Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales

Prospective randomized comparison of functional bracing versus rigid immobilization with early weightbearing after modified percutaneous achilles tendon repair under local anesthesia

OBJECTIVE

The optimal treatment and rehabilitation strategy for acute Achilles tendon rupture (ATR) remain a debate. This study aimed to compare the results of the two postoperative regimens after treatment for ATR with modified closed percutaneous repair under local anesthesia.

METHODS

In a 4-year study, 72 consecutive patients with acute complete ATR were randomized after percutaneous repair into a functional group (FG), using a modified brace (28 males, three females; mean age 41.9 [29-71] years) and an immobilization group (IG), wearing a rigid plaster (28 males, two females; mean age 42.2 [29-57] years), for a period of 6 weeks. Except for immobilization, they followed the same weight-bearing and rehabilitation protocols. The follow-up period was 3 years. The complication rate, active and passive ankle range of motion, standing heel-rise test, clinical outcome using the American Foot and Ankle Society (AOFAS) hindfoot-ankle score, return to the previous activity level, and subjective assessment were assessed.

RESULTS

There was one rerupture in the IG and two transient sural nerve disturbances in the FG and one in the IG, and one suture extrusion in the IG, with no other complications. The average AOFAS scores were 96.9 ± 4.3 and 96.0 ± 4.9 in the FG and IG, respectively. Patients in the FG reached a final range of motion and muscular strength sooner without limping and were more satisfied with the treatment. No significant differences could be detected between groups according to the results in any of the assessed parameters.

CONCLUSION

Early dynamic functional bracing in patients with ATR treated with modified closed percutaneous repair under local anesthesia resulted in earlier functional recovery with similar final results in terms of complications and functional outcomes, such as rigid postoperative immobilization with standardized rehabilitation and weight-bearing protocol.

LEVEL OF EVIDENCE

I, Prospective randomized study.

Joint Preservation Surgery Using Supramalleolar Osteotomy Combined with Posterior Tibial Tendon Release and Lateral Ligament Augmentation in Advanced Varus Ankle Arthritis

Background: Recent studies utilizing weight-bearing computed tomography have identified abnormal internal rotation of the talus in advanced varus ankle arthritis (VAA) with a large talar tilt (TT), influenced by the posterior tibial tendon (PTT). This study aimed to evaluate the clinical and radiographic results of supramalleolar osteotomy (SMO) combined with PTT release and lateral ligament augmentation for VAA with a large TT. Methods: From January 2015 to September 2018, 15 patients with VAA and a large TT (greater than 5°) underwent SMO combined with PTT release. Clinical results, including visual analog scale (VAS) for pain, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and ankle osteoarthritis scale (AOS), were assessed. Radiographic results were assessed with various parameters, including medial distal tibial angle (MDTA), anterior distal tibial angle (ADTA), talar tilt (TT), talus center migration (TCM), Meary angle, hindfoot alignment angle (HAA), and hindfoot moment arm (HMA) on foot and ankle weight-bearing radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up. Results: VAS, AOFAS ankle-hindfoot score, and AOS improved significantly from 7.5, 54.4, and 72.6 preoperatively to 3.1, 82.5, and 34.5 postoperatively, respectively. All radiographic parameters exhibited significant changes postoperatively, with the exception of the Meary angle, which demonstrated no significant change. Four patients exhibited improvement in radiographic stage postoperatively; however, average radiographic stage did not significantly improve postoperatively in all patients. One patient progressed to end-stage arthritis postoperatively, necessitating additional ankle arthrodesis. Conclusions: In conclusion, lengthening and lateral ligament augmentation combined with bony realignment procedures may be a reasonable option for treating VAA with a large TT greater that 5°.

Effectiveness of Shoe Rotation in Managing Plantar Fasciitis in Patients

Background/Objectives: Plantar fasciitis (PF) is a common condition that causes heel pain. While various conservative treatment modalities for PF exist, no previous studies have investigated the effectiveness of shoe rotation (ShR) in patients with PF pain. This study aimed to compare the therapeutic effectiveness of ShR with that of two conventional treatments for PF-namely, foot orthosis (FO) and physical therapy (PT). Methods: Charts of 42 patients with heel pain were retrospectively reviewed. Participants were allocated to one of three treatment groups: the ShR group, the customized FO group, and the PT group. Pain and functional outcomes were assessed using the Visual Analog Scale (VAS), Digital Pain Scale (DPS), Foot Function Index (FFI), Foot Pain and Function Scale (FPFS), and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) at baseline and at 4 and 12 weeks after the intervention. Results: The ShR, FO, and PT groups all showed improvements, with statistically significant decreases in VAS, DPS, and FFI scores and significant increases in FPFS and AOFAS-AHS scores over time (p < 0.05). All three interventions resulted in significant improvements from baseline to 4 weeks and further to 12 weeks (p < 0.05). The ShR group exhibited a slightly larger effect on all measurements than the other groups. Conclusions: ShR, FO, and PT contributed to pain reduction and functional improvement, and alternating the shoes alleviated PF pain. These results suggest a new approach to managing PF and serve as a basis for providing convenient treatment for patients with PF.

Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus

BACKGROUND

This study aimed to evaluate the reliability and validity of the American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) score in patients with hallux valgus in Singapore.

METHOD

A total of 121 English-literate patients with hallux valgus identified between October 2017 and May 2020 were analyzed. Reliability was assessed via Cronbach α. Construct validity was evaluated through 20 a priori hypotheses by correlating the AOFAS MTP-IP score for hallux and lesser toes with other patient-reported outcome measures (PROMs). Standardized response means (SRMs) were calculated to evaluate responsiveness at 6 months postoperative. Structural validity was evaluated via confirmatory factor analysis (CFA) whereby a good fit was indicated when comparative fit index (CFI) is >0.95, Tucker-Lewis index (TLI) is >0.95 and standardized root mean residual (SRMR) is <0.08.

RESULTS

The AOFAS MTP-IP score demonstrated reliability with a Cronbach α of 0.837. Convergent construct validity was confirmed when all a priori hypotheses were fulfilled. Structural validity was established with our AOFAS MTP-IP score model that displayed good fit for a 1-factor structure (CFI = 0.988, TLI = 0.960, SRMR = 0.034). Responsiveness of the AOFAS MTP-IP score for hallux was demonstrated by an SRM score of 1.28.

CONCLUSION

The AOFAS MTP-IP score displayed adequate reliability and validity among English-literate patients in Singapore with an operatively managed hallux valgus.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Does Preoperative Manual Reduction (Omoto Technique) Affect Surgical Outcomes for Calcaneal Fractures? A Multicenter (TRON Group) Retrospective Study

The Omoto technique is a well-known method that is commonly used for noninvasive manual repair of calcaneal fractures. However, there have been no detailed studies on its clinical outcomes in preoperative closed reduction for surgical cases. This multicenter retrospective study aimed to compare the clinical and radiographic outcomes of calcaneal fractures treated with and without the preoperative Omoto technique, assessing its effectiveness. We extracted 335 patients with calcaneal fracture who underwent surgery between 2015 and 2020 from our multicenter database, named TRON. We evaluated the clinical outcomes using the American Orthopedic Foot and Ankle Society (AOFAS) score, the Böhler angle (BA) for radiographic analysis, and noted any complications. We divided the patients into those managed with the Omoto technique (group O) and those managed without the Omoto technique (group N). Patients were matched by age, sex, and fracture type, resulting in 43 patients per group. The use of the Omoto technique at the time of injury significantly improved the Böhler angle (BA). Furthermore, there were no significant differences in AOFAS, postoperative complications, or BA values at the final follow-up. In conclusion, our study demonstrates that the Omoto technique, when used preoperatively for calcaneal fractures, does not negatively impact the outcomes of subsequent surgical treatments. For patients who prefer to avoid surgery, the Omoto technique can be an effective initial intervention. Additionally, our findings suggest that the Omoto technique may facilitate less invasive surgical options in certain cases.

Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study

PURPOSE

We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures.

METHODS

We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented.

RESULTS

Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws.

CONCLUSION

Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed.

LEVEL OF EVIDENCE

IV.

Analysis of Calcaneal Avulsion Fractures Treated Surgically and Nonsurgically: A Retrospective Multicenter Study

Background

Calcaneal avulsion fractures (CAvFs) at the Achilles tendon insertion are among the more challenging fractures to treat. Although rare, they often require reoperation. The optimal treatment, including nonsurgical procedures and better implants for surgical procedures in the treatment of CAvFs, remains to be established. Therefore, our study aimed to (1) perform a descriptive evaluation of CAvFs, including cases managed nonsurgically, and (2) assess surgical procedures, including the incidence of complications and reoperation for surgically treated CAvFs.

Methods

In this multicenter retrospective study, we collected data of patients with CAvFs treated at 9 hospitals from 2012 to 2022. We performed a descriptive study of CAvFs and compared postoperative complications and reoperation rates for multiple surgical techniques and implants. The size of the bone fragments was quantified.

Results

The data of 70 patients with CAvFs were analyzed; 20 patients were treated nonsurgically, and 50 were treated surgically. The mean age of patients was 68.5 years; 67% of the patients were female. Nineteen percent of the patients had diabetes, and 19% had osteoporosis. The incidence of postoperative complications was 30%, with infection in 14%, necrosis in 26%, and loss of reduction in 18%. The reoperation rate was 22%. Surgical techniques with use of cannulated cancellous screws were performed in 80% of the surgical cases. Cannulated cancellous screw (CCS) fixation alone resulted in a reoperation rate of 35%, whereas additional augmentation, including washers with CCS fixation, resulted in a reoperation rate of 10%. CCS fixation was successfully performed, although suture anchors were used in some cases with smaller fragments.

Conclusions

CAvFs occurred more frequently in older women and had a high rate of postoperative complications. A combination of CCS with augmentation was more effective at reducing postoperative complications than CCS fixation alone, even when the bone fragment size was small.

Level of Evidence

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

Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up

BACKGROUND

Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF.

METHODS

Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively.

RESULTS

Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01).

CONCLUSIONS

SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF.

LEVEL OF EVIDENCE

IV.

Contemporary modern total ankle arthroplasty (TAA): A systematic review and meta-analysis of indications, survivorship and complication rates

BACKGROUND

This study evaluates the clinical outcomes of contemporary total ankle arthroplasty (TAAs) to primarily establish the current benefits and risks to facilitate informed decision making to secondarily establish if improvements are seen between subsequent generations of implants, bearing philosophy, and associated surgical technique.

METHODS

A systematic review and meta-analysis of published data from January 2000 to January 2020 was conducted following PRISMA guidelines.

INCLUSION CRITERIA

English language papers, adult population, ≥20 ankles with a minimum follow up ≥24 months, pre- and post-operative functional scores available. Ankle implants were characterised by generations, which were determined from the original studies and confirmed based on literature set definitions.

RESULTS

A total of 4642 TAAs in 4487 patients from 51 studies were included. The mean age was 61.9-years and follow up 57.8-months. Overall, 10-year survivorship rates were 77.63 %, with mobile bearing designs showing a small but significant advantage. Improved survivorship favoured the most modern implants at both two (p < 0.05), and 10-years (p < 0.01). The relative risk of a complication occurring improved with the evolution of implants e.g., nerve injury, and post-operative complications such as fracture, wound complications (e.g., dehiscence or heamatoma) and radiological abnormalities (e.g., radiolucencies, heterotopic bone formation and aseptic loosening). However, surgical site infection, and intra-operative fracture rates remain implant independent.

CONCLUSIONS

Modern TAA offers improved survivorship, even with a trend to lower mean implantation age, similar complexity and ever changing indications. It would appear that implant evolution has reduced risks, especially those associated with revision, without affecting functional outcomes.

A Novel Technique of Medial Displacement Calcaneal Osteotomy Using the Intramedullary Fixation of a Conventional Low-Profile Locking Wedge Plate

BACKGROUND

Postoperative heel pain arising from prominent screw heads is a common complication following medial displacement calcaneal osteotomy (MDCO). This study aims to present the clinicoradiographic outcomes of a novel MDCO technique, wherein intramedullary fixation of a conventional low-profile locking wedge plate is employed.

METHODS

A retrospective analysis, involving a comparison of clinical and radiographic parameters among consecutive patients who underwent MDCO was conducted. The patients were subjected to either intramedullary wedge plate fixation through the osteotomy site (IWPF group, n = 45 cases) or conventional cannulated screw fixation from the heel (CCSF group, n = 51 cases). Radiographic evaluation included measurement of hindfoot alignment angle, alignment ratio, and moment arm. Clinical outcomes were measured with the American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Ability Measure (FAAM) activities of daily living and sports subscales, before and at 6, 12, and ≥24 months postoperatively. The presence of heel pain was evaluated at the postoperative 6 and 12 months in both groups.

RESULTS

For both groups, a marked enhancement in all 3 radiographic parameters was observed. The extent of correction for all clinicoradiographic parameters demonstrated no statistically significant divergence between the 2 groups. However, the FAAM-Sports scores at the 6-month postoperative juncture exhibited a significant elevation in the IWPF group relative to the CCSF group. Importantly, no patient reported heel pain at postoperative 6 and 12 months in the IWPF group whereas the rates of patients having heel pain at postoperative 6 and 12 months were 56.8% (29 cases) and 33.3% (17 cases), respectively, in the CCSF group.

CONCLUSION

Both techniques yield analogous postoperative clinical and radiographic enhancements. However, the utilization of IWPF promotes a swifter clinical improvement with respect to sports activities when juxtaposed with the CCSF from the calcaneal tuberosity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Recurrence Rate After Wide Resection of Plantar Fibromatosis: A Case Series and Systematic Literature Review

BACKGROUND

The aim was to assess the recurrence rate and clinical outcome after wide resection for plantar fibromatosis.

METHODS

A total of 12 patients, 2 to 13 years after wide resection, were assessed for local and magnetic resonance imaging tomographic signs of recurrence at the clinical follow-up. In addition, a systematic review of the literature was conducted.

RESULTS

After 7.8 years (2-13), 2 patients (17%) suffered a recurrence. At the last follow-up, median Foot Functional Index was 1 (0-66) and American Orthopaedic Foot and Ankle Society score was 95 (44-100). Six studies with 109 feet (92 patients) were included in the systematic review. The recurrence rate depends on the width of the resection: 67% after local resection, 42% after wide resection, and 27% after fasciectomy.

