Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

New Insight into the Effects of Different Types of Midfoot and Hindfoot Deformities on the Functional Outcomes of Rheumatoid Arthritis Patients.

In advanced stages of rheumatoid arthritis (RA), the pattern of joint involvement leads to varied types of foot deformities such as forefoot, midfoot, and hindfoot deformities. We aim to evaluate midfoot and hindfoot deformities and their effect on functional outcomes in RA patients. In this prospective cross-sectional study clinical and radiological evaluations of 100 adult RA patients were studied for midfoot and hindfoot deformities. The RA disease activity, functional disability level, specific foot and ankle assessments, gait speed, and balance tests were assessed. Radiological examinations of the weight-bearing feet in a standing position were done. We found that the most frequent deformity type was the planovalgus foot (24%). There were statistically significant differences between the types of foot deformities and disease duration, disease activity, falls, Tinetti and Berg balance Test, and health assessment questionnaire-disability index. The multivariate regression analysis of independent correlates of falling detected that patients with equinovarus deformity were 2.5 times more liable for falling with 63.5% predictive power. According to the predictive criteria of deformity type for falling, the equinocavovarus type had accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 91%, 84.5%, 98.5%, 99%, and 84%, respectively. We found in RA patients, midfoot and hindfoot deformities cause a significant reduction of functional ability and quality of life. The early detection of foot deformities requires a good awareness of the clinical and radiographic diagnosis of different types of deformities thus reducing the possible functional disabilities via early management by combined orthotic, physiotherapy, and surgical treatments. LEVEL OF CLINICAL EVIDENCE: 4.

Management outcome of congenital talipes equinovarus (clubfoot) using Ponseti protocol at Lagos University Teaching Hospital.

Background: Idiopathic clubfoot occurs commonly in children with a prevalence of 1 in 1000. The Pirani scoring system, which consists of a midfoot contracture score and hindfoot contracture score, is traditionally used in assessing the severity of clubfoot deformity. Ponseti protocol is used in the management of clubfoot deformity. The study aimed to evaluate the outcome of the management of clubfoot using the Ponseti protocol and to correlate the outcome with the initial Pirani score. Materials and Methods: Eighty-two children aged 1 week-2 years with 128 idiopathic clubfeet were recruited into the study. The severity of their clubfoot deformities was scored using the Pirani scoring system on recruitment. They were managed with weekly serial manipulation and cast application with or without tendon-Achilles tenotomy according to Ponseti protocol. Results: The average initial Pirani score was 3.6 ± 0.9. The average number of casts used was 5.9 ± 1.3 (range: 4-9 casts). Tenotomy was done in 51.56% of the feet. The group that required tenotomy required more casts and as such longer duration of treatment than the "no tenotomy" group. There was a relapse rate of 2% in the feet of the compliant group, whereas the relapse rate was 69% in the group that was not compliant with the use of foot-abduction brace. The success rate at 6 months follow-up was 84.4%. Conclusions: Ponseti protocol is an excellent method of management of idiopathic clubfoot, and the Pirani scoring system was useful in assessing the initial severity and the outcome. The initial Pirani score correlates with the duration of treatment.

Tibio-Talo-Calcaneal Arthrodesis: Evaluation of the Effectiveness of a Specific Surgical Technique in 17 Cases.

INTRODUCTION: Ankle arthrodesis is a crucial surgical intervention for advanced hindfoot conditions, aiming to restore plantigrade walking and alleviate pain. This study evaluates the effectiveness of a specific surgical approach for tibiotalocalcaneal arthrodesis (TTCA), focusing on rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, and assesses the outcomes of this approach in terms of bone fusion and reduction of postoperative complications. MATERIALS AND METHODS: This retrospective analysis includes 17 patients who underwent TTCA in a trauma-orthopedic department over seven years. Data were collected from medical records, the HOSIX software, and patient consultations. Preoperative assessments, surgical techniques, postoperative care, and follow-up evaluations were documented. RESULTS: The mean age of patients was 42.4 years, with a male predominance. Surgical indications included post-traumatic arthropathy (53%), inflammatory arthropathy, ankle infectious pathologies, and Charcot foot and ankle prosthesis failures. All patients underwent standard preoperative evaluations and received corticocancellous grafts. An angled retrograde femoral nail in the sagittal plane was used for internal fixation. Postoperative immobilization lasted 6 to 8 weeks, with subsequent rehabilitation. The bone fusion rate was 100%, with a low complication rate (23.5%). DISCUSSION: Our study showed a younger patient population with a male predominance, different from some previous studies. Surgical techniques, including the anterior approach combined with a lateral subtalar approach, were consistent with some studies but differed from others. Corticocancellous grafts and the angled retrograde femoral nail in the sagittal plane demonstrated favorable outcomes in terms of fusion. Complication rates were lower compared to some previous reports, highlighting potential improvements in postoperative management. CONCLUSION: The surgical approach described for TTCA, emphasizing rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, led to satisfactory bone fusion and reduced postoperative complications. These results underscore the importance of this approach in achieving optimal functional outcomes in ankle arthrodesis.

