Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants.

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n = 41). The mean age was 59 (range = 39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range = 14-46) to 80 (range = 60-100) (p < .01) and VAS from 7.8 (range = 6.1-9.7) to 1.3 (range = 0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

Biomechanical study of autograft anatomic reconstruction in lateral ankle instability. / Estudio biomecánico de la reconstrucción ligamentosa anatómica con autoinjerto en la inestabilidad lateral de tobillo.

INTRODUCTION: The purpose of this work is perform a biomechanical comparison of anatomic reconstruction of the anterior talofibular ligament (ATFL) with the intact ATFL. MATERIALS AND METHODS: We studied 18 fresh cadaveric ankles with intact ATFL. Each specimen was clinically assessed with the anterior drawer (AD) and varus tilt (VT) tests and the angular movement in the three spatial planes (axial, coronal and sagittal) was measured with an arthrometer using a sensor located in the talus. RESULTS: Statistically significant differences were found in the axial plane, between the intact ATFL versus the sectioned ATFL for AD test with p = 0.012, and for VT test with p = 0.013. Regarding the coronal plane, we also observed a statistically significant difference for VT test with p = 0.016. In the sagittal plane, there are no statistically significant differences in both maneuvers. No statistically significant differences were found when comparing the biomechanics of anatomic ligament reconstruction versus the intact ATFL. CONCLUSION: Autograft anatomic reconstruction of the ATFL showed biomechanical properties similar to those of the native ATFL, at the zero moment in a cadaveric model.

How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings.

INTRODUCTION: The posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages. METHODS: The fracture pattern of PM is classified according to Haraguchi or Bartonícek classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection. RESULTS: Posterolateral approach should be the election for Haraguchi I or III and Bartonícek 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartonícek 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartonícek 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach. CONCLUSION: To address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.

Anatomical Arthroscopic Graft Reconstruction of the Anterior Tibiofibular Ligament for Chronic Disruption of the Distal Syndesmosis.

Injuries of the distal tibiofibular syndesmosis are commonly overlooked or mismanaged, and chronic instability is a debilitating condition leading to premature joint degeneration. Several methods of treatment have been described, mainly screw fixation, arthrodesis, or ligament reconstruction. Most clinical evidence is limited to case series, mainly screw fixation, and there is a general paucity of evidence regarding ligament reconstruction, which is considered to be more anatomic and to restore joint biomechanics. Most papers describe open techniques. We describe an original technique for all-inside anatomic arthroscopic graft reconstruction of the anterior-inferior tibiofibular ligament, which is simpler than other previously described reconstruction procedures. In addition to being performed through standard ankle arthroscopy portals, we believe this technique avoids potential complications.

Predicting syndesmotic injuries in ankle fractures: a new system based on the medial malleolar focus.

The early establishment of the diagnosis of a syndesmotic injury is essential for treatment selection. However, such injuries may not be apparent radiographically. Previous studies have attempted to describe correlations between medial malleolar fracture geometry and syndesmotic disruption. The main objective of this study was to create predictive models for assessing syndesmotic injuries based on an originally described angle, i.e., the medial crural-focal angle (MCFA). This study included 138 ankle fractures involving the medial malleolus. Any measure from the plain radiograph that could potentially lead to the suspicion of a syndesmotic disruption was recorded, and the newly described MCFA (formed by the main line of the medial malleolus fracture and a line perpendicular to the bearing surface of the tibial plafond) was also recorded. The inter- and intraobserver reliabilities were obtained using Krippendorff's alpha coefficients. To examine the predictive abilities of every parameter, several statistical methods were applied including logistic regression, an ad hoc clinical rule, and discriminant analysis. After variable selection, we obtained the best possible logistic model. The variables that were found to be statistically significant were the MCFA, the tibiofibular clear space (TFCS) and the type of injury in the Lauge-Hansen (L-H) classification. This model was tested by cross validation, which revealed a mean percentage of correctly classified patients of 88%. A simpler and more intuitive alternative model was sought that was based solely on the influences of the MCFA and the TFCS. Our study revealed that an absence of syndesmotic disruptions when the MCFA was under 60°, and there were no uninjured patients with tibiofibular clear space values over 6mm. Cross-validation revealed that the mean percentage of patients who were correctly classified with this model was 86%. The application of discriminant analysis to this combination of variables resulted in a function was able to correctly classify a mean of 84% of patients. In conclusion, three models that can predict syndesmotic injury using parameters from preoperative plain radiographs were obtained and validated. The MCFA measurement was in these models and found to be a reliable technique.