CONCLUSION

In patients with symptomatic plantar fibromatosis, we recommend a wide resection or fasciectomy over a local resection because of the inferior recurrence rate.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

Comparison of the Outcomes of Plating, Screw Fixation, and Pinning in Sanders Type II Fractures: A Multicenter (TRON) Retrospective Study

Calcaneus fractures Sanders type II have been historically treated with various modalities. However, few studies compared these procedures directly. The multicenter (TRON group) retrospective study compared the radiographic and clinical outcomes of operative procedures using Kirschner wires (K-wires), cannulated cancellous screws (CCSs) and plates. Between 2014 and 2020, 121 patients with Sanders type II calcaneus fractures were surgically treated in our group using K-wire (Group K: n = 31), CCS (Group C: n = 60) or plate (Group p: n = 30) fixation. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score and infection after operation as clinical outcomes and Böhler's and Preiss' angles as radiographic outcomes. The AOFAS scores of the 3 groups showed a significant difference, with Group P showing significantly inferior scores to Group C at 6 months postoperatively and at the final follow-up examination (p = .015 and p < .001, respectively). The rate of infection did not differ to a statistically significant extent, but the incidence in Group P tended to be higher in comparison to the other groups. Among the three groups, Böhler's angle did not differ to a statistically significant extent immediately after the operation (p = .113) or at the final follow-up examination (p = .383). Postoperatively, Preiss' angle did not differ to a statistically significant extent (p = .251) but was significantly smaller in the Group C at the final follow-up examination (p = .0331). In Sanders type II calcaneus fracture, CCS fixation may obtain the best functional outcomes.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability

It is important to eliminate instability related to chronic lateral ankle instability (CLAI) to prevent osteoarthritis progression. We performed arthroscopic anterior talofibular ligament (ATFL) repair and performed calcaneofibular ligament (CFL) repair if instability remained. This study aimed to assess the clinical outcomes of our arthroscopic procedure compared to that of open surgery. Forty ankles underwent arthroscopic surgery and 23 ankles underwent open surgery to repair the lateral ankle ligaments for CLAI. In the arthroscopic surgery, varus stress was applied under fluoroscopy after ATFL repair, and CFL repair was performed if instability remained. Open surgery was performed using the Broström procedure with ATFL and CFL repair. To assess clinical outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) and Karlsson-Peterson (KP) scores were collected preoperatively and at the final follow-up. The talar tilt angle (TTA) was measured preoperatively and 1 year postoperatively. The arthroscopic group showed significantly higher AOFAS and KP scores at the final follow-up compared to the open surgery group. There was no significant difference in TTA at 1 year between the groups. In open surgery, 2 patients required revision surgery. There were no major complications, but scar-related pain in 2 cases of open surgery was reported. Arthroscopic ATFL repair with the CFL repair gave satisfactory clinical outcomes compared to open surgery in CLAI because of low invasive to soft tissue including the joint capsule. It is important to minimize soft tissue dissection in repairing the lateral ankle ligament in patients with CLAI.

Comparison of foot function and physical performance between women with and without bilateral painful hallux valgus

BACKGROUND

We aimed to investigate whether foot function and physical performance differ between women with and without bilateral painful hallux valgus (HV).

METHODS

Forty-four women with bilateral painful HV and forty-three controls were included. The Foot Function Index, American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joints Scale, and Manchester-Oxford Foot Questionnaire were used. The time while walking 10 m-walkway at maximum speed and ascending and descending ten stairs as fast as possible also single-limb stance time were measured.

RESULTS

All self-reported and performance-based measures showed that women with HV had poorer foot function and physical performance than controls (p < 0.05). Women with mild HV had better self-reported foot function than those with moderate HV or severe HV (p < 0.05), but physical performance did not differ (p > 0.05).

CONCLUSIONS

Women with bilateral painful HV exhibited poorer self-reported foot function and performance-based physical function than those without HV.

LEVELS OF EVIDENCE

Level III.

Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures

OBJECTIVES

To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings.

METHODS

DESIGN

Prospective cohort.

SETTING

Level 1 academic trauma center.

PATIENT SELECTION CRITERIA

Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort.

OUTCOME MEASURE AND COMPARISONS

MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts.

RESULTS

Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up.

CONCLUSIONS

Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography.

LEVEL OF EVIDENCE

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

Endoscopic calcaneoplasty with gastrocnemius recession for Haglund's syndrome: Is it safe and effective? Results from a retrospective case series

BACKGROUND

Endoscopic calcaneoplasty (ECP) and gastrocnemius recession (GR) are procedures that have been described to effectively treat Haglund's deformity and insertional Achilles tendinopathy respectively. The purpose of our manuscript is to evaluate the efficacy and safety of ECP and GR with immediate weightbearing for the treatment of Haglund's deformity with mild to moderate insertional Achilles tendinopathy.

METHODS

We performed ECP coupled with GR on 14 patients with an average age of 52 years. All patients demonstrated < 50% tendinous degeneration on MRI. All were allowed weightbearing as tolerated in a CAM boot within the first post-operative week. AOFAS scores and plain film radiographic findings were collected pre-operatively and post-operatively.

RESULTS

The radiographic exam of the Fowler-Philip angle significantly improved from an average 60.1-40.7° (p < 0.001). The AOFAS ankle/hindfoot score significantly improved from an average 54.7-91.4 (p < 0.001). The average return to work was 7.5 weeks. There were two cases of temporary sural nerve paresthesia, and two cases of delayed wound healing.

CONCLUSIONS

This is the first mid-term study evaluating the outcomes of ECP with GR. The results of our study suggest that ECP with GR followed by immediate weightbearing is a safe and effective procedure for the treatment of Haglund's deformity and mild to moderate insertional Achilles tendinopathy.

Talus Idiopathic Versus Stress-Injury-Related Osteonecrosis and Its Resolution: A Case Report

A 34-year-old healthy long-distance runner sustained a possible stress injury to the talus. This injury progressed into osteonecrosis (ON) or might have presented idiopathically. This patient had a complete normal metabolic workup. Non-surgical management, including resting, activity modification, and bone stimulators, led to resolution. Serial exams and magnetic resonance imaging demonstrated gradual resolution of the ON. At two years old, she was pain-free and had returned to running. Talus ON is uncommon and even more so in the absence of metabolic disorders or precipitating trauma. This case presents a debatable stress injury, an overuse injury, or even an idiopathic ON. It healed with non-surgical management. Serial, advanced imaging surveillance was implemented. There is a lack of impactful literature regarding the management of early ON and a paucity of strong recommendations to guide non-surgical treatment options in the early stages. This presentation is quite debatable as to whether there was a stress fracture leading to ON or if it was idiopathic ON. Yet, these entities could easily overlap, and physicians and orthopedists should be aware.

Comparison of different fibula procedures in tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a mid-term retrospective study

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures.

METHODS

We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded.

RESULTS

Fifty-eight patients with an average age of 53.2 (range, 32-69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60-78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1 min) was longer than that of FO (119.3 ± 11.7 min) and FS (112.2 ± 12.6 min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters.

CONCLUSIONS

TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP.

LEVEL OF CLINICAL EVIDENCE

Level 3.

The completely patient-reported version of the American Orthopaedic Foot and Ankle Society (AOFAS) score: A valid and reliable measurement for ankle osteoarthritis

BACKGROUND

The American Orthopaedic Foot and Ankle score (AOFAS) is an outcome measure for ankle and hindfoot conditions, which requires scoring from both the patients and the physician. A completely patient-reported version has been developed and used before, but its measurements properties are unknown. Our goal was to determine the measurement properties and the minimally important change (MIC) of a completely patient-reported AOFAS (PR-AOFAS) in patients with ankle osteoarthritis. Additionally, the MIC of both the PR-AOFAS and the AOFAS was estimated, which had not previously been done.

MATERIALS AND METHODS

The PR-AOFAS of 112 patients was evaluated for reliability, construct validity (using the AOFAS, Foot and Ankle Outcome Score, Ankle Osteoarthritis Score, Visual Analogue Scale, and Short Form-36), and responsiveness. The MIC was estimated using the optimal cut-off point of the receiver operating characteristic curve. This was a substudy of a randomized clinical trial on the efficacy of platelet-rich plasma injections for ankle osteoarthritis (OA).

RESULTS

The PR-AOFAS had sufficient construct validity, internal consistency, test-retest reliability, and responsiveness. The smallest detectable change at group level was 2.34. The MIC was 6.5 points (95% confidence interval: 0.6-14.4).

CONCLUSIONS

The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. The minimally important change of the PR-AOFAS is smaller than its smallest detectable change, making it more suitable for use in groups of patients, such as a research setting.

LEVEL OF CLINICAL EVIDENCE

1.

