Surgical Treatment Paradigms of Ankle Lateral Instability, Osteochondral Defects and Impingement

The severity of preoperative bone marrow oedema negatively influences short-term clinical outcomes following arthroscopic bone marrow stimulation for osteochondral lesions of the talus

PURPOSE

The purpose of this study was to study the effects of the severity of preoperative bone marrow oedema (BME) on the postoperative short-term outcomes following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) and to propose a new metric that combines volume and signal density to evaluate BME.

METHODS

Sixty-five patients with symptomatic OLTs (<100 mm2) and preoperative BME, who received BMS in our institution from April 2017 to July 2021 with follow-ups of 3, 6 and 12 months, were analysed retrospectively. The area, volume and signal value of the BME were collected on preoperative magnetic resonance imaging. The enroled patients were divided into two groups according to the BME index (BMEI), which was defined as the product of oedema relative signal intensity and the relation of oedema volume to total talar volume. Visual analogue scale, American Orthopedic Foot and Ankle Society (AOFAS), Tegner, Foot and Ankle Ability Measure (FAAM)-activities of daily living (ADL) and Sports scores were assessed before surgery and at each follow-up. The relationship between the scores and the volume, relative signal intensity and BMEI was explored.

RESULTS

Sixty-five patients with preoperative BME were divided into the mild (n = 33) and severe (n = 32) groups based on the BMEI. A significant difference was found for each score with the general linear model for repeated measures through all follow-up time points (p < 0.001). For the preoperative and 12-month postoperative changes of the enroled patients, 53 patients (81.5%) exceeded the minimal clinically important difference of AOFAS and 26 (40.0%) exceeded that of FAAM-sports in this study. The mild group showed significantly more improvement in AOFAS scores at 12 months (89.6 ± 7.0 vs. 86.2 ± 6.2) and FAAM-ADL scores at 6 months (83.6 ± 7.6 vs. 79.7 ± 7.7) and 12 months (88.5 ± 8.5 vs. 84.4 ± 7.7) than the severe group (p < 0.05). No significant difference of all the scores between the groups was found at 3 months. No significant correlation was found in each group between BMEI and clinical outcomes.

CONCLUSION

The severity of the preoperative BME negatively affected short-term clinical outcomes following arthroscopic BMS for OLTs. Worse clinical outcomes were shown at postoperative 6 and 12 months in patients with a high preoperative BMEI, which could be a favourable parameter for assessing the severity of BME and assist in developing personalised rehabilitation plans and determining the approach and timing of surgery.

LEVEL OF EVIDENCE

Level III.

Proposal of a new CT arthrographic classification system of osteochondral lesions of the talus

BACKGROUND

Surgical treatment of osteochondral lesions of the talus (OLT) is warranted if medical treatments fail, achieving good results in around 85% of cases. Numerous classification systems, based on all possible imaging modalities (radiography, MRI, CT scan, scintigraphy, and CT arthrography), have been proposed to guide surgical treatments, but none has proven to be superior. A recent study demonstrated the prognostic value of CT arthrography by accurately describing the subchondral bone plate. A systematic review of the literature has brought new criteria to predict good outcome following bone marrow stimulation surgical techniques: lesions should measure less than 1 centimeter in size and 5 millimeters in depth. Based on these data, we are proposing a new simple, 3-stage CT arthrographic classification system of OLT.

MATERIALS AND METHODS

After a brief overview of the classification, 60 CT-arthrographies of ankles with OLT were organized according to this new CT arthrographic classification system by four surgeons (two juniors and two seniors). Two imaging assessments were performed one month apart. Statistical analysis was performed using the Fleiss' kappa coefficient to determine the inter- and intraobserver agreement.

RESULTS

An excellent inter- and intraobserver agreement was found with overall Fleiss' kappa coefficients of 0.897 and 0.847, respectively.

CONCLUSION

The results of our study showed an excellent inter- and intraobserver agreement for this new CT arthrographic classification system of OLT. The principal advantage of this new classification system, based on the latest data in the literature, is its ability to easily distinguish lesions that are more amenable to bone marrow stimulation techniques.

LEVEL OF EVIDENCE

II.

Ankle instability – review and new trends

Ankle instability is an old topic with increasing importance in Orthopaedics’ world, as we start now realising how underdiagnosed this pathology has been. A lot of effort has been made in recent years to better understand the pathomechanics of this injury, with new surgical techniques being tried and even new anatomic structures being described. The objective of this paper is to review and compile the most important and recent literature on this matter, in an academic way, but oriented to clinical practice, so it can help surgeons keep updated in this so important subject.

