Ankle Arthrodesis in Crippled Cases.

The current article provides an algorithm of how to approach crippled ankle by ankle arthrodesis. There is no standard pathology or treatment present, which makes the diagnosis but also surgical correction complex. A surgeon who faces this kind of deformities needs to be skilled and well familiar with the full setting of the foot and ankle armamentarium.

[Treatment of a Progressive Collapsing Foot Deformity]. / Behandlung des Plattfusses.

Treatment of a Progressive Collapsing Foot Deformity Abstract. The so-called "flat foot" can be more accurately described in German as "Knick-Senkfuss" or "kinking-flatfoot". The "kink" refers to the hindfoot axis as such, which can be identified by the intersection of the longitudinal axes of the Achilles tendon and the tuber calcanei. The designation "flat foot" marks the appearance of the longitudinal axis, that is, the medial longitudinal arch, which is easy to determine clinically. Nowadays, a new terminology has been added: Progressive collapsing foot deformity (PCFD). The forms of a PCFD are manifold, as are the possible causes. For this reason, the forms of therapy to be used are often not very simple and must be carefully considered and applied. Not always are PCFD in need of treatment. That means that there are people who have always had such deformities but never develop symptoms. For this reason, only symptomatic patients suffering from a PCFD need treatment. The degree of treatment and its success depends on the careful examination and interpretation of the findings by the orthopedic surgeon. This article deals with treatment of PCFD and attempts to provide a logical overview.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm.

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat?

This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.

Long-term Prognosis After Successful Nonoperative Treatment of Osteochondral Lesions of the Talus: An Observational 14-Year Follow-up Study.

BACKGROUND: Little is known about the long-term prognosis of osteochondral lesions of the talus (OLTs) after nonoperative treatment. PURPOSE: To evaluate the clinical and radiological long-term results of initially successfully treated OLTs after a minimum follow-up of 10 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1998 and 2006, 48 patients (50 ankles) with OLTs were successfully treated nonoperatively. These patients were enrolled in a retrospective long-term follow-up, for which 24 patients could not be reached or were available only by telephone. A further 2 OLTs (6%) that had been treated surgically were excluded from the analysis and documented as failures of nonoperative treatment. The final study group of 22 patients (mean age at injury, 42 years; range, 10-69 years) with 24 OLTs (mean size, 1.4 cm2; range, 0.2-3.8 cm2) underwent clinical and radiological evaluation after a mean follow-up of 14 years (range, 11-20 years). Ankle pain was evaluated with a visual analog scale (VAS), ankle function with the American Orthopaedic Foot and Ankle Society (AOFAS) score, and sports activity with the Tegner score. Progression of ankle osteoarthritis was analyzed based on plain ankle radiographs at the initial presentation and the final follow-up according to the Van Dijk classification. RESULTS: At final follow-up, the 24 cases (ie, ankles) showed a median VAS score of 0 (IQR, 0.0-2.25) and a median AOFAS score of 94.0 (IQR, 85.0-100). Pain had improved in 18 cases (75%), was unchanged in 3 cases (13%), and had increased in 3 cases (13%). The median Tegner score was 4.0 (IQR, 3.0-5.0). Persistent ankle pain had led to a decrease in sports activity in 38% of cases. At the final follow-up, 11 cases (73%) showed no progression of ankle osteoarthritis and 4 cases (27%) showed progression by 1 grade. CONCLUSION: Osteochondral lesions of the talus that successfully undergo an initial nonoperative treatment period have minimal symptoms in the long term, a low failure rate, and no relevant ankle osteoarthritis progression. However, a decrease in sports activity due to sports-related ankle pain was observed in more than one-third of patients.

The Use of Virtual Planning and Patient-specific Guides to Correct Complex Deformities of the Foot and Ankle.

