Ankle arthritis

Supramalleolar Distal Tibiofibular Osteotomy for Medial Ankle Osteoarthritis: Current Concepts

The supramalleolar osteotomy is a joint-preserving surgical procedure. It is a very good treatment option for the asymmetric varus ankle and medial compartment osteoarthritis. The primary objective of the procedure is to shift medial concentration of stress toward the lateral intact articular cartilage to redistribute the joint loads during ambulation. Several studies have shown that deformities of the ankle result in uneven load distribution in the ankle joint, which eventually leads to articular cartilage degeneration. Since the lateral articular cartilage is intact, joint-sacrificing procedures such as total ankle replacement or ankle arthrodesis are not the most appropriate treatment choices for medial compartment arthritis. Results of supramalleolar osteotomies are very promising in terms of functional outcome and pain relief. In younger patients with medial compartment varus ankle osteoarthritis or even with a normal tibial anterior surface angle, supramalleolar osteotomies can be performed to realign the ankle to promote regeneration of the asymmetrically damaged cartilage. In this review article, we will discuss the indications, complications, surgical techniques, and outcomes of the supramalleolar osteotomy reported in the current literature.

The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in Korea between 2007 and 2017

BACKGROUND

The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in Korea from 2007 to 2017 using national population-based data.

METHODS

We reviewed the National Health Insurance data of Korea from 2007 to 2017. The data included diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients' age, hospital grades, and insurance systems were also evaluated.

RESULTS

Primary diagnosis for primary TAA was mostly degenerative arthritis (6,501 cases; 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7,183 and 585, respectively. The number of cases in 2007 of primary TAA was 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person-years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was USD 813 (19%) and by the National Health Insurance Service was USD 3,480 (81%).

CONCLUSION

The incidence of primary TAA and revision procedures steadily increases in Korea during the 11-year study period.

The preliminary report about the modified supramalleolar tibial osteotomy for asymmetric ankle osteoarthritis

OBJECTIVE

Supramalleolar tibial osteotomy (SMO) for asymmetric ankle osteoarthritis (OA) is known to lead to satisfactory. Here, authors present a preliminary report on SMO surgical treatment in patients with asymmetric ankle arthritis.

MATERIALS AND METHODS

We reviewed cases of asymmetric ankle OA treated by modified SMO between January 2011 and October 2015. Clinical assessment was performed with the use of the ankle and hindfoot score of the American Orthopedic Foot and Ankle Society (AOFAS), foot function index, and visual analogue scale (VAS). Patient satisfaction with surgery and postoperative subjective symptoms were examined. Radiographic evaluation included preoperative and postoperative tibial anterior surface angle (TAS angle), talar tilt angle (TT angle), and tibial lateral surface angle (TLS angle). Takakura stage was measured.

RESULTS

The average follow-up period was 46.3 months. The AOFAS score was 55.7 ± 6.03 preoperatively and 76.0 ± 4.73 postoperatively. Foot function index was 60.7 ± 8.78 preoperatively and 30.8 ± 7.59 postoperatively. VAS was 7.2 ± 0.53 before surgery and 1.9 ± 0.85 after surgery. Clinical evaluations showed statistically significant improvement. The majority of patients reported satisfactory results in the subjective satisfaction evaluation. TAS angle was 84.6 ± 1.82 preoperatively and 94.0 ± 2.79 postoperatively. TLS angle was 78.8 ± 2.11 preoperatively and 81.8 ± 1.80 postoperatively. TT angle was 3.6 ± 1.26 before surgery and 2.1 ± 0.79 after surgery. Thirteen cases showed radiographic improvement of Takakura stage. Complications were not observed.

CONCLUSION

Modified SMO is a useful procedure that provides for the union and stability of osteotomy with the advantages of the existing SMO and can be performed without bone graft.

Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs

BACKGROUND

A proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification.

METHODS

A retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely "postero-lateral," "postero-medial," or "postero-central," according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system.

RESULTS

The mean trajectory angle was 21° lateral for "postero-lateral" fragments, 7° lateral for "postero-central" fragments, and 28° medial for "postero-medial" fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20° within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons).

CONCLUSIONS

There are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.

Radiographic Sagittal Tibio-Talar Offset in Ankle Arthrodesis-Accuracy and Reliability of Measurements

Radiographic outcome assessment of ankle arthrodesis (AA) requires accurate measurement techniques. This study aimed to identify the most reliable methods for sagittal tibio-talar alignment measurements with regard to the tibio-talar offset after AA. Lateral weight-bearing radiographs of 38 fused ankles were selected for retrospective review. The sagittal tibio-talar angle (STTA), the modified tibio-talar ratio (mT-T ratio) and the sagittal tibio-talar offset (tibCOR, procLAT) were measured by three independent observers. Intra- and interobserver correlation coefficients (ICC) and mean measurement differences were calculated to assess measurement reliability and accuracy. By defining the talar longitudinal axis as a line from the inferior aspect of the posterior tubercle of the talus to the most inferior aspect of the talar neck, STTA showed excellent (ICC 0.924; CI 95% 0.862–0.959) and mTT-ratio provided high (ICC 0.836; CI 95% 0.721–0.909) interobserver reliability, respectively. For tibio-talar offset measurement the tibCOR method showed superior reliability and better interobserver agreement compared to the procLAT technique. The STTA and a modified T-T ratio are recommended for future scientific radiographic measurements in AA.

Relationship of Preoperative Patient-Reported Outcome Measures (PROMs) to Postoperative Success in End-Stage Ankle Arthritis

BACKGROUND

Ankle osteoarthritis is a significant cause of pain and disability. Despite the effectiveness of treatments, a subset of patients remains with persistent pain and functional limitations. The purpose of this study was to use preoperative patient-reported outcome measures to predict which ankle osteoarthritis patients would be most likely to experience postoperative improvements in functional outcomes.

METHODS

A retrospective analysis of prospectively collected data was used to evaluate 427 patients with end-stage ankle arthritis with 5-year follow-up. Demographics, comorbidities, Ankle Osteoarthritis Scale (AOS), Ankle Arthritis Score (AAS), and the physical and mental component scores of the Short Form-36 (SF-36 Physical Components Score [PCS] and Mental Components Score [MCS]) were collected. The minimal clinically important difference (MCID) was then calculated. Receiver operating characteristic (ROC) analysis was used to choose the optimal threshold values of preoperative patient-reported outcome measure and assess the prediction performance.

RESULTS

Patients who scored worst at preoperative baseline made the greatest gains in function and pain relief, and they had a high chance of achieving MCID following surgical treatment. ROC curves demonstrated that preoperative AOS, AAS, and SF-36 PCS and MCS scores were predictive of postoperative improvements in physical and mental function. Patients with preoperative AOS score above 45.7 had an 83% probability of achieving an MCID (AUC = 0.67). Similarly, patients with a preoperative AAS score above 25.7 had a 78% probability of achieving an MCID (AUC = 0.63). Patients with a preoperative SF-36 PCS score below 31 had a 62% probability of achieving an MCID (AUC = 0.64). Patients with a preoperative SF-36 MCS below 52.7 had a 47% probability of achieving an MCID (AUC = 0.89). MCIDs for AOS, AAS, SF3-36 PCS, and SF-36 MCS score changes were 12.4, 10.0, 6.43, and 8.1, respectively.

CONCLUSION

Preoperative patient-reported outcomes measures could predict postoperative improvement in ankle arthritis patients. The results of this study may be used to facilitate discussion between physicians and patients regarding the expected benefit of surgery.