The amount of femorotibial alignment correction through total knee arthroplasty may affect postoperative hindfoot alignment.

Purpose: This study was performed to investigate the relationship between the amount of femorotibial alignment correction and the amount of improvement of hindfoot alignment in total knee arthroplasty (TKA). Methods: A total of 159 knees undergoing TKA in 120 patients were assessed preoperatively and at 2 weeks, 1 month, 3 months and 6 months postoperatively. Standing hindfoot alignment was evaluated using the leg-heel angle (LHA). The amount of change in hindfoot alignment was compared between patients with severe varus knee (Group 1) and those with moderate varus, neutral or valgus knee (Group 2). Results: The mean values of pre- and postoperative hip-knee-ankle (HKA) angle were -14 ± 4° and -1 ± 3° in Group 1 and -7 ± 5° and -1 ± 3° in Group 2, respectively. The differences between pre- and postoperative LHA were significantly larger in Group 1 than in Group 2 at 2 weeks, 1 month and 3 months postoperatively (p = 0.006, 0.001 and 0.03, respectively). At 6 months postoperatively, no differences were observed between the two groups (p = 0.31). Conclusion: The amount of change in hindfoot alignment was larger in Group 1 than in Group 2 at 2 weeks, 1 month and 3 months after TKA, but there was no significant difference between the two groups at 6 months after TKA. Level of Evidence: Prognostic Level II.

Displacement after Open vs Saw-Based Minimally Invasive Medial Displacement Calcaneal Osteotomy: A Cadaveric Study.

Background: Medial displacement calcaneal osteotomy (MDCO) is routinely used in hindfoot valgus realignment. Minimally invasive surgery (MIS) calcaneal osteotomies have been reported to be as safe and effective compared to open techniques. The aim of this cadaveric study was to compare the amount of medial tuberosity displacement obtained with fine-cut saw-based MIS vs open MDCO techniques. Methods: Eight matched cadaveric specimens had one side randomly assigned to either open or MIS MDCO. The contralateral limb was then assigned to the alternative osteotomy. The amount of medial displacement provided by the osteotomy was measured manually using a flexible metric ruler and radiographically on standardized axial calcaneal radiographs. Results: Manual measurements showed that a mean displacement of the MIS osteotomy was 7.9 mm compared with 8.7 mm for the open technique (P = .36). Radiograph measurement showed a mean displacement of the MIS osteotomy was 7.1 mm compared with 7.4 mm for the open technique (P = .83). No significant difference was found on manual and radiographic measurement of medial displacement between MIS and open MDCO. Conclusion: In a cadaveric model, we found similar magnitude of calcaneal tuberosity displacement using fine-cut saw-based MIS and open techniques for medial displacement calcaneal osteotomies. Level of Evidence: Level V, cadaveric study.

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint.

INTRODUCTION: Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge. METHODS: This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score. RESULTS: Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002). CONCLUSION: This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

Patient-specific modelling of contact characteristics in the ankle joint following triple arthrodesis in valgus, neutral and varus hindfoot positions.

