Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms

Anterior ankle impingement

Our understanding of the pathophysiology of anterior ankle impingement has steadily progressed since the princeps description almost 70 years ago. The same is true of diagnosis and treatment, which have greatly changed over time. The present study provides an update on this pathology, addressing the following questions: Anterior ankle impingement is suspected in case of anterior ankle pain reproducible by palpation and exacerbated by dorsiflexion imposed by the examiner or squatting, and Molloy's sign. Etiologies are varied: tumoral, post-traumatic, lateral ankle instability, osteoarthritis and microtrauma. Complementary cross-sectional imaging, and especially MRI, is indispensable for identifying the cause. A dichotic classification in terms of anterolateral impingement of tissular origin and anteromedial impingement of osteophytic origin is incompatible with current pathophysiological concepts. An etiological classification, completed by a topographic classification in 3 zones, provides a better guide for treatment strategy. Tumoral or post-traumatic impingement requires a specialized team. Impingement by microtrauma associated with instability or osteoarthritis is best treated arthroscopically, for exhaustive exploration of intra-articular elements that may be implicated. Treatment consists in removing osteophytes and any pathological synovial or ligamentous soft tissue. Anterior talofibular ligament or medial collateral ligament repair may be associated. Results can be expected to be good, with clear improvement in pain and function and excellent patient satisfaction. LEVEL OF EVIDENCE: V, expert opinion.

Outcome comparison of rotational ankle fractures: Supination external rotation versus pronation external rotation

BACKGROUND

Ankle fractures are among the most common types of fractures in the orthopaedic field, and the Lauge-Hansen classification is commonly used to categorize rotational ankle fractures. This study evaluated and compared the clinical and radiological outcomes of surgically treated supination external rotation (SER) and pronation external rotation (PER) injuries of grades III or IV.

METHODS

We retrospectively reviewed and enrolled 104 patients who underwent open reduction and internal fixation for SER or PER injuries classified as Grades III or IV between January 2016 and December 2021, all performed at a single center. Of these, 72 belonged to the SER group and 32 to the PER group. The average postoperative follow-up durations were 31.3 months (range, 24 to 74) for the SER group and 32.1 months (range, 24 to 71) for the PER group. Clinical and radiological outcomes were assessed 24 months after surgery and compared between the two groups. Details of concomitant surgical procedures performed and postoperative complications were also evaluated.

RESULTS

All clinical outcome variables, including the Foot and Ankle Outcome Score, Visual Analog Scale for pain, and ankle range of motion, were comparable between the two groups. Similarly, no statistically significant differences were observed in the development of post-traumatic arthritis or in the frequency of syndesmotic widening 24 months postoperatively. However, the time required for fibular union was significantly longer in the PER group, taking 5.6 ± 2.2 months compared to 3.4 ± 1.3 months in the SER group on average (p < 0.001).

CONCLUSIONS

Our study demonstrated that both types of rotational ankle fractures can achieve equivalent clinical and radiological outcomes with surgical treatment. Given the prolonged time to fibular union in the PER group, careful monitoring during postoperative follow-up is required.

The Impact of Fibular Fixation Method on Pilon Fracture Healing

Background: Pilon fractures are associated with high-energy injuries, and there is presently much debate as to optimal fixation strategies and timing of intervention. There is little evidence comparing the type of fibular fixation during pilon fracture fixation. The purpose of this study was to compare fibular fixation methods in complex pilon injuries as it relates to pilon union rates and development of post-traumatic arthritis. Methods: This was a retrospective review from an urban Level 1 trauma center from January 2009 to May 2019, including patients age ≥ 18 who sustained a pilon fracture with an associated fibula fracture. Patients were allocated into one of three groups based on fibular fracture treated with plating, intramedullary device, or no fixation. Radiographic analysis was performed postoperatively and at final follow up to evaluate for tibial or fibular nonunion, malunion, talocrural angle, and ankle Kellgren-Lawrence grade. Results: Of the 107 patients in this study, 42 underwent surgical fixation of their fibular fracture. There were no differences with respect to tibial or fibular union rates amongst the three groups. Furthermore, there were no differences in the presence of radiographic ankle arthritis at final follow up. However, Kellgren-Lawrence arthritis grading did appear to be a more severe grade in patients who did not undergo fibular fixation (p = 0.001). Conclusions: Fibular intramedullary fixation does not appear to influence tibial or fibular nonunion rates as compared to plating in complex pilon injuries.

Prevalence and Associated Factors of Ankle Osteoarthritis in Achondroplasia: A Retrospective Radiographic Assessment of 134 Patients

OBJECTIVE

The primary aim of this study is to examine the prevalence of ankle osteoarthritis in patients with achondroplasia and to assess the impact of surgical correction of lower limb alignment on this prevalence. The secondary aim is to identify radiographic parameters associated with ankle osteoarthritis.

DESIGN

This retrospective cohort study included 134 patients (268 ankles) who visited our institution between March 2014 and February 2023. Lower limb alignment was assessed using the mechanical axis deviation, lateral distal tibial angle, anterior distal tibial angle, and talar tilt angle. Ankle osteoarthritis was evaluated using the Van Dijk Osteoarthritis score and modified Kellgren-Lawrence (K-L) scale by 2 experienced orthopedic surgeons.

RESULTS

The prevalence of ankle osteoarthritis in our study cohort was 29%, and that of advanced ankle osteoarthritis defined by Van Dijk Osteoarthritis scale III or modified K-L grade 4 was 0.8% (aged <40 years, 22%, and 0%; aged ≥40 years, 42% and 2%, respectively). Talar tilt angle was the only radiographic parameter that showed a significant correlation with the degree of ankle osteoarthritis (Van Dijk Osteoarthritis score, rs = 0.403, P < 0.001; modified K-L grade, rs = 0.385, P < 0.001).

DISCUSSION

The prevalence of ankle osteoarthritis in achondroplasia is moderate, but the progression to advanced stages is uncommon. Ankle osteoarthritis in achondroplasia is strongly associated with increased talar tilt angle. This finding emphasizes caution regarding ankle osteoarthritis in achondroplasia with a nonparallel tibiotalar articular surface. Clinicians should, therefore, consider regularly assessing the talar tilt angle in patients with achondroplasia.

A systematic review: Radiological findings at a minimum of 3 years follow-up for unstable ankle fractures in adults treated with surgery

BACKGROUND

Radiological investigations are critical to diagnosis and treatment of many musculoskeletal diseases including detecting earliest degenerative changes (osteoarthritis (OA)) seen in patients with unstable ankle fractures managed surgically. Despite the high incidence of ankle OA, research into early detection using imaging remains sparse.

OBJECTIVES

To identify the incidence of OA on postoperative imaging in adults with unstable ankle fractures after a minimum follow-up of 3 years with a correlation to patient reported outcomes.

KEY FINDINGS

767 studies were identified on 5 database searches, and 492 abstract titles were screened, while 53 papers were selected for full review. From these only 8 articles met the inclusion criteria. A total of 905 participants aged 18 years and above (mean 46.4 years, 53.8 % male) presented with a range of ankle fracture classifications. This includes 423 cases of Weber classification, 225 cases of OTA/AO, 204 Lauge-Hansen classification, and 53 medial malleoli. From these, 34.7 % cases of OA were identified (minimum of the 3-year follow-up) on different imaging modalities. Our results revealed that mild to moderate OA is common, and functional outcome is mainly good to excellent.

CONCLUSION

1 in 3 patients treated for unstable ankle fracture with open reduction internal fixation will show signs of radiological OA after 3-7 years of index procedure, though with good functional outcome. We were unable to correlate the grade of radiological OA observed with clinical OA. Despite the low sensitivity of X-ray in early detection of OA, we identified a lack of studies in utilising MRI and/or CT imaging, indicating the need for further research. Clinicians should consider using MRI/CT imaging for early detection of OA for patients following unstable ankle fractures, to improve early detection and consequently improve patient reported outcomes.

LEVEL OF CLINICAL EVIDENCE

Systematic review = 1.

Osteosynthesis with anatomic reduction after malleolar fractures improves ten years outcome: a single center trial

INTRODUCTION

Malleolar fractures are the most common ankle fractures and a major risk factor for ankle osteoarthritis in the long-term. Little is known about modifiable risk factors for a satisfactory outcome. This study aimed to assess the long-term clinical, functional and radiological outcomes in patients after osteosynthesis.

METHODS

In this retrospective single center study, we assessed the difference in patients who underwent surgical intervention for malleolar fractures sustained between 2007 and 2014. The reduction was assessed on the first postoperative radiograph. At follow-up patients completed a questionnaire, including the European Foot and Ankle Society (EFAS) and Short Form-12 (SF-12) scores to evaluate patient-reported outcomes and quality of life. Ankle osteoarthritis was assessed using the Kellgren and Lawrence classification.

RESULTS

One hundred seventeen patients, 102 with anatomic reduction and 15 with malreduction, were reached at mean follow-up at 11.4 years and 10.9 years. The mean EFAS score was 18,0 for anatomic and 16,1 for nonanatomic reduction and 6.1 and 4.5 for the sport component. The rate of satisfaction with the result was 8.2 in anatomic reduction and 7.5 in the malreduction. There was no significant difference in the SF-12 group between the two groups. Anatomic reduction is a protective facture for a satisfactory outcome in the univariate model with the hazard ratio of 5.94.

