and Ankle Society (AOFAS) scale and Visual Analog Scale (VAS) were employed for the evaluation of function and pain, respectively, and the stage of ankle osteoarthritis was determined. At 1 year surgery and the last follow-up period, the surgical satisfaction was 37 (88.1%) and 35 (83.3%), respectively, and the favorable function was noted in 34 (80.9%) and 32 (76.2%), respectively. The AOFAS score significantly increased from 50.62 ± 10.81 (range 30-60) before surgery to 81.43 ± 12.00 (range 75-95) at 1 year after surgery (p < .0001) and 79.67 ± 10.34 (range 70-96) at the last follow-up period (p < .0001 vs before surgery; p = .107 vs 1 year). The VAS score reduced from 5.07 ± 1.57 (range 4-7) before surgery to 1.97 ± 1.41 (range 0-3) at 1 year (p < .0001) and 1.80 ± 1.15 (range 0-3) at the last follow-up period (p < .0001 vs before surgery; p = .265 vs 1 year). Moreover, the AOFAS score and VAS score in patients with ankle osteoarthritis at different stages were improved significantly after surgery (p < .0001). Intermediate-term follow-up period shows that nonosteotomy approaches are able to relieve pain and improve postoperative function in the treatment of early to intermediate stage ankle osteoarthritis; the improvement determined according to imaging examination is not completely consistent with that determined based on clinical function.

Effects and Safety of Intra-Articular Sodium Hyaluronate Injection for the Treatment of Ankle Osteoarthritis: A Prospective Clinical Trial

Various nonoperative treatments have been implemented to reduce pain and improve the quality of life in patients with ankle osteoarthritis. Among these treatments, intra-articular hyaluronate injection has proven efficacy and safety in patients with knee osteoarthritis. The purpose of this study was to evaluate the efficacy and complications of hyaluronate injection using various clinical scoring systems. This study included 37 patients with unilateral ankle osteoarthritis (grade 2 or 3 according to the Takakura classification) who did not respond to previous pharmacological treatment. 3 weekly hyaluronate injections (2 mL Hyruan Plus®) were administered. The efficacy of intra-articular hyaluronate injection was evaluated on the basis of patient-reported foot and ankle clinical assessment at a mean follow-up of 13.8 ± 8.3 (range 6-33) months. Ankle Osteoarthritis Scale scores for pain and disability, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, and visual analog scale for pain significantly improved at the final follow-up compared to that before intra-articular hyaluronate injection (p ≤ .05). When patients were dichotomized according to age, sex, body mass index, symptom duration, and Takakura classification, all these factors were not related to clinical outcomes. This study suggests that 3 weekly intra-articular hyaluronate injections can be performed safely to reduce pain and improve function without serious complications in patients with early or intermediate-grade ankle osteoarthritis when patients inadequately respond to medication. Larger controlled studies are needed to clarify the effects of hyaluronate injection and identify patients who can benefit most from hyaluronate injection.

Technique Tip: Correcting Malalignment of the Talus Using a Pin-Based Distracter During Arthroscopic Ankle Arthrodesis

It is technical demanding work to perform arthroscopic ankle arthrodesis to treat end-stage ankle osteoarthritis with excessive talar tilt. This article aimed to provide an effective technique tip for the treatment of Takakura stage 3b ankle osteoarthritis with a talar tilt angle more than 15 degrees under arthroscopy. A conventional anterior arthroscopic approach is used. After arthroscopic examination and debridement, one pin which is parallel to the distal tibial surface is inserted into the tibial side of the ankle, the other pin which is parallel to the talar dome surface is inserted into the talar side of the ankle, both at the coronal plane. Then a distracter is used in the medial side to open the interspace of the tibiotalar joint and correct the talar tilt through the 2 pins, under which circumstance the tibiotalar joint surface can be well prepared. Next an anti-distracter is used in the lateral side to close the tibiotalar interspace and correct the talar tilt through the 2 pins, in which condition 3 fully threaded cannulated lag screws can be inserted through guide pins in a cross pattern to fix the ankle joint. We used the pin-based distracter to open and close tibiotalar interspace, correct the talar tilt and maintain a good mechanical axis for fusion, and the outcomes were good.

Joint Preserving Surgery for Valgus Ankle Osteoarthritis

Valgus ankle OA is a complex problem with multiple etiologies that can either be isolated or superimposed on top of other medical or musculoskeletal disorders. Proper medical history, physical, and preoperative radiological examinations are crucial in deciding on surgery and planning the surgical approach. JPS, especially the varisating medial closing-wedge SMOT with solid plate fixation, has been consistently associated with good outcomes for patients with valgus ankle OA. To further improve JPS for valgus ankle OA, further clinical and biomechanical studies are required to address the long-term clinical and functional outcomes and complications.

Analysis of Whole Limb Alignment in Ankle Arthritis

A full-length standing posteroanterior radiograph that includes the calcaneus (hip-to-calcaneus radiograph) is obtained for evaluation of the mechanical axis of the entire lower limb in patients with a lower limb condition involving malalignment. Such evaluation clarifies several pathomechanical aspects of hindfoot disorders, facilitates surgical planning, and elucidates factors contributing to unsatisfactory results of a particular operation. Whole limb alignment is influenced not only by the knee joint but also by the ankle joint; thus, knee realignment influences hindfoot alignment and vice versa. It is essential to analyze alignment of the whole limb in planning corrective lower limb surgery.

