Impact of Subtalar Distraction Arthrodesis on Ankle Joint: Radiological Insights from Modified Grice-Green Procedure.

Subtalar distraction arthrodesis (SDA) is a surgical procedure designed to treat hindfoot deformities associated with isolated subtalar joint arthritis. In 1996, Fitzgibbons was the first to observe that, in some cases, hindfoot fusion appeared to be associated with the development of tibiotalar valgus tilt. Since then, few studies have addressed this issue. Given that hindfoot fusion can be performed using various techniques, this study investigated the potential tibiotalar joint frontal or sagittal modifications resulting from the modified Grice-Green technique. All the consecutive patients who underwent the modified Grice-Green procedure were included. The patient records were reviewed to extract demographic data. Weight-bearing foot and ankle radiographs were assessed to measure the talar tilt angle and the tibiotalar ratio on the same picture archiving and communication system by three independent observers. A total of 69 patients met the criteria for inclusion. The mean talar tilt showed no substantial changes, since the increase from 1.46 ± 1.62 preoperatively to 1.93 ± 2.19 at a minimum of 8 months postoperatively was not statistically significant (p = 0.47). The average preoperative tibiotalar ratio significantly increased from 33.4 ± 4.4% to 35 ± 4% postoperatively (p = 0.007), although remaining within the normal range, indicating a possible realignment of the posterior facet of the subtalar joint. In conclusion, this study highlights the effectiveness of the modified Grice-Green procedure in achieving a favorable realignment without impacting the ankle joint, particularly regarding tibiotalar valgus tilt.

Increased medial talar tilt may incite ankle pain and predispose ankle osteoarthritis after correction of severity of knee varus deformity among patients undergoing bilateral total knee arthroplasty: a prospective observation.

PURPOSE: Patients with varus knee osteoarthritis usually compensate at the ankle and typically walk with hindfoot valgus alignment. As the neutral weight-bearing axis of the lower limbs is restored with Total Knee Arthroplasty (TKA), ankle and hindfoot biomechanics also acutely change. This study aims to investigate whether any ankle clinical-radiographical changes occur as a result of bilateral mechanical TKA in patients with bilateral Osteoarthritis knee at a minimum follow-up of 6 months. METHODS: The prospective observational study included 61 patients (122 knees) undergoing simultaneous bilateral TKA (mechanical alignment). Tibio-talar angle(TTA), tibial Anterior Surface angle (TAS), lateral distal tibial angle (LDTA), talar-tilt angle (TT), anatomical talocrural angle (aTC), ground surface and distal tibial plafond angle (GP), ground surface and an upper surface of talus angle (GT)and tibial plateau and tibial plafond angle (PP) were measured on long-film radiographs to look for changes in the ankle, whereas functional assessment was done using American Foot and Ankle Society (AOFAS), Foot and Ankle Disability Index (FADI), and Forgotten Joint (FJS-12) scores. Patients were sub-grouped based on the Hip-Knee-Ankle (HKA) axis, and the effect of the severity of knee varus on the ankles after TKA was also analyzed. The minimum follow-up was 6 months. RESULTS: A significant decrease in the tibial plateau-tibial plafond (PP), ground-tibial plafond (GP), and ground-talar dome (GT) angles was noted after TKA (p-value < 0.05). Postoperative functional parameters were comparable to the preoperative status except for FADI, which significantly improved (p-value-0.03). Sub-group analysis based on the severity of knee varus (HKA) revealed GT to be most significantly reduced (p-value-0.036), while the talar tilt (TT) increased (p-value-0.044). Functional outcomes of the ankles clinically improved with the correction of severe knee varus after TKA. At a mean follow-up of 13.2 months post-TKA, 7 out of 61 (11.4%) patients complained of post-TKA ipsilateral ankle pain. CONCLUSION: Mechanically aligned bilateral TKA in severe varus deformity of the knee significantly decreases the GT angle but increases the varus tilt of the talus with lateral talar incongruency and under-coverage. Although the acute correction of severe knee varus deformity aligns the tibia more neutrally, resulting in an overall clinically evident improvement in ankle functional outcome, the increased varus talar tilt remains a deep concern. LEVEL OF EVIDENCE: Prospective, observational, comparative study Level II.