CONCLUSION

Anatomic reduction is one of the strongest protective factors for satisfactory outcome after malleolar fractures in a follow-up of more than 10 years.

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Does Deltoid Ligament Repair Influence the Progression of Posttraumatic Arthritis in Logsplitter Injuries?

OBJECTIVE

To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries.

METHODS

DESIGN

Retrospective cohort.

SETTING

Academic, Level I trauma center.

PATIENT SELECTION CRITERIA

Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation (ORIF) with or without deltoid ligament repair from January 2008 to October 2021.

OUTCOME MEASURES AND COMPARISON

The rate of posttraumatic arthritis (PTOA) development at the final follow-up (minimum 6 months) after ORIF was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2 mm, and a medial clear space ≤4 mm was assessed at 6 weeks postoperatively with weight-bearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated.

RESULTS

Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow-up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at the final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, P = 0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) than those who did not (52%), P = 0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared with those who did not (0% vs. 17%, P = 0.013).

CONCLUSIONS

Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize the risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during ORIF may facilitate acceptable reduction and decrease the rate of PTOA and progression to arthrodesis in these injuries.

LEVEL OF EVIDENCE

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

The Mid- and Long-Term Consequences After Surgically Treated Lisfranc Injuries: A Case Series and Review of the Literature

Background Long-term follow-up data are difficult to collect, especially in uncommon foot injuries. Therefore, it is rare to find publications that include patient-reported outcomes. Therefore, a case series and systematic review are provided to evaluate mid- and long-term outcomes. Methods Patients operated for a Lisfranc injury in our hospital, between 2010 and 2016, were included. Patients were invited to fill out a combined European Foot and Ankle Score (EFAS) and Short Form (SF-12) questionnaire and to undergo an x-ray of the operated foot. In addition, a systematic review of the literature was performed, and our results were compared with that review. Results Fourteen out of 29 patients (48%, four male, 10 female) were seen at a mean follow-up of 8.3 years. Initial Hardcastle & Myerson Classification was: two A (14%); one B1 (7%); 10 B2 (71%); and one C2 (7%). Three patients underwent multiple surgeries: one external fixation followed by definitive stabilization, and two received fasciotomies (14%). The median EFAS score was 15.5, the EFAS sports score was 14, the SF-mental score was 55.73, and the SF-physical score was 48.25. There was substantial variability in outcomes between patients. 12 patients (86%) also underwent a follow-up X-ray exam, demonstrating a mean Kellgren-Lawrence score of 2.7. In the systematic review, 20 studies and 1052 feet with an average follow-up of 73 months met the inclusion criteria. Most cases underwent K-wire fixation (396 feet, 37.6%). Screw-only fixation was the next most common treatment (306 feet, 29.1%), followed by plate fixation (46 feet, 4.4%). Only three studies present primary arthrodesis in 68 (7.5%) cases. In 47 of the 686 patients (6.8%) with osteosynthesis (open reduction and internal fixation (ORIF)) a secondary definitive arthrodesis of the Lisfranc joint was required later. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 75. Conclusion Patients need to be informed about the possibility of limitations of activity, including sporting activity. Mid-term follow up studies are manly limited to ORIF. No operative technique shows an advantage in the mid-term.

The volumes of amygdala subregions and peripheral programmed cell death protein-1 levels are associated with cognitive decline in individuals with knee osteoarthritis

BACKGROUND

Persistent pain is a prominent symptom of knee osteoarthritis (KOA) and has been associated with cognitive decline in individuals with KOA. The amygdala, a complex structure consisting of nine subnuclei, and programmed cell death protein-1 (PD-1) levels play crucial roles in pain regulation and cognitive processing. This study aims to investigate the relationships among amygdala subregion volumes, cognitive function, and PD-1 levels to elucidate the underlying mechanism of cognitive decline in KOA.

METHODS

In this cross-sectional study, we recruited 36 patients with KOA and 25 age/gender-matched healthy controls for neuropsychological tests, structural magnetic resonance imaging scanning, and measurement of serum PD-1 levels. We used the atlas provided by FreeSurfer software to automatically segment the amygdala subnuclei. Subsequently, we compared the volumes of amygdala subregions between groups and explored their correlation with clinical scores and PD-1 levels.

RESULTS

Compared to healthy controls, individuals with KOA exhibited significantly lower scores on global cognition tasks, such as long-delay free recall, short-delay free recall, and immediate recall tasks. Moreover, they displayed decreased volumes in lateral nucleus basal nucleus paralaminar nucleus while showing increased volumes in accessory basal nucleus, central nucleus, medial nucleus, and cortical nucleus. Within the KOA group specifically, paralaminar volume was negatively correlated with immediate recall scores; pain scores were negatively correlated with global cognition; basal volume was negatively correlated with PD-1 levels.

CONCLUSION

Our findings highlight those alterations in amygdala subregion volumes along with changes in serum PD-1 levels may contribute to observe cognitive decline among individuals suffering from KOA.

Prognostic factors and the value of radiographic osteoarthritis for persistent complaints after referral for ankle radiography

BACKGROUND

Ankle symptoms are a common reason to consult the general practitioner and often persist for years. In a population referred for ankle radiography, the prevalence of radiographic osteoarthritis (OA) is substantial, but its additional predictive value for persistent symptoms is unknown. Therefore, we examined the prognosis of symptoms 2-3 years after referral for ankle radiography, assessed clinical prognostic factors, and the additional predictive value of radiographic OA for persistent ankle complaints.

METHODS

We included 893 adults referred for ankle radiography and studied the following candidate prognostic factors at baseline: age, sex, body mass index (BMI), referral for chronic complaints (>3 months), pain during activity (NRS-11) and presence of stiffness and functional loss as predominant symptom. X-rays were scored for radiographic OA. After 2-3 years participants were invited for a follow-up questionnaire including persistence of ankle complaints. To assess prognostic factors for persistent complaints, uni- and multivariable logistic regression were used.

RESULTS

Of the 194 responders at follow-up, ankle complaints persisted in 71(36.6 %). BMI (OR 1.08; 95 % CI 1.01-1.15), stiffness as predominant symptom (OR 1.69; 95 % CI 0.89-3.21), and chronic complaints (OR 2.84; 95 % CI 1.45-5.57) were in the initial model for persistent complaints (AUC=0.69). After adding radiographic OA (OR 2.36; 95 % CI 1.01-5.50), the AUC of the final model became 0.70.

CONCLUSION

Ankle complaints persist in a considerable proportion of patients 2-3 years after referral for ankle radiography. BMI, chronic complaints and radiographic OA are prognostic factors for persistent complaints, but the additional predictive value of radiographic OA on top of clinical factors is negligible.

Incidence of post-traumatic osteoarthritis in 44B ankle fractures: Analysis of risk factors

Objective

The purpose of this study was to analyse the clinical and radiographic data of a consecutive series of patients treated surgically for AO/OTA 44B ankle fracture at Ferrara University Hospital, Italy, with a view to identifying risk factors contributing to worse clinical and radiographic outcomes with a minium follow up of 6 years.

Materials and methods

For each patient the following data were recorded: gender, age, Body Mass Index (BMI), follow up (months), previous ankle sprains, type of work, Kellgren-Lawrence (K&L) score, AO/OTA classification for ankle fracture, Foot and Ankle Disability Index (FADI score), ankle dislocation, syndesmotic transfixation, quality of reduction.

Results

FADI score in patients with AO/OTA 44B1 fracture was 95.5±7.5, in 44B2 it was 90.0±8.4 and in 44B3 it was 84.0±13.0 (p25 it was 88.6±11.4 (p=0.047 95%I.C. 0.01-8.10). In case of fracture-dislocation there was a statistically significant difference in the FADI (94.4±6.0 vs 85.8±11.98)(P=0.002 95% I.C. 0.01-8.9). In the former group, there was a statistically significant difference in the ​the K&L (1.97±0.65 vs 2.63±0.85) (P=0.006 95% I.C 0.01-1.00).Finally, the quality of the reduction was a statistically significant parameter in both the FADI and K&L (P=0.012 95% I.C. 0.90-10.60 and P=0.012 95%I.C. 0.01-1.00 respectively).

Conclusion

The most influential risk factors for worse outcome in AO/OTA 44B ankle fractures were found to be BMI, injury severity, fracture-dislocation and reduction quality.

Nonoperative Management of High Ankle Sprains: A Case Series With ≥18-Year Follow-up

BACKGROUND

High ankle sprains are common athletic injuries and can be associated with long-term sequelae. Regardless of operative or nonoperative treatment, there is a paucity of data in the literature about the long-term outcomes of high ankle sprains.

HYPOTHESIS

Nonoperative treatment of high ankle sprains utilizing a standardized protocol will result in good long-term outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who experienced a high ankle sprain without radiographic diastasis of the syndesmosis were identified from a previous study database and contacted for long-term follow-up. All patients were high school or National Collegiate Athletic Association Division IA athletes at initial injury and were treated nonoperatively with the same standardized protocol. Patients completed a questionnaire that included documentation of any interim ankle injuries, 2 different patient-reported outcome scores, and ankle radiographs to conduct Kellgren-Lawrence scoring for ankle osteoarthritis.