LEVEL OF EVIDENCE

Level III, prognostic comparative study.

Change in gait biomechanics after total ankle replacement and ankle arthrodesis: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review with meta-analysis was to determine the change in gait biomechanics after total ankle replacement and ankle arthrodesis for end-stage osteoarthritis.

METHODS

Electronic databases were searched up until May 2019. Peer-reviewed journal studies including adult participants suffering from end-stage ankle osteoarthritis and reporting pre- and post-operative kinematics, kinetics and spatio-temporal effects of total ankle replacement and ankle arthrodesis during walking were included with a minimum of 12 months follow-up. Seventeen suitable studies were identified and assessed according to methodological and biomechanical qualities. Meta-analysis was performed by calculating the effect size using standard mean differences between pre- and post-operative gait status.

FINDINGS

Seventeen studies with a total of 883 patients were included. Meta-analysis revealed moderate evidence of an improvement in lower limb kinematics, kinetics and spatio-temporal parameters after total ankle replacement. Moderate evidence indicated an increase in ankle moment, hip range of motion and walking speed after ankle arthrodesis.

INTERPRETATION

The currently available evidence base of research papers evaluating changes in gait biomechanics after total ankle replacement and ankle arthrodesis is limited by a lack of prospective research, low sample sizes and heterogeneity in the patho-etiology of ankle osteoarthritis. Following total ankle replacement, improvements were demonstrated for spatio-temporal, kinematic and kinetic gait patterns compared to the pre-operative measures. Improvements in gait mechanics after ankle arthrodesis were limited to walking speed and ankle moment. Increased hip range of motion after ankle arthrodesis could represent a sign of compensation for the lack of ankle motion.

A Comparison of Talar Surface Area Occupied by 2- Versus 3-Screw Fixation for Ankle Arthrodesis

Background. Ankle arthrodesis is a procedure utilized in the treatment of end-stage ankle arthritis. Internal fixation with screws is traditionally relied on to achieve union. Although the use of screw fixation alone has produced satisfactory outcomes, nonunion rates can range from 9% to as high as 35%. Adding an additional screw to the traditional 2-screw fixation construct may improve the likelihood of union by adding strength and stiffness; however, this addition may counteract the theoretical fusion enhancement benefit by reducing the joint surface area (SA) available for fusion. Methods. A cadaver study was performed to compare the amount of SA lost from a standard 2-screw (group 1) versus the 3-screw ankle fusion construct (group 2). A total of 10 fresh cadaveric below-knee specimens were used. Cannulated 7.0-mm partially threaded screws were placed across the ankle joint. Each talus was examined to precisely determine joint SA loss following each procedure. Results. The mean total talus SA in group 1 was 1833.71 mm² compared with 2125.76 mm² in group 2. The mean SA lost by the 2-screw construct was 5.91%, versus 9.51% in the 3-screw construct group. The talus SA loss percentage difference between groups reached statistical significance (P = .0220). Conclusion. The addition of a third 7.0-mm screw to a 2-screw ankle fusion construct raised the percentage of joint surface lost from 5.91% to 9.5%. Clinical Relevance. Surgeons may consider using extra-articular plates with 1 or 2 intra-articular screws instead of the traditional 3-screw construct if there is an elevated concern for nonunion. Levels of Evidence: Level IV: Cadaveric case series.

Current concepts in the management of ankle arthritis

Ankle arthritis is a common condition. It causes a significant socioeconomic burden, and is associated with significant morbidity. Patients with ankle arthritis are either elderly with significant co-morbidities, or young adults who have previously suffered with ankle injuries, resulting in post-traumatic arthritis. There is a wide variation in the management of these patients with ankle arthritis. We therefore present an overview of the current evidence based management of patients with symptomatic ankle arthritis.

Incidence and predictors of early complications following primary and revision total ankle arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.

METHODS

A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.

RESULTS

The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis.

CONCLUSIONS

Older age, higher BMI, and revision cases are associated with a higher risk of AEs.

Visualization and quantification of the degenerative pattern of the talus in unilateral varus ankle osteoarthritis

The aim of this study was to quantify and visualize the degenerative patterns of the talus in ankle osteoarthritis (OA). The differences in talar morphology between sides of patients with unilateral varus ankle OA (medial talar tilt > 4°) were compared. Computed tomography images of both feet of 35 patients (OA: 22 patients, control: 13 patients) were analyzed. Each surface model of the right and left tali was registered to the opposite talus via a mirror-image technique and an iterative closest point algorithm. The surface deviation between the two models was quantified and visualized by deviation color maps. The results quantitatively demonstrated that osteophytes are generated in the area under the antero-medial margin of the trochlea in OA tali. In severe OA tali, bone resorption of more than 2 mm in the medial portion of the trochlea, as well as a similar degree of osteophyte formation on the lateral surface, was also seen. Stereotypical patterns of degeneration occurring in OA tali were successfully visualized and quantified by left-right comparison of patients with unilateral ankle OA. Such information would contribute to better understanding of the development of ankle OA and preoperative planning of total ankle arthroplasty and arthrodesis.

The Salto total ankle arthroplasty - Clinical and radiological outcomes at five years

BACKGROUND

Modern designs of total ankle arthroplasty (TAA) have the potential to treat symptomatic ankle OA without adversely affecting ankle biomechanics. We present the mid-term results of a modern, mobile-bearing TAA design.

METHODS

TAA was performed in 50 consecutive patients (55 ankles) in an independent, prospective, single-centre series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of five years (range 2-10.5years).

RESULTS

A total of three patients (four ankles) died and two (two ankles) were lost to follow-up. Three TAAs were revised for aseptic loosening (in two cases) or infection. Two further patients underwent reoperations, one for arthroscopic debridement of anterolateral synovitis and one for grafting of an asymptomatic tibial cyst. With all-cause revision as an endpoint, implant survival was 93.3% at five to ten years (95% CI 80.5%-97.8%). If reoperations are included this falls to 90.2% (95% CI 75.6%-96.3%) at five years. No other patient demonstrated radiographic evidence of loosening or subsidence. PROMs and satisfaction were excellent at latest follow-up.

CONCLUSION

At five years, the outcomes for this design of TAA in this series were excellent, and were similar to those of previously published series from the designer centre.

Ankle Arthritis

Ankle arthritis is a major source of morbidity impacting a younger working age population than hip and knee arthritis. Unlike the hip and knee, more than 70% of ankle arthritis cases are post-traumatic, with the remainder being inflammatory or primary arthritis. Nonoperative treatment begins with lifestyle and shoe-wear modifications and progresses to bracing, physical therapy, anti-inflammatory medications, and intra-articular injections. Ankle arthrodesis and total ankle arthroplasty are the 2 main surgical options for end-stage ankle arthritis, with debridement, realignment osteotomy, and distraction arthroplasty being appropriate for limited indications.

Arthrodesis of a Varus Ankle

Patients with varus ankle deformity and concomitant osteoarthritis experience severe disabling pain that affects their daily activity of living. Most cases rarely respond to nonoperative treatment. One surgical option is corrective ankle arthrodesis. Unfortunately, this corrective surgery is challenging and might not be possible as a purely isolated procedure. Corrective ankle arthrodesis for varus ankle is performed with different surgical approaches and techniques, using different methods of fixations. The goal of surgery is to create a pain-free, stable, and plantigrade ankle, hindfoot, and foot. Both the foot and ankle must be correctly aligned in the optimal position for proper locomotion.

