Foot biomechanics in patients with advanced subtalar- and mid-tarsal joint osteoarthritis and poorly responding to conservative treatment.

BACKGROUND: A comprehensive insight into the effects of subtalar- and mid-tarsal joint osteoarthritis on lower limb's biomechanical characteristics during walking is lacking. Our goal was to assess joint kinematics and kinetics and compensatory mechanisms in patients with subtalar and mid-tarsal joint osteoarthritis. METHODS: Patients with symptomatic and radiographically confirmed osteoarthritis of the subtalar and mid-tarsal (n = 10) and an asymptomatic control group (n = 10) were compared. Foot joint kinematics and kinetics during the stance phase of walking were quantified using a four-segment foot model. RESULTS: During pre-swing phase, the tibio-talar range of motion in the sagittal plane of the patient group decreased significantly (P = 0.001), whereas the tarso-metatarsal joint range of motion in the sagittal plane was greater in the pre-swing phase (P = 0.003). The mid-tarsal joint showed lower transverse plane range of motion in the patient group during the loading response and pre-swing phase (P < 0.001 resp. P = 0.002). The patient group showed a lower Tibio-talar joint peak plantarflexion moment (P = 0.004), peak plantarflexion velocity (P < 0.001) and peak power generation in the sagittal plane (P < 0.001), and a lower mid-tarsal joint peak adduction and abduction velocity (P < 0.001 resp. P < 0.001) and peak power absorption (P < 0.001). CONCLUSIONS: These findings suggest that patients with subtalar and mid-tarsal joint osteoarthritis adopt a cautious walking strategy potentially dictated by pain, muscle weakness, kinesiophobia and stiffness. Since this poorly responding population faces surgical intervention on the short term, we recommend careful follow-up after fusion surgery since biomechanical outcome measures associated to this post-surgical stage is lacking.

Surgical treatment options for chronic instability of the peroneal tendons: a systematic review and proportional meta-analysis.

INTRODUCTION: Several surgical techniques for chronic instability of the peroneal tendons have been reported. Yet, the most optimal technique has not been clarified. This study aims to perform a systematic review and meta-analysis of all existing evidence and compare all published surgical techniques in both the athletic as the nonathletic population. MATERIALS AND METHODS: A systematic review and a proportional meta-analysis, with a random-effects model, were carried out according to the PRISMA guidelines, using the keywords "chronic luxation" OR "instability" AND "peroneal tendon" AND "treatment" OR "treatment protocol". Four surgical techniques were compared in patients with chronic peroneal instability, comprising superior peroneal retinaculum (SPR) repair or replacement, groove deepening procedures (primarily with additional SPR operations), rerouting procedures, and bony procedures (respectively group S, G, R and B). Outcomes of interest include the pre- and postoperative American orthopedic foot and ankle society hindfoot score, return to sports, postoperative redislocation and complications. Pooled estimates of the last two outcomes were obtained. RESULTS: For the systematic review, 31 studies were eligible. Of these, 25 papers met the criteria for inclusion in the meta-analysis. All techniques demonstrated a clinical improvement postoperatively. Group B, however, demonstrated overall more unsatisfactory results, and higher complication rates were observed for both group R and group B. The latter was established by the proportional meta-analysis as well [95% confidence interval group S: (0.01-0.10); group G: (0.02-0.10); group R: (0.13-0.57); group B: (0.24-0.40)]. Concerning surgical efficacy (= no postoperative redislocation), no significant difference was statistically observed. Finally, considerable differences in study quality were identified. CONCLUSION: Surgical treatment results in excellent clinical and functional outcomes in patients with chronic peroneal instability. More inferior results were demonstrated for rerouting and bony procedures. However, no high-quality studies are available and future randomized controlled trials are necessary to advocate for the most advantageous approach.

Reconstruction of the cervical ligament in patients with chronic subtalar instability.