RESULTS

In total, 76 cases in 74 patients were identified in the database. A total of 40 patients were successfully contacted, and 31 patients (24 collegiate and 7 high school athletes) with 33 high ankle sprains completed the survey (31/40; 77.5%). The mean age at follow-up was 45 years (range, 34-50 years), with a mean time from injury to follow-up of 25 years. Overall, 93.5% (n = 29) of the respondents were male, and 42% (n = 13) of the respondents reported an ipsilateral ankle injury since their initial injury, with 16% (n = 5) having ankle or Achilles surgery. The mean Patient-Reported Outcomes Measurement Information System-10 score was 53.4 (SD, 8.3; range, 37.4-67.7), PROMIS median (IQR), 54.1 (39.9, 68.3), and the mean Self-reported Foot and Ankle Score score was 42.7 (SD, 5.86). Follow-up ankle radiographs were obtained in 11 (35%) of the respondents; 27% had Kellgren-Lawrence grade >2 osteoarthritis, and 36% had signs of heterotopic ossification on imaging. The mean tibiofibular clear space was 4.5 mm, and the mean tibiofibular overlap was 7.15 mm, with 27% of patients demonstrating some tibiotalar narrowing.

CONCLUSION

At long-term follow-up, nonoperative management of high ankle sprains without diastasis on imaging was associated with acceptable patient-reported functional outcomes and low rates of subsequent ankle injuries. There was a high incidence of arthritis, but most cases were not clinically significant. This case series shows the natural history of nonoperatively treated high ankle sprains and may serve as a comparison for different management techniques in the future.

Weight-Bearing CT for Diseases around the Ankle Joint

Weight-bearing computed tomography (WBCT) enables acquisition of three-dimensional bony structure images in a physiological weight-bearing position, which is fundamental in understanding the pathologic lesions and deformities of the ankle joint. Over the past decade, researchers have focused on validating and developing WBCT measurements, which has significantly enhanced our knowledge of common foot and ankle diseases. Consequently, understanding the application of WBCT in clinical practice is becoming more important to produce improved outcomes in the treatment of disease around the ankle joint. This review will describe an overview of what is currently being evaluated in foot and ankle surgery using WBCT and where the course of research will be heading in the future.

Homeopathic Ankle Dislocation for Treatment of Unstable Trimalleolar Fractures Involving Posterior Die-Punch Fragment: A Retrospective Cohort Study

OBJECTIVES

Unstable trimalleolar fractures are relatively complex and more difficult to manage if die-punch fracture is present. We aimed to evaluate the curative effect of homeopathic ankle dislocation on the unstable trimalleolar fractures involving posterior die-punch fragments.

METHODS

A total of 124 patients diagnosed with unstable trimalleolar fractures combined with post-die punch fragment between June 2008 and June 2020 were retrospectively included. Patients who received homeopathic ankle dislocation were named as the experimental group, and patients who accepted conventional treatment were control group. The fracture healing time, wound healing, American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS), visual analogue scale (VAS), the Kellgren-Lawrence arthritis grading scale (KLAGS) and short-form 36 score (SF-36) scores were collected. Student t-test was used for fracture healing time. Wound healing and SF-36 were compared using the Mann-Whitney test. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS. χ2-test was used for KLAGS.

RESULTS

AOFAS showed statistically significant differences between the two groups (p = 0.001). In non-weight-bearing and weight-bearing conditions, VAS scores were significant different between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group was superior to the control group in terms of physical function (p = 0.022), role-physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042).The operation time of experimental group was shorter than that of control group (p < 0.001).

CONCLUSION

Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die-punch fragment, which can provide better functional outcomes while shortening the operation time and recovery period.

Primary Ankle Fusion Using an Antegrade Nail Into the Talus for Early Treatment of OTA Type C3 Distal Tibial Plafond Fractures: A Preliminary Report

BACKGROUND

Type C3 distal tibial plafond fractures consistently show poor outcomes with high complication rates and significant risk of posttraumatic arthritis. We describe a minimally invasive technique of performing a primary ankle fusion using an anterograde tibial nail and compare our early results to traditional methods of fixation.

METHODS

During the acute admission, the patient undergoes an arthroscopic preparation of the ankle joint and insertion of an anterograde nail into the talus. This technique is described in detail and presented alongside a retrospective 5-year review of all adult C3 distal tibial plafond fractures from our center.

RESULTS

Twenty-six patients (8 open fractures) had been fixed traditionally using open reduction internal fixation (24 patients) and circular frames (2 patients) with an average follow-up of 20 months. Those internally fixed had protected weightbearing for 3 months. Complications included deep infection (12%), nonunion (8%), malunion (4%), severe posttraumatic osteoarthritis (27%), and the secondary conversion to ankle replacement/fusion (12%) requiring an average of 3 reoperations.Six patients underwent primary fusion (3 open fractures) with an average follow-up of 18 months. Patients were allowed to immediately weightbear. There were no reported complications and the primary fusion group demonstrated shorter hospital stays, faster return to work, and higher mean self-reported foot and ankle score (SEFAS) compared to those treated with ORIF.

CONCLUSION

C3 distal tibial plafond fractures are difficult to manage and there has not been a satisfactory method of treating them that allows early return to work, has a low risk of complications, and reduces the risk of posttraumatic tibiotalar arthritis.We present our initial results with a method that uses traditional arthroscopic techniques to prepare the tibiotalar joint together with minimally invasive anterograde tibiotalar nailing. In this initial report of a small group of patients, we found that surgery can be performed once the swelling has subsided after injury and that allowing weightbearing as tolerated did not appear to have a negative effect on initial outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures: A Randomized Clinical Trial

Importance

Unstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.

Objective

To assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.

Design, Setting, and Participants

This superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.

Interventions

Once the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.

Main Outcome and Measure

Olerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).

Results

Among 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P < .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.

Conclusions and Relevance

In this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.

Trial Registration

ClinicalTrials.gov Identifier: NCT03362229.

Does a rupture of the lateral ankle ligament need to be repaired in supination-adduction type II (OTA/AO 44A2) fractures?

PURPOSE

To evaluate the outcomes of patients with supination-adduction (SAD) type II (OTA/AO 44A2) fractures who had a lateral ankle ligament rupture repaired compared with patients who did not have a lateral ankle ligament repaired using patients who underwent fibula fracture fixation as a control group.

METHODS

A retrospective analysis of all 104 patients diagnosed with SAD type II fractures from January 2011 to December 2020 and managed operatively was performed. The patients were divided into three groups: 32 patients with ruptures of the lateral ligaments that were not repaired (group A), 34 patients with ruptures of the lateral ligaments that were repaired (group B), and 38 patients with fibula fracture fixation acting as the control group (group C). The objective outcomes including radiographic findings, the ankle range of motion, the manual ankle stress tests, and complications were gained from the record of the last time in outpatient clinics. The functional outcomes including the identification of functional ankle instability (IdFAI) scores were collected postoperatively at 12-month intervals to assess clinical outcomes. The Manchester Oxford Foot Questionnaire (MOXFQ) and Karlsson scoring scale were also recorded at the last follow-up.

RESULTS

The mean follow-up of the objective and subjective functional outcomes was 23.4 (range, 13-42) and 76.9 (range, 25-134) months, respectively. There was no significant difference in the radiographic findings, the ankle range of motion and complications between the three groups. All ankles were found to be stable using the manual ankle stress test in both group A and group B. The IdFAI scores showed a significant difference between group A and group B (1.12 ± 1.3 vs 0.35 ± 0.69; p < 0.001) in the first year of follow-up and no significant difference after the first year. No differences were noted in MOXFQ scores or Karlsson scores among the groups.

CONCLUSION

Directly repairing the lateral ligament could minimize the proportion of the first year of postoperative functional ankle instability, although the final stability of the ankle and clinical outcomes were not significantly different in SAD type II fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

The modulation effects of the mind-body and physical exercises on the basolateral amygdala-temporal pole pathway on individuals with knee osteoarthritis

Background/Objective

To investigate the modulatory effects of different physical exercise modalities on connectivity of amygdala subregions and its association with pain symptoms in patients with knee osteoarthritis (KOA).

Methods

140 patients with KOA were randomly allocated either to the Tai Chi, Baduanjin, Stationary cycling, or health education group and conducted a 12 week-long intervention in one of the four groups. The behavioral, magnetic resonance imaging (MRI), and blood data were collected at baseline and the end of the study.

Results

Compared to the control group, all physical exercise modalities lead to significant increases in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score (pain relief) and serum Programmed Death-1 (PD-1) levels. Additionally, all physical exercise modalities resulted in decreased resting state functional connectivity (rsFC) of the basolateral amygdala (BA)-temporal pole and BA-medial prefrontal cortex (mPFC). The overlapping BA-temporal pole rsFC observed in both Tai Chi and Baduanjin groups was significantly associated with pain relief, while the BA-mPFC rsFC was significantly associated with PD-1 levels. In addition, we found increased fractional anisotropy (FA) values, a measurement of water diffusion anisotropy of tissue that responded to changes in brain microstructure, within the mind-body exercise groups' BA-temporal pole pathway. The average FA value of this pathway was positively correlated with KOOS pain score at baseline across all subjects.