Attenuated levels of ghrelin in synovial fluid is related to the disease severity of ankle post-traumatic osteoarthritis

Post-traumatic osteoarthritis (PTOA) of ankle joints results in pain and reduced joint function. Ghrelin, a 28-amino-acid polypeptide, has been previously identified as the first cognate natural ligand that binds to the growth hormone secretagogue receptor. In the present study, ghrelin has been validated to exert cartilage-protective and anti-inflammatory effects. The current study was aimed at investigating the potential role of the levels of serum and synovial fluid (SF) ghrelin on the severity of disease in patients suffering from ankle PTOA. Ninety-seven patients with ankle osteoarthritis who received an arthroscopical examination and debridement or replacement of the ankle joint were included in the study cohort. Meanwhile, 95 healthy individuals (whose age and sex were matched) who received periodic body checkups were enrolled as healthy controls. Enzyme-linked immunosorbent assay (ELISA) was used to analyze the ghrelin levels in serum and SF. SF was also probed for cartilage degradation enzyme matrix metalloproteinases-3 (MMP-3) and tumor necrosis factor alpha (TNF-α), which is a known pro-inflammatory cytokine. The clinical evaluation was carried out using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating scale and visual analogue scale (VAS). The radiographic severity was evaluated using the modified Kellgren-Lawrence (K-L) grading system. We scored for the modified Mankin's score to depict histopathological changes due to cartilage lesions. The diagnostic relevance of the ghrelin concentrations in the prediction of the radiographic grading (in comparison with MMP-3 and TNF-α) was evaluated by calculating the area under the curve of the receiver operating characteristic (ROC) curve. The serum abundance of ghrelin was not significantly altered between ankle PTOA patients and healthy controls. SF ghrelin was negatively correlated with radiographic progression determined by modified ankle K-L grades. In addition SF ghrelin concentrations were negatively related to VAS scores, and positively associated with AOFAS ankle-hindfoot rating. Moreover, SF ghrelin was inversely proportional to the expressions of MMP-3 and TNF-α. ROC analysis curve demonstrated that ghrelin serves as a favorable marker for the diagnosis of radiographic severity by modified ankle K-L grade. The ghrelin concentration in SF is negatively proportional to disease progression in patients suffering from ankle PTOA. Local administration of ghrelin may function as a decent adjuvant therapy to delay the progress of ankle PTOA. © 2019 BioFactors, 45(3):463-470, 2019.

Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis

BACKGROUND

The primary aim of this study was to present the incidence of clinically significant end stage osteoarthritis (cOA) after syndesmotic fixation of ankle fractures. The secondary aim was to and identify independent predictors of cOA.

METHODS

A retrospective review of consecutive patients presenting to a single University affiliated institution between March 2008 and May 2010 was undertaken. Inclusion criteria were ankle fractures with syndesmotic stabilisation. Patients were excluded if pre or postoperative radiographs were missing or were lost to follow up. Data were gathered regarding demographics, fracture pattern, fixation methods, reduction parameters, screw removal, revision surgery, complications and cOA up to seven years post injury.

RESULTS

Data were available for 120 patients (86%). In total, 13 patients (11%) developed cOA. Univariate analysis showed that increasing age, open fracture, malreduction of the syndesmosis, removal of symptomatic screws, revision surgery and complications were predictors of developing cOA. Cox regression analysis revealed increasing age (hazard ratio (HR) 1.09, p=0.006), and malreduction (HR 45.5, p=0.001) were independent predictors of developing cOA.

CONCLUSIONS

Ankle fractures with syndesmotic stabilisation represent a severe injury with a high rate of cOA. The only modifiable risk factor for developing cOA in this large series of patients was radiological malalignment. When syndesmotic stabilisation is required, careful intraoperative assessment should be undertaken to ensure the syndesmosis is reduced.

Ultrasound Intervention of the Lower Extremity/Pelvis

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.

Initial stability and stress distribution of ankle arthroscopic arthrodesis with three kinds of 2-screw configuration fixation: a finite element analysis

Background

Arthroscopic ankle arthrodesis (AAA) is recognized as the standard treatment for the end-stage ankle arthritis. Two-screw configuration fixation is a typical technique for AAA; however, no consensus has been reached on how to select most suitable inserted position and direction. For better joint reduction, we developed a new configuration (2 home run-screw configuration: 2 screws are inserted from the lateral-posterior and medial-posterior malleolus into the talar neck) and investigated whether it turned out to be better than the other commonly used 2-screw configurations.

Methods

In this study, we investigated three kinds of 2-screw configurations: 2 “home run”-screw configuration (group A), crossed transverse configuration (the screw is inserted from the medial malleolus into the anterior talus and the other from the lateral tibia maintains posterior talus, group B), and 2 parallel screw configuration (2 parallel screws are inserted from the posteromedial side of the tibia into talus, group C). The effects of the above three insertions on the loading stress of the tibio-talar joint were comparatively analyzed with a three-dimensional finite element model.

Results

Group A was better than groups B and C in respect of stress distribution uniformity and superior to both groups B and C in anti-flexion strength and anti-internal rotation strength. Group A was slightly worse than group C but better than group B in anti-dorsiflexion and anti-valgus and varus strength.

Conclusions

Two “home run”-screw configuration facilitates the reduction of anterior talus dislocation of end-stage ankle arthritis. Our finite element analysis demonstrates the configuration is superior to crossed transverse and parallel configuration for arthroscopic ankle arthrodesis in terms of stress distribution and initial stability.

3D Printed Total Talar Replacement: A Promising Treatment Option for Advanced Arthritis, Avascular Osteonecrosis, and Osteomyelitis of the Ankle

Advanced ankle arthritis, avascular osteonecrosis, and osteomyelitis of the ankle remain a surgical challenge in the foot and ankle arena with limited treatment options. Multiple medical comorbidities contribute to total loss of the talus. Collapse of the talar body as a complication of total ankle arthroplasty, talectomy in infection, and septic talus necrosis or severe bone defects caused by tumor resection may result in need for total talar replacement. Ankle arthrodesis and tibiocalcaneal fusion after talectomy can produce severe disability of the ankle and foot. Total ankle replacement is a viable option for treatment of end-stage ankle arthritis in appropriate patient populations.

Ankle arthroplasty: A review and summary of results from joint registries and recent studies

Total ankle arthroplasty offers a reasonable alternative to ankle arthrodesis in carefully selected patients.

It is debatable whether rheumatoid arthritis patients have better outcomes compared with those who have ankle arthroplasty for either primary osteoarthritis or post-traumatic arthritis.

Aseptic loosening and infection are the most common complications requiring revision.

It is worth noting that some of the best survival rates are seen in the surgeon-designer case series.

The uncemented mobile or fixed bearing prostheses have better outcomes compared with their older counterparts.

There is no convincing evidence to suggest superiority of one design over another among the currently available prostheses.

Ankle arthroplasty surgery has a steep learning curve; the prosthesis choice should be driven by the surgeon’s training and experience.

