Articular and angular dimensions of the talus: Inter-relationship and biomechanical significance

Summary of background dataResearch on biomechanics of the ankle and foot has demonstrated a complex pattern of load distribution through the ankle joint.ObjectiveInvestigating possible relationship between articular dimensions, angular parameters and overall talar morphology.MethodsTwo linear dimensions, six articular surfaces and three angular parameters were measured from dried human talar bones (left = 60; right = 82). Angular parameters were measured at the neck of the bone (junction of the head and the body). Correlation and co-variation were worked out between the values of surface area parameters and the angular orientations measured from all the samples in context of load transmission across the talus.ResultsThe total trochlear surface area of the talus totaled approximately equal to the sum of areas at the head and the lower surface of the talus. The vertical angle showed a strong correlation with the articulating surface area below the head of the talus in contact with the spring ligament.ConclusionsArticular surface areas as well as the angular orientations of talar components vary with the magnitude of stress subjected to the bone. The inter-relationship between articular and angular parameters within the talus demonstrates strong correlation for certain parameters.     

Perioperative axial loading computed tomography findings in varus ankle osteoarthritis: Effect of supramalleolar osteotomy on abnormal internal rotation of the talus

BackgroundWe used axial loading computed tomography (AL CT) to evaluate preoperative and postoperative talocrural joints of patients who underwent supramalleolar osteotomy (SMO) to treat varus ankle osteoarthritis.MethodsWe performed retrospective analyses of 16 patients (18 feet) who underwent SMO including fibular osteotomy. Radiographic assessment was performed with weightbearing radiographs and AL CT. Clinical outcomes were assessed based on American Orthopedic Foot & Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Foot and Ankle Ability Measure (FAAM).ResultsThe mean 2-year follow-up tibial-ankle surface angle, talar tilt angle, Takakura stage, and tibial-lateral surface angle were all significantly different relative to preoperative parameters (P < .05). The mean 6-month follow-up talus rotation ratio was significantly corrected compared to the preoperative value (P = .001). The mean 2-year follow-up AOFAS, VAS at gait, and FAAM scores were all significantly improved relative to preoperative measurements (P = .001).ConclusionsAbnormal internal rotation of the talus in mild to moderate varus ankle osteoarthritis found on AL CT was significantly corrected after SMO.Level of evidenceTherapeutic Level IV     

Tibial torsion correlates with talar morphology

BackgroundThere is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles.MethodsPreoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs.ResultsMeasurements indicated mean external tibial torsion of 29.2 ± 9.1? and TNBA of 35.2 ± 7.5? medial. Tibiotalar tilt ranged from 48? varus to 23.5? valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ = ?0.576, p < .0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ = ?0.239, p = .014) and plantarflexion of the talo-first metatarsal angle (ρ = ?0.218, p < .025).ConclusionWe observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology.Level of evidenceLevel III.     

Surgical repair of osteochondral lesions of the talus using biologic inlay osteochondral reconstruction: Clinical outcomes after treatment using a medial malleolar osteotomy approach compared to an arthroscopically-assisted approach

BackgroundSurgical treatment of osteochondral lesions of the talus affecting the medial aspect of the talar dome is typically performed using medial malleolar osteotomy to optimize access. This study compares clinical outcomes of lesions repaired using biologic inlay osteochondral reconstruction in patients who did or did not undergo medial malleolar osteotomy, depending on defect dimensions.MethodsPatients treated for osteochonral lesions of the talus through a medial mallolar approach or arthroscopically-assisted approach were prospectively followed. Assessment tools consisted of the visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score (AOFAS). The magnetic resonance observation of cartilage repair tissue (MOCART) score was used postoperatively.ResultsData for 24 patients (mean age 34 years, mean follow-up 22 months) was analyzed. Mean preoperative/final AOFAS and VAS in those who underwent osteotomy were 57.7/81.2 and 5.7/1.9 (p < 0.001), respectively. In those who underwent arthroscopically-assisted reconstruction, mean preoperative/final AOFAS and VAS were 54.4/84.0 and 7.6/2.0 (p < 0.001), respectively. There was no difference in mean MOCART score (p = 0.662) for those treated with osteotomy (67.3) compared to those without (70.8).ConclusionsOsteochondral lesions of the talar dome can be treated successfully by biological inlay osteochondral reconstruction technique without medial malleolar osteotomy, with good to excellent clinical outcomes expected. MRI demonstrates good integration of the graft into surrounding tissue.     