Conclusions

Our findings suggest that physical exercise has the potential to modulate both functional and anatomical connectivity of the amygdala subregions, indicating a possible shared pathway for various physical exercise modalities.

Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures?

INTRODUCTION

Surgical treatment of AO/OTA 43-C pilon fractures has not yet taken a standard form. We aimed to evaluate whether patients that appeared to be labelled as unsupported columns according to the four-column theory would affect long-term clinical and radiological outcomes.

MATERIALS AND METHODS

Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019 were included in the study. 53 fractures in 52 patients who received osteosynthesis were categorized based on the fixed columns. These groups were formed as fully supported columns (FSC- Group A), partly supported columns (PSC-Group B), Ankle range of motions (ROM), Burwell Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System, Olerud-Molander Ankle Score, Visual Analog Scale were used for evaluating radiological and functional outcomes.

RESULTS

The mean follow-up period was 72.6 (12-131) months. Mean age was 42.6 (18-76). Two groups were homogenously distributed in terms of age (p = 0.785), sex (p = 0.376), laterality (p = 0.732), smoking status (p = 0.488) and reduction quality. There was no difference in AOFAS score (p = 0.452), Olerud-Molander score (p = 0.354) and VAS scores (p = 0.589). TAS, TLS and TT angle measurements suggested no difference between groups (p = 0.493, p = 0.834, p = 0.577). There was no difference between groups in terms of infection (p = 0.734), malunion (p = 0.688) and arthritis (p = 0.483) CONCLUSION: We presented findings that contradicted the hypothesis positing the existence of four distinct columns in pilon fractures, as well as the notion that each fractured column requires support from distinct implants.

LEVEL OF EVIDENCE

Level III.

Joint capsule innervation does not explain the difference in symptoms between scaphotrapezial and trapeziometacarpal osteoarthritis

OBJECTIVES

Peritrapezial osteoarthritis (OA) includes scaphotrapezial and trapeziometacarpal OA. In clinical practice, scaphotrapezial OA seems better tolerated than trapeziometacarpal OA, with fewer complaints and better tolerance. The difference in pain could be linked to a difference in joint capsule innervation, perhaps with fewer nerve fibers in the scaphotrapezial than the trapeziometacarpal joint.

MATERIALS AND METHODS

We performed a histologic evaluation of these two joints to compare their respective innervation in 17 cadaveric specimens with peritrapezial OA. Radiographic scoring confirmed the presence of peritrapezial OA. Mean Kellgren-Lawrence score was 2.2 ± 1.1 in the trapeziometacarpal joint and 1.5 ± 0.7 in the scaphotrapezial joint (p = 0.08).

RESULTS

There was no difference between scaphotrapezial and trapeziometacarpal joints in number of neurofilaments: 5.2 ± 3.9 and 4.4 ± 4.5, respectively (p = 0.20). A significant difference was found in S100 staining (myelinated structures), with a higher rate in the scaphotrapezial joint: 11.8 ± 7.5 vs 6.6 ± 5.2 (p = 0.005).

CONCLUSION

The present study suggests that lower tolerance of trapeziometacarpal OA is not due to a difference in joint capsule innervation. On the contrary, we found a higher rate of myelinated tissues in the scaphotrapezial joint. These results suggested other pain pathways to explain clinical observations.

Imaging of osteoarthritis from the ankle through the midfoot

Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.

Intra-articular bone marrow mononuclear cell therapy improves lameness from naturally occurring equine osteoarthritis

Osteoarthritis (OA) can be debilitating and is related to impaired resolution of synovial inflammation. Current treatments offer temporary relief of clinical signs, but have potentially deleterious side effects. Bone marrow mononuclear cells (BMNC) are a rich source of macrophage progenitors that have the ability to reduce OA symptoms in people and inflammation in experimentally-induced synovitis in horses. The objective of this study was to evaluate the ability of intra-articular BMNC therapy to improve clinical signs of naturally occurring equine OA. Horses presenting with clinical and radiographic evidence of moderate OA in a single joint were randomly assigned to 1 of 3 treatment groups: saline (negative control), triamcinolone (positive control), or BMNC (treatment group). Lameness was evaluated subjectively and objectively, joint circumference measured, and synovial fluid collected for cytology and growth factor/cytokine quantification at 0, 7, and 21 days post-injection. Data were analyzed using General Estimating Equations with significance set at p < 0.05. There were no adverse effects noted in any treatment group. There was a significant increase in synovial fluid total nucleated cell count in the BMNC-treated group on day 7 (median 440; range 20-1920 cells/uL) compared to day 0. Mononuclear cells were the predominant cell type across treatments at all time points. Joint circumference decreased significantly in the BMNC-treated group from days 7 to 21 and was significantly lower at day 21 in the BMNC-treated group compared to the saline-treated group. Median objective lameness improved significantly in the BMNC group between days 7 and 21. GM-CSF, IL-1ra, IGF-1, and TNF-α were below detectable limits and IL-6, IL-1β, FGF-2 were detectable in a limited number of synovial fluid samples. Inconsistent and limited differences were detected over time and between treatment groups for synovial fluid PGE2, SDF-1, MCP-1 and IL-10. Decreased lameness and joint circumference, coupled with a lack of adverse effects following BMNC treatment, support a larger clinical trial using BMNC therapy to treat OA in horses.

Radiographic Evidence of Early Posttraumatic Osteoarthritis following Tibial Plateau Fracture Is Associated with Poorer Function

To determine if radiographic evidence of posttraumatic osteoarthritis (PTOA) following tibial plateau fracture correlates with poorer clinical and functional outcomes, patients with tibial plateau fractures were followed at 3, 6, and 12 months. All patients had baseline radiographs and computed tomography scan. Radiographs obtained at each follow-up were reviewed for healing, articular incongruence, hardware positional changes, and the development of postinjury arthritic change. Cohorts were determined based on the presence (PTOA) or absence (NPTOA) of radiographic evidence of PTOA. Demographics, fracture classification, complications, additional procedures, and functional status were compared between cohorts. Sixty patients had radiographic evidence of PTOA on follow-up radiographs at a mean final follow-up of 24.2 months. The NPTOA cohort was composed of 210 patients who were matched to the PTOA cohort based on age and Charlson comorbidity index. Mean time to fracture union for the overall cohort was 4.86 months. Cohorts did not differ in Schatzker classification, time to healing, injury mechanism, or baseline Short Musculoskeletal Function Assessment (SMFA). Patients with PTOA had a greater degree of initial depression and postoperative step-off, higher incidence of initial external fixator usage, higher rates of reoperation for any reason, and higher rates of wound complications. Associated soft tissue injury and meniscal repair did not coincide with the development of PTOA. Range of motion and SMFA scores were significantly worse at all time points in patients with PTOA. Although fracture patterns are similar, patients who required an initial external fixator, had a greater degree of initial depression or residual articular incongruity, underwent more procedures, and developed an infection were found to have increased incidence of PTOA. Radiographic evidence of osteoarthritis correlated with worse functional status in patients. The goal of surgery should be restoration of articular congruity and stability to mitigate the risk of PTOA, although this alone may not prevent degenerative changes. Patients with early loss of range of motion should be aggressively treated as this may precede the development of PTOA.

Is radiographic osteoarthritis associated with pain and disability of the ankle?

Objective

Ankle osteoarthritis (OA) is relatively understudied. It often affects younger people compared to OA in other joints. Evidence on the association between radiographic OA and ankle symptoms remains contradicting. We therefore examined the association of degree of radiographic talocrural, subtalar and talonavicular OA with severity of ankle pain, disability and predominant symptoms.

Method

A cross-sectional study was conducted in a radiology department serving primary and secondary care. From the total study population (adults referred for ankle radiography), patients with chronic ankle complaints were selected (N ​= ​231). Before radiography, participants completed a questionnaire on severity of ankle pain and disability using the Ankle Osteoarthritis Scale (AOS), and on their predominant symptoms, i.e. pain, functional loss, stiffness and/or instability. To assess the associations of the Kellgren-Lawrence scores (0, 1 or ≥2) with the primary outcomes (AOS), linear regression, and with the secondary outcomes predominant symptoms, logistic regression analyses were applied.

Results

Radiographic OA was not associated with AOS-pain and -disability. Radiographic talocrural OA was associated with functional loss (OR 3.26, 95% CI: 1.31; 8.11). A positive trend was seen between radiographic talonavicular OA and stiffness (OR 2.63, 95% CI: 0.97; 7.15).

Conclusion

The presence of radiographic OA is not associated with severity of ankle pain and disability in patients with chronic ankle complaints referred for ankle radiography. However, radiographic talocrural OA is associated with functional loss and radiographic talonavicular OA with stiffness as predominant symptom. These findings may contribute to better recognition of ankle OA in clinical practice.