Cite this article: EFORT Open Rev 2018;3:391-397. DOI: 10.1302/2058-5241.3.170029

Physical Impairments in Adults With Ankle Osteoarthritis: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Background Lower-limb osteoarthritis (OA) is associated with pain and reduced function. Most research focuses on hip and knee OA- related impairments; consequently, impairments that characterize ankle OA are not well understood. Objective To systematically review available evidence of physical impairments in individuals with ankle OA. Methods A comprehensive search of electronic databases was conducted from their inception to July 2017. Studies were screened using predefined inclusion/exclusion criteria. Studies that compared physical measures (excluding gait) between individuals with ankle OA and healthy controls or the unaffected ankle were included. Two reviewers rated studies for quality. Meta-analyses with random effects were conducted when appropriate. Results Of 4565 identified studies (563 participants), 8 satisfied the inclusion criteria and 3 studies were included in meta-analyses. All studies evaluated a range of impairments at end-stage OA, and exhibited poor reporting of missing data, assessor blinding, and measurement validity. Meta-analyses revealed large impairments of ankle sagittal plane motion and strength. Evidence from single studies indicated large deficits of ankle frontal plane motion and strength, talar translation and rotation on arthrometry, balance, and electromyography of ankle joint muscles. There were also abnormal bony alignments and greater fatty infiltrate in all calf muscle compartments. Conclusion The results of this literature review suggest significant ankle motion, strength, and functional impairments in individuals with ankle OA. The strength of the conclusions is limited, due to the small number and methodological limitations of published studies. Level of Evidence Symptom prevalence, level 1a. J Orthop Sports Phys Ther 2018;48(6):449-459. Epub 7 Apr 2018. doi:10.2519/jospt.2018.7569.

Factors Contributing to Hospital Stay and Total Inpatient Charges in Total Ankle Arthroplasty: Review of the National Inpatient Sample

Total ankle arthroplasty (TAA) is commonly performed for end-stage ankle osteoarthritis. Given rising costs and declining reimbursements, identifying variables increasing length of stay (LOS) and total inpatient charges (TICs) of TAA is necessary for providing cost-effective care. The National Inpatient Sample (NIS) database was reviewed between 1993 and 2010, identifying LOS and TIC for TAA. Using a multivariate analysis, patient comorbidities, demographics, payment, and hospital details were evaluated. Median LOS decreased from 5 to 2 days, whereas median TICs increased from $21 382.53 to $62 028.00. Regionally, the South and Midwest had decreased TICs, whereas the West had an increased TIC. There was no significant difference in LOS geographically. Rural hospitals demonstrated decreased TICs, whereas urban private hospitals showed decreased LOS and decreased TICs. Large hospitals were associated with increased LOS and TICs. Compared with Medicare, private insurers demonstrated decreased LOS with equivalent TICs. Diabetics significantly increased mean LOS by 1 day, without a significantly increased TIC. Despite a decreased LOS, hospital charges have increased between 1993 and 2010 in TAA. We found that regional differences and hospital characteristics were associated with differences in LOS and TICs. Identification of these factors provides important information to facilities and surgeons.

LEVELS OF EVIDENCE

Level IV: Economic/decision analysis.

Design Rationale for Total Ankle Arthroplasty Systems: An Update

The design of total ankle arthroplasty systems is evolving as a result of findings from longer-term studies. Our understanding of modes of failure has increased, and surgical techniques have become more refined. Currently, five total ankle arthroplasty systems are used in the United States. The landscape has changed considerably in the decade since the latest article reviewing total ankle design was published. Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. As more research showing mid- to long-term outcomes is published, the design rationale and current outcomes data for each of these implants must be considered.

Concomitant Ankle Osteoarthritis Is Related to Increased Ankle Pain and a Worse Clinical Outcome Following Total Knee Arthroplasty

BACKGROUND

Occasionally, patients experience new or increased ankle pain following total knee arthroplasty (TKA). The aims of this study were to determine (1) how the correction of varus malalignment of the lower limb following TKA affected changes in alignment of the ankle and hindfoot, (2) the difference in changes in alignment of the ankle and hindfoot between patients with and without ankle osteoarthritis (OA), and (3) whether the rate of ankle pain and the clinical outcome following TKA differed between the 2 groups.

METHODS

We retrospectively reviewed prospectively collected data of 56 patients (99 knees) treated with TKA. Among these cases, concomitant ankle OA was found in 24 ankles. Radiographic parameters of lower-limb, ankle, and hindfoot alignment were measured preoperatively and 2 years postoperatively. In addition, ankle pain and clinical outcome 2 years after TKA were compared between patients with and without ankle OA.

RESULTS

The orientation of the ankle joint line relative to the ground improved from 9.4° of varus to 3.4° of varus, and the valgus compensation of the hindfoot for the varus tilt of the ankle joint showed a 2.2° decrease following TKA. Patients in the group with ankle OA showed decreased flexibility of the hindfoot resulting in less preoperative valgus compensation (p = 0.022) compared with the group without ankle OA. The postoperative hindfoot alignment was similar between the 2 groups because of the smaller amount of change in patients with ankle OA. The group with ankle OA had a higher rate of increased ankle pain (38% compared with 16%) as well as a worse Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (mean of 22.2 compared with 14.2) following TKA.

CONCLUSIONS

A considerable proportion of patients who underwent TKA had concomitant ankle OA with reduced flexibility of the hindfoot. These patients experienced increased ankle pain following TKA and a worse clinical outcome.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study

OBJECTIVES

To identify by systematic review published prevalence estimates of radiographic ankle osteoarthritis (OA) and to subsequently estimate the prevalence of ankle pain and symptomatic, radiographic ankle OA within community-dwelling older adults from North Staffordshire, UK.

METHODS

Electronic databases were searched using terms for ankle, osteoarthritis and radiography. Data regarding population, radiographic methods, definitions and prevalence estimates of ankle OA were extracted from papers meeting predetermined selection criteria. Adults aged ≥50 years and registered with four general practices in North Staffordshire were mailed a health questionnaire. Ankle pain in the previous month was determined using a foot and ankle pain manikin. Respondents reporting pain in or around the foot in the last 12 months were invited to attend a research clinic where weight-bearing, antero-posterior and lateral ankle radiographs were obtained and scored for OA using a standardised atlas. Prevalence estimates for ankle pain and symptomatic, radiographic ankle OA were calculated using multiple imputation and weighted logistic regression, and stratified by age, gender and socioeconomic status.

RESULTS

Eighteen studies were included in the systematic review. The methods of radiographic classification of ankle OA were poorly reported and showed heterogeneity. No true general population prevalence estimates of radiographic ankle OA were found, estimates in select sporting and medical community-dwelling populations ranged from 0.0-97.1%. 5109 participants responded to the health survey questionnaire (adjusted response 56%). Radiographs were obtained in 557 participants. The prevalence of ankle pain was 11.7% (10.8,12.6) and symptomatic, radiographic ankle OA grade≥2 was 3.4% (2.3, 4.5) (grade≥1: 8.8% (7.9,9.8); grade = 3: 1.9% (1.0,2.7). Prevalence was higher in females, younger adults (50-64 years) and those with routine/manual occupations.

CONCLUSION

No general population prevalence estimates of radiographic ankle OA were identified in the published literature. Our prevalence study found that ankle pain was common in community-dwelling older adults, whereas moderate to severe symptomatic, radiographic ankle OA occurred less frequently. Further investigations of the prevalence of ankle OA using more sensitive imaging modalities are warranted.

Second-Look Arthroscopic Evaluation and Clinical Outcome After Supramalleolar Osteotomy for Medial Compartment Ankle Osteoarthritis

BACKGROUND

The aim of this study was to evaluate the clinical and radiologic outcomes of medial compartment ankle osteoarthritis after supramalleolar osteotomy (SMO) without the bone marrow stimulation procedure and confirm cartilage recovery by second-look arthroscopy.

METHODS

Twenty-two ankles that were followed for more than 1 year after SMO were retrospectively reviewed. Visual analog scale pain scores and American Orthopaedic Foot & Ankle Society ankle-hindfoot scores were used for functional evaluations. The tibial anterior surface angle and tibial lateral surface angle were measured on radiographs, and ankle osteoarthritis was classified by Takakura stage. Among the 22 patients, 21 underwent ankle arthroscopy prior to SMO, and second-look arthroscopy was performed in 16 patients 1 year postoperatively. Tibiotalar cartilage regeneration was evaluated according to the modified Outerbridge classification for the 14 patients who had undergone SMO without the bone marrow stimulation procedure.