The aim of the current study was to understand the importance of the joint alignment following triple arthrodesis by analysing the contact characteristics in a normal and arthritic ankle joint using a patient-specific numerical model developed using open source software. The alignment of the hindfoot with respect to tibia is calculated from CT scans and the ankle joint model was numerically analysed for neutral, valgus and varus positions in both normal and arthritic conditions. The contact area, the magnitude and distribution of the contact pressure on the articular surface of the talar dome was evaluated using a cell-centred Finite Volume Method implemented in open-source software OpenFOAM. It was found that all positions of the hindfoot predict higher lateral pressures during heel strike. The varus position predicts the maximum increase in lateral pressures. Comparing the valgus and neutral positions, although the neutral position predicts 9.1 % higher increase in lateral pressures during heel strike than valgus, it predicts 33.6 % decrease in pressures during heel-rise and the distribution is more medial during toe-off. In the case of arthritic ankle, it could be observed that the neutral and varus hindfoot fusion positions result in a concentrated increase of lateral pressures in heel strike and flat-foot. In the case of toe-off, the neutral alignment results in an increase of 62.3 % in the contact pressures compared to the arthritic pressure of the unfused foot and is 20.8 % higher than the valgus alignment. The study helps to conclude that the fusion is more beneficial at the neutral position of the hindfoot for the patient specific ankle. However, the 5° valgus position of hindfoot alignment could be more beneficial in the arthritic ankle. Patient-specific approach to the placement of the hindfoot with the help of numerical analysis could help address the issue of ankle degradation following arthrodesis.

Medical Malpractice Litigation Following Hindfoot Arthrodesis.

Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims which can impose significant economic and psychological burden. This study investigates malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. The database was queried for all cases involving hindfoot arthrodesis using the terms "malpractice" and either "ankle fusion," "arthrodesis," "subtalar fusion," "tibiotalar fusion," "tibiotalocalcaneal fusion," "TTC fusion," or "tibiofibular fusion" from 1987 to 2023. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (±456,179). The most alleged category of negligence was procedural/intraoperative error (75%) followed by postsurgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Given the frequency of hindfoot arthrodesis performed, this study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality.

Tibiotalocalcaneal ankle arthrodesis with posterior approach arthroscopic-assisted hindfoot nailing.

PURPOSE: End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature. METHODS: Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined. RESULTS: When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons (p < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%). CONCLUSION: The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.

Hindfoot flexibility assessment of cavovarus and planovalgus feet by modified Shriners Hospitals for Children - Greenville (mSHCG) foot model.

BACKGROUND: Multi-segment foot models have been used to quantify foot kinematics during walking. However, walking kinematics is not sufficient to assess hindfoot flexibility (available range of hindfoot varus-valgus motion). The modified Shriners Hospitals for Children - Greenville (mSHCG) foot model has been used to quantify hindfoot flexibility with Coleman block test (peak hindfoot valgus) and Root test (peak hindfoot varus). Sensitivity of mSHCG foot model to detect clinically relevant difference in hindfoot flexibility measures for planovalgus (PV) and cavovarus (CV) feet has not been demonstrated. RESEARCH QUESTION: Can mSHCG foot model detect statistically significant difference in hindfoot flexibility measures between PV, CV and typically developing (TD) feet? METHODS: Hindfoot flexibility assessment was completed for 32 PV (37 feet), 27 CV (37 feet) and 20 TD (40 feet) individuals. Hindfoot position relative to tibia in coronal plane was measured in three postures: standing, heel raise and Coleman block test. Radiographic measures in standing position were also completed for PV and CV individuals and their correlation with hindfoot flexibility measures were evaluated. RESULTS: Statistically significant (p<0.001) differences were observed between three groups (TD, PV, CV) in all three hindfoot flexibility measures- (i) Hindfoot varus in standing position (ii) Peak hindfoot varus in heel raise and (iii) Peak hindfoot valgus in Coleman block test. There was relatively stronger correlation (R2=0.407-0.854) between three radiographic measures and hindfoot varus in standing position. Correlation between hindfoot range of motion towards valgus from standing to Coleman block test and the three radiographic measures was weaker (R2=0.2329-0.3042). SIGNIFICANCE: Hindfoot flexibility assessment can detect statistically significant difference between PV, CV and TD feet and provides additional information about available dynamic range of motion of hindfoot in the coronal plane that cannot be predicted from radiographic measures. Therefore, hindfoot flexibility assessment may assist in treatment planning of foot deformities.

Biomechanical role of bone grafting for calcaneal fracture fixation in the presence of bone defect: A finite element analysis.