Radiographic analysis using the hip-to-calcaneus line and its association with lower limb joint kinetics in varus knee osteoarthritis

BACKGROUND

This study aimed to (1) determine whether the hip to ankle (HA) line or hip to calcaneus (HC) line better reflects knee coronal plane kinetics, (2) to examine whether the HC line reflects ankle coronal plane kinetics, and (3) to evaluate the radiological and biomechanical aspects of ankle in varus knee osteoarthritis (OA).

METHODS

Full-length, postero-anterior radiographs (hip-to-calcaneus radiographs) were taken and gait analysis was performed in 21 varus knee OA patients. The %HA where the HA lines pass through the tibial plateau, and the %HC and the mechanical ankle joint axis point (MAJAP), where the HC line passes through the tibial plateau and tibial plafond, respectively, were calculated. Knee adduction angular impulse (KAAI) and ankle inversion angular impulse (AIAI) were collected as kinetic data. Finally, we divided the patients into two groups with and without ankle OA, and compared each parameter between both groups.

RESULTS

The %HA and %HC were correlated with KAAI (%HA; r = -0.68, P = 0.001, %HC; r = -0.81, P < 0.001, respectively) and MAJAP was correlated with AIAI (r = -0.55, P = 0.009). MAJAP was significantly smaller, and KAAI and AIAI were significantly larger in the ankle OA group.

CONCLUSIONS

Radiographic analysis using the HC line was more strongly correlated to knee joint kinetics than the HA line and was also correlated to ankle joint kinetics. Assessing lower limb alignment using the HC line could be useful to evaluate the knee and ankle joints for varus knee OA.

Joint Preservation Strategies for Managing Varus Ankle Deformities

Joint preserving strategies have evolved to a successful treatment option in early and midstage medial ankle OA caused by varus deformity. Though talar tilt can often not be fully corrected, it provides substantial postoperative pain relief, functional improvement, and slowing of the degenerative process. Osseous balancing with osteotomies is the main step for restoration of ankle mechanics and normalization of joint load. Overall, the key for success is to understand the underlying causes that have contributed to the varus OA in each case, and to use all treatment modalities necessary to restore appropriate alignment of the hindfoot complex.

Joint Preservation Surgery for Varus and Posterior Ankle Arthritis Associated with Flatfoot Deformity

This article introduces novel types of ankle arthritis related to a flatfoot deformity. There has been a long-held belief that severe unmanaged flatfoot deformity leads to valgus ankle arthritis, due to deltoid ligament insufficiency. However, flatfoot deformity can also give rise to varus ankle arthritis as the talus and calcaneus subluxate into opposite directions. Plantarflexion and posterior translation of the talus in the sagittal plane contributes to the eccentric narrowing of the posterior aspect of the tibiotalar joint, which the authors termed posterior ankle arthritis. Subtalar arthrodesis was performed to address the opposing dynamics of the talus and calcaneus, and was combined with a medial longitudinal arch reconstruction in most cases of posterior ankle arthritis and in selected cases of varus ankle arthritis, and satisfactory clinical and radiological results were achieved.

[Arthrodesis vs. prosthesis for end-stage osteoarthritis of the ankle joint : A scientific argument]

The gold standard in operative treatment of end-stage ankle osteoarthritis remains controversial even now. Endoprosthetic treatment, which has undergone significant improvements in recent years competes with arthrodesis, which can achieve excellent results particularly in the arthroscopically assisted technique. Both procedures offer specific advantages and disadvantages so that the decision about indications for treatment should always be made individually, taking specific needs and the individual constellation of findings of the patient into consideration.

[Conversion osteotomy for arthrosis of the ankle joint (supramalleolar and inframalleolar)-What can be expected? : Critical review of the literature]

The aim of supramalleolar conversion osteotomy is to reduce the pain of the patient and stop or at least slow down joint degeneration. The indication for supramalleolar osteotomy is asymmetric osteoarthritis of the ankle joint with varus or valgus deformity. Good clinical results for arthritis can be achieved in the early or middle stages. Besides closing and opening wedge osteotomies dome osteotomy is sometimes indicated, especially for larger deformities. The preoperative preparation of individual patient-specific section blocks facilitates the intraoperative implementation and seems to increase the precision. Further studies are necessary to support this. The indications for additional procedures, such as fibular osteotomy are still being discussed. Inframalleolar osteotomy and soft tissue interventions are frequently necessary for balancing the foot.

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

BACKGROUND

We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy.

METHODS

We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups.

RESULTS

There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P > .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs -2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01).

CONCLUSION

In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Repositional Subtalar Arthrodesis Combined With Supramalleolar Osteotomy for Late-Stage Varus Ankle Arthritis With Hindfoot Valgus

BACKGROUND

Late-stage varus ankle arthritis is thought to be associated with varus of the tibial plafond and hindfoot. However, some late-stage varus arthritis show hindfoot valgus, which can be explained by subtalar subluxation with opposite directional motion between the talus and calcaneus. We hypothesized that late-stage varus ankle arthritis with hindfoot valgus could improve with repositional subtalar arthrodesis and supramalleolar osteotomy (SMO). The purpose of this study was to investigate the clinical and radiographic results of the repositional subtalar arthrodesis combined with SMO for late-stage varus ankle arthritis with hindfoot valgus.