RESULTS

The mean visual analog scale and American Orthopaedic Foot & Ankle Society scores significantly improved from 6.5 preoperatively to 1.1 postoperatively and from 60.7 preoperatively to 87.1 postoperatively, respectively ( P < .05). The mean tibial anterior surface and tibial lateral surface angles significantly improved from 83.5° and 76.9° preoperatively to 93.8° and 80.2° postoperatively, respectively ( P < .05). All preoperative Takakura stage IIIa cases and IIIb case improved to postoperative stage II. On second-look arthroscopy, cartilage regeneration of the medial compartment of the tibiotalar joint was observed in 12 of 14 patients (85%), whereas cartilage deterioration was not observed in any patient.

CONCLUSIONS

SMO without the bone marrow stimulation procedure for medial ankle osteoarthritis demonstrated cartilage regeneration in the medial tibiotalar joint in most patients by second-look arthroscopy, as well as satisfactory clinical and radiologic outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Total Ankle Arthroplasty for Rheumatoid Arthritis in Japanese Patients: A Retrospective Study of Intermediate to Long-Term Follow-up

Background:

Outcomes after total ankle arthroplasty (TAA) combined with additive techniques (augmentation of bone strength, control of soft-tissue balance, adjustment of the loading axis) for the treatment of rheumatoid arthritis were evaluated after intermediate to long-term follow-up. The influences of biologic treatment on the outcomes after TAA were also evaluated.

Methods:

We performed a retrospective observational study involving 50 ankles (44 patients) that underwent TAA for the treatment of rheumatoid arthritis. The mean duration of follow-up was 7.1 years. Clinical outcomes were evaluated with use of the Japanese Society for Surgery of the Foot (JSSF) scale score and a postoperative self-administered foot-evaluation questionnaire (SAFE-Q). Radiographic findings were evaluated as well. These parameters also were compared between patients managed with and without biologic treatment.

Results:

This procedure significantly improved the clinical scores of the JSSF rheumatoid arthritis foot and ankle scale (p < 0.0001). Forty-eight of the 50 ankles had no revision TAA surgery. Subsidence of the talar component was seen in 8 ankles (6 in the biologic treatment group and 2 in the non-biologic treatment group); 2 of these ankles (both in the biologic treatment group) underwent revision TAA. The social functioning score of the SAFE-Q scale at the time of the latest follow-up was significantly higher in the biologic treatment group (p = 0.0079). The dosage of prednisolone (p = 0.0003), rate of usage of prednisolone (p = 0.0001), and disease-activity score (p < 0.01) at the time of the latest follow-up were all significantly lower in the biologic treatment group.

Conclusions:

TAA is recommended for the treatment of rheumatoid arthritis if disease control, augmentation of bone strength, control of soft-tissue balance, and adjustment of the loading axis are taken into account. The prevention of talar component subsidence remains a challenge in patients with the combination of subtalar fusion, rheumatoid arthritis, and higher social activity levels.

Level of Evidence:

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

An original fibular shortening osteotomy technique in tibiotalar arthrodesis

Tibiotalar arthrodesis (TTA) is the gold-standard treatment for advanced ankle osteoarthritis. We describe an original fibular shortening osteotomy (FSO) performed during TTA, to allow complete talar ascension and reduce the nonunion rate. Forty-two FSOs were associated to TTA (19 fixed by cross-screwing and 23 by anatomic plates) and assessed clinically and radiographically. At 24.7 months' follow-up, fusion rates were 97.6% for TTA and 100% for FSO, with mean fusion time of 5.2 months. One infection and 1 nonunion (4.7%) required further surgery, with complete resolution. Radiological and clinical outcome in TTA, lack of specific complications of FSO and ease of implementation encourage us to publish the technique.

Screening for Chikungunya virus infection in aged people: Development and internal validation of a new score

Background

This study aimed to derive and validate a score for Chikungunya virus (CHIKV) infection screening in old people admitted to acute care units.

Methods

This study was performed in the Martinique University Hospitals from retrospective cases. Patients were aged 65+, admitted to acute care units for suspected CHIKV infection in 2014, with biological testing using Reverse Transcription Polymerase Chain Reaction (RT-PCR). RT-PCR was used as the gold standard. A screening score was created using adjusted odds ratios of factors associated with positive RT-PCR derived from a multivariable logistic regression model. A ROC curve was used to determine the best cut-off of the score. Bootstrap analysis was used to evaluate its internal validity.

Results

In all, 687 patients were included, 68% with confirmed CHIKV infection, and 32% with laboratory-unconfirmed CHIKV infection. Mean age was 80±8 years, 51% were women. Four variables were found to be independently associated with positive RT-PCR (fever: 3 points; arthralgia of the ankle: 2 points; lymphopenia: 6 points; absence of neutrophil leucocytosis: 10 points). The best cut-off was score ≥12; sensitivity was 87% (83%-90%) and specificity was 70% (63%-76%).

Conclusion

This score shows good diagnostic performance and good internal validation and could be helpful to screen aged people for CHIKV infection.

Peri-talar re-alignment osteotomy for joint preservation in asymmetrical ankle osteoarthritis

Various types of re-alignment surgery are used to preserve the ankle joint in cases of intermediate ankle arthritis with partial joint space narrowing.The short-term and mid-term results after re-alignment surgery are promising, with substantial post-operative pain relief and functional improvement that is reflected by high rates of patient satisfaction.In this context, re-alignment surgery can preserve the joint and reduce the pathological load that acts on the affected area.Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. Cite this article: EFORT Open Rev 2017;2:324-331. DOI: 10.1302/2058-5241.2.160021.

Sports and Recreational Activities following Total Ankle Replacement

Purpose  In literature, there is a controversy regarding whether patients who have undergone total ankle replacement (TAR) can participate in sports and recreational activities. The purpose of this study was to report change in sports activity level after TAR.

Methods  A retrospective study was performed, enrolling 76 patients with symptomatic end-stage ankle arthritis who underwent TAR from May 2011 to October 2014. Patients were mainly males (44/76; 58%) and 56 years old on average (range: 22.3–79.6 years) at the time of surgery. They were treated with mobile-bearing prosthesis implanted with an anterior approach. Patients were evaluated preoperatively and 12 months postoperatively. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, the visual analog scale (VAS) pain score, and the 12-Item Short Form Health Survey (SF-12) – physical component summary (PCS) and mental component summary (MCS). Activity level was assessed with the University of California at Los Angeles (UCLA) activity scale.

Results  At 12 months postoperatively, statistically significant increase was reported for AOFAS scores (from 32.8 ± 12.7 preoperatively to 72.6 ± 13.3; p  < 0.001), SF-12 PCS (from 34.3 ± 5.1 preoperatively to 45.4 ± 6.4; p  < 0.001), and SF-12 MCS (from 39.8 ± 7.5 preoperatively to 51.4 ± 6.1; p  < 0.001). A statistically significant decrease was detected in VAS pain score (from 8.7 ± 1.6 preoperatively to 2.2 ± 1.6; p  < 0.001). The UCLA activity levels increased significantly from 2.4 ± 0.8 to 6.3 ± 2.3 ( p  < 0.001).

Conclusion  Pain and function significantly improved in patients affected by ankle osteoarthritis, who underwent TAR, at 1-year follow-up. In addition, activity level showed a significant increase respect to preoperative condition.