BACKGROUND: The purpose of this study was to compare the biomechanical stress and stability of calcaneal fixations with and without bone defect, before and after bone grafting, through a computational approach. METHODS: A finite element model of foot-ankle complex was reconstructed, impoverished with a Sanders III calcaneal fracture without bone defect and with moderate and severe bone defects. Plate fixations with and without bone grafting were introduced with walking stance simulated. The stress and fragment displacement of the calcaneus were evaluated. FINDINGS: Moderate and severe defect increased the calcaneus stress by 16.11% and 32.51%, respectively and subsequently decreased by 10.76% and 20.78% after bone grafting. The total displacement was increased by 3.99% and 24.26%, respectively by moderate and severe defect, while that of posterior joint facet displacement was 86.66% and 104.44%. The former was decreased by 25.73% and 35.96% after grafting, while that of the latter was reduced by 88.09% and 84.78% for moderate and severe defect, respectively. INTERPRETATION: Our finite element prediction supported that bone grafting for fixation could enhance the stability and reduce the risk of secondary stress fracture in cases of bone defect in calcaneal fracture.

Hindfoot kinematics and kinetics - A combined in vivo and in silico analysis approach.

BACKGROUND: The complex anatomical structure of the foot-ankle imposes challenges to accurately quantify detailed hindfoot kinematics and estimate musculoskeletal loading parameters. Most systems used to capture or estimate dynamic joint function oversimplify the anatomical structure by reducing its complexity. RESEARCH QUESTION: Can four dimensional computed tomography (4D CT) imaging in combination with an innovative foot manipulator capture in vivo hindfoot kinematics during a simulated stance phase of walking and can talocrural and subtalar articular joint mechanics be estimated based on a detailed in silico musculoskeletal foot-ankle model. METHODS: A foot manipulator imposed plantar/dorsiflexion and inversion/eversion representing a healthy stance phase of gait in 12 healthy participants while simultaneously acquiring 4D CT images. Participant-specific 3D hindfoot rotations and translations were calculated based on bone-specific anatomical coordinate systems. Articular cartilage contact area and contact pressure of the talocrural and subtalar joints were estimated using an extended foot-ankle model updated with an elastic foundation contact model upon prescribing the participant-specific rotations measured in the 4D CT measurement. RESULTS: Plantar/dorsiflexion predominantly occurred at the talocrural joint (RoM 15.9±3.9°), while inversion/eversion (RoM 5.9±3.9°) occurred mostly at the subtalar joint, with the contact area being larger at the subtalar than at the talocrural joint. Contact pressure was evenly distributed between the talocrural and subtalar joint at the beginning of the simulated stance phase but was then redistributed from the talocrural to the subtalar joint with increasing dorsiflexion. SIGNIFICANCE: In a clinical case study, the healthy participants were compared with four patients after surgically treaded intra-articular calcaneal fracture. The proposed workflow was able to detect small but meaningful differences in hindfoot kinematics and kinetics, indicative of remaining hindfoot pathomechanics that may influence the onset and progression of degenerative joint diseases.

Association of Timing of Hindfoot Arthrodesis and Early Reoperation Rates for Total Ankle Arthroplasty.

BACKGROUND: Prior literature has demonstrated that ipsilateral hindfoot arthrodesis may increase the risk for reoperation after total ankle arthroplasty (TAA) and that simultaneous hindfoot arthrodesis with TAA could result in short-term clinical and radiologic improvements. The purpose of this study is to compare the reoperation rates after TAA with prior hindfoot arthrodesis vs simultaneous arthrodesis and TAA. METHODS: Patients who underwent primary TAA were identified in the PearlDiver database. Patients were sorted into 2 study cohorts: hindfoot arthrodesis prior to TAA and simultaneous arthrodesis and TAA. Propensity matched control cohorts were identified for each study group. Multivariate analysis was conducted to account for any confounding variables and covariates when identifying differences in complications between cohorts. RESULTS: 297 patients underwent TAA with prior hindfoot arthrodesis and 174 underwent TAA and hindfoot arthrodesis concurrently. The incidence of reoperation (13.8% vs 5.2%, P < .001) and infection (12.6% vs 5.9%, P = .011) for the simultaneous cohort was higher when compared to the matched control cohort. In contrast, there was no statistically significant difference when comparing the prior arthrodesis cohort to the matched control cohort in reoperation rates (5.1% vs 4.7%, P = .787) or infection rates (4.4% vs 4.8%, P = .734). Those undergoing simultaneous procedures had increased incidences of reoperation, wound complications, infection, and emergency department visits (P < .0167) when compared to the TAA with prior arthrodesis cohort. CONCLUSION: Patients undergoing TAA and hindfoot arthrodesis concurrently were found to have higher rates of reoperation and infection when compared to the matched control cohort . In contrast, there was no difference in these rates in patients undergoing TAA with prior hindfoot arthrodesis compared with their matched control cohort. Patients undergoing simultaneous procedures had increased rates of reoperations, wound complications, infection, and emergency department visits compared to the TAA with prior arthrodesis cohort.

