Post-sprain versus post-fracture post-traumatic ankle osteoarthritis: Impact on foot and ankle kinematics and kinetics

Static posture weightbearing joint angle differences in patients with varus ankle osteoarthritis

BACKGROUND

Advanced varus ankle osteoarthritis is a debilitating disease that can present with limited physical function, severe pain, and diminished quality of life. Weightbearing computed tomography enables submillimeter 3-dimensional visualization, computational analyses, and enhanced diagnoses in reporting complex degenerative changes more accurately.

RESEARCH QUESTION

This study set to compare static posture weightbearing joint angle differences in healthy and varus ankle osteoarthritis patients (compensated and non-compensated).

METHODS

Our retrospective assessment included 70 individuals, 44 of whom were diagnosed with advanced varus ankle osteoarthritis, and the remaining 26 were healthy participants to serve as controls. An automatic anatomic coordinate system was applied to each patient's 3-dimensional talus and calcaneus bone reconstructions from weightbearing computed tomography scans. Subtalar and midtarsal joint angles were calculated using Euler angles.

RESULTS

We report statistical differences between the healthy group and both advanced varus osteoarthritis groups for midtarsal inversion/eversion. Specifically, both osteoarthritis groups' midtarsal joints were more inverted and plantarflexed as compared to healthy participants. Compensated and non-compensated subtalar joints were statistically different with respect to inversion/eversion. Non-compensated ankles exhibited a similar mean to healthy ankles who were both less inverted than compensated ankles.

SIGNIFICANCE

Our study helps physicians to better understand underlying mechanisms of peritalar compensation in varus ankle osteoarthritis. Patients featuring hindfoot compensation on average had a greater subtalar joint angle indicating greater inversion than healthy and non-compensated patients.

The morphology of osseous structure in subtalar joint with chronic ankle instability

BACKGROUND

Osseous structures have been demonstrated as risk factors for chronic ankle instability (CAI). Previously, the researchers only focused on the osseous structures of ankle, but ignored the osseous structures of subtalar joint(STJ). Accordingly, the aim of our study was to investigate the morphological characteristics of STJ osseous structures in CAI.

METHODS

52 patients with CAI and 52 sex- and age- matched control subjects were enrolled from The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. The lateral radiographs of ankle in weight-bearing were used to compare the diversity of the two groups. Specifically, The Length of calcaneus, Calcaneal facet height and Absolute foot height, Böhler's angle, Gissane's angle, Calcaneal inclination angle, Talocalcaneal angle, Tibiotalar angle, Tibiocalcaneal angle, Talar-horizontal angle, talar declination angle, facet inclination angle were gauged in the two groups.

RESULTS

The Böhler's angle, Calcaneal inclination, Talocalcaneal angle, Tibiotalar angle, Talar-horizontal angle, Talar declination angle, Facet inclination angle and Absolute foot height of CAI group were significantly higher than normal control group (P < 0.05). There were no significant differences in Gissane's angle, Tibiocalcaneal angle, Length of calcaneus and Calcaneal facet height between patients with CAI and normal controls (P > 0.05).

CONCLUSIONS

The osseous structures of STJ in CAI patients are different from normal people in morphology. Therefore, we should pay more attention to the changes of STJ anatomical parameters in the diagnosis and prevention of CAI.

LEVEL OF EVIDENCE

Ⅲ.

Outcomes of Total Ankle Arthroplasty in Postfracture Ankle Arthritis

BACKGROUND

Ankle arthritis that develops after fracture accounts for a significant portion of ankle arthritis necessitating total ankle arthroplasty (TAA). It remains unknown whether TAA in postfracture patients produces equivalent outcomes to those without fracture history. The purpose of this study was to evaluate the medium-term outcomes of TAA in postfracture ankle arthritis compared to those without fracture history.