Platelet-Rich Plasma Power-Mix Gel (ppm)-An Orthobiologic Optimization Protocol Rich in Growth Factors and Fibrin

Platelet- and fibrin-rich orthobiologic products, such as autologous platelet concentrates, have been extensively studied and appreciated for their beneficial effects on multiple conditions. Platelet-rich plasma (PRP) and its derivatives, including platelet-rich fibrin (PRF), have demonstrated encouraging outcomes in clinical and laboratory settings, particularly in the treatment of musculoskeletal disorders such as osteoarthritis (OA). Although PRP and PRF have distinct characteristics, they share similar properties. The relative abundance of platelets, peripheral blood cells, and molecular components in these orthobiologic products stimulates numerous biological pathways. These include inflammatory modulation, augmented neovascularization, and the delivery of pro-anabolic stimuli that regulate cell recruitment, proliferation, and differentiation. Furthermore, the fibrinolytic system, which is sometimes overlooked, plays a crucial role in musculoskeletal regenerative medicine by regulating proteolytic activity and promoting the recruitment of inflammatory cells and mesenchymal stem cells (MSCs) in areas of tissue regeneration, such as bone, cartilage, and muscle. PRP acts as a potent signaling agent; however, it diffuses easily, while the fibrin from PRF offers a durable scaffolding effect that promotes cell activity. The combination of fibrin with hyaluronic acid (HA), another well-studied orthobiologic product, has been shown to improve its scaffolding properties, leading to more robust fibrin polymerization. This supports cell survival, attachment, migration, and proliferation. Therefore, the administration of the "power mix" containing HA and autologous PRP + PRF may prove to be a safe and cost-effective approach in regenerative medicine.

Middle-sized posterior malleolus fractures: Fixed versus non-fixed - A prospective randomized study

PURPOSE

This study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome.

METHODS

A prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10-25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years.

RESULTS

Demographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001).

CONCLUSION

Although there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor.

LEVEL OF EVIDENCE

Level I; prospective randomized controlled study.

Salvage of Chronic Syndesmosis Instability: A Retrospective Review With Mid-Term Follow-Up

Malreduced syndesmotic injuries lead to poor outcomes. No consensus exists regarding preferred surgical treatment. This study aims to assess clinical and radiographic outcomes in patients undergoing distal tibiofibular arthrodesis or stabilization. Retrospective review identified patients undergoing distal tibiofibular arthrodesis or stabilization between 2003 and 2019. Surgical factors, revision surgeries, and American Orthopedic Foot and Ankle Score ankle-hindfoot scores were collected. Radiographs were independently evaluated by 4 surgeons. Seventy patients were included. Mean American Orthopedic Foot and Ankle Score scores (n = 33) improved from 48 ± 16 preoperatively to 85 ± 14 (p < .001) at a median follow-up of 31.1 months. Mean Kellgren scores (n = 47) increased from 2.1 ± 1 to 2.5 ± 1 (p < .001) and the mean medial clear space decreased from 3.2 mm ± 0.8 mm to 2.8 mm ± 0.8 mm (p <.001) with no differences between the arthrodesis and stabilization groups. Zero patients progressed to arthroplasty or fusion. Patients demonstrated significant functional improvement after distal tibiofibular arthrodesis and stabilization. Progression of arthritis, while statistically significant, was not clinically significant.

Metabolite asymmetric dimethylarginine (ADMA) functions as a destabilization enhancer of SOX9 mediated by DDAH1 in osteoarthritis

Osteoarthritis (OA) is a degenerative disease with a series of metabolic changes accompanied by many altered enzymes. Here, we report that the down-regulated dimethylarginine dimethylaminohydrolase-1 (DDAH1) is accompanied by increased asymmetric dimethylarginine (ADMA) in degenerated chondrocytes and in OA samples. Global or chondrocyte-conditional knockout of ADMA hydrolase DDAH1 accelerated OA development in mice. ADMA induces the degeneration and senescence of chondrocytes and reduces the extracellular matrix deposition, thereby accelerating OA progression. ADMA simultaneously binds to SOX9 and its deubiquitinating enzyme USP7, blocking the deubiquitination effects of USP7 on SOX9 and therefore leads to SOX9 degradation. The ADMA level in synovial fluids of patients with OA is increased and has predictive value for OA diagnosis with good sensitivity and specificity. Therefore, activating DDAH1 to reduce ADMA level might be a potential therapeutic strategy for OA treatment.

Prevalence of radiographic ankle osteoarthritis in different subgroups of patients referred for ankle radiography

BACKGROUND

Ankle osteoarthritis(OA) has detrimental effects on physical health and has a relatively early disease onset compared to OA in other joints. However, the prevalence of radiographic ankle OA in different subgroups of patients referred for ankle radiography remains unknown. Therefore, we aimed to determine the prevalence of radiographic talocrural, subtalar and talonavicular OA(Kellgren-Lawrence scale ≥2) in a population referred for ankle radiography. Moreover, we aimed to identify differences in prevalence between specific subgroups of patients i.e. Body Mass Index (BMI), sex, age and reason for referral.

METHODS

A cross-sectional study was conducted at a radiology department serving primary and secondary care. Patients completed a questionnaire before radiography. Features of radiographic ankle OA were assessed for subgroups of patients, including; BMI, sex, age and reason for referral (chronic vs (sub)acute complaints). To examine the difference in (features of) radiographic OA for subgroups, multinomial and logistic regression were used to calculate Odds Ratios (ORs), with adjustment for age, sex and BMI.

RESULTS

Data from 893 patients that visited the radiology department across 16 months in 2017 or 2018 were included for analysis. Prevalence of radiographic ankle OA was 9.2%, 0.4% and 7.0%, for the talocrural, subtalar and talonavicular joint, respectively. Obesity was associated with radiographic talonavicular OA (adjusted OR 2.16, 95%CI:1.09; 5.26). Radiographic talocrural and talonavicular OA were both positively associated with male sex [(adjusted OR 4.64, 95%CI:276; 7.81) and (adjusted OR 1.95, 95%CI:1.13; 3.35), respectively].

CONCLUSION

Radiographic ankle OA was more common in men and obese patients that were referred to radiology.

Ankle Pain After Medial Opening-Wedge High Tibial Osteotomy in Patients With Knee Osteoarthritis and Concurrent Ankle Osteoarthritis

BACKGROUND

Medial opening-wedge high tibial osteotomy (MOWHTO) in patients with varus knee osteoarthritis (OA) causes changes to ankle and hindfoot alignment. However, the compensatory ability of the ankle and hindfoot varies according to the severity of ankle OA.

PURPOSE

To investigate whether the changes in ankle symptoms and ankle and hindfoot alignments differ after MOWHTO according to the severity of preoperative ankle OA.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The data of 130 patients who were followed for ≥4 years were reviewed. Patients were classified into 2 groups according to their severity of ankle OA: group 1, modified Kellgren-Lawrence grade 0 and 1; group 2, grade ≥2. Four radiographic parameters were examined to evaluate ankle alignment: tibial plafond inclination, talar tilt, talar inclination, and tibial surface angle. The hindfoot alignment was evaluated using the varus-valgus angle (VVA) of the calcaneus. A visual analog scale (VAS) was used to evaluate ankle pain. The patient-reported outcome measure of the knee joint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score.

RESULTS

There were 110 patients in group 1 and 20 patients in group 2. In group 2, the change in talar inclination after MOWHTO was significantly greater and the changes in tibial plafond inclination, talar tilt, and VVA were significantly smaller compared with in group 1 (all P < .05). Ankle pain VAS scores were more severe in group 2 than in group 1 pre- and postoperatively (all P < .05), and group 2 reported that ankle pain worsened postoperatively (P < .05). In both groups, knee WOMAC scores improved, and there were no differences between groups pre- or postoperatively (all P > .05). A multivariate regression analysis demonstrated that a small VVA change (odds ratio, 0.775; P = .027) and severe OA grade of the ankle joint preoperatively (Kellgren-Lawrence grades 2-4 vs 0 and 1; odds ratio, 4.241 [P = .046]) predicted increased ankle pain VAS scores after MOWHTO.

CONCLUSION

Although the patient-reported outcome measures for the knee joint improved irrespective of the presence of ankle OA, ankle pain worsened after MOWHTO in patients with ankle OA. Inadequate compensatory change in hindfoot alignment increased ankle pain in these patients.

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients

BACKGROUND

Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk.

METHODS

We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months.

RESULTS

A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications.

CONCLUSION

In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Outcomes of tibial pilon fracture fixation based on four-column theory

OBJECTIVES

To assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based on the four-column theory in adults.

METHODS

A retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed.

RESULTS

There were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups.

CONCLUSIONS

Kinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.

An Objective Computational Method to Quantify Ankle Osteoarthritis From Low-Dose Weightbearing Computed Tomography

BACKGROUND

The treatment of ankle osteoarthritis (OA) varies depending on the severity and distribution of the associated joint degeneration. Disease staging is typically based on subjective grading of appearance on conventional plain radiographs, with reported subpar reproducibility and reliability. The purpose of this study was to develop and describe computational methods to objectively quantify radiographic changes associated with ankle OA apparent on low-dose weightbearing CT (WBCT).