Static posture weightbearing joint angle differences in patients with varus ankle osteoarthritis.

BACKGROUND: Advanced varus ankle osteoarthritis is a debilitating disease that can present with limited physical function, severe pain, and diminished quality of life. Weightbearing computed tomography enables submillimeter 3-dimensional visualization, computational analyses, and enhanced diagnoses in reporting complex degenerative changes more accurately. RESEARCH QUESTION: This study set to compare static posture weightbearing joint angle differences in healthy and varus ankle osteoarthritis patients (compensated and non-compensated). METHODS: Our retrospective assessment included 70 individuals, 44 of whom were diagnosed with advanced varus ankle osteoarthritis, and the remaining 26 were healthy participants to serve as controls. An automatic anatomic coordinate system was applied to each patient's 3-dimensional talus and calcaneus bone reconstructions from weightbearing computed tomography scans. Subtalar and midtarsal joint angles were calculated using Euler angles. RESULTS: We report statistical differences between the healthy group and both advanced varus osteoarthritis groups for midtarsal inversion/eversion. Specifically, both osteoarthritis groups' midtarsal joints were more inverted and plantarflexed as compared to healthy participants. Compensated and non-compensated subtalar joints were statistically different with respect to inversion/eversion. Non-compensated ankles exhibited a similar mean to healthy ankles who were both less inverted than compensated ankles. SIGNIFICANCE: Our study helps physicians to better understand underlying mechanisms of peritalar compensation in varus ankle osteoarthritis. Patients featuring hindfoot compensation on average had a greater subtalar joint angle indicating greater inversion than healthy and non-compensated patients.

Varus knee osteoarthritis with ankle osteoarthritis demonstrates greater hindfoot inversion and larger ankle inversion loading during gait following total knee arthroplasty compared to varus knee osteoarthritis alone.

PURPOSE: Although patients with varus knee osteoarthritis (KOA) and concurrent ankle osteoarthritis (AOA) may experience increased ankle joint pain after total knee arthroplasty (TKA), the underlying mechanism remains unclear. This study aimed to investigate the effects of concurrent AOA on ankle and hindfoot alignment, frontal plane ankle and hindfoot biomechanics during gait following TKA and the clinical outcomes. METHODS: Twenty-four patients with varus KOA who underwent TKA were included in this retrospective cohort study. Patients were categorized into two groups: with and without AOA. Radiographic evaluations of lower-limb, ankle and hindfoot alignment, and knee and ankle clinical outcomes were conducted preoperatively and 6 months postoperatively. In addition, gait analyses were performed to investigate knee, ankle and hindfoot kinematics and kinetics. Each data was compared between patients with and without AOA. RESULTS: Concomitant AOA was found in eight ankles. The AOA group exhibited greater postoperative hindfoot varus and increased postoperative ankle pain than the non-AOA group. Gait analysis showed no significant differences in knee varus alignment or tibial tilt after TKA between the groups. However, the AOA group demonstrated significantly greater hindfoot inversion and larger ankle inversion loading. CONCLUSION: One third of patients who underwent TKA had concurrent AOA associated with hindfoot varus. Despite achieving proper coronal knee alignment postoperatively, these patients experienced greater hindfoot and ankle joint inversion load during gait. Surgeons should consider the inability to evert the hindfoot and the possibility of increased ankle joint pain when planning and performing TKA. LEVEL OF EVIDENCE: Level III.

Does the Subtalar or Tibiotalar Joint Need Fused in Primary Retrograde Tibiotalocalcaneal Nailing for Fragility Ankle Fractures?