METHODS

This study includes 16 consecutive patients (16 ankles) with late-stage varus ankle arthritis of Takakura stage 3-b and hindfoot valgus who were treated using repositional subtalar arthrodesis combined with SMO and followed for a minimum of 2 years. Clinical results were assessed with the visual analog scale (VAS) and the Foot Function Index (FFI). Radiographic results were assessed with standard parameters measured on weightbearing foot and ankle radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up.

RESULTS

VAS and FFI significantly improved after surgery. Mean talar tilt angle improved from 12.8 ± 2.8 degrees to 3.9 ± 3.1 degrees (P < .001). Talus center migration and Meary angle significantly improved after surgery. Medial distal tibial angle, lateral talocalcaneal angle, hindfoot moment arm, and talonavicular coverage angle significantly changed after surgery. Radiographic stage improved in 15 ankles (93.8%) after surgery.

CONCLUSION

In this series with minimum 2-year follow-up, we found that late-stage (Takakura stage 3-b) varus ankle arthritis with hindfoot valgus clinically and radiographically improved with repositional subtalar arthrodesis combined with SMO.

LEVEL OF EVIDENCE

Level IV, prognostic.

Decreased physical activity in patients with ankle osteoarthritis. A case-control study comparing daily step counts

BACKGROUND

The purpose of this study was to compare physical activity levels and the proportion of patients who met physical activity recommendations in patients with ankle osteoarthritis and controls.

METHODS

Ankle osteoarthritis patients (n = 50) and controls (n = 50) were recruited. physical activity was measured using an accelerometer-based monitor. Physical activity parameters, including the step count/day, the proportion of patients who met physical activity recommendations of ≥7000 steps/day, and moderate to vigorous physical activity minutes/day, were compared between the patient groups.

RESULTS

The patients with ankle osteoarthritis walked 3998 steps/day, while the controls walked 6531 steps/day (P < .001). Only 7 (14%) ankle osteoarthritis patients and 17 (34%) controls met the physical activity recommendations of ≥7000 steps/day (P =  .01). Time spent performing moderate to vigorous physical activity was 58 and 78 min/day in the ankle osteoarthritis and controls, respectively.

CONCLUSIONS

The physical activity level of ankle osteoarthritis patients was lower than that of controls. Only a limited proportion of ankle osteoarthritis patients met the physical activity recommendation.

Joint Preservation Surgery for Varus Ankle Arthritis with Large Talar Tilt

BACKGROUND

Varus ankle arthritis with large talar tilt (TT) is a challenging condition when considering joint preservation surgery. Three-dimensional deformity of the talus has been demonstrated with weightbearing computed tomography in varus ankle arthritis with large TT. The aim of this study was to investigate the clinical and radiographic results of posterior tibial tendon (PTT) transfer generally combined with bony realignment for varus ankle arthritis with large TT in nonparalytic ankle arthritis and to determine the indications for PTT transfer.

METHODS

This study includes 23 ankles with varus arthritis and TT larger than 7.5 degrees. Patients were categorized into improved (19 ankles) and unimproved (4 ankles) groups according to the postoperative clinical results at the last follow-up. Clinical and radiographic results were compared between the groups. A cut-off point for preoperative TT that indicated a borderline between improved and unimproved groups was determined to suggest the appropriate indication for joint preservation surgery.

RESULTS

In the improved group, TT, radiographic stage, Meary angle, and hindfoot alignment significantly improved at 6 months after surgery and were maintained at the last follow-up. In the unimproved group, the radiographic parameters mentioned above did not improve at 6 months after surgery, and TT decreased to 0.8 degrees as radiographic stage had progressed to end-stage arthritis at the last follow-up. In this small series, the cut-off point for predicting failure of surgery was 14.3 degrees of preoperative TT.

CONCLUSION

PTT transfer often combined with bony realignment procedures may be a reasonable option for treating painful varus ankle arthritis with TT less than 14 degrees and hindfoot varus.

LEVEL OF EVIDENCE

Level IV, case series.

Patient Pain and Function After Correction of Posterior Malleolar Malunion

BACKGROUND

The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus.

METHODS

We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score.

RESULTS

Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery.

CONCLUSION

An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

Introduction

There are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.

Presentation of case

The patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.

Discussion

The patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.

Conclusion

We reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.

•

Ankle osteoarthritis and malalignment can be followed by osteotomy.

•

One-stage ankle arthrodesis and deformity correction should be considered.

•

Anterolateral plate was useful for arthrodesis and correction.

Outcomes of Joint Preservation Surgery in Valgus Ankle Arthritis Without Deltoid Ligament Insufficiency

BACKGROUND

To date, information about the role of proximal alignment correction in treating nontraumatic valgus ankle arthritis is limited. This study aimed to report outcomes of realignment surgery, including supramalleolar correction in valgus arthritic ankles without evidence of deltoid ligament insufficiency.

