Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: A prospective and comparative study

PurposeSyndesmosis injury is common in external-rotation type ankle fractures (ERAF). Trans-syndesmosis screw fixation, the gold-standard treatment, is currently controversial for its complications and biomechanical disadvantages. The purpose of this study was to introduce a new method of anatomically repairing the anterior-inferior tibiofibular ligament (AITFL) and augmentation with anchor rope system to treat the syndesmotic instability in ERAF with posterior malleolus involvement and to compare its clinical outcomes with that of trans-syndesmosis screw fixation.Methods53 ERAFs with posterior malleolus involvement received surgery, and the syndesmosis was still unstable after fracture fixation. They were randomised into screw fixation group and AITFL anatomical repair with augmentation group. Reduction quality, syndesmosis diastasis recurrence, pain (VAS score), time back to work, Olerud–Molander ankle score and range of motion (ROM) of ankle were investigated.ResultsOlerud–Molander score in AITFL repair group and screw group was 90.4 and 85.8 at 12-month follow-up (P > 0.05). Plantar flexion was 31.2° and 34.3° in repair and screw groups (P = 0.04). Mal-reduction happened in 5 cases (19.2%) in screw group while 2 cases (7.4%) in repair group. Postoperative syndesmosis re-diastasis occurred in 3 cases in screw group while zero in repair group (P > 0.05). Pain score was similar between the two groups (P > 0.05). Overall complication rate and back to work time were 26.9% and 3.7% (P = 0.04), 7.15 months and 5.26 months (P = 0.02) in screw group and repair group, respectively.ConclusionsFor syndesmotic instability in ERAF with posterior malleolus involvement, the method of AITFL anatomical repair and augmentation with anchor rope system had an equivalent functional outcome and reduction, earlier rehabilitation and less complication compared with screw fixation. It can be selected as an alternative.     

Prognostic factors for intermediate-term clinical outcomes following Bosworth fractures of the ankle joint

BackgroundThis retrospective comparative study was performed to evaluate the clinical outcomes after surgical treatment for Bosworth fracture-dislocation, and to analyse the prognostic factors related to postoperative outcomes.MethodsFifteen patients were followed for ≥2 years after Bosworth fracture-dislocation. Twenty-five ankle fracture-dislocations as control group were enrolled to compare clinical outcomes. Clinical evaluation consisted of the AOFAS and Olerud–Molander scores. Patient and injury factors were analysed to identify the outcome predictors.ResultsThere were no significant differences in either clinical evaluation score as compared to control group (P = 0.245, .302, respectively). The time interval to operation and number of manual reduction attempts were found to be predictive factors for poor outcomes (P = 0.004, .038, respectively).ConclusionAs compared to more common patterns of ankle fracture-dislocations, intermediate-term clinical outcomes after Bosworth fracture-dislocations were statistically comparable. Delayed surgical reduction and repeated attempts at closed reduction appear to be negative outcome predictors.     

Simulated weight reduction using an anti-gravity treadmill – A pilot study of the impact of weight loss on foot and ankle arthritis

BackgroundDespite a paucity of evidence, obesity is frequently cited as an exacerbator of symptoms in foot and ankle arthritis. The aims of the current study were to determine whether simulated weight loss would improve symptoms in obese patients with foot and ankle arthritis.MethodsPatients walked on an “anti-gravity” treadmill allowing simulated weight reduction. Pain was recorded at baseline weight and then compared with pain at simulated normal BMI.ResultsSimulated reduction to BMI 25 caused a significant reduction in pain. Mean pain scores improved from baseline to BMI 25 by 32% (15.9 points, p = 0.04). Paired analysis showed a significant improvement in pain scores (p = 0.016) from BMI of 30 to 25.ConclusionSimulated weight loss from high to normal BMI improved arthritic symptoms. This could be used to power future studies to further investigate the effects of weight loss in foot and ankle patients.Level of evidence Level II – repeated measures cohort study.     