PURPOSE: Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI. METHODS: This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score. RESULTS: After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ± 13.5 (median 37, range 10-55) to a mean postoperative Karlsson score was 89.6 ± 8.5 (median 90, range 72-100) (P < 0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3). CONCLUSION: Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability. LEVEL OF EVIDENCE: Level III.

The different subtalar ligaments show significant differences in their mechanical properties.

BACKGROUND: Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint. METHODS: Eighteen paired fresh-frozen cadaveric feet were used to obtain bone-ligament-bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-interosseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load. RESULTS: The stiffness of ACaL-ITCL complex (mean: 150 ± 51 N/mm, 95% confidence interval (CI): 125.0-176.6 N/mm) was significantly higher than both CFL (mean: 55.8 ± 23.0 N/mm, CI: 43.8-67.7 N/mm) and CL (mean: 63.9 ± 38.0 N/mm, CI: 44.4-83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 ± 158 N, CI: 304.1-460.8 N) and the CFL (mean:320.4 ± 122.0 N, CI: 257.5-383.2 N) were significantly higher than that of the CL (mean:163.5 ± 58.0 N, CI: 131.3-195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens. CONCLUSION: The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.

The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis.

BACKGROUND: A lateral ankle sprain (LAS) is the most common musculoskeletal injury in the physically active population. It is uncertain what percentage of these patients develop persisting symptoms including pain, recurrent sprains and subjective instability. This systematic review was conducted to assess the presence and duration of persistent symptoms after a first LAS. METHODS: A systematic review of the Medline, Web of Sciences, Embase, CINAHL and Pedro databases was performed to identify peer-reviewed articles concerning the occurrence and duration of remaining symptoms after a first LAS. Inclusion criteria focused on selection of patients without previous ankle injuries and study quality. One of the following outcomes had to be described: subjective instability, resprains, remaining symptoms. RESULTS: In total, 15 studies were included. The occurrence of patients with subjective instability decreased from 37.9% (95%CI [6.0-69.7]) at 3 months to 16.1% (95%CI [7.8-24.3]) at 6 months and 8.1% (95%CI [3.3-13.3]) at 12 months. The occurrence of patients with a recurrent LAS was 15.8% (95%CI [6.3-25.3]) at 12 months. The occurrence of patients with residual pain decreased from 48.6% (95%CI [23.6-73.5]) at 3 months, to 21.5% (95%CI [2.8-40.2]) at 6 months and 6.7% (95%CI [3.2-10.1]) at 12 months. CONCLUSION: This study offers new insights in the presence of remaining symptoms after a first LAS and the development of chronic ankle instability. Twelve months following an initial LAS, a significant number of patients may still have symptoms. The incidence of subjective instability, and pain, continues to decrease until 12 months post-injury. This new information may suggest that a longer period of non-operative treatment may be warranted before recommending surgical intervention in patients with a first LAS.

3D imaging added value in the treatment and diagnosis of displaced intra-articular calcaneal fractures (DIACF): measuring the orientation of the posterior talo-calcaneal facet in the space.

PURPOSE: Measure the reduction quality of calcaneal fractures on 3 D segmented images. METHODS: The Ethics Review Board approved this study and written informed consent was collected from all patients. Bilateral CT scans of fifty-four patients with unilateral displaced calcaneal fracture were obtained before and after osteosynthesis. Orientation angle of the posterior subtalar joint facet (PTC) of displaced intra-articular calcaneal fractures of 54 patients was measured on segmented 3 D images before and after surgery and compared to the uninjured side. This orientation angle (OAC) is the average of every normal vector of each point of the PTC, as compared to the main calcaneal axis (calculated by first principal component analysis). The PTC is a well-known anatomical structure, relatively easy to identify on 3 D imaging. RESULTS: This OAC angle was low before surgery (mean= 95°, std dev= 6°), statistically significantly different from the uninjured side value, p < 0.001. The OAC angle of the operated bone was nearly equal to the uninjured side (mean= 103°, std dev= 5°), without any statistically significant difference between postoperative values and uninjured side values. We found linear correlation between the quality of the reduction when assessed with this OAC and the functional score (AOFAS) (Adjusted R2=0.62, p = 0.04). CONCLUSIONS: This angle seems to be useful to quantify the quality of the operative reduction of displaced intra-articular calcaneal fractures.