Effectiveness and safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus: a prospective, single-centre, randomized, double-blind study

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm2. However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Methods

Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans.

Results

A total of 40 patients were enrolled and randomly divided into the two groups, with 20 in each. There was no statistically significant difference in the baseline characteristics of the groups. No complications, such as wound infection or neurovascular injury, were found during follow-up of 12 months. The mean AOFAS scores in the rESWT group were significantly higher than those in the control group at three, six, and 12 months postoperatively (p < 0.05). The mean VAS pain scores in the rESWT group were also significantly lower than those in the control group at these times (p < 0.05). The mean area of bone marrow oedema in the rESWT group was significantly smaller at six and 12 months than in the control group at these times (p < 0.05).

Conclusion

Local shockwave therapy was safe and effective in patients with osteochondiritis of the talus who were treated with a combination of arthroscopic surgery and rESWT. Preliminary results showed that, compared with arthroscopic microfracture alone, those treated with arthroscopic microfracture combined with rESWT had better relief of pain at three months postoperatively and improved weightbearing and motor function of the ankle.

Long-term outcome of flexor hallucis longus tendon transfer for chronic Achilles tendon rupture with large defect: A retrospective series

There are multiple surgical options for treatment of chronic Achilles tendon (AT) rupture according to the classifications and length of defect. However, no gold standard method has been confirmed, and there is no clear evidence to support the superiority of 1 procedure over others. This study aimed to evaluate the long-term clinical outcome of flexor hallucis longus tendon (FHL) transfer for chronic AT rupture with large defect. Clinical data of patients treated with FHL transfer due to chronic AT rupture between January 2009 and October 2019 were reviewed retrospectively. All cases were presented with AT rupture for more than 4 weeks after injury. The gap between ruptured ends was > 5 cm after debridement in all patients. The harvest of FHL was performed through a single incision in accordance with AT rupture debridement in all cases. Clinical outcomes were assessed with AOFAS ankle-hindfoot scale, Achilles tendon total rupture score and AOFAS hallux metatarsophalangeal-interphalangeal scale. Twenty-eight patients were followed successfully for 62.6 ± 22.2 months. According to the complete datasets obtained from 28 patients, none of the tendons re-ruptured. The AOFAS ankle-hindfoot scale and Achilles tendon total rupture score at last follow-up visit was 90.4 ± 5.7 and 89.8 ± 5.3 respectively, which revealed statistically significant improvement from the preoperative score of 61.1 ± 6.7 and 53.8 ± 8.3. The AOFAS hallux metatarsophalangeal-interphalangeal scale at last follow-up visit was 87.5 ± 6.1. The FHL transfer through a single incision for chronic AT rupture with large defect is a safe and simple method with low risk of morbidity and complications.

Single anchor versus double anchor for arthroscopic anterior talofibular ligament repair: A systematic review and mate-analysis of cohort studies

PURPOSE

To determine whether a double anchor is more effective than a single anchor in the surgical repair of the anterior talofibular ligament (ATFL) in patients with ankle instability.

METHODS

This study searched PubMed, Embase and the Cochrane Library to identify potential studies that compared the clinical outcomes of double anchors and single anchors for ATFL repair from inception to July 31st, 2023. The study aligned with the 2020 Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines and checklist. The Risk of Bias in Nonrandomized Studies-of Interventions (ROBINS-I) tool was used to evaluate methodologic quality and risk of bias. The meta-analysis was performed with random effects. Outcomes, including American Orthopaedic Foot & Ankle Society Score (AOFAS), Karlsson Ankle Functional Score (KAFS), Tegner activity score, return to sport rate, complications and revision surgery events, were recorded.

RESULTS

A total of 845 articles were identified after an initial search of the three databases. Four retrospective studies involving 231 individuals were included for further analysis. There was no significant difference between the single-anchor group and the two-anchor group in terms of the AOFAS (risk ratio, -0.44, [-2.22; 1.34]) or KAFS (mean difference, -2.81, [-6.87; 1.25]). However, in terms of the Tegner activity score and the return to sport rate, the single-anchor group had significantly lower scores and longer times than the double-anchor group. No complications or revision surgery events were reported.

CONCLUSIONS

In patients with chronic ankle instability, both single anchors and double anchors can provide good functional outcomes. For patients who participate in physically demanding sports, double anchors may be a superior option.

LEVEL OF EVIDENCE

Level Ⅲ, meta-analysis of Level Ⅲ.

Is the Small Ossicle of Type 1 Accessory Navicular a Cause of Foot Pain?-A Case Report

Background and objectives: An accessory navicular (AN) bone is often classified into types 1-3 according to the Veitch classification, and symptomatic type 1 patients usually receive non-surgical treatment. However, there are cases in which AN cannot be classified into one of these three types using this classification system, and the small ossicle of type 1 AN may not be the cause of foot pain. This report aimed to present a case of symptomatic type 1 AN that required surgical treatment without the excision of the small ossicle after long-term conservative treatment had failed. Case presentation: A 15-year-old girl who was diagnosed with symptomatic type 1 AN was referred to our department. Medial-side foot pain had prevented her from playing soccer well. She had been treated conservatively for type 1 AN for more than 12 months at several orthopedic clinics. Tenderness of the prominent navicular tubercle was identified, and computed tomography and magnetic resonance imaging findings suggested that the cause of her foot pain was derived from the prominent navicular tubercle not the small ossicle itself. Osteotomy of the prominent navicular tubercle with the advancement of the tibialis posterior tendon, without excision of the ossicle, was performed. At the 12-month follow-up examination, she was completely free from foot pain, and the patient-reported outcome measures were excellent. She now plays soccer at the pre-injury level. Conclusions: We report the case of a patient with symptomatic type 1 AN who underwent osteotomy of the prominent navicular tubercle with advancement of the tibialis posterior tendon, without excision of the ossicle, and who showed favorable short-term clinical outcomes. The evaluation of symptomatic patients with AN based on the Veitch classification alone may lead to inappropriate management. The small ossicle of type 1 AN was not the cause of foot pain in the present case.

Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis

BACKGROUND

Hallux valgus is the most common foot deformity and affects 23% to 35% of the general population. More than 150 different techniques have been described for surgical correction. Recently, there has been increasing interest in the use of minimally invasive surgery to correct hallux valgus deformities. A variety of studies have been published with differing outcomes regarding minimally invasive surgery. However, most studies lack sufficient power and are small, making it difficult to draw adequate conclusions. A meta-analysis can therefore be helpful to evaluate and compare minimally invasive and open surgery.

QUESTIONS/PURPOSES

We performed a systematic review and meta-analysis of randomized controlled trials and prospective controlled studies to answer the following question: Compared with open surgery, does minimally invasive surgery for hallux valgus result in (1) improved American Orthopaedic Foot and Ankle Society (AOFAS) scores and VAS scores for pain, (2) improved radiologic outcomes, (3) fewer complications, or (4) a shorter duration of surgery?