The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging

ObjectiveTo evaluate the feasibility of point-of-care ankle ultrasound compared with magnetic resonance imaging (MRI) for diagnosing major ligaments and Achilles tendon injuries in patients with recurrent ankle sprain and chronic instability, and to evaluate inter-observer reliability between an emergency physician and a musculoskeletal radiology fellow.Material and methodsA prospective cross-sectional study was conducted in an emergency department. Patients with recurrent ankle sprain and chronic instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Findings were classified normal, partial tear, and complete tear. MRI was used as the reference standard. We calculated diagnostic values for point-of-care ankle ultrasound for both reviewers and compared them using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and between the two reviewers.ResultsEighty-five patients were enrolled. Point-of-care ankle ultrasound showed acceptable sensitivity (96.4–100%), specificity (95.0–100%), and accuracy (96.5–100%); these performance markers did not differ significantly between reviewers. Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC = 0.846–1.000; musculoskeletal radiology fellow, ICC = 0.930–1.000), as was inter-observer agreement (ICC = 0.873–1.000).ConclusionPoint-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. Moreover, it may reduce the interval from emergency department admission to admission for surgical intervention, and may save costs.     

Doctor,when can I drive? — Range of functional ankle motion during driving

BackgroundDriving a motor vehicle needs a specific joint mobility and yet only limited knowledge exists regarding the necessary ankle range of motion. The goal of this study is to characterize the sequence and range of ankle motion.MethodsThe arc of plantarflexion/dorsiflexion and supination/pronation was recorded in the right and left ankle using electrogoniometers while thirty laps were driven by fifteen healthy participants around a course in a manual transmission car with a left sided steering wheel. The driver was required to perform the following maneuvers during each lap: (I) Vehicle acceleration and gear change, (II) Sudden evasion, (III) Routine turning, (IV) Rapid turning, (V) Vehicle acceleration followed by emergency braking.ResultsDriving required the right ankle to plantarflex 13 ± 9 and dorsiflex 22 ± 7 while supinating 15 ± 7 degrees and pronating minimally. The left ankle plantarflexed 19 ± 10and dorsiflexed 17 ± 10 while supinating 15 ± 7 degrees and pronating minimally. The right ankle dorsiflexed significantly more (p = 0.00), and yet the left ankle had a significantly higher maximum plantarflexion and range of plantarflexion/dorsiflexion (p = 0.00). Emergency braking resulted in a significantly higher maximum plantarflexion as well as plantarflexion/dorsiflexion range when compared to other maneuvers.ConclusionThis study describes the range of ankle motion identified to drive a car with a manual transmission and a left-sided steering wheel. The right and left ankle exhibit different arcs of motion during driving. This knowledge may assist when evaluating a patient’s driving capability. Further studies are needed to investigate whether movement restrictions impair driving.Level of evidenceBasic science study.     

There is a difference in functional ankle stability between different types of footwear in male athletes: A cross-sectional study

ContextLateral ankle sprains (LAS) are among the most common injuries in sports, with a poor long – term prognosis due to high chronicity and recurrence rates. Chronic ankle instability (CAI) results up to 40% of people that endured a first – time LAS.ObjectiveThe aim of this study was to compare ankle stability between groups characterised by the use of different types of footwear during their sport activities.DesignCross-sectional study.SettingFirm training surface, local sport clubs.ParticipantsFifty - one male subjects were recruited, distributed in four groups based on the type of footwear they use during their sport activities.Main outcome measuresAll subjects performed four clinical ankle stability tests, and completed the Dutch version of the Cumberland Ankle Instability Tool (CAIT) and Profile of Mood States (POMS). All clinical ankle stability tests were performed barefoot.ResultsSubjects performing their sport activities barefoot scored better than subjects performing their sport with shoes at the multiple hop test (p = .002 to .047) and executed the figure–of–8 hop test significantly faster than subjects with submalleolar ankle support (AS) (p = .019). Subjects with submalleolar AS and studs showed significantly better results than subjects with supramalleolar AS on the CAIT– score (p = .024, p = .030) and the side– hop test (p = .050, p = .045). They also scored significantly better than subjects with submalleolar AS for the side – hop test (p = .032), foot – lift test (p = .019) and figure–of 8 hop test (p = .011).ConclusionBarefoot sports performing subjects appear to have better ankle stability compared to subjects performing their sports with shoe support. Subjects performing sports with high AS appear to have worst ankle stability.Level of evidence: Level III, Cross–sectional study.     

Bipolar fresh total osteochondral allograft in the ankle: Is it a successful long-term solution?