METHODS

Two patients with ankle OA and 1 healthy control who had all undergone WBCT of the foot and ankle were analyzed. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification using plain radiographs. For each ankle, a volume of interest (VOI) was centered on the tibiotalar joint. Initial computation analysis used WBCT image intensity (Hounsfield units [HU]) profiles along lines perpendicular to the subchondral bone/cartilage interface of the distal tibia extending across the entire VOI. Graphical plots of the HU distributions were generated and recorded for each line. These plots were then used to calculate the joint space width (JSW) and HU contrast.

RESULTS

The average JSW was 3.89 mm for the control ankle, 3.06 mm for mild arthritis (KL 2), and 1.57 mm for severe arthritis (KL 4). The average HU contrast was 72.31 for control, 62.69 for mild arthritis, and 33.98 for severe arthritis. The use of 4 projections at different locations throughout the joint allowed us to visualize specifically which quadrants have reduced joint space width and contrast.

CONCLUSION

In this technique report, we describe a novel methodology for objective quantitative assessment of OA using JSW and HU contrast.

CLINICAL RELEVANCE

Objective, software-based measurements are generally more reliable than subjective qualitative evaluations. This method may offer a starting point for the development of a more robust OA classification system or deeper understanding of the pathogenesis and response to ankle OA treatment.

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months

BACKGROUND

This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence.

METHODS

32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration.

RESULTS

After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction.

CONCLUSIONS

Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.

Midterm Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder

BACKGROUND

In cases of large osteochondral lesions of the talus (OLTs), fresh structural or bulk osteochondral allograft transplantation has yielded favorable outcomes in several retrospective and few prospective case series. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation of the talar shoulder.

METHODS

A prospective evaluation of patients who received a fresh structural allograft of an OLT was performed. Preoperative imaging included magnetic resonance imaging (MRI) and/or computed tomography (CT) with plain radiographs. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 36-Item Short-Form Health Survey (SF-36), visual analog scale (VAS) for pain, and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative imaging were evaluated for allograft assimilation, evidence of arthritic changes, or functional range of motion abnormalities.

RESULTS

Thirty-one patients with a mean age of 41.4 years (±14.1, range 18-69) underwent structural fresh osteochondral allograft transplantation to the talar shoulder and were included in this study. The mean follow-up was 56.2 months (±36.1, range 24-142). The majority of patients were female (n=17, 54.8%), reported some history of prior ankle trauma (n=21, 67.7%), and underwent prior ankle surgery (n=23, 74.2%). The mean lesion size on CT scan was 1879 mm³ (n = 27) compared to the mean lesion size of 3877 mm³ (n = 21) on MRI. There was a significant improvement in the mean preoperative VAS score (P < .0001), SF-36 score (P < .0005), SMFA bother index (P < .0015), and the SMFA function index (P < .0001) at final follow-up. A total of 15 (48.4%) patients underwent an additional surgery following their osteochondral allograft transplant, most commonly arthroscopic debridement or removal of hardware, performed at an average of 25.2 (±13.0) from their index procedure. There was one failure that required a total ankle replacement. The overall graft survival rate was 96.8%.

CONCLUSION

Fresh, structural allograft transplantation resulted in significant improvement in patient-reported postoperative pain and function in patients suffering from OLTs. The graft survival rate was 96.8% at a mean of 56.2 months follow-up, with half of patients requiring a second procedure.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Diagnostic Performance of Ultrasonography for Evaluation of Osteoarthritis of Ankle Joint: Comparison With Radiography, Cone-Beam CT, and Symptoms

OBJECTIVES

To determine the diagnostic performance of ultrasonography (US) for evaluation of the ankle joint osteoarthritic (OA) changes. Cone-beam computed tomography (CT) was used as the gold standard and US performance was compared with conventional radiography (CR). As a secondary aim, associations between the imaging findings and ankle symptoms were assessed.

METHODS

US was performed to 51 patients with ankle OA. Every patient had prior ankle CR and underwent cone-beam CT during the same day as US examination. On US, effusion/synovitis, osteophytes, talar cartilage damage, and tenosynovitis were evaluated. Comparison to respective imaging findings on CR and cone-beam CT was then performed. Single radiologist blinded to other modalities assessed all the imaging studies. Symptoms questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), was available for 48 patients.

RESULTS

US detected effusion/synovitis of the talocrural joint with 45% sensitivity and 90% specificity. For the detection of anterior talocrural osteophytes, US sensitivity was 78% and specificity 79%. For the medial talocrural osteophytes, they were 39 and 83%, and for the lateral talocrural osteophytes 54 and 100%, respectively. Considering cartilage damage of the talus, US yielded a low sensitivity of 18% and high specificity of 97%. Overall, the performance of US was only moderate and comparable to CR. The imaging findings showed only weak associations with ankle symptoms.

CONCLUSIONS

The ability of US to detect ankle OA is only moderate. Interestingly, performance of CR also remained moderate. The associations between imaging findings and WOMAC score seem to be weak in ankle OA.

The Role of Anterior Ankle Arthroscopy in the Management of Ankle Arthritis: Literature Review, Patient Evaluation, Goals of Treatment and Technique

The current body of literature regarding anterior ankle arthroscopic debridement for anterior ankle impingement (AAI) cases with ankle osteoarthritis (OA) has significant limitations. The reported poor outcomes lack the necessary rigor in patient selection, preoperative evaluations and in most reports, the use of a systematic operative approach. Furthermore, the lack of postoperative evaluation by authors using physical examination and radiologic studies to determine the etiology of ongoing pain leaves open the possibility that treatment of impingement was incomplete. For these reasons, it would be inappropriate to conclude that anterior arthroscopic debridement has no role in the treatment of ankle OA. Critical analysis of some studies provides encouragement that this can be a useful intermediate treatment of appropriately selected patients with AAI and ankle OA. The level of required detail in the physical examination and radiologic evaluation is much greater than for more straight-forward cases of soft tissue impingement or simple osteophyte impingement in otherwise healthy joints. The success of the treatment requires a systematic approach to the evaluation and performance of the procedure, which is perhaps why results in the literature have been suboptimal in most series. Future studies should apply this rigorous approach to patient selection, procedure performance, and postoperative analysis to best clarify which patients can be best served with this procedure as part of the various intermediate treatment options for ankle OA.

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Injury Characteristics, Radiographic Outcomes, and Factors Affecting the Rate of Posttraumatic Arthritis in Logsplitter Injuries

OBJECTIVES

To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing posttraumatic arthritis in high-energy transsyndesmotic ankle fracture dislocations or "logsplitter" injuries.

DESIGN

Retrospective cohort study.

SETTING

Academic level one trauma center.

PATIENTS/PARTICIPANTS

Twenty-seven adult patients with logsplitter injuries.

INTERVENTION

All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair.

MAIN OUTCOME MEASUREMENTS

The rate of posttraumatic arthritis at one year along with rate and reasons for reoperation.

RESULTS

Twenty-seven patients were included with a mean follow-up of 14.5 ± 12.5 months. At one-year postoperative, 14 of the 20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. The reoperation rate was 51.9%. There was no significant difference in the arthritis rate with the number of syndesmosis screws used, quality of reduction, or addition of deltoid repair.

CONCLUSIONS

The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required.

LEVEL OF EVIDENCE

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

Radiographic Severity May Not be Associated with Pain and Function in Glenohumeral Arthritis

BACKGROUND

Despite the routine use of plain radiographs to stratify the severity of glenohumeral osteoarthritis, little is known about the relationship between radiographic measures and patient-perceived pain and function.

QUESTIONS/PURPOSES

(1) What radiographic findings are associated with worse pain and function in patients with glenohumeral osteoarthritis? (2) What demographic factors are associated with worse pain and function in patients with glenohumeral osteoarthritis?

METHODS

This retrospective study included patients presenting for an initial office visit for primary glenohumeral osteoarthritis. Patients with other concurrent shoulder pathologic findings, prior surgery, lack of pain and functional scores, recent injection, or inadequate radiographs were excluded. Between January 2017 and January 2019, 3133 patients were eligible based on these inclusion criteria; 59% (1860) had outcome assessments and 48% (893) of those had radiographs. An additional 42% (378) of those with radiographs were excluded because of other shoulder findings, recent injection, prior surgery, or inadequate radiographs, leaving 16% (515 of 3133) who were fully analyzed in this study. A radiographic review included the joint space width, posterior humeral head subluxation, inferior humeral head osteophyte size, cystic change, and head asphericity. Additionally, radiographic arthritis was classified according to the Walch, Samilson-Prieto, and Kellgren-Lawrence classifications by two separate reviewers. Radiographic and demographic criteria as well as the presence of psychologic or mental illness were correlated with VAS Pain (range 1-10; minimal clinically important difference [MCID] 1.6), American Shoulder and Elbow Surgeons (ASES; range 0-100; MCID 13.6), Single Assessment Numeric Evaluation (SANE; range 0-100; MCID 14), and Simple Shoulder Test (SST; range 0-12; MCID 1.5) scores using univariate and multivariable regression analyses.