Level of Evidence  Level IV, retrospective case series.

Ankle Arthrodesis Versus Total Ankle Arthroplasty

Reoperation rates are higher in total ankle arthroplasties (TAAs) compared with ankle arthrodesis. Infection rates for primary TAAs are 1.4% to 2.4%. The survival rate of TAA is approximately 75% to 90% at 10 years. Arc of motion is maintained with TAAs compared with ankle arthrodesis. Ankle arthrodesis increases arc of motion through the talonavicular joint. Several factors are strong reasons to favor ankle fusion rather than TAA. TAA and ankle arthrodesis are effective treatments of end-stage ankle arthritis but the choice must be tailored to individual patients.

A Cross-sectional Analysis of Radiographic Ankle Osteoarthritis Frequency and Associated Factors: The Johnston County Osteoarthritis Project

OBJECTIVE

Because there are no epidemiologic data regarding the frequency of ankle osteoarthritis (OA) in a general population, we sought to analyze this disabling condition in a large, well-characterized, community-based cohort of older individuals.

METHODS

Cross-sectional data, including ankle radiographs, were from the most recent data collection (2013-2015) of the Johnston County OA Project. Radiographic ankle OA (rAOA) was defined as a Kellgren-Lawrence arthritis grading scale of ≥ 2 on weight-bearing lateral and mortise radiographs. The presence of pain, aching, or stiffness in the ankles as well as history of ankle injury (limiting ability to walk for at least 2 days) were assessed. Chi-square statistics (categorical variables) and Student t tests (continuous variables) were used to compare all participant characteristics by rAOA status. Joint-based logistic regression models with generalized estimating equations were used to examine associations of rAOA and covariates of interest [age, body mass index (BMI), sex, race, ankle symptoms, and injury history].

RESULTS

Of 864 participants with available data, 68% were women, 34% were African American, with a mean age of 72 years and BMI of 31 kg/m2. Nearly 7% of this sample had rAOA. Increasing age, high BMI, history of ankle injury, and presence of ankle symptoms were all independently associated with greater odds of having rAOA; no significant differences were seen by sex or race.

CONCLUSION

The frequency of rAOA was higher than estimates generally quoted in the literature. While injury was an important contributor, other factors such as age, BMI, and symptoms were also significantly associated with rAOA.

Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments

The pathogenesis of hallux valgus deformity is multifactorial. Conservative treatment can alleviate pain but is unable to correct the deformity. Surgical treatment must be adapted to the type and severity of the deformity. Success of surgical treatment ranges from 80% to 95%, and complication rates range from 10% to 30%.Ankle osteoarthrosis most commonly occurs as a consequence of trauma. Ankle arthrodesis and total ankle replacement are the most common surgical treatments of end stage ankle osteoarthrosis. Both types of surgery result in similar clinical improvement at midterm; however, gait analysis has demonstrated the superiority of total ankle replacement over arthrodesis. More recently, conservative surgery (extraarticular alignment osteotomies) around the ankle has gained popularity in treating early- to mid-stage ankle osteoarthrosis.Adult acquired flatfoot deformity is a consequence of posterior tibial tendon dysfunction in 80% of cases. Classification is based upon the function of the tibialis posterior tendon, the reducibility of the deformity, and the condition of the ankle joint. Conservative treatment includes orthotics and eccentric muscle training. Functional surgery is indicated for treatment in the early stages. In case of fixed deformity, corrective and stabilising surgery is performed. Cite this article: Crevoisier X, Assal M, Stanekova K. Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments. EFORT Open Rev 2016;1:58-64. DOI: 10.1302/2058-5241.1.000015.

Quality of Life in Bilateral Vs. Unilateral End-Stage Ankle Arthritis and Outcomes of Bilateral Vs. Unilateral Total Ankle Replacement

BACKGROUND

We performed a retrospective cohort study to compare preoperative health-related quality of life (HRQoL) between patients with bilateral and those with unilateral end-stage ankle arthritis. We also compared midterm outcomes in a subgroup of patients who had undergone staged bilateral total ankle replacement (TAR) with the outcomes in the group treated with unilateral TAR.

METHODS

The HRQoL before surgical treatment was compared between 53 patients with bilateral end-stage ankle arthritis identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database and 106 patients with unilateral arthritis selected from the same database. Short Form-36 (SF-36) and American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM) scores were used to assess preoperative HRQoL. Midterm outcomes (implant survival, HRQoL, and reoperation and revision rates) were compared between 37 patients who had undergone staged bilateral TAR and 106 patients treated with unilateral TAR; all patients were followed for at least 2 years.

RESULTS

Preoperatively, patients with unilateral disease had a higher prevalence of posttraumatic arthritis, whereas patients with bilateral disease had a higher prevalence of primary and secondary arthritis (p < 0.001). The mean preoperative SF-36 physical component summary (PCS) score in the unilateral group was higher than that in the bilateral group (p < 0.002). The mean postoperative follow-up (and standard deviation) was 5.0 ± 2.0 years in the bilateral TAR group and 4.0 ± 1.8 years in the unilateral TAR group. The patients who underwent either unilateral or staged bilateral TAR demonstrated improved SF-36 PCS scores between the preoperative and postoperative evaluations (p < 0.001). The postoperative SF-36 PCS scores were similar between the patients with unilateral TAR and those with bilateral TAR (p = 0.70). Six ankles (6%) in the unilateral cohort and 6 ankles (8%) in the bilateral cohort required revision of the metal component (p = 0.52). The mean implant survival time was 10.9 years (95% confidence interval [CI] = 10.1 to 11.7 years) in the bilateral cohort and 9.2 years (95% CI = 8.5 to 9.8 years) in the unilateral cohort (p = 0.60).

CONCLUSIONS

Preoperative SF-36 scores demonstrated that bilateral end-stage ankle arthritis is a more debilitating condition than unilateral arthritis. Patients who underwent staged bilateral TAR benefited as much as patients who underwent unilateral TAR, despite having a worse preoperative health status. Metal component revision rates and implant survival were similar between the 2 groups.

LEVEL OF EVIDENCE

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

Large BM Intra-Articular Allograft

Posttraumatic tibiotalar arthritis is a challenging problem in young, active patients. Many of these patients do not want to pursue ankle arthrodesis after they fail conservative treatment measures, as they wish to preserve joint motion. Osteochondral shell allograft arthroplasty has been described as a reasonable alternative for treating these patients. The procedure itself is technically demanding; however, with improvements in surgical technique and adequate preoperative patient counseling, it provides improvement in ankle function and has good outcomes for most patients at long-term follow-up.

Talolisthesis in end stage ankle arthrosis

BACKGROUND

Sagittal displacement in patients with end stage ankle arthritis has been described as the tibiotalar ratio (TTR). Yet the incidence, distribution and predictive factors of talolisthesis are unknown.

METHODS

The radiographs of 470 cases of ankle arthritis were compared with a control group of 49 normal ankles. The TTR was measured for both groups. Additional co-variables included the anterior and lateral distal tibial angles, and talar tilt.

RESULTS

The mean TTR in the arthritis cohort was 34.8+9.12 compared to the normal group of 34.1+2.62. Twenty-eight percent of the ankles had anterior displacement and twenty-eight percent had posterior talolisthesis, while forty-four percent had normal tibiotalar alignment. Multivariate linear regression revealed significant predictors of anterior distal tibial angle (p<0.0001) and talar tilt (p=0.0007) for abnormal TTR.