METHODS

The systematic review and meta-analysis was conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Intervention and the Preferred Reporting Items for Systematic Reviews and Meta-analyses. A search was performed in the PubMed, Embase, Scopus, CINAHL, and CENTRAL databases on May 3, 2022. Studies were eligible if they were randomized controlled or prospective controlled studies that compared minimally invasive surgery and open surgery to treat patients with hallux valgus. We defined minimally invasive surgery as surgery performed through the smallest incision required to perform the procedure accurately, with an incision length of approximately 2 cm at maximum. Open surgery, on the other hand, involves a larger incision and direct visualization of deeper structures. Seven studies (395 feet), consisting of six randomized controlled studies and one prospective comparative study, were included in the qualitative and quantitative data synthesis. There were no differences between the minimally invasive and open surgery groups regarding age, gender, or severity of hallux valgus deformity. Each included study was assessed for the risk of bias using the second version of the Cochrane tool for assessing the risk of bias in randomized trials or by using the Newcastle-Ottawa Scale for comparative studies. Most of the included studies had intermediate quality regarding the risk of bias. We excluded one study from our analysis because of its high risk of bias to avoid serious distortions in the meta-analysis. We performed a sensitivity analysis to confirm that our meta-analysis was robust by including only studies with a low risk of bias. The analyzed endpoints included the AOFAS score (range 0 to 100), where higher scores represent less pain and better function; the minimum clinically important difference on this scale was 29 points. In addition, the VAS score was analyzed, which is based on a pain rating scale (range 0 to 10), with higher scores representing greater pain. Radiologic outcomes included the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle. Complications were qualitatively assessed and evaluated for differences. A random-effects model was used if substantial heterogeneity (I 2 > 50%) was found; otherwise, a fixed-effects model was used.

RESULTS

We found no clinically important difference between minimally invasive and open surgery in terms of the AOFAS score (88 ± 7 versus 85 ± 8, respectively; mean difference 4 points [95% CI 1 to 6]; p < 0.01). There were no differences between the minimally invasive and open surgery groups in terms of VAS scores (0 ± 0 versus 0 ± 1, respectively; standardized mean difference 0 points [95% CI -1 to 0]; p = 0.08). There were no differences between the minimally invasive and open surgery groups in terms of the hallux valgus angle (12° ± 4° versus 12° ± 4°; mean difference 0 points [95% CI -2 to 2]; p = 0.76). Radiographic measurements of the intermetatarsal angle did not differ between the minimally invasive and open surgery groups (7° ± 2° versus 7° ± 2°; mean difference 0 points [95% CI -1 to 1]; p = 0.69). In addition, there were no differences between the minimally invasive and open surgery groups in terms of the distal metatarsal articular angle (7° ± 4° versus 8° ± 4°; mean difference -1 point [95% CI -4 to 2]; p = 0.28). The qualitative analysis revealed no difference in the frequency or severity of complications between the minimally invasive and the open surgery groups. The minimally invasive and open surgery groups did not differ in terms of the duration of surgery (28 ± 8 minutes versus 40 ± 10 minutes; mean difference -12 minutes [95% CI -25 to 1]; p = 0.06).

CONCLUSION

This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the source studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. Given the associated learning curves-during which patients may be harmed by surgeons who are gaining familiarity with a new technique-we are unable to recommend the minimally invasive approach over traditional approaches, in light of the absence of any clinically important benefits identified in this meta-analysis. Future research should ensure studies are methodologically robust using validated clinical and radiologic parameters, as well as patient-reported outcome measures, to assess the long-term outcomes of minimally invasive surgery.

Validation of the Foot and Ankle Outcome Score for Use in Infracalcaneal Heel Pain

There is growing interest in adopting validated and reliable patient-reported outcome measures following surgery. While the Foot and Ankle Outcome Score (FAOS) has previously been validated for use in multiple foot/ankle conditions, it has not yet been validated in patients with infracalcaneal heel pain. In this study we aimed to validate the FAOS by looking at 4 psychometric properties of the survey: construct validity, content validity, reliability, and responsiveness, using patients in our practice with a clinical diagnosis of plantar fasciitis. A total of 150 patients (mean age 49.7 ± 12.1 years [36 men and 114 women]) were included in one or more of the 4 components of this study. All FAOS subscales demonstrated adequate construct validity when compared with the physical health component of the 12-Item Short Form Health Survey (SF-12), and 2 out of 5 subscales demonstrated moderate correlation with the mental health component of SF-12 (all Spearman rho >0.3, and p values <0.05). Most FAOS subscales demonstrated content validity and were found to contain relevant questions from the patient's perspective. All 5 subscales demonstrated good test-retest reliability with intraclass correlation coefficients ≥ 0.827. Finally, 4 out of the 5 subscales (all but other symptoms) were responsive to change at a mean follow up of 12.2 months after surgery (p < .05). We conclude that the FAOS is a responsive, reliable, and valid instrument for use in infracalcaneal heel pain. We believe that due to its ease of use and broad applicability, the FAOS could be more widely adopted in foot/ankle practices as patient-centered healthcare delivery and research becomes increasingly prioritized in the US and abroad.

Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis

BACKGROUND

The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT.

METHODS

PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95 % confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4).

RESULTS

Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia.

CONCLUSIONS

The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

LEVEL OF EVIDENCE

II.

Trimalleolar Fractures Treated by Open Reduction Internal Fixation Compared With Arthroscopically Assisted Reduction and Minimally Invasive Surgery

BACKGROUND

Currently, the standard of treatment for trimalleolar (TM) fracture is osteosynthesis through open reduction and internal fixation (ORIF). This study assessed whether arthroscopically assisted reduction and minimally invasive surgery (AARMIS) can be an alternative surgical method for TM fractures.

METHODS

This retrospective cohort study included 49 patients with TM that were surgically treated. 27 patients received ORIF and 22 patients underwent AARMIS . At baseline, we recorded the patient's demographic features, fracture pattern (AO-OTA and Haraguchi classification), and surgical method. For postoperative results, we examined the patient's radiographic outcome, including time to union, quality of fracture reduction, as well as functional outcomes (American Orthopaedic Foot & Ankle Society ankle hindfoot score, ankle range of motion, and visual analog scale of pain) and perioperative complications.

RESULTS

At mean follow-up of 46.6±24.6 (ORIF) and 36.4±18.5 months (AARMIS), both groups had comparable radiographic outcomes. No significant difference in rates of early ankle OA were detected. In terms of functional outcome, VAS pain and AOFAS score at postoperative day 3, postoperative month 3, and at final follow-up were not different. In terms of range of motion, we did not find a significant difference in mean range of motion.

CONCLUSION

Patients with TM fractures treated with AARMIS achieved satisfactory results and was not significantly different in radiographic and functional performance compared with ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Effectiveness of Arthroscopically Assisted Surgery for Ankle Arthrodesis

Regarding the treatment of ankle arthritis, the choice of arthroscopic ankle arthrodesis (AAA) or open ankle arthrodesis (OAA) remains controversial. To guide clinical decision-making, we conducted a meta-analysis on the optimal treatment of ankle arthrodesis. We identified eligible studies published from June 1, 1969 to June 1, 2020 using the Cochrane Library, PubMed, OVID, Embase, and Medline searched the references of relevant studies. Randomized and non-randomized studies that compared outcomes of AAA and OAA were included. After the methodologic assessment, available data were extracted and statistically reviewed. The primary outcomes were overall complications rate, tourniquet time, length of the hospital stay, non-union rate, and rate to fusion. The secondary outcomes were delayed union and postoperative infection rate. We included 9 studies comparing arthroscopic and open in patients with ankle arthrodesis, comprising 467 participants. AAA had the advantage of demonstrating a lower overall complication rate (odds ratio [OR], 0.44 [95% confidence interval [CI], 0.26-0.73]; p = .002), shorter intraoperative tourniquet time (mean difference [MD], -16.49 [95% CI, -23.51 to -9.46]; p < .001), shorter length of the hospital stay (MD -1.75, 95% CI -1.94 to -1.2, p < .001),lower non-union rate (OR, -0.07 [95% CI, -0.13 to -0.02]; p <.01) and higher rate to fusion (OR, 4.2 [95% CI, 1.96-8.99]; p < .001) in comparison with OAA. Yet, no significant differences were found in delayed union (OR, 0.46 [95% CI, 0.10-2.04]; p = .30) and postoperative infection rate (OR, 0.45 [95% CI, 0.17-1.15]; p = .09) between the groups. Our results suggest that arthroscopic ankle arthrodesis is superior to open ankle arthrodesis alone in the treatment of ankle arthritis based on the overall complication rate, intraoperative tourniquet time, length of the hospital stay, non-union rate and rate to fusion. However, further high-quality randomized controlled trials with appropriate blinding methods are needed to confirm the findings.