[Effectiveness comparison of supramalleolar osteotomy and ankle arthrodesis in treatment of inverted ankle osteoarthritis in Takakura 3A stage with talus tilt].

Objective: To compare the effectiveness of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) in the treatment of inverted ankle osteoarthritis (OA) in Takakura 3A stage with talus tilt. Methods: The clinical data of 41 patients with inverted ankle OA in Takakura 3A stage with talus tilt admitted between January 2016 to January 2020 and met the selection criteria were retrospectively analyzed, and they were divided into SMOT group (21 cases) and AA group (20 cases) according to the surgical method. There was no significant difference in baseline data such as gender, age, affected side, cause of injury, and preoperative talar tilt angle (TT), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score, short-form 36 health survey scale (SF-36) score, and sagittal range of motion (ROM) between the two groups ( P>0.05). The operation time, intraoperative blood loss, partial weight-bearing time, and complications were recorded in the two groups. AOFAS ankle-hindfoot score, VAS score, SF-36 score, and sagittal ROM were used to evaluate the effectiveness. Bone healing was observed and the time of bony healing was recorded. In the SMOT group, the tibial lateral surface angle (TLS), TT, and the tibial articular surface angle (TAS) were measured on ankle joint weight-bearing anteroposterior and lateral X-ray films and compared with those before operation. And Takakura staging assessment was also performed. Results: The operation time and intraoperative blood loss in AA group were significantly less than those in SMOT group ( P<0.05). Patients in both groups were followed up 24-36 months, with an average of 28.9 months. Incision infection occurred in 2 patients in SMOT group and 1 patient in AA group, respectively, and no vascular or nerve injury occurred in both groups. The partial weight-bearing time of SMOT group was significantly less than that of AA group ( P<0.05), but there was no significant difference in bony healing time between the two groups ( P>0.05). At last follow-up, the difference of VAS score and SF-36 score before and after operation of AA group were less than those of SMOT group, and the difference of sagittal ROM before and after operation in SMOT group was less than that of AA group, with significant differences ( P<0.05). The difference of AOFAS ankle-hindfoot score before and after operation in AA group was slightly greater than that in SMOT group, but the difference was not significant ( P>0.05). The above scores in both groups significantly improved when compared with those before operation ( P<0.05). Sagittal ROM in AA group was significantly less than that before operation ( P<0.05), while there was no significant difference in SMOT group ( P>0.05). In the SMOT group, 17 patients (81.0%) showed improvement in imaging staging, 2 patients (9.5%) showed no improvement in staging, and 2 patients (9.5%) showed stage aggravation. TLS, TAS, and TT significantly improved when compared with those before operation ( P<0.05). At last follow-up, 2 patients in SMOT group received AA due to pain and stage aggravation, and 1 patient with bone nonunion underwent bone graft. Subtalar joint fusion was performed in 1 case of subtalar arthritis in AA group. Conclusion: For inverted ankle OA in Takakura 3A stage with talus tilt, both SMOT and AA can significantly releave pain, improve foot function and quality of life, but AA has more definite effectiveness and better patient satisfaction.

Deformities Influencing Different Classes in Progressive Collapsing Foot.

Background: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high. Methods: We retrospectively assessed weight bearing CT (WBCT) measurements of 32 feet with PCFD diagnosis. The classes and their associated radiographic measurements were defined as follows: class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by Meary's angle, class D (peritalar sub-luxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. A p-value <0.05 was considered significant. Results: Class A showed substantial positive correlation with class C (ρ=0.71; R2=0.576; p=0.001). Class B was substantially correlated with class D (ρ=0.74; R2=0.613; p=0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R2=0.576; p=0.001) and class D (ρ=0.75; R2=0.559; p=0.001). Class D showed substantial positive correlation with class B and class C (ρ=0.74; R2=0.613; p=0.001), (ρ=0.75; R2=0.559; p=0.001) respectively. Class E did not show correlation with class B, C or D (ρ=0.24; R2=0.074; p=0.059), (ρ=0.17; R2=0.071; p=0.179), and (ρ=0.22; R2=0.022; p=0.082) respectively. Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features. Level of Evidence: III.