CONCLUSION

Sagittal displacement is common in end stage ankle arthritis and is affected by ligamentous laxity and joint morphology.

Cross-cultural adaptation and validation of the Ankle Osteoarthritis Scale for use in French-speaking populations

BACKGROUND

The Ankle Osteoarthritis Scale (AOS) is a self-administered score specific for ankle osteoarthritis (OA) with excellent reliability and strong construct and criterion validity. Many recent randomized multicentre trials have used the AOS, and the involvement of the French-speaking population is limited by the absence of a French version. Our goal was to develop a French version and validate the psychometric properties to assure equivalence to the original English version.

METHODS

Translation was performed according to American Association of Orthopaedic Surgeons (AAOS) 2000 guidelines for cross-cultural adaptation. Similar to the validation process of the English AOS, we evaluated the psychometric properties of the French version (AOS-Fr): criterion validity (AOS-Fr v. Western Ontario and McMaster Universities Arthritis Index [WOMAC] and SF-36 scores), construct validity (AOS-Fr correlation to single heel-lift test), and reliability (AOS-Fr test-retest). Sixty healthy individuals tested a prefinal version of the AOS-Fr for comprehension, leading to modifications and a final version that was approved by C. Saltzman, author of the AOS. We then recruited patients with ankle OA for evaluation of the AOS-Fr psychometric properties.

RESULTS

Twenty-eight patients with ankle OA participated in the evaluation. The AOS-Fr showed strong criterion validity (AOS:WOMAC r = 0.709 and AOS:SF-36 r = -0.654) and construct validity (r = 0.664) and proved to be reliable (test-retest intraclass correlation coefficient = 0.922).

CONCLUSION

The AOS-Fr is a reliable and valid score equivalent to the English version in terms of psychometric properties, thus is available for use in multicentre trials.

Preoperative radiography versus computed tomography for surgical planning for ankle fractures

PURPOSE

To review preoperative radiography and computed tomography (CT) of the ankle in 69 patients who underwent surgery for ankle fractures to determine the value of CT in diagnosis and surgical planning.

METHODS

Preoperative radiography and CT of the ankle of 46 women and 23 men aged 17 to 90 (mean, 48.8) years were reviewed. CT was deemed necessary when radiographs showed the following features: (1) comminuted fracture of the medial malleolus involving the tibial plafond, (2) comminuted fracture of the posterior malleolus, (3) presence of loose bodies, and/or (4) suspected Chaput or Volkman fracture fragment. Two orthopaedic surgeons independently reviewed the radiographs to look for any of the above features for which CT was indicated. In patients whose radiographs did not show any of the above features, each surgeon formulated a surgical plan based on radiographs alone and decided if any modification was needed after reviewing the CT scan.

RESULTS

Based on radiographs of the 69 patients, 19 (28%) patients had features of posterior malleolar comminution (n=7), medial malleolar comminution (n=7), suspected Chaput fracture fragment (n=1), suspected Volkman fracture fragment (n=1), and combination of 2 lesions (n=3), and were deemed to require CT. In 10 (20%) of the remaining 50 patients, the surgical plan was modified after review of the CT scan. The intra- and inter-observer agreement was good to excellent.

CONCLUSION

Radiography alone is not adequate for surgical planning for ankle fractures. More accurate imaging tools such as CT are needed to enable a more accurate diagnosis and surgical planning.

Reliability of the Radiographic Sagittal and Frontal Tibiotalar Alignment after Ankle Arthrodesis

Background

Accurate measurement of the tibiotalar alignment is important in radiographic outcome assessment of ankle arthrodesis (AA). In studies, various radiological methods have been used to measure the tibiotalar alignment leading to facultative misinterpretation of results. However, to our knowledge, no previous study has investigated the reliability of tibiotalar alignment measurement in AA. We aimed to investigate the reliability of four different methods of measurement of the frontal and sagittal tibiotalar alignment after AA, and to further clarify the most reliable method for determining the longitudinal axis of the tibia.

Methods

Thirty-eight weight bearing anterior to posterior and lateral ankle radiographs of thirty-seven patients who had undergone AA with a two screw fixation technique were selected. Three observers measured the frontal tibiotalar angle (FTTA) and the sagittal tibiotalar angle (STTA) using four different methods. The methods differed by the definition of the longitudinal tibial axis. Method A was defined by a line drawn along the lateral tibial border in anterior to posterior radiographs and along the posterior tibial border in lateral radiographs. Method B was defined by a line connecting two points in the middle of the proximal and the distal tibial shaft. Method C was drawn „freestyle”along the longitudinal axis of the tibia, and method D was defined by a line connecting the center of the tibial articular surface and a point in the middle of the proximal tibial shaft. Intra- and interobserver correlation coefficients (ICC) and repeated measurement ANOVA were calculated to assess measurement reliability and accuracy.

Results

All four methods showed excellent inter- and intraobserver reliability for the FTTA and the STTA. When the longitudinal tibial axis is defined by connecting two points in the middle of the proximal and the distal tibial shaft, the highest interobserver reliability for the FTTA (ICC: 0.980; CI 95%: 0.966–0.989) and for the STTA (ICC: 0.997; CI 95%: 0.996–0.999) is provided. Intergroup analysis for FTTA measurements revealed a statistically significant difference between the method in which the lateral border of the tibia was used to determine the longitudinal axis of the tibia, and the other methods in which the longitudinal axis was defined by bisecting the tibia.

Conclusions

When the longitudinal axis of the tibia is defined by connecting two points in the middle of the proximal and the distal tibial shaft for measuring the FTTA and STTA, the most favorable interobserver reliability is provided. Therefore, this method can be recommended for evaluating the frontal and the sagittal alignment on anterior to posterior and lateral radiographs after ankle arthrodesis.

Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population

PURPOSE

To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus.

METHODS

A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity.

RESULTS

The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee.

CONCLUSION

The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Value of Early Postoperative Computed Tomography Assessment in Ankle Fractures Defining Joint Congruity and Criticizing the Need for Early Revision Surgery

Previous investigators have questioned the reliability of plain radiographs in assessing the accuracy of ankle fracture reduction when these were compared with the computed tomography (CT) evaluation in the preoperative setting, in particular, in fractures with syndesmosis injuries or trimalleolar fragments. The role of CT assessment, however, has not been investigated in the early postoperative setting. In the early postoperative setting, reduction still relies most commonly on fluoroscopy and plain radiographs alone. In the present study, we hypothesized that early postoperative CT assessment of ankle fractures with syndesmosic injuries and posterior malleolar fragments can add valuable information about the joint congruity compared with plain radiographs alone and that this information could affect the decisions regarding the need for early revision surgery. A total of 352 consecutive operated ankle fractures were reviewed. Of these, 68 (19%) underwent early postoperative CT assessment and were studied further to identify the causes that prompted revision surgery. Of the 68 cases, despite acceptable reduction found on the plain radiographs, 20 (29%) underwent early (within 1 week) revision surgery after studying the CT scans, which revealed malreduction of the syndesmosis, malreduction of the posterior lip fragment, and intra-articular fragments. We concluded that in ankle fractures involving disruptions of the syndesmosis or posterior malleolar fragments, early postoperative CT assessment could be justified, because it will reveal malreduction and prompt early revision intervention for a substantial proportion of these patients.

Atlas of radiographic features of osteoarthritis of the ankle and hindfoot

OBJECTIVE

To develop a radiographic atlas of osteoarthritis (OA) for use as a template and guide for standardized scoring of radiographic features of OA of the ankle and hindfoot joints.