Reviving the debate: Articular cartilage preservation during disarticulation at the lower limb? A systematic review.

BACKGROUND: The need for preservation(P) or removal(R) of articular cartilage during disarticulations remains unanswered. METHODS: Medline database was used to conduct a systematic review regarding all types of minor disarticulations and some types of major disarticulations in patients with diabetes mellitus, peripheral arterial disease or trauma related disarticulations. Fisher-exact statistical test was used to perform calculations for the entire group as for subgroups. RESULTS: A total of 444 disarticulations at the Chopart joint, ankle and knee were included (P = 255 vs. R = 189). There was no difference in wound healing, functionality and mortality. Reamputation rate was lower in the P-group (9.4% vs. 16.9%). Infection rate was not significantly different. Differences in reamputations (R = 10.6% vs. P = 1.0%) and infections (R = 4.4% vs. P = 22.6%) were only present for the ankle subgroup. CONCLUSIONS: There is no difference in wound healing, functionality and mortality between the preservation and removal of articular cartilage in the lower limb.

The intrinsic subtalar ligaments have a consistent presence, location and morphology.

BACKGROUND: Chronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing the anatomy of the intrinsic subtalar ligaments is limited and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion. METHODS: In 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. RESULTS: The cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9 ± 1.5 mm, posterior length 18.5 ± 2.9 mm, talar width 13.6 ± 2.2 mm, calcaneal width 15.8 ± 3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations. CONCLUSION: This study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

PURPOSE: Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. METHODS: The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. RESULTS: For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. CONCLUSION: Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

The Biomechanical Behavior of Distal Foot Joints in Patients with Isolated, End-Stage Tibiotalar Osteoarthritis Is Not Altered Following Tibiotalar Fusion.

Ankle arthrodesis is considered to be an optimal treatment strategy to relieve pain during walking in patients with isolated, end-stage tibiotalar osteoarthritis. The aim of this study was to investigate the post-operative effect of an arthrodesis on the ankle and foot joint biomechanics. We included both patients (n = 10) and healthy reference data (n = 17). A multi-segment foot model was used to measure the kinematics and kinetics of the ankle, Chopart, Lisfranc, and first metatarsophalangeal joints during a three-dimensional (3D) gait analysis. These data, together with patient reported outcome measures, were collected at baseline (pre-operative) and one year post-operatively. Patients experienced a decrease in pain and an increase in general well-being after surgery. Compared to the baseline measurements, patients only demonstrated a significant average post-operative increase of 0.22 W/kg of power absorption in the ankle joint. No other significant differences were observed between baseline and post-operative measurements. Current findings suggest that the biomechanical behavior of distal foot joints is not altered one year after fusion. The pain relief achieved by the arthrodesis improved the loading patterns during walking. Clinical significance of this study dictates that patients do not have to fear a loss in biomechanical functionality after an ankle arthrodesis.

Does subtalar instability really exist? A systematic review.