IntroductionSevere post-traumatic ankle arthritis poses a reconstructive challenge in young and active patients. Although technically demanding and despite unsolved immunological issues, bipolar fresh total osteochondral allograft (BFTOA) represent an intriguing option to arthrodesis and prosthetic replacement. The purpose of this paper is to evaluate the outcomes of a series of 48 ankle BFTOA at 10 years follow up and to investigate the rate of survival long term.Methods58 patients underwent BFTOA, of these 48 were available for follow up. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using either a lateral or a direct anterior approach. Patients were evaluated clinically and radiographically preoperatively, and at a mean 121 ± 18 months of follow-up.ResultsThe AOFAS score improved from 31 ± 11 pre operatively, to 65 ± 25 at the last (p < 0.0005). Fourteen failures occurred, with 70.8% allograft rate of survival. All the surviving allografts showed a reduction of the ankle joint movement, still associated with a satisfactory clinical result.ConclusionThe use of BFTOA represents an intriguing option to arthrodesis or arthroplasty. A satisfactory clinical result associated to a good movement of the transplanted joint is to be expected up to short-mid-term, overtime. Long term, the range of motion (ROM) is progressively decreased up to spontaneous arthrodesis in some cases, still the joint results pain free and patient’s perception is of a well functioning ankle. A deeper knowledge of the immunological behavior of transplanted cartilage is needed in order to improve the durability of this fascinating technique.     

Impact of trimalleolar ankle fractures: How do patients fare post-operatively?

BackgroundWe aim to evaluate the clinical and functional outcome of trimalleolar fractures and the ability of patients to return to sporting activities.MethodsA retrospective review of 31 patients with operatively managed trimalleolar fractures was conducted. Their Olerud and Molander scores and ability to return to sports was analyzed at 1 year postoperatively.ResultsDislocations were more likely to result from trimalleolar fractures (p < 0.001). 11 (52.4%) of our patients had residual pain at 1 year. 13 (61.9%) and 10 (47.6%) had persistent ankle stiffness and swelling. Out of 12 patients who were involved in sports pre-operatively, only 4 (33.3%) patients were able to return to sports. 3 (25%) patients were unable to do sports at all. Increasing posterior malleolar fragment size correlates with poorer functional outcome.ConclusionsPatients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures. Residual deficits affect the majority of our patients and a notable proportion was unable to return to sporting activities.     

Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study

BackgroundProspective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance.MethodsPatients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n = 8) and a healthy control group (n = 8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected.ResultsImprovements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p ≤ .02).ConclusionsStudy findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.     

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup.MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6 months and 24 months after surgery.ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9 ± 1.2, open: 3.8 ± 1.1, p < 0.001) and shorter length of hospitalization stay (arthroscopic: 2.1 ± 0.7 open: 3.5 ± 1.7, p < 0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6 months (arthroscopic: 58.4 ± 27.1, open: 47.1 ± 24.0, p < 0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9 ± 18.9, open: 68.9 ± 24.7, p < 0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups.ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24 months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24 months, shorter length of stay, fewer postoperative complications and followup operations.Level of evidenceLevel III, retrospective comparative series.     

External versus internal fixation for arthrodesis of chronic ankle joint infections — A comparative retrospective study

BackgroundArthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard.We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.MethodsAll patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.ResultsSeventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p = 0.019), achieved full weightbearing significantly more often (p = 0.042) and faster and developed significantly fewer complications (p < 0.001). Forty-three patients showed bone fusion without significant differences between the groups.ConclusionsAnkle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.     

Does perceived injustice correlate with pain intensity and disability in orthopaedic trauma patients?

IntroductionIndividuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.MethodsA total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.ResultsThe IEQ was associated with PROMIS Physical Function (r = −0.36; P < 0.001) and PROMIS Pain Intensity (r = 0.43; P < 0.001). In multivariable analysis, however, Caucasian race (β = 5.1, SE: 2.0, P = 0.013, 95% CI: 1.1–9.2), employed work status (β = 5.1, SE: 1.5, P = 0.001, 95% CI: 2.1–8.2), any cause of injury other than sports, mvc, or fall (β = 7.7, SE: 2.1, P < 0.001, 95% CI: 3.5–12), and higher self-efficacy (PSEQ-2; β = 0.93, SE: 0.23, P < 0.001, 95% CI: 0.48–1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β = 1.2, SE: 0.12, P < 0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.ConclusionPerceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.     