RESULTS

After accounting for age, gender, and psychologic illness in the multivariable analysis, we found that patients with Samilson-Prieto Grade 4 arthrosis had lower VAS Pain scores (β = -1.9; p = 0.02) than those with Grade 0 or 1 did; however, no clinically important associations were found between Samilson-Prieto Grade 4 and ASES (β = 7; p = 0.25), SANE (β = 4; p = 0.63), or SST (β = 0.5; p = 0.62) scores. No clinically important associations were found between Kellgren-Lawrence Grade 3 and VAS Pain (β = 1.4; p = 0.10), ASES (β = -8; p = 0.22), SANE (β = -13; p = 0.11), or SST scores (β = 0.4; p = 0.66). Radiographic joint space and posterior subluxation also did not have any clinically important associations with VAS Pain or functional scores. In assessing Walch glenoid type, there was no clinically important association between glenoid type and VAS Pain (F = 3.1; p < 0.01), ASES (F = 1.9; p = 0.15), SANE (F = 0.45; p = 0.66), or SST scores (F = 0.76; p = 0.71). Men had higher SST scores than women did (β = 2.0; p < 0.01), but there were no clinically important differences in VAS Pain (β = -0.4; p = 0.04), ASES (β = 6; p < 0.01), or SANE (β = 4; p = 0.07) scores. No clinically important association was found between age or the presence of any psychologic illness and VAS Pain or functional scores.

CONCLUSION

In patients with glenohumeral arthritis, no consistent clinically important differences in pain or function were discovered with respect to radiographic or demographic factors. Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity. Future studies can build on these findings by examining other non-radiographic or demographic factors that affect pain in patients with shoulder arthritis, such as psychological factors.

LEVEL OF EVIDENCE

Level III, prognostic study.

Poor Outcomes After Anterior Impaction Pilon Fractures

INTRODUCTION

Pilon fractures occur through high-energy axial-loading trauma and are frequently associated with complications. The goal of this study was to assess whether anterior impaction (AI) tibial pilon fractures are associated with increased rates of posttraumatic osteoarthritis (PTOA), secondary surgeries, and lower patient-reported outcomes compared with patients with non-AI pilon fractures.

METHODS

In this retrospective cohort study, 52 pilon fractures in 50 patients were included. The average follow-up was 25 months (range, 12 to 62 in non-AI and 12 to 66 in AI). The Kellgren and Lawrence (KL) score for PTOA, tibiotalar ratio for anterior-posterior talar subluxation, coronal tibiotalar angle, Patient-Reported Outcomes Measurement Information System score, and rates of secondary surgeries and infection were assessed.

RESULTS

The AI group showed radiographic evidence of more advanced PTOA at the final follow-up (KL score 3.1 vs. 2.5, P = 0.021) and a higher rate of implant removal for pain (39% vs. 13%, P = 0.030). AI also had greater anterior talar subluxation on preoperative (P < 0.001) and final follow-up radiographs (P = 0.026). A higher KL score was associated with greater anterior talar displacement on preoperative (r = -0.421, P = 0.003) and final follow-up radiographs (r = -0.359, P < 0.009). No differences were seen in 1-year Patient-Reported Outcomes Measurement Information System scores.

DISCUSSION

AI pilon fractures are associated with recurrent anterior talar subluxation, more severe PTOA, and a higher rate of implant removal for pain compared with non-AI fractures.

Balance is impaired in symptomatic ankle osteoarthritis: A cross-sectional study

BACKGROUND

Ankle osteoarthritis (OA) is associated with several physical impairments but investigations into balance impairments in this population are limited. Understanding balance impairments in ankle OA may help inform the management of this condition.

RESEARCH QUESTION

Does balance overall performance differ between individuals with symptomatic radiographic ankle OA, asymptomatic radiographic ankle OA and healthy controls? Are there any differences in mediolateral or anteroposterior balance, or confidence to perform balance tasks between these groups?

METHODS

Ninety-six volunteers (31 symptomatic radiographic ankle OA, 41 asymptomatic radiographic ankle OA and 24 healthy controls) completed six static balance tasks: bilateral stance on a firm surface, bilateral stance on foam, and tandem stance, all performed with eyes open and closed. Centre of pressure (COP) data were collected using force plates. Confidence to perform each balance task was collected using an 11-point numerical rating scale.

RESULTS

Compared to controls, participants with symptomatic radiographic ankle OA had greater COP area when standing on a firm surface, foam and in tandem with eyes closed (all p < 0.05) and greater total COP sway in both firm surface and tandem stance conditions (p < 0.04). Participants with symptomatic ankle OA had greater COP area (p < 0.04) and total COP sway (p = 0.01) than those with asymptomatic ankle OA during tandem stance. Total COP sway and area were similar between asymptomatic ankle OA and control participants. Some differences in mediolateral and anteroposterior balance were identified between groups. Individuals with symptomatic ankle OA had lower confidence to perform the tandem stance eyes closed task compared to controls.

SIGNIFICANCE

Balance impairments and decreased balance confidence were identified in those with symptomatic radiographic ankle OA compared to asymptomatic individuals with and without radiographic ankle OA. This suggests that balance deficits in ankle OA may be related to symptoms, rather than radiographic evidence of disease.

Plafond Malreduction and Talar Dome Impaction Accelerates Arthrosis After Supination-Adduction Ankle Fracture

BACKGROUND

Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis.

METHODS

A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented.

RESULTS

A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series.

CONCLUSION

Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Investigation of the Effect of Bone Mineral Density on the Postoperative Outcome of Ankle Fractures in Elderly Patients

BACKGROUND

The association between ankle fractures in elderly patients and low bone mineral density (BMD) has recently been recognized, but the effect of BMD on the postoperative outcome of these fractures is unknown. The aim of this study was to investigate the effect of BMD on the postoperative outcome of ankle fractures in elderly patients to evaluate the need for BMD screening.

METHODS

We retrospectively reviewed 48 patients aged 65 years or older who had ankle fractures and underwent dual-energy x-ray absorptiometry to assess BMD after surgical treatment of the fracture. Postoperative outcomes were assessed using the Olerud-Molander Ankle Score (OMAS), visual analog scale (VAS) score for pain, Kellgren and Lawrence (K&L) grading scale score, and quality of fracture reduction. The correlation between the BMD and the outcome measures at 12 months after surgery was analyzed using the Pearson correlation coefficient.

RESULTS

The mean absolute value of BMD was 0.6 ± 0.1 g/cm² (T-score, -1.5 ± 1.2) at the femoral neck and 0.8 ± 0.2 g/cm² (T-score, -1.2 ± 1.5) at the lumbar spine. Osteoporosis was present in 33% of female patients and in 11% of male patients. At 12 months after surgery, the OMAS was 70 ± 17 and the VAS score for pain was 18 ± 17. Of the patients, 20, 21, 5, 1, and 1 had K&L grades of 0, 1, 2, 3, and 4, respectively. None of the clinical and radiographic outcome measures were correlated with the BMD values of the patients.

CONCLUSION

The postoperative outcome of the ankle fractures in elderly patients at 12 months after surgery showed no correlation with femoral neck or lumbar spine BMD at the time of fracture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Midterm Outcome of Subtalar Joint Revision Arthrodesis

BACKGROUND

The outcomes of revision subtalar arthrodesis have received relatively little focus in research compared with primary subtalar arthrodesis outcomes. This study aimed to assess the midterm clinical and radiologic results of subtalar joint revision arthrodesis and to analyze the risk factors that might influence the outcome of this procedure.

METHODS

We performed a retrospective review of 20 patients after subtalar joint revision arthrodesis for malunion, using interposition of iliac crest bone graft. The mean age was 55.75 years and the average follow-up lasted for 48.93 months. Eighty-five percent of the patients had at least 1 risk factor identified prior to revision. Patients' satisfaction and functional outcomes were evaluated with the American Orthopaedic Foot & Ankle Society Scale (AOFAS), the Foot and Ankle Outcome Score (FAOS), the Foot Function Index (FFI), and dynamic pedobarography.

RESULTS

A fusion rate of 80% was recorded whereas 20% of the cases ended with a painful pseudarthrosis requiring additional surgery. Pedobarographic measurements demonstrated that loading has a propensity toward the lateral column, but no substantial effect on the gait of patients. In this group, the following patient-reported outcomes were observed: 70% of the patients were satisfied, 20% of the patients found the result fair, and 10% were not satisfied with the results. Compared with the preoperative evaluation, postoperative functional scores showed significant improvement on the FOAS, AOFAS, and FFI outcome scales.

CONCLUSION

Revision arthrodesis of the subtalar joint remains a challenging issue with a relatively high rate of nonunion, especially in a population of patients with multiple risk factors.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Total Ankle Arthroplasty With Valgus Deformity

BACKGROUND

A substantial coronal plane deformity is common in the context of end-stage ankle osteoarthritis. Recent literature shows a trend toward extending the indication of total ankle arthroplasty in increasingly severe coronal deformities, showing promising results when correct alignment is achieved. Nevertheless, the results of lateral transfibular total ankle replacement (LTTAR) in valgus has not been extensively studied. We aimed to evaluate if the outcomes of LTTAR in ankles with valgus deformity were similar to those with no major deformity at short-term follow-up.

METHODS

This retrospective cohort study included 228 LTTARs. Patients were classified into 2 groups according to the preoperative coronal plane tibiotalar angle (TTS): neutral (less than 10 degrees of coronal deformity, 209 patients) and valgus (above 10 degrees of valgus, 19 patients). Clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS), 12-Item Short Form Health Survey 12 (SF-12) regarding its Physical and Mental Component Summary items. The radiographic evaluation considered anteroposterior and lateral ankle radiographs. Complications were also registered and classified as major or minor. The minimum follow-up was 2 years.