BACKGROUND: Subtalar joint instability (STI) is considered as a potential source of chronic lateral hindfoot instability. However, clinical diagnosis of STI is still challenging. This systematic review was conducted to assess the consistency of the clinical entity "subtalar instability", to investigate the reliability of available diagnostic tools and to provide a critical overview of related studies. METHODS: A systematic review of the Medline, Web of Sciences and EMBASE databases was performed for studies reporting on tests to investigate subtalar instability or lesions of the subtalar ligaments. To investigate the relation with chronic STI, studies focusing on sinus tarsi syndrome (STS) or acute lesions of the subtalar ligaments were also included in the search strategy and were assessed separately. RESULTS: This review identified 25 studies focusing on different topics: chronic STI (16), acute lesions of the subtalar ligaments (5) and STS (4). Twelve studies, assessing STI, demonstrated the existence of a subgroup with instability complaints related to abnormal increased subtalar motion (7) or abnormalities of the subtalar ligaments (6). We found insufficient evidence for measuring subtalar tilting using stress radiographs. MRI was able to assess abnormalities of the ligaments and stress-MRI detected abnormally increased motion. CONCLUSION: Complaints of instability can be related to subtalar ligaments injuries and an abnormally increased motion of the subtalar joint. Stress radiographs should be interpreted with caution and should not have the status of a reference test. Clinical diagnosis should rely on several parameters including MRI.

An oblique fibular tunnel is recommended when reconstructing the ATFL and CFL.

PURPOSE: A bone tunnel is often used during the reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The purpose of this study is to compare proposed directions for drilling this fibular tunnel and to assess potential tunnel length, using a 5-mm-diameter tunnel and surrounding bone. METHODS: Anonymous DICOM data from spiral CT-scan images of the ankle were obtained from 12 Caucasian patients: 6 females and 6 males. Virtual tunnels were generated in a 3D bone model with angles of 30°, 45°, 60° and 90° in relation to the fibular long axis. Several measurements were performed: distance from entrance to perforation of opposing cortex, shortening of the tunnel, distance from tunnel centre to bone surface. RESULTS: A tunnel in a perpendicular direction resulted in an average possible tunnel length of 16.8 (± 2.7) mm in the female group and 20.3 (± 3.4) mm in the male group. A tunnel directed at 30° offered the longest length: 30.9 (± 2.5) mm in the female group and 34.4 (± 2.9) mm in the male group. The use of a 5-mm-diameter tunnel in a perpendicular direction caused important shortening of the tunnel at the entrance in some cases. The perpendicular tunnel was very near to the digital fossa while the most obliquely directed tunnels avoided this region. CONCLUSION: An oblique tunnel allows for a longer tunnel and avoids the region of the digital fossa, thereby retaining more surrounding bone. In addition, absolute values of tunnel length are given, which can be useful when considering the use of certain implants. We recommend drilling an oblique fibular tunnel when reconstructing the ATFL and CFL.

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial.

BACKGROUND: Despite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found. The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity. METHODS: Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36. RESULTS: Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported. CONCLUSIONS: This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.

Long-Term Outcome After Operative Management of Talus Fractures.

BACKGROUND:: Controversies remain regarding the preferred treatment strategy for talus fractures. The primary goal of this study was to evaluate the long-term outcome after operative management of talus fractures. Secondarily, we identified those factors that affected the outcome and defined strategies to improve the outcome. METHODS:: This is a retrospective outcome study of 84 patients with an average follow-up time of 9.1 years. We assessed the functional results, return to daily activities, and general health status using the Foot Function Index-5pt, a numeric rating scale for pain, and the Short Form-36 Health Survey. Furthermore, we conducted a correlation analysis between the outcomes and 14 demographic, clinical, and radiologic variables. RESULTS:: We found moderate mean Foot Function Index pain and disability scores of 30.2 and 28.7, respectively. The mean numeric rating scale score was 3.2. Of all responders, 41% (27/66) did not return to their daily activities. We reported low physical, but good mental, Short Form-36 component summary scores of 42.7 and 48.3, respectively. We recorded a complication rate of 56%. Osteoarthritis, articular incongruence and talus body fractures correlated significantly with a poorer functional outcome. Delayed surgery after trauma was associated with better outcome measures. CONCLUSIONS:: Talus fractures have a major long-term impact on ankle and hindfoot function and on physical health. Success of operative treatment depends on the occurrence of osteoarthritis postoperatively, type of fracture, and quality of fracture reduction. Because only the latter is modifiable, efforts should be made to restore articular congruence in order to improve the outcome. Therefore, we recommend reviewing the quality of the reduction postoperatively on CT. Furthermore, talus fractures should not be considered operative emergencies, but rather treated after recovery of the soft-tissues. LEVEL OF EVIDENCE:: Level III, comparative study.