METHODS

This study reviewed 178 ankles from 171 consecutive patients who underwent TAA in our institution between 2007 and 2017 and completed a minimum 5-year follow-up. Four different TAA systems were utilized by 6 surgeons. Based on fracture history, patients were divided into 2 groups: the postfracture group (n = 63; median age 65.7 years; median follow-up 5.9 years) and the nonfracture group (n = 115; median age 64.4 years; median follow-up 6.2 years). Types and rates of complications including revision and reoperation were compared. Minimum 5-year Foot and Ankle Outcome Score (FAOS) and postoperative improvement were investigated. A subgroup analysis was performed to determine whether outcomes differ between intraarticular fracture patients (n = 43) and extraarticular fracture patients (n = 20).

RESULTS

Both groups exhibited comparable postoperative improvement and final FAOS scores. The postfracture group had a significantly higher reoperation rate than the nonfracture group (20 of 63, 31.7%, vs 17 of 115, 14.8%; P = .011), with gutter impingement being the most common cause. There were 3 revisions in each group. In the subgroup analysis, we found no evidence of statistical difference between the intraarticular fracture group and the extraarticular fracture group in terms of FAOS scores, revision, and reoperation rates.

CONCLUSION

In this single-center, retrospective comparative study, we found total ankle arthroplasty in patients with a history of fractures around the ankle joint had no evidence of statistical difference in patient-reported outcomes and implant survivorship but led to a higher rate of nonrevision reoperation following surgery. In the much smaller subset of patients with previous fracture, we did not find that those with a history of intraarticular fracture had inferior outcomes after TAA when compared to those with a history of extraarticular fracture.

LEVEL OF EVIDENCE

Level III, case-control study.

Decreased Mechanical Work Demand in the Chopart Joint After Total Ankle Replacement

BACKGROUND

The success of total ankle replacement (TAR) must be based on restoring reasonable mechanical balance with anatomical structures that can produce mechanical joint work through elastic (eg, tendons, fascia) or viscoelastic (eg, heel pad) mechanisms, or by active muscle contractions. Yet, quantifying the work distribution across the affected joint and the neighboring foot joints after TAR is lacking. Therefore, the objective of this study was to investigate if there is a change in the joint work distribution across the Ankle, Chopart, Lisfranc and Metatarsophalangeal joints during level walking before and after patients undergo TAR.

METHODS

Fifteen patients with end-stage ankle osteoarthritis scheduled for primary TAR for pain relief were recruited and peer-matched with a sample of 15 control subjects. All patients underwent a 3D gait analysis before and after surgery, during which a kinetic multisegment foot model was used to quantify intersegmental joint work.

RESULTS

The contribution of the Ankle joint (P = .007) to the total foot and ankle positive work increased significantly after TAR. In contrast, a significant decrease in the contribution to the total foot and ankle joint positive work (P < .001) were found at the Chopart joint after TAR. The foot joints combined produced a significant increase in a net mechanical work from +0.01 J/kg before surgery to +0.05 J/kg after TAR (P = .006).

CONCLUSION

The findings of this study corroborate the theoretical rationale that TAR reduces significantly the compensatory strategy in the Chopart joint in patients with end-stage ankle osteoarthritis after TAR. However, the findings also showed that the contribution of the ankle joint of patients after TAR to the total foot and ankle joint positive work remained impaired compared to the control group.

[Comparison of short-term effectiveness of metal screws and absorbable screws in repair of distal tibiofibular syndesmosis]

OBJECTIVE

To compare the short-term effectiveness of repairing distal tibiofibular syndesmosis with metal screws and absorbable screws.

METHODS

A retrospective analysis was performed on the clinical data of 63 patients with ankle fracture combined with injury of the distal tibiofibular syndesmosis admitted between January 2017 and January 2020. Among them, 31 patients were treated with absorbable screw fixation of the distal tibiofibular syndesmosis (research group) and 32 patients were treated with metal screw fixation of the distal tibiofibular syndesmosis (control group). There was no significant difference in gender, age, cause of injury, surgical side, time from injury to operation, fracture type, preoperative visual analogue scale (VAS) score, and American Orthopaedic Foot & Ankle Society (AOFAS) score between the two groups ( P>0.05). The operation time and fracture healing time were recorded and compared between the two groups. X-ray film was taken to evaluate the effect of ankle joint reduction and fixation. Olerud-Molander ankle fracture efficacy score (short for OM score), AOFAS score, and VAS score were used to evaluate the effectiveness.