Validity and Reliability of the European Foot and Ankle Society (EFAS) Score in Patients With Hallux Valgus in Singapore

The European Foot and Ankle Society score is a popular tool for monitoring treatment outcomes of foot or ankle conditions. However, few studies have assessed its psychometric properties in patients with hallux valgus. We aimed to validate the European Foot and Ankle Society score in patients with hallux valgus in Singapore. This is a cohort study of 121 patients with operatively managed hallux valgus from a tertiary referral hospital, evaluated preoperatively and at 6 months postoperatively with the primary endpoint of restoring patients to premorbid status. Internal consistency was assessed via Cronbach's alpha. Construct validity was assessed through 7 a priori hypotheses by correlating the European Foot and Ankle Society score with other patient-reported outcomes measures. Structural validity was assessed via Confirmatory Factor Analysis, whereby a good fit was indicated when Comparative Fit Index >0.95, Tucker-Lewis Index >0.95, Root Mean Square Error of Approximation <0.06, and Standardized Root Mean Residuals <0.08. Among our subjects, the European Foot and Ankle Society score demonstrated reliability, reflected by a good internal consistency (Cronbach's alpha = 0.773). Six out of the 7 a priori hypotheses were fulfilled, indicating both convergent and divergent construct validity. Structural validity was confirmed with our European Foot and Ankle Society score model which showed good fit for a 1-factor structure (Confirmatory Factor Analysis = 0.998, Tucker-Lewis Index = 0.996, Root Mean Square Error of Approximation = 0.025 [90% CI: 0-0.111], Standardized Root Mean Residuals = 0.027). In conclusion, the European Foot and Ankle Society score was validated for monitoring treatment outcomes of patients with hallux valgus in Singapore.

Operative outcome of mucous cyst of lesser toes: A comparison between cyst excision with osteophytectomy and distal interphalangeal fusion

BACKGROUND

To date, the optimal operative treatment for mucous cysts of the lesser toes (MCLT) has not been discussed in detail, although many previous studies have focused on treating finger lesions. Therefore, we evaluated the operative outcomes of two different procedures for MCLT: cyst excision with osteophytectomy and cyst excision with distal interphalangeal (DIP) fusion.

METHODS

We retrospectively reviewed and compared the clinico-radiographic outcomes of patients who underwent cyst excision with osteophytectomy (group 1, 22 cases) or cyst excision with DIP fusion (group 2, 16 cases) for MCLT between January 2010 and August 2021. The minimum follow-up duration for inclusion in the study was 12 months. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) lesser toes metatarsophalangeal-interphalangeal scale and the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale. We also collected information on postoperative recurrence and operation-related complications.

RESULTS

The preoperative and postoperative AOFAS and FAAM-ADL scores were not significantly different between the two groups (P > 0.05, each). However, the postoperative recurrence rate was 31.8 % in group 1 (7 of 22 cases), whereas no recurrence was observed in group 2. Every recurrence occurred within 8 postoperative weeks (mean, 4.8 weeks; range, 3-8 weeks). Nonunion of the fusion site was observed in one patient (6.3 %).

CONCLUSION

We confirmed that postoperative recurrence was significantly lower in the case of cyst excision with DIP fusion than in cyst excision with osteophytectomy for the treatment of MCLT. Clinical outcomes were not significantly different between the two procedures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Surgical treatment options for plantar fasciitis and their effectiveness: a systematic review and network meta-analysis

BACKGROUND

To date, there are no systematic reviews on the utility of surgical management for plantar fasciitis to guide best practice. This review aimed to evaluate the operative options for plantar fasciitis and their effectiveness.

METHODS

A systematic review and network meta-analysis were carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool.

RESULTS

17 studies involving 865 patients were included. Surgical options considered were open and endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy and dry needling. All interventions resulted in improvement in VAS and AOFAS scores. No major complications were seen from any treatment modality.

CONCLUSIONS

Surgical interventions are effective in providing short- to medium-term symptomatic relief for plantar fasciitis refractory to non-operative management. Current evidence is equivocal regarding treatment choice. Further large randomised studies are required to establish long-term outcomes and a management algorithm.

LEVEL OF EVIDENCE

Level III.

Randomized Controlled Trial Comparing Early Mobilization vs Six Weeks of Immobilization in a Walking Cast Following Total Ankle Replacement

Rehabilitation for patients after total ankle replacement traditionally involves weeks of immobilization in a plaster cast followed by progressive mobilization. In a small randomized trial, we compared teh outcomes of patients who received a 3-component cementless, unconstrained, mobile-bearing prosthesis and were initially immobilised in a plaster cast for 6 weeks to thoese who received the same prosthesis but were allowed to mobilise early. Gait, clinical, patient-reported, and radiologic outcomes were measured. The study included 20 patients, 10 in the plaster cast group and 10 in the early mobilization group, and the demographics of the groups did not differ significantly. All patients were followed-up for 24 months. There were no significant differences between the 2 groups 2 years after surgery in ankle dorsiflexion, spatiotemporal gait characteristics, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, Timed Up and Go Test times, WOMAC (pain, stiffness, function) scores, SF-36 (quality-of-life) scores, or patient satisfaction (pain relief, daily-living, recreational activities, and overall) (all p > .05). Bone mineral density decrease of the medial malleolus and increase at middle tibia, calculated with DEXA scans, was significantly better in early mobilization than plaster cast group at one and 2 years postoperatively, but this was also the case preoperatively. The lack of differences in outcomes suggests that early ankle mobilization may be a safe and reliable method to enhance recovery following ankle arthroplasty with a 3-component cementless, unconstrained, mobile-bearing prosthesis. Compared to traditional plaster casting, patients who are engaged in early mobilization after arthroplasty may enjoy similar functional, mobility, quality-of-life, pain relief, activity level, and satisfaction outcomes.

Does ankle arthrodesis induce satisfactory changes in the medial longitudinal arch height of the foot for severe varus ankle arthritis?

PURPOSE

We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA).

METHODS

We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2 mm or < 2 mm).

RESULTS

A post-operative MCH decrease of ≥ 2 mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2 mm than in those with < 2 mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172).

CONCLUSION

Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.

Subjective and Objective Outcomes of Ankle Joint Arthrodesis with Either Ilizarov or Internal Fixation

After arthroplasty, arthrodesis of the ankle joint is the most common method to treat advanced ankle osteoarthritis. The goal of the study was to assess the subjective and objective outcomes in 2 different types of fixation for ankle joint arthrodesis. We retrospectively assessed 47 patients who had undergone ankle joint arthrodesis with fixation either via an Ilizarov apparatus (group 1) (n = 21) or cannulated screws (group 2) (n = 26). The outcomes were measured by: (1) the quantity of analgesics administered, (2) the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) general patient satisfaction, (4) the patients' decision to undergo the same procedure given another chance, and (5) the necessity of blood transfusion during hospitalization. Data was collected at the last postoperative follow-up visit. The AOFAS scores in group 1 and group 2 patients were 73.9   ± 13 and 72.7  ±  14.3, respectively. In group 1, 17 patients (81%) were very satisfied with the results, while in group 2, 19 patients (73%) were very satisfied with the results (p = .043). Two group 1 patients (10%) and four group 2 patients (15.3%) reported that they were satisfied with the outcomes (p = .035). Two patients (10%) from group 1 and three patients (11%) from group 2 were fairly satisfied. Seventeen patients (81%) after arthrodesis with Ilizarov fixation and 21 patients (81%) after arthrodesis with internal fixation would choose the same procedure given the opportunity to choose again. In group 1 there were no patients who required blood transfusion; in group 2 one patient (4%) required blood transfusion; the difference was statistically significant (p = .039). Nineteen group 1 patients (90%) were administered an analgesic preoperatively, while postoperatively only 6 (29%) required analgesics. In group 2, 24 patients (92%) were administered analgesics preoperatively, with 8 (31%) of them still requiring analgesics postoperatively. Ankle arthrodesis patients from both group 1 and group 2 achieved good subjective and objective results of treatment. We noted slightly better results in the Ilizarov apparatus group.