METHODS

Thirteen patients (13 ankles) who underwent joint preservation surgery for valgus ankle arthritis without evidence of deltoid ligament insufficiency were reviewed. Medial opening wedge supramalleolar osteotomy (n = 11) and varization supramalleolar dome osteotomy (n = 2) were performed to realign the hip-knee-ankle-hindfoot axis. Concomitant hindfoot correction was accompanied with either medial displacement calcaneal osteotomy (n = 8) or subtalar arthrodesis (n = 5). Pain, functional outcome (Foot Function Index [FFI]), radiographic arthritis grade (grades 0-4), 9 plain radiographic parameters, and 2 weightbearing computed tomography parameters were evaluated pre- and postoperatively. All patients completed a minimum 2-year follow-up.

RESULTS

Preoperatively, 10 ankles (77%) demonstrated a varus tibial plafond, and 3 ankles (23%) demonstrated a valgus or neutral tibial plafond. Postoperatively, radiographic arthritis grade improved in all except 1 patient, and the mean talar tilt angle improved from 5.5 to 1.7 degrees. The mean pain score (visual analog scale) decreased significantly from 7.3 to 2.5 (P < .05), and the mean FFI improved significantly from 57.7 to 18.6 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up.

CONCLUSION

This study demonstrated a possible relationship between lower limb malalignment and valgus ankle arthritis. Realignment surgery, including supramalleolar osteotomies, which straightens the mechanical axis and decreases the slope of the tibial plafond, may be a reasonable approach in joint preservation of valgus ankle arthritis without deltoid ligament insufficiency.

LEVEL OF EVIDENCE

Level IV, case series.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

INTRODUCTION

Traumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.

PATIENTS AND METHODS

The subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.

RESULTS

The 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.

CONCLUSION

Intra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

The Effect of Supramalleolar Osteotomy without Marrow Stimulation for Medial Ankle Osteoarthritis: Second-Look Arthroscopic Evaluation of 29 Ankles

BACKGROUND

The effect of supramalleolar osteotomy without a bone marrow-stimulating procedure for articular cartilage regeneration in the ankle joint remains unknown. We investigated whether supramalleolar osteotomy yielded favorable clinical and radiographic outcomes. We also evaluated the joint tissue appearance after supramalleolar osteotomy without a bone marrow-stimulating procedure with use of second-look arthroscopy and its correlation with the outcome.

METHODS

Twenty-nine ankles were retrospectively reviewed at a mean of 2.9 years after supramalleolar osteotomy without a bone marrow-stimulating procedure. All 29 ankles had had second-look arthroscopy to evaluate tibiotalar joint tissue regeneration at a minimum of 1 year postoperatively. A visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and patient satisfaction were used for functional evaluations. Ankle osteoarthritis was classified with the Takakura staging system, and the tibial anterior surface (TAS) angle and tibial lateral surface (TLS) angle were measured on radiographs.

RESULTS

The mean VAS and AOFAS scores improved from 6.2 (95% confidence interval [CI], 5.7 to 6.8) preoperatively to 1.5 (95% CI, 0.9 to 2.1) postoperatively and from 60.5 (95% CI, 54.9 to 66.1) preoperatively to 88.3 (95% CI, 84.3 to 92.3) postoperatively, respectively. Patient satisfaction with the outcome of the procedure was classified as very satisfied or satisfied for 27 ankles (93.1%). Sixteen of 21 ankles that were classified as Takakura stage-IIIa and 2 of 3 ankles that were classified as stage-IIIb preoperatively improved to stage II postoperatively. The mean TAS and TLS angles significantly improved from 83.5° (95% CI, 82.2° to 84.7°) and 77.0° (95% CI, 75.4° to 78.7°) preoperatively to 94.2° (95% CI, 92.7° to 95.7°) and 80.4° (95% CI, 78.3° to 82.5°) postoperatively, respectively. On second-look arthroscopy, 26 ankles (89.7%) showed tissue regeneration of the medial compartment of the ankle joint and no patient showed cartilage deterioration.

CONCLUSIONS

Medial tibiotalar tissue regeneration was identified in most patients with medial compartment ankle osteoarthritis following supramalleolar osteotomy without a bone marrow-stimulating procedure. The procedure results in satisfactory clinical and radiographic outcomes with high patient satisfaction.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Relationship Between the Distal Tibial Fibular Syndesmosis and the Varus Deformity in Patients With Varus Ankle Osteoarthritis

Background:

The impact of varus ankle osteoarthritis (OA) on the distal tibial fibular syndesmosis is poorly described. This study aimed to investigate the possible relationship between the condition of the distal tibial fibular syndesmosis and the degree of the varus deformity using weightbearing simulated computed tomography (CT), in patients with varus ankle OA.

Methods:

This retrospective comparative study included 155 varus ankles, divided into 4 Takakura-Tanaka groups (stage 2, 3a, 3b, and 4). A control group comprised 35 ankles without prior ankle disorders. The angles between the tibial shaft and the articular surface of the tibial plafond on the anteroposterior view (TAS), and articular surfaces of the tibial plafond and talar dome (TTW) were measured from weightbearing ankle radiographs. The varus angle of the ankle (VA) was defined as 90 – TAS + TTW. On the CT axial view, 1 cm proximal to the tibial plafond, the area of the syndesmosis (“CT-area”) and the distance between the fibula and the tibia (CT-FCS) were measured.

Results:

The CT area in stages 2, 3a, 3b, 4, and control group were 99, 79, 77, 103, and 97 mm², respectively. The CT-FCS were 3.5, 3.1, 2.9, 4.3, and 3.9 mm, respectively. In all 155 OA ankles, CT area and CT-FCS were negatively correlated with the VA (correlation coefficient r = –0.38, P < .01; and r = 0.38, P < .01, respectively). Both CT area and CT-FCS were significantly smaller in stages 3a and 3b than in the control group (P < .01).

