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Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. OBJECTIVE: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. METHODS: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. RESULTS: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. CONCLUSION: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.
A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.
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Background: Vitamin D and protein deficiencies are common conditions in the general population. In Orthopaedic surgery, they can result in wound complications or poor bone healing. The goal of this study was, therefore, to determine the prevalence of vitamin D and albumin deficiencies in patients scheduled for elective Orthopaedic procedures. Methods: We performed an observational, noninterventional study using the demographic characteristics via means chart analysis of in-patients with an elective surgery in a single Swiss Orthopaedic centre. The following variables were collected and analysed: age, gender, BMI, ASA score, rate of vitamin D supplementation before surgery, and serum preoperative levels of vitamin D, albumin, Haemoglobin, calcium, and phosphate. Results: A total of 336 patients were analysed; there were 218 women (64.9%) and 118 men (35.1%). The average age was 59.4 years (17-89 years). The average BMI was 26.8 kg/m2 (17.8-37.6) and the average ASA score was II (I-III). The overall prevalence of vitamin D deficiency was 82.1%, being more common in the male (89.8%) than female patients (77.9%). Patients who received vitamin D supplements before surgery had an average vitamin D level in the normal range. Of the subgroup of 170 patients who were over 60 years of age, 78.8% of the patients were Vitamin D deficient, with deficiency once again being more common in men (93.3%) than in women (92%). Albumin deficiency was documented in 58.9% of the cases. A total of 62.8% of all the female patients were albumin deficient, and 51.7% of all male patients were. Of the subgroup of 170 patients who were over 60 years of age, 71.8% of the patients were albumin deficient, with the deficiency being practically identical in men (71.1%) and women (72%). Conclusions: Despite increased awareness in the medical community, vitamin D and albumin deficiencies remain highly prevalent in elective Orthopaedic patients. Pre/perioperative screening and addressing possible vitamin D and albumin deficiencies are of great importance for good outcomes in Orthopaedic surgery.
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ABSTRACT Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. Objective: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. Methods: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. Results: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. Conclusion: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.
RESUMO A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.
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Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.
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Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.
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Fraturas do Tornozelo , Traumatismos do Tornozelo , Entorses e Distensões , Humanos , Articulação do Tornozelo/patologia , Tornozelo , Ligamentos Articulares , Entorses e Distensões/diagnóstico , Entorses e Distensões/terapia , Entorses e Distensões/complicações , Traumatismos do Tornozelo/diagnóstico , Traumatismos do Tornozelo/terapia , Traumatismos do Tornozelo/complicações , Fraturas do Tornozelo/complicaçõesRESUMO
Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.
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Traumatismos do Tornozelo , Instabilidade Articular , Entorses e Distensões , Humanos , Tornozelo , Articulação do Tornozelo/cirurgia , Articulação do Tornozelo/patologia , Instabilidade Articular/diagnóstico , Instabilidade Articular/etiologia , Instabilidade Articular/cirurgia , Entorses e Distensões/diagnóstico , Entorses e Distensões/terapia , Entorses e Distensões/complicações , Traumatismos do Tornozelo/complicações , Traumatismos do Tornozelo/diagnóstico , Traumatismos do Tornozelo/cirurgiaRESUMO
INTRODUCTION: Revision Total Ankle Arthroplasty (TAA) surgery due to TAA aseptic loosening is increasing. It is possible to exchange the talar component and inlay to another system for isolated talar component loosening in a primary mobile-bearing TAA: Hybrid-Total Ankle Arthroplasty (H-TAA). The purpose of this study was to analyze the results of the revision surgery of an isolated aseptic talar component loosening in a mobile-bearing three-component TAA with a H-TAA solution. METHODS: In this prospective case study, nine patients (six women, three men; mean age 59.8 years; range 41-80 years) with symptomatic isolated aseptic loosening of the talar component of a mobile-bearing TAA were treated with an isolated talar component and inlay substitution. In all nine cases, a hybrid TAA revision surgery was performed by implanting a VANTAGE TAA talar and insert component (Flatcut talar component: six cases, standard talar component: three cases). The patients were reviewed with the pain score (VAS Pain Score 0-10), Dorsiflexion/Plantarflexion (DF/PF) Range of Motion (ROM; degrees), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score (0-100 points), Sports Frequency Score (Level 0-4), and subjective Patients' Satisfaction Score (0-10 points). RESULTS: The average Pain score improved significantly from preoperative 6.7 points to postoperative 1.1 points (p < 0.001). Average Dorsiflexion/Plantarflexion ROM values increased significantly post-surgery: 21.7° preoperative to 45.6° postoperative (p < 0.001). The postoperative AOFAS scores were significantly greater than the preoperative values: 47.7 points preoperative, 92.3 points postoperative (p < 0.001). The sports activity improved from preoperative to postoperative where, preoperative, none of the patients were able to perform sports. Postoperative, eight patients were able to be sports-active again. The overall average postoperative level of sports activity was 1.4. The postoperative average patient's satisfaction was 9.3 points. CONCLUSIONS: In painful talar component aseptic loosening of a three-component mobile-bearing TAA, H-TAA is a good surgical solution for reducing pain, restoring ankle function, and improving patients' life quality.