METHOD

Under Institutional Review Board approval, ankle and hindfoot images were selected from a cohort study and from among cases that underwent ankle radiography during a 6-month period at Duke University Medical Center. Missing OA pathology was obtained through supplementation of cases with the assistance of a foot and ankle specialist in Orthopaedic surgery and a musculoskeletal radiologist. Images were obtained and reviewed without patient identifying information. Images went through multiple rounds of review and final images were selected by consensus of the study team. For intra-rater and inter-rater reliability, the kappa statistic was calculated for two readings by three musculoskeletal radiologists, a minimum of two weeks apart, of ankle and hindfoot radiographs from 30 anonymized subjects.

RESULTS

The atlas demonstrates individual radiographic features (osteophyte and joint space narrowing (JSN)) and Kellgren-Lawrence grade for all aspects of the talocrural (ankle joint proper) and talocalcaneal (subtalar) joints. Reliability of scoring based on the atlas was quite good to excellent for most features indicated. Additional examples of ankle joint findings are illustrated including sclerosis, os trigonum, subchondral cysts and talar tilt.

CONCLUSIONS

It is anticipated that this atlas will assist with standardization of scoring of ankle and hindfoot OA by basic and clinical OA researchers.

Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle

BACKGROUND

The cause of ankle osteoarthritis (OA) is usually trauma. Patients are relatively young, since ankle trauma occurs at a relatively young age. Several conservative treatment options are available, evidence of the benefits and harms of these options are lacking.

OBJECTIVES

To assess the benefits and harms of any conservative treatment for ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, issue 9), MEDLINE (Ovid) (1946 up to 11 September 2014), EMBASE (1947 to September 2014), PsycINFO (1806 to September 2014), CINAHL (1985 to September 2014), PEDro (all years till September 2014), AMED until September 2014, ClinicalTrials.gov, Current Controlled Trials, The Dutch Register. To identify potentially relevant studies we screened reference lists in retrieved review articles and trials.

SELECTION CRITERIA

We considered randomised or controlled clinical trials investigating any non-surgical intervention for ankle OA for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

No other RCT concerning any other conservative treatment besides the use of hyaluronic acid (HA) for ankle OA was identified. Six randomised controlled trials (RCTs) were included.A total of 240 participants diagnosed with ankle OA were included in this review. The primary analysis included three RCTs (109 participants) which compared HA to placebo. One study compared HA to exercise therapy, one compared HA combined with exercise therapy to an intra-articular injection of botulinum toxin and one compared four different dosages of HA.Primary analysis: a pooled analysis of two trials (45 participants) found that the Ankle Osteoarthritis Scale (AOS) total score (measuring pain and physical function) was reduced by 12% (95% CI -24% to -1%) at six months (mean difference (MD) -12.53 (95% CI -23.84 to -1.22) on a scale of 0 to 100; number needed to treat for an additional beneficial outcome (NNTB) = 4 (95% CI 2 to 205); this evidence was graded as low quality, due to limitations in study design (unclear risk of selection bias for two studies and unclear risk for attrition bias for one study) and imprecision of results: a small population size (45 participants). It is not known if a mean difference of 12.53 points on a 100 point scale is clinically relevant. No minimal important clinical difference is known for this score. Pain and function outcomes were not reported separately. Radiographic joint structure changes were not investigated. For the mean quality of life at six months (two trials; 45 participants) no meta-analysis could be performed due to missing data. No serious adverse events (SAEs) were noted and no participants withdrew because of an adverse event. There were a few adverse events (AEs) 5/63 (8%) in the HA group and 2/46 (4%) in the placebo group. The Peto odds ratio (Peto OR) to have an adverse event was 2.34 higher compared to the control group (95% CI 0.45 to 12.11). This evidence is inconclusive because of a wide CI and a small number of events.For comparing HA to exercise therapy (30 participants) the results for pain on a Visual Analogue Scale (VAS 0 to 10) at 12 months are inconclusive (MD 0.70, 95% CI -2.54 to 1.14). The American Orthopedic Foot and Ankle Society score (AOFAS score) was 13.10 points (MD) higher in favour of HA (95% CI 2.97 to 23.23) on a scale of 0 to 100. The evidence was graded as low. No adverse events were found. Radiographic structure changes were not measured; no participants withdrew due to AEs; no SAEs were found.For the comparison of HA injection combined with exercise therapy to an intra-articular injection of botulinum toxin A (BoNT-A) (75 participants), the outcome of the AOS pain score of the affected joint at six months is inconclusive (MD 0.10, 95% CI -0.42 to 0.62). The physical function (the AOS disability score) at six months is inconclusive (MD 0.20, 95% CI -0.34 to 0.74). The same number of AEs were found in both groups; HA 2/37 (5.9%), BoNT-A 2/38 (5.8%) (risk ratio (RR) 1.03, 95% CI 0.15 to 6.91). Radiographic changes were not examined, no SAEs were found and no participants withdrew because of an AE. The evidence was graded as low.The RCT comparing four different dosing schedules for HA (26 participants) showed the best median decrease in pain on walking VAS (on a scale of 0 to 100) for 3 x 1 ml at 27 weeks with a median decrease of 30. Physical function, radiographic changes and quality of life were not measured.Twenty-seven percent of all participants had AEs, most of them in the 2ml group (57% in this group). No participants withdrew due to an AE and no SAEs were noted.Overall the quality of the evidence showed some serious limitations. The evidence was graded low for the primary analysis comparing HA to placebo. This was based on a limitation in design and implementation: sample sizes were small (45 to 92 participants) and and imprecision in results: there was an unclear risk of bias for several items concerning the three studies used in the meta analysis.

AUTHORS' CONCLUSIONS

Currently, there is insufficient data to create a synthesis of the evidence as a base for future guidelines for ankle OA. Since the aetiology of ankle OA is different, guidelines that are currently used for hip and knee OA may not be applicable for ankle OA. Simple analgesics as recommended for hip and knee OA seem however a reasonable first step to treat ankle OA. It is unclear if there is a benefit or harm for HA as treatment for ankle OA compared to placebo at six months based on a low quality of evidence. Inconclusive results were found comparing HA to other treatments. HA can be conditionally recommended if patients have an inadequate response to simple analgesics. It remains unclear which patients (age, grade of ankle OA) benefit the most from HA injections and which dosage schedule should be used.

Use of Soft-Tissue Procedures for Managing Varus and Valgus Malalignment with Total Ankle Replacement

Achieving frontal plane alignment of the ankle joint during total ankle replacement is essential for long-term success. Tendon and ligament lengthening, ligament reinforcement, tendon transfer, nonanatomic tendon transfer ligament reconstruction, and periarticular osteotomies are safe, straightforward, minimally invasive, and reproducible procedures to correct varus and valgus deformities associated with end-stage degenerative joint disease. Using reproducible topographic anatomic landmarks is essential to these techniques properly and limit complications. The approach to frontal plane deformities is stepwise, with liberal use of tendon and ligament lengthening and reconstruction, a low threshold for nonanatomic tendon transfer ligament reconstructions, and tendon transfers and/or periarticular osteotomies.

Supramalleolar Osteotomy: Indications and Surgical Techniques

Supramalleolar osteotomies are a surgical treatment option for asymmetric varus or valgus ankle arthritis where at least 50% of the joint surface is spared. Procedure selection requires significant preoperative planning for appropriate execution. Thus, the surgeon must be familiar with the principles of deformity correction. With appropriate patient selection and proper preoperative planning, the procedure has been shown to yield excellent results, redistributing forces more evenly across the ankle joint by restoring the mechanical axis of the lower leg with minimal complications.