RESULTS

There was no significant difference in operation time between the two groups ( t=-0.683, P=0.497). In the control group, 1 case of delayed healing and 1 case of poor healing occurred in the lateral incision after operation, which healed after dressing change; the rest of the patients had primary healing of the incision. Patients in both groups were followed up 12-24 months, with an average of 13.8 months. In the control group, 1 patient with fracture of pronation and external rotation walked with full weight bearing after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks after operation, the anatomical plate of the lateral malleolus was broken, and the lateral malleolus was fixed again and recovered after 5 months; 1 patient had mild ankle pain after operation, and the pain disappeared after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks. No complication such as nerve and blood vessel injury occurred in all patients. There was no significant difference in fracture healing time between the two groups ( t=-1.128, P=0.264). The AOFAS and VAS scores significantly improved in both groups at 12 months after operation ( P<0.05). There was no significant difference between the two groups in the OM scores, and the difference of AOFAS and VAS scores between before and after operation ( P>0.05).

CONCLUSION

Using absorbable screws to repair the distal tibiofibular syndesmosis can effectively restore the ankle acupoint structure, prevent ankle instability, and restore good ankle function. There is no significant difference in effectiveness between absorbable screws and metal screws, and there is no need for secondary operation to remove screws.

The Efficacy of Targeted Perioperative Management for Diabetic Patients with Traumatic Calcaneal Fractures

Objective

To assess the efficacy of targeted perioperative management for diabetic patients with traumatic calcaneal fractures.

Methods

Between April 2020 and December 2020, 100 diabetic patients with traumatic calcaneal fractures treated in our institution satisfying the inclusion criteria were enrolled and assigned to receive either conventional treatment with surgery or plaster fixation (observation group) or targeted treatment with surgery or plaster fixation (experimental group) via the random number table method, with 50 patients in each group. All eligible patients were followed up for 1 year postoperatively. Outcome measures included length of hospital stay, recovery time, fracture healing, duration of postoperative wound drainage, complication rate, blood glucose, and treatment satisfaction. The Maryland score was used for the assessment of foot function.

Results

The duration of postoperative wound drainage, length of hospital stay, and recovery time in the experimental group (3.63 ± 1.04 d, 12.13 ± 3.77 d, and 111.22 ± 16.24 d) were significantly shorter than those in the observation group (5.71 ± 2.34 d, 15.28 ± 4.42 d, 123.10 ± 22.82 d) (P < 0.01). The experimental group obtained a markedly higher complete healing rate versus the observation group (P < 0.001). A significantly lower complication rate was observed in the experimental group than in the observation group (P < 0.05). The Maryland scores results were dichotomized into good (≥75 points) and poor (<75 points). The experimental group showed significantly higher Maryland scores good rate and treatment satisfaction versus the observation group (P < 0.01). The experimental group patients were associated with better postoperative fasting glucose and 2 h postprandial glucose versus those in the observation group (P < 0.05).

Conclusion

Targeted treatment in the perioperative management of diabetic patients with traumatic calcaneal fractures significantly promotes the recovery of patients, reduces the incidence of complications, increases treatment satisfaction, and ameliorates the doctor-patient relationship.

Concomitant osteochondral lesions of the talus affect the stair descent biomechanics of patients with chronic ankle instability: A pilot study

BACKGROUND

Previous studies on the kinematics of patients with chronic ankle instability (CAI) that did not incorporate MRI and arthroscopic assessment could not differentiate between patients with CAI without osteochondral lesion of the talus (OLT) and patients with CAI and OLT and have thus presented contradictory results.

RESEARCH QUESTION

This study aimed to investigate the kinematic and electromyographic differences between patients with and without OLT.

METHODS

Sixteen subjects with CAI (eight without OLT and eight with OLT confirmed through MRI and arthroscopic assessment) and eight healthy subjects underwent gait analysis in a stair descent setting. The three groups' patient-reported outcomes; ankle joint range of motion in flexion, inversion and rotation; and muscle activation of the peroneus, tibialis anterior, and gastrocnemius during a gait cycle were analyzed and compared. A curve analysis, namely, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalized time series.