A cadaveric study investigating the role of the anterior inferior tibio-fibular ligament and the posterior inferior tibio-fibular ligament in ankle fracture syndesmosis stability

BackgroundThis cadaveric study aimed to investigate the role AITFL and PITFL have on preventing talar shift in ankle fractures, as well as investigating the role of AITFL reconstruction in preventing talar shift.MethodsTwelve lower limb cadavers were used. Talar shift was measured following: Step 1- no ligaments cut; Step 2- entire deltoid ligament division; Step 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; Step 4- group A had AITFL divided whilst group B had PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated.ResultsWith no ligaments divided, mean talar shift was 0.8 mm for group A and 0.7 mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8 mm compared to 4.7 mm in group B (P = 1.00). The mean shift in group A after PITFL division was 6.0 mm, increasing the talar shift by an average of 1.2 mm. In group B after AITFL division mean talar shift was 8.3 mm (P = 0.06), increasing talar shift by an average of 3.6 mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0 mm and in group B was 10.9 mm (P = 0.29). Three times more talar shift occurred after the AIFTL was divided compared to the PITFL (P = 0.06).ConclusionConsequently, repairing the PITFL in isolation (for example by fixation of a posterior malleolus avulsion fracture) may not adequately prevent talar shift; we feel consideration should also be given to reconstruction of the AITFL to augment the syndesmosis fixation, which may provide a stronger restoration of ankle stability.Level of Clinical Evidence: 5.     

The geometrical axis of the talocrural joint—Suggestions for a new measurement of the talocrural joint axis

BackgroundDespite intensive research there is no consensus about the talocrural joint axis. The aim of the present study is a new method to determinate the geometric rotational axis of the talocrural joint.MethodsWe analyzed 98 CT-scans of full cadaver Caucasian legs. We generated three-dimensional reconstruction models of the talus. A best fitting cone was orientated to the talar articular surface. The geometric rotational axis was defined to be the axis of this cone.ResultsThe geometric rotational axis of the talocrural joint is orientated from lateral–distal to medial–proximal (85.6° ± 10 compared to anatomical tibial axis in torsional plane), from posterior–distal to anterior–proximal (81.43° ± 44.35 compared to anatomical tibial axis in sagittal plane) and from posterior–medial to anterior–lateral (169.2° ± 5.91 compared to intermalleolar axis in axial plane).ConclusionsThe consideration of our results might be helpful for better understanding of ankle biomechanics.     

Giant osteochondroma of the talar neck

Giant osteochondroma is an uncommon entity and it is rare in the foot and ankle region. It is extremely rare to originate from the talus. In this case report we present a case of giant osteochondroma arising from the talar neck measuring 100 mm × 90 mm × 30 mm It is unique because of the size, site and the age at presentation.     

Matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach- 5-year-follow-up in 100 patients

BackgroundThe aim of the study was to assess the 5-year-follow-up after matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach.MethodsIn a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to May 31, 2012 were included. Size and location of the chondral lesions, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10 min, 1500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide) that was fixed into the chondral lesion with fibrin glue.ResultsOne hundred and twenty patients with 124 chondral lesions were included in the study. Age at the time of surgery was 35 years on average (range, 12–65 years), 74 (62%) were male. VAS FA before surgery was 45.2 on average (range, 16.4–73.5). Lesions were located at medial talar shoulder, n = 55; lateral talar shoulder, n = 58 (medial and lateral, n = 4); tibia, n = 11. Lesion size was 1.7 cm² on average (range, .8–6 cm²). One hundred patients (83%) completed 5-year-follow-up after. VAS FA improved to 84.4 (range, 54.1–100; t-test, p < 0.01).ConclusionsMAST as part of a complex surgical approach led to improved and high validated outcome scores in the mid-term-follow-up. No method related complications were registered. Even though a control group is missing, we conclude that MAST as part of a complex surgical approach is an effective method for the treatment of chondral lesions of the ankle for at least five years.     