Arthroscopic Broström-Gould repair has comparable radiological and clinical outcomes compared to traditional open Broström-Gould repair in high-demand patients

PURPOSE

This study sought to confirm whether traditional open Broström-Gould repair and arthroscopic Broström-Gould repair for chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients.

METHODS

This retrospective case-cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström-Gould repair and were followed up for ≥ 2 years. Patients were divided into the arthroscopic Broström-Gould repair group (AS Group) and the open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically.

RESULTS

A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K-P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.).

CONCLUSIONS

Traditional open and arthroscopic Broström-Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair in high-demand patients.

LEVEL OF EVIDENCE

Level III.

Comparative analysis of bone consolidation chronology in claw toes operated through minimal invasive osteotomies in diabetic vs. non-diabetic patients

Objective

To compare bone healing time in osteotomies performed in claw toes correction through minimal invasive surgery in diabetic vs. non-diabetic patients. The relation between the patient's ages and the American Orthopedic Foot and Ankle Surgery Society (AOFAS) functional scores before and after surgery was also analyze in the two types of patients.

Method

A series of 45 women, 23 of them suffering from Diabetes Mellitus, were operated to correct claw toes. The surgery was always performed through minimal invasive digital osteotomies. After the intervention, bone healing was controlled by a fluoroscopic weekly follow-up until a complete bone consolidation was reached. Bone healing time was compared in in two groups of patients, diabetic and non-diabetic. All patients were evaluated with AOFAS scale 48 h before and 90 days after the intervention.

Results

The time of bone healing ranged from 24 to 40 days after the surgery and took shorter time of consolidation in non-diabetic patients although the Mann Withney U test did not show statistically significant differences (p = 0,409, effect size (ES) = 0,14 [-0.20 to 0.45]) between both groups. A statistically significant association (r = 0.71, R ²= 50%, p < 0.001) was found between the healing days and the day of medical discharge, also between the ages of the patients and the medial discharge (r = 0.36, R ²= 13%, p < 0.001). However, no statistically significant associations were found between pre-intervention glycemia and days of bone consolidation, neither in medical discharge (r = 0.07, p = 0.646 y r = 0.07, p = 0.648, respectively). AOFAS test scores and the diabetes status showed statistically significant differences, both in the main effect of Diabetes (F_[1,41]= 9.41, p = 0.004) as in the interaction between diabetes and age (F_[1,41]= 9.17, p = 0.004).

Conclusions

The bone healing time in claw toes operated through minimal invasive osteotomy surgery is not influenced by the presence of diabetes. The consolidation speed and the improvement in AOFAS functional scale score post-surgery in diabetic and elder patients was related to duration of the medical discharge.

Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis

BACKGROUND

Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation.

METHODS

A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software.

RESULTS

11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant.

CONCLUSION

Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.

Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture

Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon total rupture score and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The preinjury median TAS score was 4 point and unchanged at the last follow-up. The mean Achilles tendon Total Rupture Scores and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score 1 point lower than that at preinjury and with less favorable clinical outcomes.

Clinical Outcomes of Supramalleolar Osteotomy in Intermediate Stage of Varus Ankle Osteoarthritis in Joint Preservation

Supramalleolar osteotomy (SMO) is an effective treatment for intermediate-stage varus ankle osteoarthritis (OA). This study aimed to investigate how clinical outcomes were associated with radiological changes and cartilage regeneration shown on arthroscopy before and after SMO in patients with intermediate-stage varus ankle OA. Twenty-six cases with intermediate-stage varus ankle OA underwent SMO with at least 1 year of postoperative follow-up. Clinical assessment was performed preoperatively and postoperatively using the visual analog scale (VAS), American Orthopedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, and their associations with postoperative changes in tibial ankle surface angle (TAS), talar tilt, tibial lateral surface angle, and heel alignment ratio. The degrees of cartilage regeneration in the tibia plafond and talar dome were observed via second-look arthroscopy. Afterward, their associations with the corresponding clinical outcomes were analyzed. There were significant changes in the TAS, talar tilt, and heel alignment ratio (p < .001, for all). However, there were no significant changes in the tibial lateral surface angle (p = .864) at the final follow-up compared to its preoperative value. Postoperative changes in TAS (p = .013) and the degree of cartilage regeneration (p = .028) in the talar dome significantly influenced the final follow-up AOFAS score. Changes in the TAS angle and the degree of cartilage regeneration after SMO were predictors of clinical outcomes after SMO. In particular, greater changes in the TAS angle corresponded to better clinical outcomes.

Ankle Mortise Instability in Multiple Hereditary Exostoses

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Longitudinal Plantar Approach for Excision of Morton's Neuroma: Long-Term Results

Longitudinal plantar approaches are generally considered at risk for wound healing problems. Thus, we wanted to investigate long-term outcomes after a primary Morton's neuroma excision through a longitudinal plantar approach. A retrospective study of patients with primary neuroma excision was conducted. Twenty-four patients (28 feet) were evaluated at a mean 9-year follow-up (range, 6-14) by a single trained examiner using a specific postoperative evaluation protocol, including AOFAS Forefoot subjective and objective scores. Good-to-excellent outcomes were reported in 25 (89.3%) cases. A hypertrophic scar formation and keratosis occurred in only 2 cases (7.1%). All the patients, with a single exception, achieved full weightbearing with a postoperative shoe from the first day after the operation. A longitudinal plantar approach can lead to long-term, good-to-excellent outcomes with no case of recurrence or reoperation. Accurate wound closure and immediate weightbearing with a postoperative shoe can minimize the rate of complications. This approach should be considered for primary resection of Morton's neuromas.

Fifth Metatarsal Base Fracture Combined With Fracture of the Os Peroneum

Fracture of the os peroneum is rare, and displacement of the fracture can be indicative of a tear in the peroneal longus tendon. A fifth metatarsal base fracture is a common injury caused by sudden inversion and plantar flexion of the hindfoot. We observed a rare case of a fifth metatarsal base zone I fracture combined with a displaced os peroneum fracture in a 34-year-old woman. The patient was treated with resection of the os peroneum and repair of the peroneal longus tendon, as well as open reduction and internal fixation of the fifth metatarsal base. After exposing the fragment of the fifth metatarsal base, the distal part of the fractured os peroneum was found to be located just under the fracture site. There were no complications or discomfort of the foot or ankle at 2 years postoperatively. Resection of the os peroneum and direct repair of the peroneal longus tendon were easily performed after the fifth metatarsal base fragment was exposed. This was an innovative method for performing peroneal longus tendon repair in the deep portion of the midfoot.

Factors influencing postoperative residual diastasis after the operative treatment of acute Lisfranc fracture dislocation

INTRODUCTION

Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3-dimensional computed tomography (3D-CT).

MATERIALS AND METHODS

Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t test was used to compare continuous numeric parameters, while a Chi-square test was used for the proportional parameters. Statistical significance was set at P value less than 0.05 for all analyses.

RESULTS

The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P > 0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (> 25% of 2nd tarsometatarsal joint involvement), displaced (> 2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P = 0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P = 0.001).

CONCLUSIONS

While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Functional and radiological outcomes after treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique: a retrospective single-center study

BACKGROUND

Congenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT.

MATERIALS AND METHODS

This retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes.

RESULTS

This study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case.