Conclusion:

There may be a relationship between the narrowing of the syndesmosis and the varus deformity in patients with varus ankle OA, especially in stages 3a and 3b.

Clinical Relevance:

Clinicians should be aware of the impact of varus ankle arthritis on the distal tibial fibular syndesmosis when operatively treating varus ankle OA. For some patients, the isolated treatment for the tibiotalar joint may be insufficient, and treatment for the syndesmosis as well as tibiotalar joint may be needed.

Level of Evidence:

Level III, retrospective case control study.

Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy

BACKGROUND

There have been debates on the necessity of fibular osteotomy (FO) in supramalleolar osteotomy (SMOT) for the treatment of varus ankle osteoarthritis. The purpose of the current study was to compare the clinical and radiological outcomes between SMOT with and without FO in the treatment of varus ankle osteoarthritis.

METHODS

The SMOT group included 39 patients, and the SMOT with FO group included 24 patients. The basic information reached no significant difference between groups. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS), modified Takakura stage and range of motion (ROM) were used for the functional evaluation. The radiologic parameters were assessed at the last follow-up to compare the degree of talar reduction between the two groups.

RESULTS

Both groups achieved significant improvements in AOFAS scores, modified Takakura stage, as well as AOS pain and functional scores (P < 0.001). The ROM of the ankle joint in the SMOT group was significantly decreased (P = 0.022). In both groups, all of the radiological parameters were significantly improved (P < 0.01). The tibiofibular clear space (TFCS) was significantly widened in the SMOT group (P < 0.001). No significant difference was found between the two groups according to the functional outcomes. However, the talar tilt angle (TT) and hindfoot alignment angle (HFA) in the SMOT with FO group were significantly smaller than those in the SMOT group (P < 0.05). The TFCS was significantly widened in the SMOT group (P = 0.001). The medial displacement of the talus (MDT) was better reduced in the SMOT with FO group (P = 0.006).

CONCLUSION

SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. If SMOT is combined with FO, talar tilt and medial displacement will be better reduced.

Mini-Screws-Only Fixation Method for Small Fragments of Medial Malleolus Fractures

Backgroud

Open reduction and internal fixation is the standard treatment for a displaced medial malleolus fracture (MMFx), achieving ankle stability and bony union to prevent post-traumatic arthritis. Previous fixation techniques including tension band wiring and unicortical screw fixation are not optimal for fixation of small fragments in MMFx due to their small size and poor manipulability. Here, we describe a novel surgical method using mini-screws only for fixation of small fragments in MMFx.

Methods

We conducted a retrospective consecutive study of patients who underwent surgery using mini-screws for small fragment MMFx between April 2013 and March 2018. We reviewed the patients' clinical characteristics and assessed the fracture features radiographically. Clinical outcomes were assessed by measuring the range of motion of both ankle joints and investigating symptomatic implants. We reviewed the radiographic outcomes of the medial malleolus and the functional outcomes using the Foot and Ankle Outcome Score (FAOS) at the last follow-up.

Results

Nine patients were included in the study. The minimal follow-up period was 27 months. There was no incidental bone breakage during the procedure. All MMFx healed without reduction loss, nonunion, or implant failure at the last follow-up. Two patients had mild osteoarthritic changes of the ankle joint. The mean FAOS score of the patients was 80.99 (range, 65.44–98.42). No patients required removal of the hardware.

Conclusions

Fixation of comminuted fractures of the medial malleolus using mini-screws for young adult patients is a straightforward and simple technique. Safe fixation of the anterior and posterior colliculi reduces the risk of implant irritation symptoms that necessitate implant removal.

Distal tibial oblique osteotomy for reconstruction of ankle joint congruity and stability

Teramoto distal tibial oblique osteotomy (DTOO) is a joint-preserving surgery for ankle osteoarthritis (AOA). However, there are few articles on the radiological assessment of DTOO. The purpose of this study was to report the clinical outcomes and radiological evaluations of weight-bearing radiographs before and after DTOO. We retrospectively reviewed 52 patients who underwent DTOO between 2007 and 2018. We recorded the Tanaka-Takakura classification, fixation methods, Japanese Society for Surgery of the Foot Ankle/Hindfoot Scale (JSSF scale), and complications. The tibial articular surface angle (TAS), medial malleolar angle (MMA), tibial lateral surface angle (TLS), talar tilt angle (TTA), and tibiotalar surface angle (TTS) were evaluated using weight-bearing ankle radiographs. The median patient age was 66 years, and the mean follow-up duration was 46 ± 23 months. Two stage 2, 9 stage 3a, 30 stage 3b, and 11 stage 4 according to the Tanaka-Takakura classification were performed using DTOO. The JSSF scale improved significantly from 39.9 ± 13.8 before surgery to 87.2 ± 7.5 after surgery. Seven cases were fixed using a locking plate, and 45 cases were fixed using a circular external fixator. The TAS, MMA, TLS, TTA, and TTS significantly changed before and after DTOO. Radiological evaluation indicated that DTOO influences talar behavior during weight-bearing, and improves the clinical outcomes of AOA.