Screwless scarf osteotomy for hallux valgus: Evaluation of radiologic correction.

BACKGROUND: The scarf osteotomy is a standard procedure to correct hallux valgus. Recent modifications in the technique allow for important translations of the bone fragments without the need for screw fixation. We performed the first prospective analysis of radiographic parameters after a screwless scarf osteotomy. Prospective study of pre- and postoperative standing radiographs of the feet let us quantify angle reduction and shortening, lengthening or lowering of the first metatarsal. METHODS: 100 patients undergoing a screwless scarf osteotomy were evaluated radiographically before and after surgery. The 1-2 IM angle, HVA, length of the first metatarsal, protrusion length and height of the first metatarsal head were measured. RESULTS: The mean 1-2 IM angle was reduced significantly, to a normal range. The mean reduction of the first metatarsal length and protrusion length was 0.3 and 0.14cm respectively. The metatarsal head was lowered 0.3cm on average. CONCLUSIONS: A minimal mean reduction of the first metatarsal length was observed, but it is possible to lengthen the first metatarsal if necessary. In 23% of cases, an increase of protrusion length was obtained. The screwless scarf osteotomy results in a good correction of the 1-2 IM angle and HVA. If necessary, plantarisation of the first metatarsal head could be obtained. Secondary displacement was seen in 1 patient. LEVEL OF EVIDENCE: IIa, prospective controlled trial.

Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized Clinical Trial.

BACKGROUND: It is unclear whether proximal interphalangeal joint (PIPJ) resection or fusion leads to superior clinical outcome in patients undergoing hammertoe surgery. The purpose of this study was to prospectively evaluate a series of patients undergoing this surgery. METHODS: Patients with one or more toes with rigid PIP flexion deformity were prospectively enrolled. These patients were randomly assigned to undergo either PIPJ resection or PIPJ fusion. In addition to the PIPJ procedure, a metatarsophalangeal joint (MTPJ) release was performed if deemed necessary. Follow-up was up to 1 year postoperatively. Twenty-six patients (39 toes) were included in the PIPJ resection group and 29 (50 toes) in the PIPJ fusion group. RESULTS: Thirty-four underwent an MTPJ release. No significant difference in foot outcome scores (American Orthopaedic Foot & Ankle Society scale, the Foot Function Index, and visual analog scale pain) could be detected after 1-year follow-up. A statistically significant difference was found regarding the toe alignment in the sagittal plane in favor of PIPJ fusion. CONCLUSIONS: Our randomized controlled study did not show any clinical outcome difference between PIPJ fusion and PIPJ resection. Both procedures resulted in good to excellent outcome in pain and activity scores. LEVEL OF EVIDENCE: Level II, lesser quality RCT or prospective comparative study.

Prospective randomized comparative study on V-Y and pants-over-vest capsulorraphy in chevron and scarf osteotomy.

The contribution of capsulorraphy techniques at hallux valgus surgery to sustain the longevity of the achieved correction is not well documented. This study aims to evaluate the outcome of two different capsulorraphies (V-Y and pants-over-vest). 88 feet were prospectively included and followed for 2 years. Capsulorraphy type was determined by randomisation. Primary outcome was the correction of the intermetatarsal angle (IMA) and the metatarso-phalangeal angle (MPA). Secondary endpoints were the Kitaoka-MTP1-score and the SF-36. A linear model for repeated measures was used for statistical analysis. VY and PV showed a comparable evolution for IMA (p = 0.42) and MPA (p = 0.36). However, a tendency to loss of MPA correction was noted in the scarf group for PV as compared to VY (p = 0.037). Secondary outcomes showed no significant differences between PV and VY in evolution over time for SF-36 total (p = 0.45) nor for the Kitaoka score (p = 0.15). We observed a complication rate comparable with those previously reported. The 2 year follow up did not reveal significant loss of correction of the IMA, regardless of the capsulorraphy used. The SF-36 and Kitaoka score results were stable over the study period.