Supramalleolar Osteotomy vs Arthrodesis for the Treatment of Takakura 3B Ankle Osteoarthritis.

BACKGROUND: To compare the clinical/functional outcomes of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) for the treatment of modified Takakura stage 3B ankle osteoarthritis. METHODS: Outcomes of 28 SMOT patients and 30 AA patients were reviewed at an average of 50 and 51 months, respectively. The baseline characteristics of the 2 groups were similar. The preoperative tibial articular surface angle and talar tilt angle in the SMOT group were 82.6 and 10 degrees and in the AA group, 83.9 and 9.1 degrees, respectively. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, 12-item Short-Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores, range of motion (ROM), radiologic parameters, and complications were compared. RESULTS: The AOFAS, VAS, and SF-12 MCS and PCS scores improved significantly postoperatively in both groups (P < .001). The VAS and SF-12 PCS scores indicate marginally better improvement in the AA group (P < .05). The patient satisfaction value (P = .028) and the possibility of repeated surgery value (P = .012) were also significantly higher in the AA group. The early (P = .905) and late (P = .181) complications did not significantly differ between the 2 groups. The reoperation rate was significantly higher in the SMOT group (P = .038). CONCLUSION: Both SMOT and AA showed improvements in function, pain, alignment, and quality of life after surgery. Patients in the AA group reported better pain relief, had a lower reoperation rate, and better hindfoot alignment during a short- to mid-term follow-up time. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The effect of partial deltoid ligament injuries on the external rotation stability: A cadaveric study.

BACKGROUND: The anterior and posterior part of the deltoid ligament have different functions during ankle flexion motion. Partial ligament injuries have been demonstrated in previous clinical reports. However, the efficacy of external rotation stress test in partial injured cases is unavailable till now. METHODS: Thirty-two fresh cadaveric specimens were included and allocated into two destabilization groups. In the first group, the anterior portion of deltoid ligament (DL) and syndesmotic ligament were sequentially severed, while in the second group, the posterior portion of DL and syndesmotic ligament were sequentially severed. Mortise view radiographs were taken after each destabilization stage when the ankles were placed at plantarflexion and dorsiflexion positions and stressed in standard external rotation force. The medial clear space (MCS) and talar tilt (TT) angle were measured and compared among different destabilization stages. RESULTS: When the ankles were placed at neutral position, the TT significantly increased in all destabilization stages. The MCS significantly increased after the partial deltoid ligament ruptures only with presence of syndesmotic ligament injuries. There was no significant difference of MCS at plantarflexion for all stages of destabilization if the anterior portion of DL is preserved. Similarly, no significant increase of MCS was detected at dorsiflexion if the posterior portion of DL and posterior inferior tibiofibular ligament are intact. CONCLUSION: Partial DL rupture causes ankle rotational instability at different ankle joint positions, especially when combined with syndesmotic injuries. The neutral position is recommended for diagnosis of partial DL ruptures under external rotation stress.

Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound imaging.