RESULTS

The patients with and without OLT had no difference in patient-reported outcomes. The maximal ankle plantarflexion of the patients without OLT and the healthy subjects was significantly larger than that of patients with OLT (p = 0.005). The maximal ankle internal rotation of patients without OLT was significantly larger than that of patients with OLT (p = 0.048). The peroneal activation during 0-6% of the gait cycle of patients with OLT was reduced compared with the healthy subjects.

SIGNIFICANCE

Patients with CAI and OLT and patients with CAI without OLT have no difference in patient-reported outcomes, but patients with OLT can be differentiated using the post-initial-contact peroneal activation deficit and the restriction of ankle plantarflexion and internal rotation during stair descent. These variables can be utilized to monitor the function of patients with CAI and their possibility of developing OLT.

The Amsterdam Foot Model: a clinically informed multi-segment foot model developed to minimize measurement errors in foot kinematics

Background

Foot and ankle joint kinematics are measured during clinical gait analyses with marker-based multi-segment foot models. To improve on existing models, measurement errors due to soft tissue artifacts (STAs) and marker misplacements should be reduced. Therefore, the aim of this study is to define a clinically informed, universally applicable multi-segment foot model, which is developed to minimize these measurement errors.

Methods

The Amsterdam foot model (AFM) is a follow-up of existing multi-segment foot models. It was developed by consulting a clinical expert panel and optimizing marker locations and segment definitions to minimize measurement errors. Evaluation of the model was performed in three steps. First, kinematic errors due to STAs were evaluated and compared to two frequently used foot models, i.e. the Oxford and Rizzoli foot models (OFM, RFM). Previously collected computed tomography data was used of 15 asymptomatic feet with markers attached, to determine the joint angles with and without STAs taken into account. Second, the sensitivity to marker misplacements was determined for AFM and compared to OFM and RFM using static standing trials of 19 asymptomatic subjects in which each marker was virtually replaced in multiple directions. Third, a preliminary inter- and intra-tester repeatability analysis was performed by acquiring 3D gait analysis data of 15 healthy subjects, who were equipped by two testers for two sessions. Repeatability of all kinematic parameters was assessed through analysis of the standard deviation (σ) and standard error of measurement (SEM).

Results

The AFM was defined and all calculation methods were provided. Errors in joint angles due to STAs were in general similar or smaller in AFM (≤2.9°) compared to OFM (≤4.0°) and RFM (≤6.7°). AFM was also more robust to marker misplacement than OFM and RFM, as a large sensitivity of kinematic parameters to marker misplacement (i.e. > 1.0°/mm) was found only two times for AFM as opposed to six times for OFM and five times for RFM. The average intra-tester repeatability of AFM angles was σ:2.2[0.9°], SEM:3.3 ± 0.9° and the inter-tester repeatability was σ:3.1[2.1°], SEM:5.2 ± 2.3°.

Conclusions

Measurement errors of AFM are smaller compared to two widely-used multi-segment foot models. This qualifies AFM as a follow-up to existing foot models, which should be evaluated further in a range of clinical application areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00543-6.

Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures

Background

Ankle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time.

Methods

Fourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated.

Results

Statistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53–75%: p = 0.001) and patients after 26 weeks (58–70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15–40%: p < 0.001; 56,5–70%: p = 0.007; 82–88%: p = 0.033; 97–98,5%: p = 0.048) as well as patients after 26 weeks (62,5–65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0–17%: p < 0.001; 21–37%: p < 0.001; 41–54%: p < 0.001; 60–64%: p = 0.013) as well as patients after 26 weeks (0–1,5%: p = 0.046; 5–15%: p < 0.001; 27–33%: p = 0.001; 45–49%: p = 0.005; 57–59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks.

Conclusions

This study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients’ values tend to get closer to those of the control group.

Trial registration

This study is registered at the German Clinical Trials Register (DRKS00023379).