Risk of chronic ankle instability: A reliability study on radiographic assessment of the ankle joint geometry

BackgroundChronic ankle instability (CAI) is a multifactorial disabling condition. Ideally all factors contributing to CAI are identified and implemented in a risk assessment model. However, they need to meet strict reliability requirements. To assess usability of radiographic factors for this risk assessment model and future clinical practice, the objective of the current study was to assess the intra and inter observer reliability of three radiographic measurements.Methods and methodsThe radiographs of 39 consecutive patients, at least 16 years, who visited the Emergency Department after sustaining a lateral ankle sprain (LAS), were assessed by four observers. The radiographic measurements included absolute and relative ankle alignment, sagittal fibular position and ankle joint congruency (talar radius and height, and tibiotalar sector), performed twice by all observers independently. Reliability was assessed by calculating the Intraclass Correlation Coefficient (ICC) which was considered good when ICC > 0.70.ResultsThe intra observer reliability of the absolute and relative fibular position, and talar height were good to excellent, (ICC 0.84–0.98, 0.85–0.98, and 0.79–0.93, respectively). The talar radius (ICC 0.69–0.89) was moderate to good. The overall inter observer reliability was good for the absolute and relative fibular position, and talar radius (ICC 0.84, 0.86, and 0.79, respectively). Other measurements had ICC values of <0.70.ConclusionsIn an effort to identify the multifactorial nature of CAI, both the fibular position and the talar radius measurements showed good observer reliability, and will be implemented in a future risk assessment models. The other measurements are too prone for measurement errors, for future reference.Level of evidenceIV Case Series.     

A biomechanical study of proximal tibia bone grafting through the lateral approach

BackgroundAutologous bone graft remains the gold standard source of bone graft. Iliac crest has traditionally been the most popular source for autologous bone graft. However, iliac crest bone graft harvesting is associated with high donor site morbidity. Bone graft harvesting from the proximal tibia has shown great potential with reported low complication rates. However, there is a paucity of biomechanical studies concerning the safety as well as yield of proximal bone graft harvesting.PurposeThis biomechanical study was designed to investigate (1) the stability of the harvested proximal tibial during physiological loading, and (2) the maximum size of the cortical window that can be safely created and (3) volume of accessible bone graft.MethodsBone grafts were harvested from eleven cadaveric tibiae using a circular cortical window along the lateral proximal tibia. These harvested proximal tibiae were then loaded under physiological conditions (mean 2320N, range 1650–3120N) using a customized test fixture. Strain rosettes were mounted at 7 locations in the harvested proximal tibia to record the changes in strain at the harvested proximal tibia. The change in strain with increasing cortical window size (10–25 mm diameter) was also studied. Bone principal strains as well as volume of bone harvested were recorded.ResultsA repeated measures ANOVA was used to analyze the change in bone strains with the cortical window size. Statistically significant (p < 0.05) increases in bone strains at the anterior and medial aspects of the tibia were observed with increasing size of osteotomies (−328.85 με, SD = 232.21 to −964.78 με, SD = 535.89 and 361.64 με, SD = 229.90 to −486.08 με, SD = 270.40 respectively), and marginally significant changes in strain at the lateral and posterior aspects. None of the tibiae failed under normal walking loads even with increasing osteotomies size of 10–25  mm diameter. A smaller osteotomy of 10 mm diameter yielded an average volume of 7.15 ml of compressed bone graft, while a larger osteotomy of 25 mm diameter yielded on average an additional 3.64 ml of bone graft. Bone grafting of the proximal tibia through the lateral approach with a circular osteotomy is a feasible option even with osteotomies of 25 mm diameter. Even though increased bone strains were observed, the strains did not exceed the yield strain of cortical bone when loaded under normal walking conditions. The quantity of bone harvested from the proximal tibia is comparable to that harvested from the iliac crest.ConclusionsThis biomechanical study demonstrated the stability of the harvested proximal tibia under conditions of full weight bearing ambulation. It has also refined the technique of proximal bone graft harvesting by determining the maximum size of the cortical window. The findings of this study add to the overall understanding of proximal tibial bone graft harvesting, providing objective data regarding stability as well as yield. This information would be useful during selection of source of autologous bone graft.     