Clinical Outcome of Kissing Mosaicplasty for Treatment of Asymmetric Medial Tibiotalar Osteoarthritis: A Case Report

CASE

We report a case of asymmetric medial ankle arthritis that was treated by medial malleolar osteotomy and oblique fibular osteotomy to expose and resurface both the medial talar dome and medial tibial plafond articular surfaces.

CONCLUSION

This technique permitted a unique application of mosaicplasty in which osteochondral plugs were placed in a "kissing" orientation. The outcome seen here suggests the possibility of mosaicplasty as a viable option for treatment of localized ankle arthritis. In addition, this exposure technique is also applicable to treating isolated lesions of the medial tibial plateau.

Simulated weightbearing computed tomography for verification of radiographic staging of varus ankle osteoarthritis: a cross-sectional study

Background

Varus ankle osteoarthritis is classified using only weightbearing anteroposterior ankle radiographs; however, sagittal ankle alignment may also affect the position and extent of joint space obliteration. We hypothesized that the sagittal alignment of the ankle may also affect the position and extent of joint space obliteration visible on the coronal section; therefore, we identified the sites of joint space obliteration in patients with stage 3 varus ankle osteoarthritis for comparison with the sites observed on simulated weightbearing computed tomography and investigated the effects of anterior and posterior ankle subluxation.

Methods

Simulated weightbearing computed tomography scans of 83 ft with varus ankle osteoarthritis (26 stage 3a, 57 stage 3b) were performed to check for joint space obliteration in the ankle. Further classification as exhibiting either anterior, posterior, or no subluxation on weightbearing lateral radiographs was performed.

Results

Anterior, posterior, and no subluxation was seen in 5, 9, and 12 ankles among the 26 classified as stage 3a, respectively, and in 22, 12, and 23 ankles among the 57 classified as stage 3b, respectively. The mean tibial lateral surface angle on weightbearing lateral radiographs in stage 3a ankles was 75.6, 83.3, and 80.3 degrees in the anterior, posterior, and no subluxation groups, respectively; and 75.5, 86.6, and 82.7 degrees in stage 3b ankles (p < .05). In stage 3b ankles, widespread joint space obliteration was observed at the anterior distal articular surface of the tibia in all 22 ankles with anterior subluxation and at the posterior distal articular surface of the tibia in all 12 ankles with posterior subluxation.

Conclusions

Simulated weightbearing computed tomography revealed joint space obliteration at the anterior distal articular surface of the tibia in stage 3b ankles with anterior subluxation and at the posterior side in stage 3a and 3b ankles with posterior subluxation. In some patients with stage 3 varus ankle osteoarthritis, the obliteration of the joint space is difficult to evaluate accurately using only weightbearing anteroposterior radiographs; weightbearing lateral radiographs should also be performed.

The Potential of Bone Debris as a Bioactive Composite for Bone Grafting in Arthroscopic Ankle Arthrodesis

Arthroscopic ankle arthrodesis (AAA) has advantages of being less invasive and achieving a high bone union rate. However, there are still some nonunion or delayed union cases, especially those of high-grade deformity. During AAA, curettage of the subchondral bone using an abrader burr provides bone debris, and there is the possibility of bone debris being used as autograft to improve bone union. The purpose of this study is to analyze bone debris histologically, and the effect of its implantation on bone union of AAA. Bone debris from 6 patients was collected during AAA. Bone debris/atelocollagen composite was made and cultured for 4 weeks. Histological analyses were performed before and after culture. Twenty-six patients with AAA were divided into 2 groups with or without bone debris implantation, and the time to union after surgery was evaluated. In histological analysis of bone debris/atelocollagen composite, bone debris contained bone, cartilage and synovium fragment at time 0. After 4 weeks of culture, osteocalcin positive cells migrated and proliferated in the gel. Ki67 positive cells significantly increased after culture. In clinical cases, time to union was significantly shorter in the bone debris group (9.3 ± 1.3 weeks) than that in the control (12.4 ± 3.1 weeks). This study showed that bone debris contained the osteochonductive and osteoinductive properties, and there is the potential for its implantation into the ankle joint to improve bone union in ankle arthrodesis.

Open-wedge high tibial osteotomy for the treatment of osteoarthritis of both knee and ankle in the same leg: A report of two cases

We report two cases of patients with concurrent osteoarthritis of the knee and ipsilateral ankle. The patients were treated with high tibial osteotomy (HTO). In well-planned and selected cases, HTO may be effective in treating not only the knee, but also the ankle in patients with ipsilateral double-joint osteoarthritis.

Comparison of Mechanical Axis of the Limb Versus Anatomical Axis of the Tibia for Assessment of Tibiotalar Alignment in End-Stage Ankle Arthritis

BACKGROUND

Coronal plane ankle joint alignment is typically assessed using the tibiotalar angle (TTA), which relies on the anatomical axis of the tibia (AAT) and the articular surface of the talus as landmarks. Often, the AAT differs from the mechanical axis of the lower limb (MAL). We set out to test our hypothesis that the TTA using the MAL would differ from the TTA measured using the AAT in patients with ankle osteoarthritis.