STUDY DESIGN: A quasi-experimental. BACKGROUND: The talar tilt test and the anterior drawer test are clinically used to evaluate the length of the anterotalofibular (ATFL) and calcaneofibular (CFL) ligaments. Based on the current literature, there is no clear diagnostic utility or preference for either test. This study investigated ligament lengthening during these special tests and compared the talar tilt test to the long axis distraction test for the CFL length. METHODS: A convenience sample of 47 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging (MSK US) was used to measure the length of the ATFL and CFL during the talar tilt and anterior drawer tests. Additionally, CFL lengthening during the talar tilt was compared to the long axis distraction test. OUTCOMES: A significant difference was found (p < .001) in ATFL length between the talar tilt and anterior drawer test. This indicates that the talar tilt test is preferred to maximally lengthen the ATFL. There was a significant difference in CFL length (p < .001) between the talar tilt test and the long axis distraction test. DISCUSSION: The results of this study identified that the talar tilt test resulted in more ATFL lengthening than the anterior drawer test and thus is the preferred test to assess ligament length. Additionally, both the long axis distraction test and the talar tilt test cause lengthening of the CFL. Therefore, the long axis distraction test can be used as a differentiation test to determine if either the ATFL or the CFL is the structure with increased laxity.

Systematic review and meta-analysis: surgical reparative treatment for orthopedic patients with ankle fracture complicated by peripheral tissue injury.

BACKGROUND: This study aimed to apply meta-analysis to study the efficacy of surgical repair treatment on ankle fractures. METHODS: The Boolean logic search method was adopted to retrieve relevant randomized control trials (RCTs), with "Fracture", "Ankles", "Fractured Foot", "Fractures Merge", and "Surgical Treatment" as search terms. The databases PubMed, Medline, HowNet, and others were searched from the time of their establishment. The software Review Manager (Rev Man 5.3) was used for meta-analysis. RESULTS: A total of 10 references were included in the study, and most of them had low-risk bias (medium-high quality). The results of meta-analysis showed that after surgical repair treatment, gait was good, while the gait score of the non-surgical group was poor. The result was Chi2 (Chi-squared Test) =57.91, df (degree of freedom) =5, I2=91%, P<0.1, mean difference (MD) =-9.21, 95% CI: -10.25 to -8.17, Z=17.36, P<0.05. The non-surgical group showed a higher degree of pain and poorer ankle and hindfoot functions vs. the surgical group. Also, the pain degree of the non-surgical repair combined with surrounding tissue group was higher, and the ankle and hindfoot functions were poorer vs. the surgical repair treatment group. The Pain intensity results of the surgical and non-surgical groups were Chi2 =12.89, df =2, I2=84%, P<0.1, MD =-9.51, 95% CI: -10.47 to -8.55, Z=19.39, P<0.05; the AOFAS scores of surgical repair treatment and non-surgical repair treatment were Chi2 =27.07, df =6, I2=78%, P<0.1, MD =8.89, 95% CI: 8.26 to 9.71, Z=24.30, P<0.05. It was revealed that surgical repair treatment can significantly reduce the postoperative pain of patients with ankle joint fractures, while the non-surgical repair treatment group had a higher degree of postoperative pain. The result was (MD =2.32, 95% CI: 2.16 to 2.48, I2=100%, Z=28.33, P<0.05). DISCUSSION: Surgical repair treatment of ankle fracture demonstrated significant curative effects, with fewer adverse reactions, and the stability of the ankle joint was well restored.

Lack of Definition of Chronic Ankle Instability With Arthrometer-Assisted Ankle Joint Stress Testing: A Systematic Review of In Vivo Studies.

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability.

A Rare Pattern of Ligamentous Injury of the Ankle: A Case Report and Review of the Literature.

Ankle sprains are the most frequent sport related injuries with involvement of the lateral collateral ligament complex occurring in 85% of cases. Isolated anterior talofibular ligament injury is by far the commonest followed by combined anterior talofibular and calcaneofibular ligament strain. The posterior talofibular ligament is the strongest component of the lateral collateral ligament complex and is injured in severe ankle injury along with the other lateral collateral ligaments. While isolated calcaneofibular ligament strain has been reported, calcaneofibular ligament and posterior talofibular ligament strains with an intact anterior talofibular ligament are rare and reported in cadaveric studies. We present a case of radiologically diagnosed calcaneofibular ligament and posterior talofibular ligament injury and will discuss the anatomy, stress radiography, and magnetic resonance image findings and the mechanism of this particular injury.