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BackgroundThe aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.MethodsSix patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4 ± 1.9 years (range 1.0–6.5).ResultsOne patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.ConclusionIn the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.     

Splinting vs temporary external fixation in the initial treatment of ankle fracture-dislocations

BackgroundTo compare the efficacy, functional outcome, and complication frequency of splinting and external fixation in the initial treatment of ankle fracture-dislocations.MethodAnkles with poor soft tissue conditions who underwent temporary stabilization due to using a splint or external fixator due to an ankle fracture-dislocation between 2012 and 2019 were retrospectively evaluated. Ankles were divided into two groups as the splint (n = 69) and external fixator (n = 48). The time between the injury to definitive surgery, reduction loss, operation time, functional outcome, pain, and soft-tissue complication frequency before and after definitive surgery were compared.ResultsThe frequency of reduction loss (25% vs. 4%, p = 0.019) and skin necrosis (22% vs. 6%, p = 0.028) were significantly higher in the splint group. Posterior malleolar fracture fragment ratio was calculated by dividing the fracture fragment axial length by the total axial length of the articular surface on computed tomography. Posterior malleolar fracture fragment ratio was found to be significantly higher in ankles with reduction loss in both the splint (25% vs 75%, p = 0.032) and fixator groups (4% vs 96%, p = 0.021). The mean time period between injury and definitive surgery was significantly shorter in the external fixator group (11 ± 5 vs 7 ± 4 days, p = 0.033). Before definitive treatment, pin tract infection was observed in two ankles in the fixator group.ConclusionSplint immobilization of ankle fracture-dislocations may predispose to reduction loss, soft tissue complications, and a longer time period between injury and definitive fixation. The risk of these potential complications can be reduced with the use of an external fixator.     

Short-term and mid-term outcome of total ankle replacement in haemophilic patients

BackgroundAnkle arthropathy is very frequent in haemophilic patients. Prostheses are valuable alternatives to arthrodesis in non-haemophilic patients. We report the experience of a single centre in France on the use of prostheses in haemophilic patients.MethodsRetrospective study of 21 patients with haemarthropathy who underwent ankle arthroplasty (32 ankles), with additional surgery, if needed, from July 2002 to September 2009 (mean follow-up 4.4 ± 1.7 years). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot scale was used to evaluate pain, function, ankle mobility and alignment.ResultsThe overall AOFAS score improved from 40.2 ± 19.4 (pre-surgery) to 85.3 ± 11.4 (post-surgery). The function score increased from 23.6 ± 7.7 to 35.9 ± 6.7 and dorsiflexion from 0.3° ± 5.0° to 10.3° ± 4.4°. Two patients underwent further ankle arthrodesis. On X-ray, both tibial and talar components were stable and correctly placed in all ankles. Alignment was good.ConclusionAnkle arthroplasty is a promising alternative to arthrodesis in haemophilic patients.     

Balloon Angioplasty as the Primary Treatment for Failing Infra-inguinal Vein Grafts

BackgroundWe sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses.MethodsPatients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair.ResultsFour hundred and eleven grafts were followed up for a median of 19 months (range: 2–61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P = 0.08) or amputation rates (P = 0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51–4.53), (P = 0.006)], diabetes [OR: 2.55 (95% CI: 1.49–4.35), (P = 0.006)], renal failure [OR: 1.89 (95% CI: 1.19–3.38), (P = 0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63–4.69), (P < 0.001)] were risk factors for graft occlusion.ConclusionsBalloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.     

When is Thrombolysis for Acute Lower Limb Ischemia Worthwhile?