This article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle. Based on 3-dimensional data obtained from CT scans, surgeons are able to create a virtual plan of how to correct a complex deformity. This plan is transferred into the production of true patient-specific guides, designed to perform a specific surgical intervention. The authors have extensive experience with this technique and were involved in the development of the method. The current article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle.

Scientific Evidence in the Treatment of Metatarsalgia.

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Clinical and Radiological 2- to 8-Year Follow-up Study.

BACKGROUND: Autologous matrix-induced chondrogenesis (AMIC) has become an interesting treatment option for osteochondral lesions of the talus (OLTs) with promising clinical short- to midterm results. PURPOSE: To investigate the clinical and radiological outcome of the AMIC procedure for OLTs, extending the follow-up to 8 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-three patients (mean age, 35.1 years; body mass index, 26.8) with osteochondral lesions of the medial talar dome were retrospectively evaluated after open AMIC repair at a mean follow-up of 4.7 years (range, 2.3-8.0 years). Patients requiring additional surgical procedures were excluded. All OLTs (mean size, 0.9 cm2; range, 0.4-2.3 cm2) were approached through a medial malleolar osteotomy, and 28 patients received subchondral autologous bone grafting. Data analysis included the visual analog scale for pain, the American Orthopaedic Foot and Ankle Society score for ankle function, the Tegner score for sports activity, and the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system for repair cartilage and subchondral bone evaluation. RESULTS: Mean ± SD visual analog scale score improved significantly from 6.4 ± 1.9 preoperatively to 1.4 ± 2.0 at latest follow-up ( P < .001). The mean American Orthopaedic Foot and Ankle Society score was 93.0 ± 7.5 (range, 75-100). The Tegner score improved significantly from 3.5 ± 1.8 preoperatively to 5.2 ± 1.7 at latest follow-up ( P < .001), and 79% returned to their previous sports levels. The MOCART score averaged 60.6 ± 21.2 (range, 0-100). Complete filling of the defect was seen in 88% of cases, but 52% showed hypertrophy of the cartilage layer. All but 1 patient showed persistent subchondral bone edema. The patient's age and body mass index, the size of the osteochondral lesion, and the MOCART score did not show significant correlation with the clinical outcome. There were no cases of revision surgery for failed AMIC. Fifty-eight percent underwent reoperation, mainly for symptomatic hardware after malleolar osteotomy. CONCLUSION: AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging.

The Role of Plantar Fascia Tightness in Hallux Limitus: A Biomechanical Analysis.

Restriction of greater toe dorsiflexion without degeneration of the first metatarsophalangeal joint is defined as hallux limitus. We assume that in hallux limitus the limitation of greater toe dorsiflexion takes place in the terminal stance phase because of massive tightening of the calf and plantar structures. The current study investigated the role of a tight plantar fascial structure in impairing dorsiflexion of the greater toe. For the purpose of the study, 7 lower limbs from Thiel-fixated human cadavers were evaluated. To simulate double-limb standing stance, the tibia and fibula were mounted on a materials testing machine and constantly loaded with 350N. Additionally, the tendons of the specimens were loaded using a custom-made system. The plantar fascia was fixed to a clamp and tensioned using a threaded bar. Four different tensile forces were then applied to the plantar fascia (approximately 100, 200, 300, and 350 N) and the extension of the first toe was measured. The results show a significant positive correlation between the decrease in extension of the hallux and the tension applied to the plantar fascia reaching a maximum mean decrease of 4.2° (117% compared with the untightened situation) for an applied tension of 364N.

Coalitions of the Tarsal Bones.

Tarsal coalitions are the result of impaired mesenchymal separation of the tarsal bones. The most common types include calcaneonavicular or talocalcaneal coalitions. Subtalar stiffness results in pathologic kinematics with increased risk of ankle sprains, planovalgus foot deformity, and progressive joint degeneration. Resection of the coalition yields good results. Tissue interposition may reduce the risk of reossification, and concomitant deformity should be addressed in the same surgical setting.

Subtalar Distraction Arthrodesis.