Knotless All-Inside Arthroscopic Modified Broström Procedure for Lateral Ankle Instability.

One reported complication of the arthroscopic modified Broström operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Broström operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Broström operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

Characteristics of medial gutter arthritis on weightbearing CT and plain radiograph.

OBJECTIVE: An ankle arthritis with medial gutter obliteration is known to have good results after joint preservation surgery. However, the diagnosis is often missed on radiographs. The aims of this study were to investigate sensitivity of radiographs in the identification of medial gutter arthritis, incidence and direction of the talar tilt on weightbearing CT (WBCT), and to assess radiographic alignment of the medial gutter arthritis. MATERIALS AND METHODS: Radiographic data was retrospectively evaluated in 102 ankles which were diagnosed medial gutter arthritis by using the WBCT at our clinic between January 2017 and June 2019. Among the 102 ankles, proportion of ankles which showed medial gutter arthritis on plain radiograph was obtained. The presence and direction of talar tilt were assessed on three coronal WBCT images at the anterior, middle, and posterior aspect of the ankle. Plain radiographic parameters were compared between the 102 ankles and control group. RESULTS: Plain radiograph showed medial gutter arthritis only in 63 ankles (62%) among the 102 ankles. Most of the ankles with medial gutter arthritis showed talar tilt on WBCT, and about half of all ankles showed valgus talar tilt at the anterior aspect of ankle on WBCT. In ankles with medial gutter arthritis, the mechanical axis of the lower extremity and the tibial plafond were varus angulated and the talus was medially translated compared to the control group. CONCLUSION: Radiographs were less sensitive than WBCT in demonstrating medial gutter arthritis. Anterior aspect of ankles with medial gutter arthritis often showed valgus direction of talar tilt. Varus mechanical axis deviation and varus tibial plafond are commonly associated with the medial gutter arthritis.

Stress radiography in the diagnosis and assessment of the outcomes of surgical treatment of chronic anterolateral ankle instability.

BACKGROUND: In about 20-40% of patients, damage to the soft tissues surrounding the ankle leads to recurrent and chronic pain with signs of instability of the talus in the tibiofibular fork. PURPOSE: The aim of the study was to assess the usefulness of stress X-ray images in the diagnosis of long-term outcomes of conservative versus surgical treatment of anterolateral ankle instability. MATERIAL AND METHODS: Thirty patients with chronic ankle instability (CAI) were recruited for the study. The participants were divided into two groups. The first group consisted of 15 non-operatively treated individuals diagnosed with anterior talofibular ligament (ATFL) damage. The second group consisted of 15 patients who had undergone surgical reconstruction of the ATFL. In both groups of patients, the contralateral normal limb was used as a control. In all patients, anteroposterior and lateral view stress radiographs of both ankles were taken using the TELOS Stress Device (GA - III/E, Hungen, Germany). RESULTS: Statistical tests showed that the surgically treated patients had a significantly greater ankle stability compared to the non-surgically treated patients (P = 0.001 for talar tilt angle and P = 0.009 for anterior drawer distance). The results obtained in this study indicate that this method can also be used in postoperative assessment of the function of the reconstructed lateral ankle ligaments. CONCLUSIONS: Stress radiography is a reliable and safe tool for diagnosing CAI. This imaging method is an objective instrument that can be successfully used in postoperative assessment of the function of the reconstructed ATFL.

Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization for varus ankle osteoarthritis with excessive talar tilt angle.