CONCLUSIONS

The Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation. Level of evidence Level IV.

Ankle Arthrodesis Combined With Mosaic Bone Autograft Transplantation for End-Stage Ankle Osteoarthritis With Large Cysts of Talar Dome

End-stage ankle osteoarthritis with large cysts of talar dome can be challenging to treat. Twenty patients diagnosed as end-stage ankle arthritis with large talar cysts between 04/2010 and 02/2016 were randomly divided into experimental group (10 cases) and conventional group (10 cases) by random number method. Patients in the experimental group were treated with ankle arthrodesis combined with a concomitant procedure of mosaic bone autograft transplantation, the conventional group under the ankle arthrodesis. The operation time, intraoperative blood loss, postoperative hospital stay, the time of bone union, and postoperative height of the talus between the 2 groups were compared. The preoperative and postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score were also recorded and compared. There was no significant difference in the operation time, intraoperative blood loss, and postoperative hospital stay between the 2 groups. The postoperative height of the talus body and the time of bone union were better in the experimental group than that in the conventional group (p < .05). The results of follow-up showed that the American Orthopaedic Foot and Ankle Society scores of the conventional group were lower than those in the experimental group (p < .001). And the incidence of complication (10%) in the experimental group was significantly lower than that in the conventional group (40%). The use of tibiotalar arthrodesis combined with mosaic bone autograft transfer may be potentially an effective option for the treatment of end-stage ankle arthritis with large talar cysts.

A Refined Minimally Invasive Distal First Metatarsal Osteotomy for Moderate Hallux Valgus Treatment: The BC Procedure

During the last 2 decades, there was an increasing interest in mini-invasive procedures for hallux valgus correction. In this scenario the Bösch technique appears to be a reproducible distal metatarsal osteotomy (DMO) to achieve a proper correction. Our DMO variant, called BC, was planned to combine the stability and predictability of the chevron osteotomy, with the power of correction, low surgical time and mini-invasive approach of the Bösch-SERI technique. The purpose of this investigation is to describe the surgical technique and report the results of this modified procedure at a minimum 2-year follow-up. Sixty-three patients who underwent the BC technique for mild and moderate hallux valgus were prospectively evaluated. Mean follow-up was 36.5 (range 23.4-59.8) months, the mean American Orthopedic Foot and Ankle Society score improved from a median of 47.4 points preoperatively to a median of 88 points postoperatively (p < .05). First MTPJ ROM did not change from preoperative period (mean 32.5°) to the postoperative period (mean 31.8°) (p > .65). All osteotomies went on to bony healing in the 6-week follow-up visit. Fifty-two (82%) of patients were either very satisfied or satisfied with the procedure (p < .05). With our numbers, BC osteotomy is shown to be a technique that can treat both mild and moderate deformities, achieving correction that is maintained over the follow-up evaluated, with a 24 relatively simple procedure and short operative time.

Characteristics of Chronic Ankle Instability Requiring Both Anterior Talofibular and Calcaneofibular Ligament Repair

Chronic ankle instability (CAI) leads to the ankle osteoarthritis (OA), and ligament repair is performed to restore ankle stability. However, anterior talofibular ligament (ATFL) repair alone is not sufficient to stabilize the ankle in some cases, which additionally require calcaneofibular ligament (CFL) repair. This study aimed to explore characteristics of CAI that necessitated the repair of both ATFL and CFL. Forty-three patients (44 ankles) with CAI treated operatively were retrospectively reviewed. After ATFL repair, patients with residual ankle instability revealed by the varus stress under fluoroscopy additionally underwent CFL repair. Preoperative condition and intraoperative findings of the combined ATFL and CFL repair (AC) (n = 24) and only ATFL repair (A) (n = 20) groups were compared. The ankle activity score of group AC was significantly higher (p < .05) than that of group A. OA changes at the medial gutter were observed in 62.5% (15/24) in the group AC and 20% (4/20) in group A. Chondral/osteochondral lesions were seen in 66.7% (16/24) in the group AC and 20% (4/20) in group A. The remnant quality in group AC was inferior to that of group A. CAI that necessitated both ATFL and CFL repair exhibited characteristic findings such as high ankle activity score, high rate of chondral/osteochondral lesions and/or OA changes, and poor quality of ATFL remnants compared to those in CAI that required only ATFL repair. The repair of both ATFL and CFL should be considered in CAI which exhibit these characteristics to ensure complete correction of the instability.

Influence of the Length Ratio Between Second and Third Metatarsals After Modified Weil Osteotomy on Clinical Outcomes

Metatarsalgia is a frequent foot disorder. The objective was to evaluate whether the length ratio between the second and the third metatarsals after Weil osteotomy influences clinical outcomes. This retrospective study included 37 patients (53 feet). Preoperative planning consisted of keeping the second metatarsal greater than or equal to the third metatarsal after Weil osteotomy of the second metatarsal or the second and third metatarsals. Based on postoperative weightbearing and digital AP radiographs after Weil osteotomy, we divided the patients into 2 groups: group 1, the second metatarsal was longer than or equal to the third metatarsal; and group 2, the second metatarsal was shorter than the third metatarsal. We investigated whether there were differences between the groups. In 35 (66%) feet, the second metatarsal was longer than or equal to the third metatarsal (group 1), and in 18 (34%) feet, the second metatarsal was shorter than the third metatarsal (group 2). Postoperative American Orthopaedic Foot and Ankle Society scores were 86.2 and 82.7, respectively (p = .32). Postoperative Visual Analog Scale scores were 1.26 and 1.67, respectively (p = .39). The sample showed 11.3% of transfer metatarsalgia to the third metatarsal. Group 1 had 9% of transfer metatarsalgia, whereas group 2 had 17% of transfer metatarsalgia (p = .40). The presence of a second metatarsal shorter than the third metatarsal, after Weil osteotomy of the second metatarsal or the second and third metatarsals, does not influence outcomes or incidence of transfer metatarsalgia to the third metatarsal.

Clinical Outcomes of Osteochondral Fragment Fixation Versus Microfracture Even for Small Osteochondral Lesions of the Talus

BACKGROUND

The bone marrow stimulation (BMS) technique is performed for osteochondral lesions of the talus (OLTs) with a lesion size of <100 mm². The lesion defect is covered with fibrocartilage, and the clinical outcomes deteriorate over time. In contrast, the osteochondral fragment fixation can restore the native articular surface. The difference in clinical outcomes between these procedures is unclear.

PURPOSE

To compare the clinical outcomes of BMS and osteochondral fragment fixation for OLTs and examine the characteristics of patients with poor clinical outcomes of BMS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In total, 62 ankles in 59 patients with OLTs were included. BMS was performed for 26 ankles, and fixation was performed for 36 ankles. Clinical outcomes, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Scale and bone marrow edema (BME) as identified on magnetic resonance imaging, were compared between the 2 groups. On computed tomography scans, the lesion location was compared with or without BME in each group.

RESULTS

The AOFAS scores in the fixation group (97.3 ± 4.3 points) were significantly higher than those in the BMS group (91.3 ± 7.7 points), even when the lesion size was <100 mm² (P < .05). When comparing the ankles with or without BME in each group, the AOFAS scores at the final follow-up were significantly lower for the ankles with BME (88.6 ± 7.8 points) than for those without BME (95.0 ± 6.1 points) in the BMS group (P < .05). Lesions with BME in the sagittal plane were located more centrally than those without BME in the BMS group. In the fixation group, there were no significant differences in AOFAS scores and location of the lesion in ankles with or without BME.

CONCLUSION

The clinical outcomes of osteochondral fragment fixation are superior to those of BMS in OLTs, even for lesions sized <100 mm². Fixation is recommended even for small lesions, especially for more centralized lesions in the medial and lateral sides of the talus.