The subtalar joint can be altered in its anatomy and biomechanical behavior. It is important to know how to assess the talar declination angle in order to assess the deformity at the subtalar joint. Consider a straight posterior approach to the subtalar joint and remain liberal in the use of z-shaped Achilles tendon lengthening. A structural bone graft should be used to elevate the talus. Positioning screws should be used to lock the construct.

Three-Dimensional Correction of Complex Ankle Deformities With Computer-Assisted Planning and Patient-Specific Surgical Guides.

Three-dimensional computer-assisted preoperative planning, combined with patient-specific surgical guides, has become an effective technique for treating complex extra- and intraarticular bone malunions by corrective osteotomy. The feasibility and accuracy of such a technique has not yet been evaluated for ankle deformities. Four surgical cases of varying complexity and location were selected for evaluation. Three-dimensional bone models of the affected and contralateral healthy lower limb were generated from computed tomography scans. The preoperative planning software permitted quantification of the deformity in 3 dimensions and subsequent simulation of reduction, yielding a precise surgical plan. Patient-specific surgical guides were designed, manufactured, and finally applied during surgery to reproduce the preoperative plan. Evaluation of the postoperative computed tomography scans indicated adequate reduction accuracy with residual translational and rotational errors of <3 mm and <6°, respectively. Two patients required revision surgery owing to anterior osseous impingement or delayed union of the osteotomy. All patients were satisfied with the postoperative course and were pain free at a mean follow-up period of 2.5 (range 1 to 4) years. These promising results require confirmation in a clinical study with a larger sample size.

The V sign in lateral talar process fractures: an experimental study using a foot and ankle model.

BACKGROUND: Lateral talar process fractures (LTPF) are often missed on conventional radiographs. A positive V sign is an interruption of the contour of the LTP. It has been suggested, but not proven to be pathognomonic for LTPF. The objective was to study whether the V sign is pathognomonic for LTPF and if it can be properly assessed in different ankle positions and varying fracture types. METHODS: An experimental study was conducted. Two investigators assessed lateral radiographs (n = 108) of a foot and ankle model. The exposure variables were different ankle positions and fracture types. The primary outcome was the correct detection of a V sign. The secondary outcomes were the detection of the V sign depending on ankle position and fracture type as well as the uncertainty. RESULTS: The interobserver agreement on the V sign and type of fracture were fair (κ = 0.35, 95% CI 0.18-0.53, p < 0.001 and κ = 0.37, 95% CI 0.26-0.48, p < 0.001). The mean sensitivity, specificity, PPV, NPV, and likelihood ratio for the detection of the V sign were 77% (95% CI 67-86%), 59% (95% CI 39-78%), 85% (95% CI 75-92%), 46% (95% CI 29-63%), and 2. The mean uncertainty in the V sign detection was 38%. The V sign identification stratified by ankle position and fracture type showed significant better results with increasing inversion (p = 0.035 and p = 0.011) and type B fractures (p = 0.001 and p = 0.013). CONCLUSIONS: The V sign may not be pathognomonic and is not recommended as the only modality for the detection of LTPF. It is better visualized with inversion, but does not depend on plantar flexion or internal rotation. It is also better seen in type B fractures. It is difficult to detect and investigator-dependent. It may be helpful in a clinical setting to point into a direction, but a CT scan may be used if in doubt about a LTPF.

Osteolysis in Total Ankle Replacement: How Does It Work?

Aseptic loosening of implants remains the most common reason for revision surgery for hip, knee, or ankle prostheses. Although a great scientific effort has been made to explain the underlying mechanisms it remains poorly understood, complex, and multifactorial. Many factors, including age, body weight, activity lesions, implant design, fixation methods, material proprieties, immunologic responses, and biomechanical adaptations to total ankle replacement all contribute to the development of periprosthetic osteolysis.