Outcomes After Arthroscopic Surgery for Anterior Impingement in the Ankle Joint in the General and Athletic Populations: Does Sex Play a Role?

BACKGROUND

Although anterior ankle impingement is a common pathology within the athletic population, there have been limited data evaluating outcomes of arthroscopic intervention and whether patient sex affects treatment outcomes.

PURPOSE

To provide an overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement and to determine if patient sex affects outcomes.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature search of the MEDLINE, Embase, and Cochrane databases was performed during August 2019. The following combination of search terms was utilized: "ankle," "impingement," "talus," "osteophyte," "arthroscopy," "surgery," "procedures," and "treatment." Two reviewers independently performed data extraction.

RESULTS

A total of 28 articles evaluating 1506 patients were included in this systematic review. Among the studies, 60% (17/28) and 14% (4/28) assessed anterolateral and anteromedial impingement, respectively. Good to excellent results were reported after arthroscopy in patients with anterior ankle impingement, with a success rate of 81.04%. All studies that evaluated functional outcomes (16/16; 100%) cited improvements in American Orthopaedic Foot & Ankle Society scale, visual analog scale, and Foot Function Index. The average complication rate was 4.01%, with the most common complications being mild nerve symptoms and superficial infection. The most common concomitant pathologies included synovitis, osteophytes, meniscoid lesions, and anterior inferior tibiofibular ligament injury. Four studies (15%) failed to report sex as a demographic variable. Only 7 (25%) studies included analysis by sex, with 4 (57%) of these demonstrating differences when comparing outcomes by patient sex. When compared with male patients, female patients exhibited higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement.

CONCLUSION

Our systematic review demonstrates that arthroscopic treatment for anterior ankle impingement provides good to excellent functional outcomes, low complication rates, and good return-to-sports rates in both the general and the athletic population. This study also reports a lack of statistical analysis evaluating outcomes comparing male and female populations. The included studies demonstrate that, compared with male patients, female patients have higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement; therefore, particular attention should be paid to addressing such concomitant pathology.

Early functional treatment or trivialization? - current treatment strategies in lateral ligament injuries of the ankle

Introduction: Ankle injuries are common in daily orthopaedic trauma practice, with a high incidence of lateral ligament complex (lat-lig-com) injuries of the ankle joint (AJ). Primarily, these lat-lig-com injuries heal sufficiently, although there is a risk of developing chronic ankle instability. However, there is a lack of knowledge about the clinical application and routine for rehabilitation strategies so as to prevent chronic instability. This study investigates the current rehabilitation concepts in clinical routine after ligament injuries of the AJ. Methods: Rehabilitation protocols, provided by orthopaedic and trauma surgery institutions in German speaking countries, were analysed in terms of weight-bearing, range of motion (ROM), physiotherapy and choice of orthosis. All protocols for operatively and non-operatively (nop) treated ligament ruptures of the AJ were included. Results: 120 of 213 institutions provided protocols of lat-lig-com injuries of the AJ. Regarding the orthosis, the nop-treatment group mainly used ankle braces; in contrast, the operative group preferred the use of an ankle boot. The operative group recommends 6-12 weeks for duration of orthosis in contrast to only 6 weeks in the nop group. Significant differences prevail in ROM, with free ROM in non-operative treatment from the first day after trauma (p<0.001) in contrast to a careful increase in ROM in the first 6 weeks post-operatively. Conclusion: Early functional treatment is clinical standard in rehabilitation after lat-lig-com injuries of the ankle. Regarding current literature the differences of restrictions in ROM and orthosis treatment after lat-lig-com injuries suggest a trivialization of conservative treatment in the first period after trauma compared to post-operative aftercare.

Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects : Operative technique

Objective

Provision of a natural scaffold, good quality cells, and growth factors in order to facilitate the replacement of the complete osteochondral unit with matching talar curvature for large medial primary and secondary osteochondral defects of the talus.

Indications

Symptomatic primary and secondary medial osteochondral defects of the talus not responding to conservative treatment; anterior–posterior or medial–lateral diameter >10 mm on computed tomography (CT); closed distal tibial physis in young patients.

Contraindications

Tibiotalar osteoarthritis grade III; multiple osteochondral defects on the medial, central, and lateral talar dome; malignancy; active infectious ankle joint pathology.

Surgical technique

A medial distal tibial osteotomy is performed, after which the osteochondral defect is excised in toto from the talar dome. The recipient site is microdrilled in order to disrupt subchondral bone vessels. Then, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exact fitting shape to match the extracted osteochondral defect and the talar morphology as well as curvature. The graft is implanted with a press-fit technique after which the osteotomy is reduced with two 3.5 mm lag screws and the incision layers are closed. In cases of a large osteotomy, an additional third tubular buttress plate is added, or a third screw at the apex of the osteotomy.