ObjectivesTo find variables associated with outcome following thrombolytic treatment for acute lower limb ischemia.DesignRe-analysis of a prospective multicentre study.Material and methodsOne hundred and twenty-one patients with acute lower limb ischemia previously included in a randomised study comparing high- with low-dose thrombolysis were re-analysed ignoring the mode of lytic treatment. All possibly predictive variables were subjected to multivariate analyses to find associations with outcome.ResultsPrevious successful thrombolysis, ankle–brachial index over 0.33, absence of motor dysfunction, presence of cardiac arrhythmia, and lysis of a vascular graft were all associated with successful thrombolysis (p = 0.003). Previous thrombolysis, age less than 70 years, and ankle–brachial index over 0.33 were all perfect predictors of absence of life-threatening complications or death. Successful lysis, age < 70, and lysis of a native artery as opposed to a vascular graft were all associated with clinical success (preserved patency, limb, and life) after one year (p = 0.002).ConclusionsPrevious thrombolysis, age under 70 years, and non-severe ischemia predict successful thrombolysis free from severe complications. Successful thrombolysis is strongly predictive of amputation-free survival with vascular patency for at least one year. Occluded grafts could often be reopened, but long-term outcome is better after thrombolysis of native arteries.     

Treatment of tibial nonunion with posterolateral bone grafting

ObjectivesPosterolateral bone grafting to treat nonunions of the distal two-thirds of the tibia avoids the often traumatized and more tenuous anterior soft-tissue envelope. Few modern reports of its effectiveness are available. We assessed whether posterolateral bone grafting leads to high union and low complication rates.MethodsWe conducted a retrospective review at a Level I trauma center. Our study group was 59 patients with distal two-thirds tibial fractures treated with posterolateral bone grafting. Patients included those with history of deep surgical site infection (SSI) before bone grafting (n = 17), established nonunions (n = 42), and impending nonunions associated with open fractures and bone gaps (n = 17). All patients were followed for a minimum of 12 months unless they achieved union before that time point. Our primary outcome measurement was fracture union. Secondary outcome measurements were any complication associated with the approach and infection requiring return to the operating room.ResultsFracture union was achieved in 44 (75%) of 59 patients without further intervention. The mean interval to union was 9.9 months (range, 3–22). Of 11 infected nonunions treated, nine progressed to union. Seventeen of 23 patients with defects >2 cm, including defects up to 5.4 cm without infection, were successfully treated. Two patients who underwent grafting at least 10 years after initial injury achieved union. No complications were associated with the approach (specifically, no wound breakdown, vascular injury, or tendon injury). Fourteen percent of patients experienced SSI after bone grafting. Seven of eight deep SSI occurred in patients with previous infection or positive intraoperative cultures. Only one (3%) of 36 patients without infection pre- or intraoperatively experienced SSI.ConclusionsEven in this relatively difficult patient cohort that included large bone gaps and history of infection, union was achieved at a relatively high rate with posterolateral bone graft. The approach seems to be safe, considering no known complications specifically associated with the approach occurred, and seems to reduce the risk of SSI in the absence of previous infection.     

Comparison Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC + PBC) in chondral lesions at the ankle—A clinical matched-patient analysis

BackgroundThe aim of the study was to compare Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC + PBC) in chondral lesions at the ankle.MethodsIn a matched-patient clinical follow-up study, patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to July 15, 2016, and patients that were treated with AMIC + PBC from July 17, 2016 to May 31, 2017 were included and compared. Size and location of the chondral lesions and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Bone Marrow Aspirate Concentrate (BMAC) was used for MAST and Peripheral Blood Concentrate (PBC) for AMIC + PBC to impregnate a collagen I/III matrix (Chondro-Gide, Wollhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.ResultsOne hundred and twenty-nine patients with 136 chondral lesions were included in both groups. The chondral lesions were located as follows (MAST/AMIC + PBC, n (%)), medial talar shoulder only, 59 (43)/62 (46); lateral talar shoulder only, 44 (32)/42 (31); medial and lateral talar shoulder, 7 (10)/7 (10); tibia, 19 (14)/18 (13). The lesion size was 1.6/1.8 cm² on average and VAS FA was 46.9/45.7 (MAST/AMIC + PBC). For MAST/AMIC + PBC groups, 107 (83%)/105 (81%) with 112/110 previous chondral lesions completed the defined 2-year-follow-up after 24.4/23.8 months on average. VAS FA improved to 82.3/79.8 (MAST/AMIC + PBC). No parameter significantly differed between MAST and AMIC + PBC groups.ConclusionsMAST and AMIC + PBC as part of a complex surgical approach led to improved and high validated outcome scores in 2-year-follow-up. MAST and AMIC + PBC showed similar results.     