METHODS

Standardized standing long leg radiographs of 61 ankles with end-stage osteoarthritis were analyzed. We measured the MAL and the AAT. A line was drawn along the talar articular surface (TA) and the TTA was calculated using both the MAL (MAL-TA) and the AAT (AAT-TA). The mechanical axis of the tibia (MAT) was also recorded and the MAL-MAT angle calculated. The difference between MAL-TA and AAT-TA and its correlation with the MAL-MAT angle were assessed. Intra- and interobserver agreement were measured for MAL-TA and AAT-TA.

RESULTS

The mean MAL-TA was 91.4 degrees (95% CI, 88.5-94.4) and the mean AAT-TA was 91.2 degrees (95% CI, 88.6-93.9). The difference ranged from -8.1 to 7.8 degrees, and was greater than 2 and 3 degrees in 42% and 18% of the patients, respectively. The difference, as an absolute value, also strongly correlated with the MAL-MAT angle (r = 0.91, P < .001). Intra- and interobserver reliability were excellent for both MAL-TA (intraclass correlation coefficient [ICC], 0.93 and 0.91, respectively) and AAT-TA (ICC, 0.91 and 0.89, respectively).

CONCLUSION

We recommend that surgeons consider using the MAL-TA, which relies on long leg radiographs, especially with proximal deformity, to more accurately measure coronal plane ankle joint alignment.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study

AIMS AND OBJECTIVES

To examine clinical and functional outcomes in patients with intra- and extra-articular distal tibial fractures treated definitively by Ilizarov fixation.

MATERIALS AND METHODS

Patients with tibial fractures extending within 1 Müller square of the ankle joint were identified from our Ilizarov database over a 5-year period. Data on treatment and outcome were assembled from this database and supplemented by a review of patient records. General measures of health-related quality of life and limb-specific functional outcome scores were recorded. Adverse events were documented according to Paley's classification.

RESULTS

One hundred and sixty-eight patients with 169 fractures were identified, 28% were open and 63% intra-articular. One hundred and sixty-five (98%) of the fractures united, two following bone grafting in their original frames, at a median of 166.5 days (range 104-537). Three patients with nonunions united with further treatment. One patient (an end-stage diabetic) elected to undergo amputation following multiple early complications during treatment. Closed fractures united more rapidly than open (median 157 vs 183 days; p = 0.005) and true Pilon (43C3) fractures took longer to unite than other fractures (median 157 vs 177 days; p = 0.01).Sixty-seven percent of patients completed functional outcome scores. Sixty-two percent reported good or excellent ankle scores at more than 6 months post frame removal, 38% fair and 10% poor. Patients with intra-articular fractures reported significantly worse ankle scores than those with extra-articular injuries. General measures of health-related quality of life (EuroQol-5D) revealed significant ongoing effects despite good clinical outcomes.

CONCLUSION

This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries.

HOW TO CITE THIS ARTICLE

Giannoudis VP, Ewins E, Taylor DM, et al. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strategies Trauma Limb Reconstr 2021;16(2):86-95.

Anterior placement of the talar component in total ankle arthroplasty: A risk factor for talar component subsidence

BACKGROUND

Component subsidence is considered as a cause of revision surgery. The talar component subsidence may be a risk factor for revision surgery; however, there are no reports regarding talar component placement and subsidence amount following total ankle arthroplasty (TAA). We therefore investigated the relationship between talar component placement and subsidence amount.

METHODS

Fifty-two ankles from 49 patients (age: 71 years [range 62-83], 13 male/ 36 female), who underwent TAA with mean follow-up of 36 months (range 12-83), were included. The subjects were divided into two groups based on talar component placement: anterior placement (n = 20, group A) and posterior placement (n = 32, group P) using weight-bearing lateral plain radiographs. The amount of the talar component subsidence and clinical outcomes, which included the Japanese Society for Surgery of the Foot (JSSF) scale, range of the motion (ROM) and the revision rate, were compared between the groups.

RESULTS

Talar component subsidence was significantly higher in group A (2.1 ± 2.0 mm) than in group P (0.6 ± 1.4 mm, P = .017). There was no significant difference in the JSSF scale and ROM between group A and group P. The revision rate was 10.0% in group A and 6.3% in group P, albeit not statistically significant.

CONCLUSION

Greater talar component subsidence was observed when the talar component was placed more anteriorly, suggesting that anterior placement of the talar component may need to be avoided during the surgery in order to minimize the postoperative talar component subsidence.

Hindfoot Alignment Change After Total Ankle Arthroplasty for Varus Osteoarthritis

BACKGROUND

In patients with end-stage varus ankle osteoarthritis (OA), hindfoot varus malalignment resulting from the varus deformity of the ankle joint is common. Although total ankle arthroplasty (TAA) performed to correct varus deformity of the ankle joint has the effect of correcting hindfoot alignment, no reports to date have described how much hindfoot alignment correction can be achieved. The purpose of this study was to identify correlation between ankle deformity correction and hindfoot alignment change after performing TAA in patients with end-stage varus ankle OA.

METHODS

A total of 61 cases that underwent TAA for end-stage varus ankle OA and followed up for at least 1 year were enrolled for this study. Correlation between changes of tibial-ankle surface angle (TAS), talar tilt (TT), and tibiotalar surface angle (TTS) and changes of hindfoot alignment angle (HA), hindfoot alignment ratio (HR), and hindfoot alignment distance (HD) measured preoperatively and at postoperative year 1 was analyzed.