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PURPOSE: The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates. METHODS: Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5 mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy. RESULTS: Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement. CONCLUSION: The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
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Fraturas Intra-Articulares , Tálus , Humanos , Tálus/cirurgia , Estudos Retrospectivos , Radiografia , Osteotomia/métodosRESUMO
INTRODUCTION: Impaired hip kinematics and kinetics may incite patellar instability. This study tested the hypothesis that hip adduction and internal rotation angles during gait are higher in adolescents with recurrent patellar dislocations compared to healthy controls. MATERIAL AND METHODS: Case-control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Peak hip, knee and pelvis kinematics and kinetics were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates) and compared between the two groups. One cycle (100%) consisted of 51 data points. The mean of six trials was computed. RESULTS: Peak hip adduction angles and abduction moments were significantly higher in patients with recurrent patellar dislocation compared to the control group (p < 0.001 and 0.002, respectively). Peak internal hip rotation did not differ significantly. CONCLUSION: Elevated hip adduction angles and higher hip abduction moments in gait of adolescents with recurrent patellar dislocation may indicate an impaired function of hip abductors that contributes to patellar instability.
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Instabilidade Articular , Luxação Patelar , Articulação Patelofemoral , Humanos , Adolescente , Estudos de Casos e Controles , Marcha , Articulação do Joelho , Fenômenos BiomecânicosRESUMO
Treatment of the ankle joint with total ankle arthroplasty (TAA) is an established and safe surgical treatment for osteoarthritis of the ankle. Modern implants have low revision rates and are superior to ankle arthrodesis in terms of patient-reported outcomes. The importance of primary TAA treatment of ankle fractures is unclear. There are currently no studies in the literature on this topic. In view of the increasing number of cases of unstable ankle fractures, especially in older patients and with increasing functional demands also in old age, it is important to consider TAA in the management of these fractures in the future. Clinical studies are necessary to evaluate the treatment of ankle fractures using TAA.
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Fraturas do Tornozelo , Artroplastia de Substituição do Tornozelo , Humanos , Idoso , Fraturas do Tornozelo/cirurgia , Procedimentos Cirúrgicos Eletivos , Articulação do Tornozelo/diagnóstico por imagem , ArtrodeseRESUMO
Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients. Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active. The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA. Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms. After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures. In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease. Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.
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Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3-119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) (p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.
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Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.
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Osteoporotic ankle fractures result from mechanical forces that would not ordinarily result in fracture, known as 'low-energy' trauma, such as those equivalent to a fall from a standing height or less. Osteoporotic ankle fractures in frail patients are becoming more and more frequent in daily practice and represent a therapeutic challenge for orthopaedic surgeons. The main problems with frail patients are the poor condition of the soft tissues around the ankle, dependence for activities of daily living and high comorbidity. The decision to operate on these patients is complex because conservative treatment is poorly tolerated in unstable fractures and conventional open reduction and internal fixation is associated with a high rate of complications. The authors conducted a narrative review of the literature on primary tibiotalocalcaneal nailing of ankle fractures in frail patients and categorized the different factors to consider when treatment is indicated for this conditon. Difficulty of ambulation, age over 65 years old, deteriorated baseline state and instability of the fracture were the most frequently considered factors. Finally, the authors propose an easy and quick clinical scoring system to help in the decision-making process, although further comparative studies are required to explore its validity.
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Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the foot and ankle (including acute traumatic injuries and fractures, tumor, infection, osteochondral lesions, arthritis, and tendinopathy) and procedures, including osteotomy or fusion. Promising and established treatment modalities include 1) bone-based therapies (such as cancellous or cortical autograft from the iliac crest, proximal tibia, and/or calcaneus, fresh-frozen or freeze-dried cortical or cancellous allograft, including demineralized bone matrix putty or powder combined with growth factors, and synthetic bone graft substitutes, such as calcium sulfate, calcium phosphate, tricalcium phosphate, bioactive glasses (often in combination with bone marrow aspirate), and polymers; proteins such as bone morphogenic proteins; and platelet-derived growth factors; 2) cartilage-based therapies such as debridement, bone marrow stimulation (such as microfracture or drilling), scaffold-based techniques (such as autologous chondrocyte implantation [ACI] and matrix-induced ACI, autologous matrix-induced chondrogenesis, matrix-associated stem cell transplantation, particulated juvenile cartilage allograft transplantation, and minced local cartilage cells mixed with fibrin and platelet rich plasma [PRP]); and 3) blood, cell-based, and injectable therapies such as PRP, platelet-poor plasma biomatrix loaded with mesenchymal stromal cells, concentrated bone marrow aspirate, hyaluronic acid, and stem or stromal cell therapy, including mesenchymal stem cell allografts, and adipose tissue-derived stem cells, and micronized adipose tissue injections. LEVEL OF EVIDENCE: Level V, expert opinion.