BACKGROUND: Although supramalleolar osteotomy is the main joint-preserving method for the treatment of varus ankle osteoarthritis, it tends to be ineffective when ankle osteoarthritis presents in combination with an excessive talar tilt angle. The purpose of this study was to present a new surgical technique, supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization, for the treatment of varus ankle osteoarthritis with an excessive talus tilt angle and to evaluate the clinical and radiological results. METHODS: From January 2013 to October 2016, a total of 17 patients with 17 cases of varus ankle arthritis with excessive talar tilt angles (larger than 7.3°) underwent surgical treatment using our new technique. The American Orthopaedic Foot and Ankle Society (AOFAS) clinical ankle-hindfoot scale and a visual analogue scale (VAS) were used to evaluate ankle function and pain before surgery and at the last follow-up. The medial distal tibial angle (MDTA), anterior distal tibial angle (ADTA), talar tilt angle (TTA), and hindfoot moment arm values (HMAVs) were evaluated on weight-bearing radiographs acquired preoperatively and at the last follow-up. RESULTS: The AOFAS score improved significantly from 45.8 ± 2.1 before surgery to 84.8 ± 1.8 after surgery (p < 0.001), and the VAS score decreased from 4.9 ± 0.4 to 1.1 ± 0.2 (p < 0.001). The MDTA, TTA, and HMAV changed from 80.9° ± 0.4° to 90.1° ± 0.4°, 11.7° ± 0.6° to 1.4° ± 0.3°, and 12.6 mm ± 0.8 mm to 4.2 mm ± 0.6 mm, respectively (each p < 0.001). The ADTA showed no obvious change (p = 0.370). The staging of 11 cases (65%) improved. Intramuscular vein thrombosis of the lower limbs occurred in 1 patient 1 week after surgery, and superficial infection occurred in 1 patient. CONCLUSIONS: Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization can correct the load of the weight-bearing ankle and effectively improve the ankle function. As the talar tilt angle can be significantly improved after surgery, this technique can be used for the treatment of varus ankle osteoarthritis with an excessive TTA.

Radiologic Factors Affecting Ankle Pain Before and After Total Knee Arthroplasty for the Varus Osteoarthritic Knee.

The aim of the present study was to evaluate the radiologic factors related to ankle pain before and after total knee arthroplasty (TKA) among patients with a varus osteoarthritic knee. Fifty-five patients (65 ankles) with a varus osteoarthritic knee who had undergone TKA and were followed up for >24 months were enrolled. For clinical assessment, the visual analog scale for pain and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were used. For radiologic assessment, the mechanical axis deviation angle, talar tilt, tibial anterior surface angle, distal medial clear space, medial tibiotalar joint space, frontal tibial ground angle, and hindfoot alignment view angle were measured. The patients with ankle pain before TKA (11 ankles) had a larger hindfoot alignment view angle (9.2° ± 2.6°) than that of patients without ankle pain before TKA (54 ankles; 5.5° ± 4.8°; p = .007). The patients with newly developed ankle pain or experienced an aggravation of existing pain after TKA (8 ankles) had a significantly larger degree of residual varus (5.1° ± 2.1°) than did the patients without ankle pain before and after TKA or those with ankle pain before surgery. However, the severity of the pain was not different during the follow-up period (52 ankles; 1.6° ± 2.5°; p = .001). The results of the present study showed that residual varus deformity was associated with ankle pain after TKA. Surgeons should perform evaluations of the ankles of patients who complain of pain before and after TKA and should give careful attention to the correction of alignment during TKA.

Magnetic Resonance Imaging and Stress Radiography in Chronic Lateral Ankle Instability.