BACKGROUND: As an alternative to traditional open reduction internal fixation of ankle fragility fractures, primary retrograde tibiotalocalcaneal (TTC) nailing has been investigated as a treatment option. These results suggest that this treatment is an acceptable alternative treatment option for these injuries. There are still questions about the need for formal joint preparation at the subtalar or tibiotalar joint when performing primary TTC nailing for fragility fractures. METHODS: In this study, we retrospectively evaluated 32 patients treated with primary retrograde TTC nail without subtalar or tibiotalar joint preparation for a mean of 2.4 years postoperatively. We specifically reviewed the charts for nail breakages at either joint, patients developing subtalar or tibiotalar joint pathology requiring additional treatment, including return to the operating room for formal joint preparation. RESULTS: Fracture union occurred in 100% of patients. There were 3 cases (10.0%) of hardware failure, and 2 of these cases were asymptomatic and did not require any treatment. One patient (3.3%) developed hardware failure with nail breakage at the subtalar joint. This patient developed progressive pain and symptoms requiring revision surgery with formal arthrodesis of the subtalar and tibiotalar joint. CONCLUSIONS: This study shows that retrograde hindfoot nailing without formal subtalar or tibiotalar joint preparation is an acceptable potential treatment option in ankle fragility fractures. Mid-term follow-up demonstrates favorable outcomes without the need for formal joint preparation in this high-risk population. Comparative studies with higher patient numbers and long-term follow-up are needed to confirm the results of this study.Levels of Evidence: Level IV.

The evolution of patient-reported outcome measures after a first lateral ankle sprain: A prospective study.

PURPOSE: A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain. METHODS: A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test. RESULTS: All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value <.0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value <.01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24. CONCLUSION: The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies. LEVEL OF EVIDENCE: Level II (prospective cohort study).

The Outcomes of Isolated Tibiocalcaneal Arthrodesis: A Systematic Review.

Background: Tibiocalcaneal arthrodesis (TCA) can be achieved by internal fixation (intramedullary nail or plate), external fixation, or a combination. Evidence for the optimal approach is limited. This systematic review examines the outcomes of these different approaches to guide surgical management. Methods: A MEDLINE and Oxford SOLO search was performed using "tibiocalcaneal," "ankle," "fusion OR arthrodesis." The primary outcome was union. Secondary outcomes included rates of postoperative complications, weightbearing status, rates of revision surgery, and PROMs. We included any studies with follow-up greater than 6 months that contained our primary outcome and at least 1 secondary outcome. Results: The initial search yielded 164 articles, of which 9 studies totaling 53 cases met the criteria. The majority of articles were excluded because they were nonsurgical studies, or were not about isolated TCA but were for tibiotalocalcaneal arthrodesis, more complex reconstructions (eg, Charcot), case reports, and/or did not include the predetermined outcome measures.TCA union rate was 86.2% following external fixation, 82.4% for intramedullary nail fixation, and 83.3% for plate fixation. One patient underwent a hybrid of external and internal fixation, and the outcome was nonunion. The rate of complications following TCA was 69.8%. Conclusion: There is limited evidence on the best operative approach for isolated tibiocalcaneal arthrodesis. Both external and internal fixation methods had comparable union rates. External fixation had frequent complications and a more challenging postoperative protocol. Novel techniques such as 3D-printed cages and talus replacement may become a promising alternative but require further investigation.

Talus-derived reference coordinate system for 3D calcaneal assessment: A novel approach to improve morphological measurements.

In 3D-analysis of the calcaneus, a consistent coordinate system aligned with the original anatomical directions is crucial for pre- and postoperative analysis. This importance stems from the calcaneus's key role in weight-bearing and biomechanical alignment. However, defining a reliable coordinate system based solely on fractured or surgically reconstructed calcanei presents significant challenges. Given its anatomical prominence and consistent orientation, the talus offers a potential solution to this challenge. Our work explores the feasibility of talus-derived coordinate systems for 3D-modeling of the calcaneus across its various conditions. Four methods were tested on nonfractured, fractured and surgically reconstructed calcanei, utilizing Principal Component Analysis, anatomical landmarks, bounding box, and an atlas-based approach. The methods were compared with a self-defined calcaneus reference coordinate system. Additionally, the impact of deviation of the coordinate system on morphological measurements was investigated. Among methods for constructing nonfractured calcanei coordinate systems, the atlas-based method displayed the lowest Root Mean Square value in comparison with the reference coordinate system. For morphological measures like Böhler's Angle and the Critical angle of Gissane, the atlas talus-based system closely aligned with ground truth, yielding differences of 0.6° and 1.2°, respectively, compared to larger deviations seen in other talus-based coordinate systems. In conclusion, all tested methods were feasible for creating a talus derived coordinate system. A talus derived coordinate system showed potential, offering benefits for morphological measurements and clinical scenarios involving fractured and surgically reconstructed calcanei. Further research is recommended to assess the impact of these coordinate systems on surgical planning and outcomes.