Progressive rehabilitation of the sprained ankle: A novel treatment method

ObjectivesThis randomised, single blinded cohort study was designed to assess the immediate effect of manual fascial manipulation on walking pain and the range of ankle dorsiflexion within the first 4 days after ankle trauma.MethodsMeasurements were taken from 19 subjects, 5 female and 14 male, who presented with grade I–III ankle sprains. Ankle dorsiflexion was photographed in a standardised position and calculated by means of the Dartfish® Advanced Video Analysis Software and SPSS® (version 17) was used to compare the pre- and post-treatment data.ResultsAfter one treatment session 13 of the 19 subjects were walking pain free and 3 of the 19 where walking with only little pain. The highly significant (p < 0.001) mean improvement of ankle dorsiflexion was 7.9° (±5.8°). All, apart from one subject, whom were walking pain free after treatment showed a minimum of 4° increased dorsiflexion.ConclusionEarly fascia work around the injured ankle improves ankle dorsiflexion and reduces walking pain. It may reduce the delay of tissue healing and, thus, optimise further rehabilitation of the sprained ankle which may also reduce socio-economic costs.     

A novel tool for continuous fracture aftercare – Clinical feasibility and first results of a new telemetric gait analysis insole

Weight bearing after lower extremity fractures still remains a highly controversial issue. Even in ankle fractures, the most common lower extremity injury no standard aftercare protocol has been established. Average non weight bearing times range from 0 to 7 weeks, with standardised, radiological healing controls at fixed time intervals. Recent literature calls for patient-adapted aftercare protocols based on individual fracture and load scenarios. We show the clinical feasibility and first results of a new, insole embedded gait analysis tool for continuous monitoring of gait, load and activity.Ten patients were monitored with a new, independent gait analysis insole for up to 3 months postoperatively. Strict 20 kg partial weight bearing was ordered for 6 weeks. Overall activity, load spectrum, ground reaction forces, clinical scoring and general health data were recorded and correlated. Statistical analysis with power analysis, t-test and Spearman correlation was performed.Only one patient completely adhered to the set weight bearing limit. Average time in minutes over the limit was 374 min. Based on the parameters load, activity, gait time over 20 kg weight bearing and maximum ground reaction force high and low performers were defined after 3 weeks. Significant difference in time to painless full weight bearing between high and low performers was shown. Correlation analysis revealed a significant correlation between weight bearing and clinical scoring as well as pain (American Orthopaedic Foot and Ankle Society (AOFAS) Score r_s = 0.74; Olerud–Molander Score r_s = 0.93; VAS pain r_s = −0.95).Early, continuous gait analysis is able to define aftercare performers with significant differences in time to full painless weight bearing where clinical or radiographic controls could not. Patient compliance to standardised weight bearing limits and protocols is low. Highly individual rehabilitation patterns were seen in all patients. Aftercare protocols should be adjusted to real-time patient conditions, rather than fixed intervals and limits. With a real-time measuring device high performers could be identified and influenced towards optimal healing conditions early, while low performers are recognised and missing healing influences could be corrected according to patient condition.     

Ankle block in forefoot reconstruction before or after inflation of tourniquet—Does timing matter?

BackgroundForefoot surgery causes postoperative pain frequently requiring strong painkillers. Regional blocks are now increasingly used in order to control postoperative pain especially in the first 24 h when the pain is at its worst. We conducted a prospective study to see if timing of ankle block i.e. before or after inflation of tourniquet showed any difference in efficacy in postoperative pain control in first 24 h.MethodsA prospective randomised study was conducted between September 2010 and August 2011 involving 60 patients. Group A (n = 30) had the ankle block administered after and Group B (n = 30) had a block before inflation of a thigh tourniquet. Patients were given assessment forms to chart their pain on visual analogue scale (VAS) score at 4 h and 24 h postoperatively.ResultsBoth groups demonstrated good postoperative pain control. Average VAS pain score at four and twenty fours after surgery was 2.5 and 4.5 in Group A and 3.9 and 6.3 in Group B respectively. Pain control, both at 4 and 24 h surgery was better in Group A but this was statistically significant only at 24 h.ConclusionsA regional anaesthetic ankle block should be routinely used in forefoot surgery to control postoperative pain. The ankle block should be applied after the inflation of tourniquet as this appears to provide better pain control.     