RESULTS

TAS, TT, and TTS changed from 83.9 ± 4.1 degrees, 5.8 ± 5.0 degrees, and 78.1 ± 5.9 degrees, respectively, before operation to 89.2 ± 2.1 degrees, 0.4 ± 0.5 degrees, and 88.7 ± 2.3 degrees, respectively, after operation. HA, HR, and HD also changed from -9.2 ± 4.6 degrees, 0.66 ± 0.18, and -11.2 ± 6.9 mm to -3.7 ± 4.1 degrees, 0.48 ± 0.14, and -5.0 ± 5.3 mm. All the changes were statistically significant (P < .001, respectively). The regression slope of correlation was 0.390 (R² = 0.654) between TTS and HA; 0.017 (R² = 0.617) between TTS and HR; and 0.560 (R² = 0.703) between TTS and HD.

CONCLUSION

In patients with end-stage varus ankle OA, changes of hindfoot alignment could be predicted based on degree of ankle deformity corrected with TAA.

LEVEL OF EVIDENCE

Level IV, case series.

Bone Marrow Stimulation for Osteochondral Lesions of the Talus: Are Clinical Outcomes Maintained 10 Years Later?

BACKGROUND

Arthroscopic bone marrow stimulation (BMS) is considered the first-line treatment for osteochondral lesions of the talus (OLTs). However, the long-term stability of the clinical success of BMS remains unclear.

PURPOSE

To investigate the long-term clinical outcomes among patients who underwent BMS for OLT and to identify prognostic factors for the need for revision surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was performed on 202 ankles (189 patients) that were treated with BMS for OLT and had a minimum follow-up of 10 years. The visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Outcome Score (FAOS) were assessed by repeated measures analysis of variance. Prognostic factors associated with revision surgery were evaluated with Cox proportional hazard regression models and log-rank tests.

RESULTS

The mean lesion size was 105.32 mm² (range, 19.75-322.79); 42 ankles (20.8%) had large lesions (≥150 mm²). The mean visual analog scale for pain improved from 7.11 ± 1.73 (mean ± SD) preoperatively to 1.44 ± 1.52, 1.46 ± 1.57, and 1.99 ± 1.67 at 1, 3 to 6, and ≥10 years, respectively, after BMS (P < .001). The mean ankle-hindfoot score also improved, from 58.22 ± 13.57 preoperatively to 86.88 ± 10.61, 86.17 ± 10.23, and 82.76 ± 11.65 at 1, 3 to 6, and ≥10 years after BMS (P < .001). The FAOS at the final follow-up was 82.97 ± 13.95 for pain, 81.81 ± 14.64 for symptoms, 83.49 ± 11.04 for activities of daily living, 79.34 ± 11.61 for sports, and 78.71 ± 12.42 for quality of life. Twelve ankles underwent revision surgery after a mean 53.5 months. Significant prognostic factors associated with revision surgery were the size of the lesion (preoperative magnetic resonance imaging measurement ≥150 mm²; P = .014) and obesity (body mass index ≥25; P = .009).

CONCLUSION

BMS for OLT yields satisfactory clinical outcomes at a mean follow-up of 13.9 years. The success of the surgery may depend on the lesion size and body mass index of the patient.

Osteotomy combined with lateral ligament reconstruction in treating osteochondral lesion in patients with talar injury and varus ankle

This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results.

Endoprothetik am oberen Sprunggelenk

Arthrosis of the upper ankle is usually the long-term consequence of an ankle fracture. In the case of advanced osteoarthritis - after all conservative therapy options have been exhausted - the therapeutical options are reduced to the choice between arthrodesis and prosthesis, the technique and follow-up treatment of which this article presents. The mobility achieved after endoprosthetic treatment is usually less than the normal physiological level, but still functionally sufficient.

Anterior distal tibial plafond-plasty for the treatment of posttraumatic ankle osteoarthritis with anterior translation of the talus

Posttraumatic ankle osteoarthritis (OA) represents a significant challenge to orthopedic surgeons, especially in cases of anterior talar translation and concomitant impaction of the anterior distal tibial plafond. The aim of this study was to evaluate the clinical outcomes of an intra-articular osteotomy for the management of these patients. A total of 21 patients meeting our criteria were retrospectively reviewed. Sixteen patients sustained initial pilon fractures, while five patients had Weber type C ankle fractures. Anterior distal tibial plafond-plasty was performed to address the impaction and anterior translation of the talus. The American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) score were utilized as clinical outcomes. The lateral talar station (LTS), tibial lateral surface (TLS) angle, tibial anterior surface angle and talocrural angle were evaluated pre- and postoperatively. The modified Kellgren-Lawrence score was used for the evaluation of sagittal ankle OA. The average age at surgery was 35 years, and the average follow-up duration was 34 months. The AOFAS hindfoot score increased from 26 to 71 (p < 0.01), and the VAS score improved from 7 to 2 (p < 0.01). The LTS improved from 9.0 to 2.3 mm (p < 0.01), and the TLS angle improved from 72° to 81° (p < 0.01). Of the 21 patients, 18 showed improvement in or no worsening of ankle OA on the sagittal plane, while 3 developed advanced ankle OA. A congruent ankle joint on the sagittal plane could be achieved by anterior distal tibial plafond-plasty. This is a valuable treatment option for the salvage of posttraumatic ankle OA with anterior translation of the talus.