Postoperative management

Non-weight bearing cast for 6 weeks, followed by another 6 weeks with a walking boot. After 12 weeks, a CT scan is performed to assess consolidation of the osteotomy and the inserted autograft. The patient is referred to a physiotherapist.

Results

Ten cases underwent the TOPIC procedure, and at 1 year follow-up all clinical scores improved. Radiological outcomes showed consolidation of all osteotomies and all inserted grafts showed consolidation. Complications included one spina iliaca anterior avulsion and one hypaesthesia of the saphenous nerve; in two patients the fixation screws of the medial malleolar osteotomy were removed.

[Mid-to-long term outcomes and influence factors of postoperative concurrent chronic ankle instability and posterior ankle impingement]

OBJECTIVE

To investigate the mid-to-long-term efficacy of patients with chronic ankle instability combined with posterior impingement syndrome after 3-9 years of follow-up, and to analyze the influencing factors.

METHODS

From February 2010 to December 2015, 46 patients underwent concurrent lateral ankle ligament repair with posterior ankle arthroscopic surgery at the Institute of Sports Medicine, Peking University Third Hospital. The patient was first placed in a prone position and underwent arthroscopic debridement for the posterior impingement. After finishing the posterior arthroscopy, the surgeon and assistants first translated the patient to the affected side, then turned to the healthy side, and changed the position to the supine position. During the turning over, another assistant held the arthroscope and the instrument to ensure that it was sterile and could be used without replacement. The anterior ankle arthroscopy was operated if necessary and the lateral ankle ligament repair was anatomic repaired with anchors. The 42 patients were followed up, including 26 males and 16 females. The average age was (28.9±10.0) years. The patient's clinical symptoms, joint stability, mobility and motor function were compared by questionnaire and physical examination. The preoperative and postoperative visual analogue scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores were compared, and the clinical scores and the patient age, gender, height and weight were compared. The correlations between body mass index (BMI), preoperative duration, surgery duration, and cartilage injury were analyzed.

RESULTS

The mean follow-up time was (71.8±22.8) months. The postoperative VAS scores (1.0 vs. 5.0, P<0.001), AOFAS scores (92 vs. 80, P<0.001), and Tegner scores (6.5 vs. 2, P<0.001) were significantly superior to the preoperative levels. The excellent and good rate was 97.6%. The postoperative VAS score (t=2.719, P=0.10), AOFAS score (t=-2.853, P=0.10), Tegner score (t=-3.443, P=0.001) and time to return exercise (t=2.814, P=0.008) were negatively correlated with the patient age, and the postoperative VAS score was negatively correlated with cartilage injury (Z=-2.195, P=0.028).

CONCLUSION

The mid-to-long-term clinical outcomes of the chronic ankle ligament instability combined with the posterior impingement were good. The age of the patients was negatively correlated with the clinical outcome. The combined cartilage injury could aggravate the postoperative pain.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.

Implications of Classification of Os Trigonum: A Study Based on Computed Tomography Three-Dimensional Imaging

BACKGROUND The os trigonum is an accessory bone that is not fully fused with the talus during secondary ossification, and is one of the risk factors of posterior malleolus impact syndrome. The purpose of this study was to classify the os trigonum and to guide the diagnosis and treatment of related clinical diseases. MATERIAL AND METHODS Ankle computed tomography (CT) scans of 586 Chinese patients between October 2014 and October 2018 were reviewed. CT images of 1011 ankle joints were reconstructed to evaluate the classification of the os trigonum and the measurement of anatomical parameters. RESULTS The incidences of os trigonum in 3 groups were determined as type I (1.9%), type II (10.5%), and type III (14.7%). The macro-axis of type II (0.89±0.31) cm was significantly larger than with type I (0.65±0.24 cm) and type III (0.74±0.23 cm) (p<0.05).The minor axis of similar of type I (0.41±0.23 cm) was significantly shorter than that of type II (0.58±0.32 cm) and type III (0.55±0.16 cm) (p<0.05).The distance from os trigonum to calcaneal tubercle was significantly different than that of type I (1.33±0.52 cm), type II (1.67±0.55 cm), and type III (1.84±0.45 cm) (p<0.05). CONCLUSIONS This study showed that os trigonum has a high incidence. Type I was the least common, the volume of type II was larger, and type III was more common. The anatomical parameters of each type may improve treatment of related diseases and the further development of ankle arthroscopic surgery.