Evaluation of the results of Watson Jones tenodesis in chronic lateral instability of the ankle

ObjectiveTo evaluate the results of Watson Jones tenodesis in chronic lateral instability of the ankle.Material and methodThis study includes 16 chronically unstable ankles in 15 patients treated surgically with the use of a Watson Jones tenodesis. The patients were followed for a mean duration of 4 years and 8 months (range, 2–8 years) postoperatively.ResultsResults were classified according to both the criteria proposed by Good et al., and the American Orthopaedic Foot and Ankle Society classification. Of 16 ankles, 9 (56.25%) had an excellent result (grade 1), four (25%), had a good result (grade 2), three (18.75%), had a fair result (grade 3).ConclusionWatson Jones tenodesis is an effective non-anatomic reconstructive procedure for restoration of the ankle stability. No evidence of deterioration of clinical results occured over time. No narrowing of the joint space was detected in any ankle. No loss of peroneal muscle strength was detected, a decrease in calf circumference reported in all case range from 0.5 to 1.5 cm with a mean of 0.65 ± 0.5 cm. No relationship was detected between the clinical results and radiological osteoarthritic changes over the duration of follow up.     

Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years

BackgroundWe retrospectively evaluated the mid-term results of surgery for talar process fractures (lateral and posterior processes) and exploratively analyzed parameters that potentially impact treatment outcomes.MethodsFifteen patients who underwent internal fixation (January 2000 to December 2015) were examined for radiological and clinical functional outcomes. The independent parameters evaluated were age, sex, extent of general injury, soft-tissue damage, surgical latency, and fracture type.ResultsAll fractures healed completely. Three patients developed osteoarthritis. The American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Scale score was 79.5 ± 18.6, the Functional Foot Index score was 31.1 ± 31.4, and the physical and mental component summary scores of the Short Form 36, version 2, were 46.6 ± 11.8 and 50.3 ± 9.1, respectively. No influence on the above scores was determined.ConclusionsThe clinical outcomes of internal fixation of talar process fractures were good. Delayed surgical treatment (≥14 days) did not significantly lead to poorer outcomes in our patients.     

The mechanical consequence of actual bone loss and simulated bone recovery in acute spinal cord injury

IntroductionSpinal cord injury (SCI) is characterized by rapid bone loss and an increased risk of fragility fracture around regions of the knee. Our purpose was to quantify changes in torsional stiffness K and strength T_ult at the proximal tibia due to actual bone loss and simulated bone recovery in acute SCI.MethodsComputed tomography scans were acquired on ten subjects with acute SCI at serial time points separated by a mean of 3.9 months (range 3.0 to 4.8 months). Reductions in bone mineral were quantified and a validated subject-specific finite element modeling procedure was used to predict changes in K and T_ult. The modeling procedure was subsequently used to examine the effect of simulated hypothetical treatments, in which bone mineral of the proximal tibiae were restored to baseline levels, while all other parameters were held constant.ResultsDuring the acute period of SCI, subjects lost 8.3 ± 4.9% (p < 0.001) of their bone mineral density (BMD). Reductions in K (− 9.9 ± 6.5%; p = 0.002) were similar in magnitude to reductions in BMD, however reductions in T_ult (− 15.8 ± 13.8%; p = 0.005) were some 2 times greater than the reductions in BMD. Owing to structural changes in geometry and mineral distribution, T_ult was not necessarily recovered when bone mineral was restored to baseline, but was dependent upon the degree of bone loss prior to hypothetical treatments (r ≥ 0.719; p ≤ 0.019).ConclusionsTherapeutic interventions to halt or attenuate bone loss associated with SCI should be implemented soon after injury in an attempt to preserve mechanical integrity and prevent fracture.