BACKGROUND: Studies regarding magnetic resonance imaging (MRI) findings of the lateral ankle ligaments in chronic lateral ankle instability and their clinical relevance for surgery are lacking. This study classified the lateral ankle ligament MRI findings of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in chronic lateral ankle instability (CLAI) and correlated these findings with ankle stress radiographs. METHODS: We included 132 ankles with CLAI that underwent ligament reconstructions from 2006 to 2013. The distributions of the ATFL and CFL morphologies were evaluated using the following categories: (1) the amount of thickness: normal/thickened/attenuated/non-visualized, (2) the presence of discontinuity, (3) wavy or irregular contour, and (4) increased signal intensity on T2-weighted images. The relationships between the ligament morphologies and stress radiographs were analyzed. RESULTS: The ATFL was normal in 5 (4%) ankles, thickened in 35 (27%), attenuated in 76 (58%), and non-visualized in 16 (12%), while the CFL was normal in 39 (30%) ankles, thickened in 42 (32%), attenuated in 44 (33%), and non-visualized in 7 (5%). Discontinuity of the ATFL or CFL was observed in 46 (35%) ankles. Wavy or irregular contours were observed in 55 (42%) ATFLs and 37 (28%) CFLs, and signal intensity of both ligaments was increased in 19 (14%) ankles. ATFL ( P < .001) and CFL thickness ( P = .007) correlated with the talar tilt angle. CONCLUSIONS: The MRI findings of CLAI showed several morphologies and specific incidences for each morphology. Attenuated, wavy appearance was the most frequent MRI pattern. Thickness was related to the degree of instability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Examining Ankle-Joint Laxity Using 2 Knee Positions and With Simulated Muscle Guarding.

CONTEXT: Several factors affect the reliability of the anterior drawer and talar tilt tests, including the individual clinician's experience and skill, ankle and knee positioning, and muscle guarding. OBJECTIVES: To compare gastrocnemius activity during the measurement of ankle-complex motion at different knee positions, and secondarily, to compare ankle-complex motion during a simulated trial of muscle guarding. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Thirty-three participants aged 20.2 ± 1.7 years were tested. INTERVENTION(S): The ankle was loaded under 2 test conditions (relaxed, simulated muscle guarding) at 2 knee positions (0°, 90° of flexion) while gastrocnemius electromyography (EMG) activity was recorded. MAIN OUTCOME MEASURE(S): Anterior displacement (mm), inversion-eversion motion (°), and peak EMG amplitude values of the gastrocnemius (µV). RESULTS: Anterior displacement did not differ between the positions of 0° and 90° of knee flexion (P = .193). Inversion-eversion motion was greater at 0° of knee flexion compared with 90° (P < .001). Additionally, peak EMG amplitude of the gastrocnemius was not different between 0° and 90° of knee flexion during anterior displacement (P = .101). As expected, the simulated muscle-guarding trial reduced anterior displacement compared with the relaxed condition (0° of knee flexion, P = .008; 90° of knee flexion, P = .016) and reduced inversion-eversion motion (0° of knee flexion, P = .03; 90° of knee flexion, P < .001). CONCLUSIONS: In a relaxed state, the gastrocnemius muscle did not appear to affect anterior ankle laxity at the 2 most common knee positions for anterior drawer testing; however, talar tilt testing may be best performed with the knee in 0° of knee flexion. Finally, our outcomes from the simulated muscle-guarding condition suggest that clinicians should use caution and be aware of reduced perceived laxity when performing these clinical examination techniques immediately postinjury.

Individuals with both perceived ankle instability and mechanical laxity demonstrate dynamic postural stability deficits.

BACKGROUND: Chronic ankle instability is a frequent and serious consequence of lateral ankle sprains. The contribution of perceived instability and potential for mechanical laxity to contribute to the overall deficit in dynamic postural stability is unclear. The purpose was to determine if those with mechanical laxity demonstrated significant differences in dynamic postural stability compared to controls, copers and those with perceived instability. METHODS: Of 93 participants, 83 recreationally active individuals were divided into 4 groups: controls, copers, those with perceived instability, and those with both perceived instability and mechanical laxity. Injury history and the Cumberland Ankle Instability Tool were collected, and an instrumented arthrometer was applied. Participants completed a single limb jump landing, balancing upon completion. Ground reaction force data were collected, scaled to body mass, and the Dynamic Postural Stability Indices were calculated for anterior-posterior, medial-lateral, vertical and composite. One-way ANOVAs with Tukey post-hoc tests (α<0.05) were conducted on each of the stability indices among the four groups. FINDINGS: The mechanically lax group had significantly greater mean (standard deviation) medial-lateral stability index scores 0.57 (0.62) than the coper group 0.24 (0.20; P=0.02) and significantly greater composite index scores 0.73 (0.57) than the perceived instability 0.49 (0.09) and coper groups 0.47 (0.12 P=0.05). No other indices were significantly different among groups. INTERPRETATION: Individuals with perceived instability and mechanical laxity exhibited dynamic postural deficits compared to copers and those with perceived instability alone. Mechanical laxity may contribute to the deficits in dynamic postural stability.