RESULTS

The average AOFAS, VAS, and SF-12 scores improved significantly postoperatively (P < .001), without differences between groups. At final radiographic follow-up, the valgus alignment group did not show significant differences with the neutral alignment group regarding TTS, lateral distal tibial angle, or anterior distal tibial angle (P > .05).

CONCLUSION

LTTAR in cases with valgus deformity achieved and maintained correction at short-term follow-up, as obtained in neutral alignment ankles. Clinical outcomes improved significantly regardless of preoperative valgus deformity.

LEVEL OF EVIDENCE

Prognostic Level III, retrospective cohort study.

Association of acute inflammatory cytokines, fracture malreduction, and functional outcome 12 months after intra-articular ankle fracture-a prospective cohort study of 46 patients with ankle fractures

BACKGROUND

Several malreduction criteria have been proposed for ankle surgery, but the criteria of most importance for functional outcome remain undetermined. Furthermore, the acute inflammatory response in the ankle joint after fracture is hypothesized to result in osteoarthritis development, but no study has investigated the correlation between the levels of these inflammatory cytokines and post-surgical functional outcomes. We aimed to identify malreduction criteria and inflammatory cytokines associated with functional outcome after ankle surgery.

METHODS

During surgery, synovial fluid from the fractured and healthy contralateral ankles of 46 patients was collected for chemiluminescence analysis of 22 inflammatory cytokines and metabolic proteins. The quality of fracture reduction was based on 9 criteria on plain X-rays and 5 criteria on weight-bearing computed tomography (WBCT) scans. After 3 and 12 months, we recorded scores on American Orthopedic Foot and Ankle Society (AOFAS) scale, the Danish version of Foot Function Index (FFI-DK), EQ-5D-5L index score, the Kellgren-Lawrence score, and joint space narrowing.

RESULTS

Tibiofibular (TF) overlap (p = 0.02) and dime sign (p = 0.008) correlated with FFI-DK. Tibiotalar tilt correlated positively with joint space narrowing at 3 months (p = 0.01) and 12 months (p = 0.03). TF widening correlated with FFI-DK (p = 0.04), AOFAS (p = 0.02), and EQ-5D-5L (p = 0.02). No consistent correlations between synovial cytokine levels and functional outcomes were found at 12 months.

CONCLUSIONS

Malreduction of TF overlap, TF widening, and tibiotalar tilt were the most important criteria for functional outcome after ankle surgery. Increased inflammatory cytokine levels after fracture did not affect functional outcome at 12 months.

TRIAL REGISTRATION

This cohort study is registered the 10th of December 2018 at ClinicalTrials.gov ( NCT03769909 ), was approved by the local committee on health ethics (The Regional Committees on Health Research Ethics for Southern Denmark: J.No. S-20170139), and was reported to the National Danish Data Protection Agency (17/28505).

Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up

OBJECTIVES

To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification.

DESIGN

Retrospective.

SETTING

Main Trauma Center, University Hospital.

PATIENTS AND INTERVENTIONS

One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records.

MAIN OUTCOME MEASURES

Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification.

RESULTS

Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up.

CONCLUSIONS

The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term.

LEVEL OF EVIDENCE

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

Serum level of Adrenomedullin in patients with primary knee osteoarthritis; relation to disease severity

Background

Adrenomedullin (AM) is a peptide which was suggested to be involved in the pathogenesis of osteoarthritis through its anti-inflammatory and anti-apoptotic effect. AM was found to be elevated in some inflammatory rheumatic diseases as rheumatoid arthritis and ankylosing spondylitis.

The current study was performed to measure serum Adrenomodullin (AM) concentrations in patients with primary knee osteoarthritis (KOA) and to assess association with severity of the disease. The study was performed on 50 patients with primary KOA diagnosed according to American College of Rheumatology (ACR) Revised Criteria for Early Diagnosis of Knee Osteoarthritis and 20 age- and sex-matched controls with no clinical features of KOA. The Kellgren and Lawrence (KL) classification was used to evaluate the disease severity of knee OA. Disease activity was assessed by The Western Ontario and McMaster Universities Arthritis Index (WOMAC). Blood samples had been collected from patients with OA and controls for assessing Adrenomodullin in patients’ sera by ELISA.

Results

There were a significant increase in serum Adrenomedullin concentrations in KOA patients compared to controls (10.64 ±19.2 ng/ml vs. 1.39 ±1.6 ng/ml in cases and controls respectively) (p value = 0.036). There was positive significant correlation of serum Adrenomedullin levels with KL grades (r=0.608, p value <0.001). OA patients with VAS score >6 have significantly higher serum Adrenomedullin levels than OA patients with VAS Score <6. No detected significant correlation between any of (patients’ age, BMI, disease duration, tenderness score, and WOMAC score) with serum Adrenomedullin levels among studied OA cases (p values >0.05).

Conclusion

This study concluded that serum Adrenomedullin (AM) level is elevated in patients with KOA and is positively correlated with the severity of disease.

Risk factors of ankle osteoarthritis in the treatment of critical bone defects using ilizarov technique

Background

Distraction osteogenesis using the Ilizarov external circular fixator has been applied in lower limb reconstructive surgery widely. The increasing ankle osteoarthritis (OA) progression and severity are often associated with the period of external fixator and the greater relative instability of the ankle joint, but few studies have quantified risk factors directly during this technique.

Methods

The study was conducted on 236 patients who underwent bone transport surgery for tibias using the Ilizarov external circular fixator from 2008 to 2018. The cumulative incidence of ankle OA diagnoses in patients after the Ilizarov technique treatment was calculated and stratified by risk factors from preoperative and postoperative management. After the data were significant through the Mann-Whitney U test analyzed, odds ratios were calculated using logistic regression to describe factors associated with the OA diagnosis including gender, age, BMI, location of bone defect, diabetes, hypertension, osteoporosis, the history of metal allergy and glucocorticoid intake, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-HF scale scores, defect size (DS), the type of bone transport, the bone union time, external fixator time (EFT), and external fixator index (EFI).

Results

There were 199 males and 37 females with a mean age of 47 years (range 28–59 years). Out of 236 patients, 49 had an additional treatment for ankle OA after the Ilizarov technique treatment of bone defects (average follow-up time 2.1 years, range 1.6–4.2 years). The incidence of postoperative ankle OA was 20.8 %, with 19 patients classified as K&L grade 3 and seven patients as grade 4. The top five risk factors included double-level bone transport (OR3.79, P = 0.005), EFI > 50days/cm (OR3.17, P = 0.015), age > 45years (OR2.29, P = 0.032), osteoporosis (OR1.58, P < 0.001), BMI > 25 (OR1.34, P < 0.001). Male, BMI > 25, diabetes, osteoporosis, and AOFAS ankle-HF scale scores are the independent risk factors.

Conclusions

Ilizarov external circular fixator is a safe and effective method of treatment for critical bone defects. The double level bone transport, EFI > 50days/cm, age > 45years, osteoporosis, BMI > 25 are the top five relevant risk factors of ankle OA. The probability of developing ankle OA among patients having three or more risk factors is 50–70 %.

The modified Shriners Hospitals for Children Greenville (mSHCG) multi-segment foot model provides clinically acceptable measurements of ankle and midfoot angles: A dual fluoroscopy study

BACKGROUND

Several multi-segment foot models have been developed to evaluate foot and ankle motion using skin-marker motion analysis. However, few multi-segment models have been evaluated against a reference standard to establish kinematic accuracy.

RESEARCH QUESTION

How accurately do skin-markers estimate foot and ankle motion for the modified Shriners Hospitals for Children Greenville (mSHCG) multi-segment foot model when compared against the reference standard, dual fluoroscopy (DF), during gait, in asymptomatic participants?

METHODS

Five participants walked overground as full-body skin-marker trajectory data and DF images of the foot and shank were simultaneously acquired. Using the mSHCG model, ankle and midfoot angles were calculated throughout stance for both motion analysis techniques. Statistical parametric mapping assessed differences in joint angles and marker positions between skin-marker and DF motion analysis techniques. Paired t tests, and linear regression models were used to compare joint angles and range of motion (ROM) calculated from the two techniques.

RESULTS

In the coronal plane, the skin-marker model significantly overestimated ROM (p = 0.028). Further, the DF model midfoot ROM was significantly positively related to differences between DF and skin-marker midfoot angles (p = 0.035, adjusted R² = 0.76). In the sagittal plane, skin-markers underestimated ankle angles by as much as 7.26°, while midfoot angles were overestimated by as much as 9.01°. However, DF and skin-marker joint angles were not significantly different over stance. Skin-markers on the tibia, calcaneus, and fifth metatarsal had significantly different positions than the DF markers along the direction of walking for isolated portions that were less than 10 % of stance. Euclidean distances between DF and skin-markers positions were less than 9.36 mm.

SIGNIFICANCE

As the accuracy of the mSHCG model was formerly unknown, the results of this study provide ranges of confidence for key angles calculated by this model.