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.     

Current practice for safe return-to-play after lateral ankle sprain: A survey among French-speaking physicians

BackgroundRecommendations are available for assessment criteria for safe return-to-play (RTP) after a lateral ankle sprain. However, their current use among physicians is unknown.MethodsFrench-speaking physicians in Belgium, France and Switzerland were asked to complete an online survey and report their clinical assessment of selected RTP criteria.ResultsThe respondent sample (n = 109) included physicians with and without Sports Medicine education, varied level of experience and proportion of athletes in their practice population. Pain was the most selected criterion for safe RTP (90% of physicians), followed by ability to engage in functional tasks (82%), functional instability (73%), range of motion (61%), proprioception (47%), mechanical instability (39%), strength (38%) and swelling (31%). A low proportion of physicians use quantitative measures to assess these criteria (between 4% and 53%).ConclusionsA large proportion of physicians consider the recommended criteria for RTP decisions. However, physicians do not frequently use quantitative measures.     

Overtightening of the syndesmosis revisited and the effect of syndesmotic malreduction on ankle dorsiflexion

BackgroundAnkle syndesmotic injuries are a significant source of morbidity and require anatomic reduction to optimize outcomes. Although a previous study concluded that maximal dorsiflexion during syndesmotic fixation was not required, methodologic weaknesses existed and several studies have demonstrated improved ankle dorsiflexion after removal of syndesmotic screws.The purposes of the current investigation are: (1) To assess the effect of compressive syndesmotic screw fixation on ankle dorsiflexion utilizing a controlled load and instrumentation allowing for precise measurement of motion. (2) To assess the effect of anterior & posterior syndesmotic malreduction after compressive syndesmotic screw fixation on ankle dorsiflexion.Material and methodsFifteen lower limb cadaveric leg specimens were utilized for the study. Ankle dorsiflexion was measured utilizing a precise micro-sensor system after application of a consistent load in the (1) intact state, (2) after compression fixation with a syndesmotic screw and (3) after anterior & (4) posterior malreduction of the syndesmosis.ResultsFollowing screw compression of the nondisplaced syndesmosis, dorsiflexion ROM was 99.7 ± 0.87% (mean ± standard error) of baseline ankle ROM. Anterior and posterior malreduction of the syndesmosis resulted in dorsiflexion ROM that was 99.1 ± 1.75% and 98.6 ± 1.56% of baseline ankle ROM, respectively. One-way ANOVA was performed showing no statistical significance between groups (p-value = 0.88).Two-way ANOVA comparing the groups with respect to both the reduction condition (intact, anatomic reduction, anterior displacement, posterior displacement) and the displacement order (anterior first, posterior first) did not demonstrate a statistically significant effect (p-value = 0.99).ConclusionMaximal dorsiflexion of the ankle is not required prior to syndesmotic fixation as no loss of motion was seen with compressive fixation in our cadaver model. Anterior or posterior syndesmotic malreduction following syndesmotic screw fixation had no effect on ankle dorsiflexion. Poor patient outcomes after syndesmotic malreduction may be due to other factors and not loss of dorsiflexion motion.Level of Evidence: IV     

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.     

Kinematic analysis of ankle stiffness in subjects with and without flat foot

BackgroundAlthough the magnitude of ankle motion is influenced by joint congruence and ligament elasticity, there is a lack of understanding on ankle stiffness between subjects with and without flat foot.ObjectiveThis study investigated a quantified ankle stiffness difference between subjects with and without flat foot.MethodsThere were forty-five age- and gender-matched subjects who participated in the study. Each subject was seated upright with the tested foot held firmly onto a footplate that was attached to a torque sensor by the joint-driving device.ResultsThe flat foot group (mean ± standard deviation) demonstrated increased stiffness during ankle dorsiflexion (0.37 ± 0.16 for flat foot group, 0.28 ± 0.10 for control group; t = −2.11, p = 0.04). However, there was no significant group difference during plantar flexion (0.35 ± 0.15 for flat foot group, 0.33 ± 0.07 for control group; t = 0.64, p = 0.06).ConclusionThe results of this study indicated that the flat foot group demonstrated increased ankle stiffness during dorsiflexion regardless of demographic factors. This study highlights the need for kinematic analyses and joint stiffness measures during ankle dorsiflexion in subjects with flat foot.