Radiological morphology of peritalar instability in varus and valgus tilted ankles.

BACKGROUND: Varus and valgus talar tilt in weight-bearing ankles can be explained by loss of peritalar stability allowing the talus to shift and rotate on the calcaneal and navicular surfaces. Little is known about the underlying destabilization process or the resulting talar malpositions. The purpose of this study was to determine talar position in 3 radiographic planes of varus and valgus tilted ankles. METHODS: Standard weight-bearing radiographs of 126 varus ankles (118 patients [mean age 62 ± 12 years]) and 81 valgus ankles (75 patients [mean age 65 ± 10 years]) were retrospectively evaluated. The tibiotalar surface angle, sagittal talocalcaneal inclination angle, and horizontal talometatarsal I angle were used to determine the frontal, sagittal, and horizontal position of the talus. A control group was used for comparison. RESULTS: Isolated talar varus malposition was found in 33.3% of the ankles (42/126), and malposition in 1 or both additional planes was found in 49.2% (62/126) and 17.5% (22/126), respectively. In valgus ankles, the percentages were 52% (42/81), 43% (35/81), and 5% (4/81), respectively. Seven out of 9 possible varus and 5 out of 9 possible valgus talar malposition configurations were found. The 4 predominant varus malposition configurations (89.7%, or 113/126) were dorsiflexion or neutral (sagittal plane) combined with neutral/external rotation and neutral/internal rotation (horizontal plane), respectively. The 3 predominant valgus malposition configurations (95%, or 77/81) were neutral or plantar flexion (sagittal plane) combined with neutral/external rotation and neutral (horizontal plane), respectively. CONCLUSION: In varus and valgus tilted ankles, talar frontal plane alignment does not predict talar sagittal and horizontal position, indicating that peritalar instability leads to various talar malpositions. Prior to operative treatment of varus and valgus tilted ankles, thorough 3-dimensional analysis of talar position may minimize failure in properly balancing the talus within the ankle mortise. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Narrowing the normal range for lateral ankle ligament stability with stress radiography.

Stress radiographs are commonly performed to evaluate lateral ankle ligament stability; however, little agreement exists on the physiologic limits obtained from the anterior drawer and talar tilt stress tests. Published studies have reported the normal range for the anterior drawer test to be 3 to 10 mm and the normal range for the talar tilt test to be 0° to 23° for the uninjured ankle, leading to inconsistent interpretation. The primary objective of the present study was to narrow the threshold for the diagnosis of ankle ligament injury using stress radiographs by refining the values seen in the normal ankle. An improved understanding of normal ankle motion could allow for a more accurate determination of ligament injury using stress imaging. Conducted in a simplified, yet reproducible, manner, we hoped the present study would draw a parallel with generalized use in an office setting and would allow physicians the ability to more effectively diagnose ankle ligament injury. Bilateral radiographic images of anterior drawer and talar tilt stress tests were taken of 50 participants (100 ankles) with no history of ankle fracture or surgical intervention for ankle instability. Participants with a previous ankle sprain were later excluded from the result computations. Factors such as patient age and gender were evaluated. In the final analysis, 46 participants (76 ankles) were included, with a mean anterior drawer test result of 2.00 mm ± 1.71 mm and talar tilt test result of 3.39° ± 2.70° in the normal ankle. The results of the present study suggest that stress radiographs for lateral ankle stability can be performed in a simple and reliable manner. These results also support a much lower threshold for the diagnosis of lateral ankle injury than previously reported.