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Produtos Biológicos , Ortopedia , Tornozelo , Cartilagem/transplante , Condrogênese , HumanosRESUMO
Background and Objectives: Knee osteoarthritis (OA) is a frequent cause of pain, functional limitations, and a common reason for surgical treatment, such as joint replacement. Conservative therapies can reduce pain and improve function; thus, delaying or even preventing surgical intervention. Various individual conservative therapies show benefits, but combination therapies remain underexplored. The aim of this prospective case-study was to assess the effect of a conservative combination therapy in patients with painful varus knee OA. Materials and Methods: With strong inclusion and exclusion criteria, nine patients with painful varus knee OA (mean age 56 years (range 51−63 years) were selected and monitored over six months, using the following clinical outcome scores: pain visual analog scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC score), short-form−36 items (SF-36) quality of life score, and the sports frequency score. All patients received a standardized conservative trio-therapy with varus-reducing hindfoot shoe-insoles with a lateral hindfoot wedge, oral viscosupplementation, and physiotherapy for six months. Results: The pain was reduced significantly from initial VAS values of 5.4 points (range, 3−10) to values of 0.6 points (range, 0−3; p < 0.01), at the end of treatment. After six months, seven out of nine patients reported no pain at all (VAS 0). The WOMAC score improved significantly, from initial values of 35 (range, 10−56) to values of 2 (range, 0−9; p < 0.01). The SF-36 score showed significant improvement after six months in all four domains of physical health (p < 0.01) and in two of the four domains of mental health (p < 0.05). The sports frequency score increased by at least one level in six out of nine patients after six months. Conclusions: The conservative trio-therapy in patients with varus knee OA showed positive initial clinical results: less pain, higher function, better quality of life, and higher sport activity. Further studies are required to evaluate the long-term effect.
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Osteoartrite do Joelho , Pré-Escolar , Tratamento Conservador , Humanos , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/terapia , Dor/etiologia , Medição da Dor , Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND: Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures, and instability. In this study, we present the results of salvage procedure of the ankle Charcot neuroarthropathy using aggressive debridement and Ilizarov frame fusion with early weight bearing. METHODS: Twenty-three patients with severely infected ulcerated and unstable Charcot neuroarthropathy of the ankle were treated between 2013 and 2018. The mean age was 63.5 ± 7.9 years; 16 males and seven females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, was performed followed by external fixation with an Ilizarov frame along with early weight-bearing. The primary outcome was a stable plantigrade infection-free foot and ankle that allows weight-bearing in accommodative footwear. RESULTS: Limb salvage was achieved in 91.3% of cases at the end of a mean follow-up time of 19 months (range: 17-29). Fifteen (71.4%) solid bony unions evident clinically and radiographically were achieved, while six (28.5%) patients developed stable painless pseudarthrosis. Two patients had below-knee amputations due to uncontrolled infection. CONCLUSION: Aggressive debridement and arthrodesis using ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing, and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection.
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Tornozelo , Artropatia Neurogênica , Idoso , Amputação Cirúrgica/efeitos adversos , Articulação do Tornozelo/cirurgia , Artrodese/efeitos adversos , Artrodese/métodos , Artropatia Neurogênica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.
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Valgus ankle OA is a complex problem with multiple etiologies that can either be isolated or superimposed on top of other medical or musculoskeletal disorders. Proper medical history, physical, and preoperative radiological examinations are crucial in deciding on surgery and planning the surgical approach. JPS, especially the varisating medial closing-wedge SMOT with solid plate fixation, has been consistently associated with good outcomes for patients with valgus ankle OA. To further improve JPS for valgus ankle OA, further clinical and biomechanical studies are required to address the long-term clinical and functional outcomes and complications.
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Tornozelo , Osteoartrite , Articulação do Tornozelo/cirurgia , Humanos , Osteoartrite/cirurgia , Osteotomia , Radiografia , TíbiaRESUMO
BACKGROUND: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE: Level V, mechanism-based reasoning.