Is there an Added Value of T1-Weighted Contrast-Enhanced Fat-suppressed Spin-Echo MR Sequences Compared to STIR Sequences in MRI of the Foot and Ankle?

OBJECTIVES: To prospectively compare T1-weighted fat-suppressed spin-echo magnetic resonance (MR) sequences after gadolinium application (T1wGdFS) to STIR sequences in patients with acute and chronic foot pain. METHODS: In 51 patients referred for MRI of the foot and ankle, additional transverse and sagittal T1wGdFS sequences were obtained. Two sets of MR images (standard protocol with STIR or T1wGdFS) were analysed. Diagnosis, diagnostic confidence, and localization of the abnormality were noted. Standard of reference was established by an expert panel of two experienced MSK radiologists and one experienced foot surgeon based on MR images, clinical charts and surgical reports. Patients reported prospectively localization of pain. Descriptive statistics, McNemar test and Kappa test were used. RESULTS: Diagnostic accuracy with STIR protocol was 80% for reader 1, 67% for reader 2, with contrast-protocol 84%, both readers. Significance was found for reader 2. Diagnostic confidence for reader 1 was 1.7 with STIR, 1.3 with contrast-protocol; reader 2: 2.1/1.7. Significance was found for reader 1. Pain location correlated with STIR sequences in 64% and 52%, with gadolinium sequences in 70% and 71%. CONCLUSIONS: T1-weighted contrast material-enhanced fat-suppressed spin-echo magnetic resonance sequences improve diagnostic accuracy, diagnostic confidence and correlation of MR abnormalities with pain location in MRI of the foot and ankle. However, the additional value is small. KEY POINTS: • Additional value of contrast-enhanced MR over standard MR with STIR sequences exists. • There is slightly more added value for soft tissue than for bony lesions. • This added value is limited. • Therefore, application of contrast material cannot be generally recommended.

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis.

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.

Stage I and II Posterior Tibial Tendon Dysfunction: Return to Running?

Posterior tibial tendon dysfunction can be a difficult entity to treat in the athletic population. Understanding the deformity components allows the physician to maximize nonoperative intervention with orthotics and physical therapy. Not all patients improve with nonoperative treatment, and surgical intervention can be successful in minimizing symptoms. Although return to full athletic activity is not universally possible, an active lifestyle is possible for many after surgical reconstruction.

Natural history of nonoperatively treated osteochondral lesions of the talus.

BACKGROUND: We hypothesized that patients undergoing nonoperative treatment for asymptomatic or minimally symptomatic osteochondral lesions of the talus (OLTs) would not deteriorate clinically or radiologically over time. METHODS: Forty-eight patients (mean age = 48 years; range, 13-78 years) with an OLT confirmed by magnetic resonance imaging (MRI) who had not undergone ankle joint surgery were retrospectively reviewed. All patients were evaluated after a minimum follow-up of 2 years (mean = 52 months; range, 27-124 months). All patients filled out an individual questionnaire and underwent a physical and radiographic assessment (radiograph and hindfoot MRI). RESULTS: At final follow-up, 43 ankles (86%) in 41 patients were pain-free (visual analogue scale [VAS] 0, n = 12) or less painful (VAS 1-3, n = 31). Radiographically, osteoarthritis was absent in 47%, and grade 1 and 2 osteoarthritis each were found in 27% (van Dijk classification). Magnetic resonance imaging revealed no substantial progression in staging or lesion size. Pain at time of follow-up correlated with the depth of the lesion at initial MRI (P < .05) and with subchondral cyst formation and presence or change of bone marrow edema at follow-up MRI (P < .05). CONCLUSION: Minimally symptomatic OLTs did not appear to progress or worsen over time when treated nonoperatively. LEVEL OF EVIDENCE: Level IV, case series.

Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis.

BACKGROUND: Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results. METHODS: A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA. RESULTS: Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found. CONCLUSION: Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively. LEVEL OF EVIDENCE: Level III, retrospective case series.