Donor site morbidity after articular cartilage repair procedures: a review.

In order to perform an Osteochondral Autologous Transplantation (OAT) or an Autologous Chondrocyte Implantation (ACI), the integrity of healthy intact articular cartilage at a second location needs to be violated. This creates the possibility for donor site morbidity. Only recently have any publications addressed this issue. The aim of this manuscript is to review the current knowledge on donor site morbidity after an OAT or an ACI. Reports were identified by searching Medline and Pubmed up to March 2010. Donor site morbidity was described mostly considering a clinical outcome, both in a qualitative (parameters in history or physical examination) and/or quantitative way (knee status reported by means of a numerical score). An increasing rate of problems is noted when using quantitative instead of qualitative parameters, and when donor site morbidity is the focus of attention, affecting up to more than half of the patients, in particular for an OAT procedure. The decision to harvest an osteochondral or cartilage biopsy to perform a repair procedure should therefore be taken with caution. This also underscores the need for further research to identify safe donor sites or to develop techniques that eliminate the need for a formal biopsy ccompletely.

Iatrogenic osteochondral kissing lesion after transmalleolar drilling of the talar dome: a case report.

Ankle injuries can lead to early osteoarthrosis when diagnosis is delayed. The clinical presentation of an osteochondral lesion of the talar dome is often difficult to diagnose in the initial setup of an ankle sprain or fracture. Once the lesion is adequately imaged and staged, open or arthroscopic treatment can be initiated. We discuss the arthroscopic treatment of a posteromedial talar dome lesion in this case report. Transmalleolar drilling was performed to treat an osteochondral lesion of the talar dome in a 24-year-old female. Her ankle evolved toward a severe clinical and radiologic condition in which a combined talar and tibial (kissing) lesion was seen during her follow-up. Therefore, we recommend the use of retrograde drilling or arthroscopic microfracture with minimal iatrogenic risk, instead of transmalleolar drilling, as the treatment of choice in these specific osteochondral lesion of the talar dome cases.

The posteromedial rim of the talar dome as the site for harvesting cartilage in the ankle: an anatomic study.

PURPOSE: The goal of this study was to determine whether a biopsy specimen of a fixed size can be harvested reliably and consistently by arthroscopy at the posteromedial rim of the talar dome. METHODS: A cartilage biopsy specimen was taken post mortem arthroscopically from the posteromedial rim of the talar dome in 20 ankles. We aimed to take a full-thickness biopsy specimen of 10 x 5 mm in size. The shape, length, width, position, and depth of the created defect were determined. Subsequently, 2 observers analyzed the biopsy sites twice. The same set of parameters and the surface area of the lesion were determined. Differences between aimed and observed sizes were studied. RESULTS: In all ankles the aimed biopsy site could be seen and reached. The observed mean size of the biopsy specimens, when compared with the aimed size, was only significantly different for the mediolateral size. A wide variation of surface area was found. Nearly all biopsy specimens started exactly at the posterior border of the dome, but they were somewhat more lateral than intended. In only half of the biopsy specimens was the shape linear or oval, the others being rounded or irregular. In case a pre-existing posteromedial cartilage lesion was present, its position did not coincide with that of the biopsy specimen. CONCLUSIONS: A limited cartilage biopsy specimen could be harvested reliably and consistently by arthroscopy at the posteromedial rim of the talar dome, although the size tended to be somewhat larger than we intended. Containment of a pre-existing posteromedial lesion was never jeopardized. CLINICAL RELEVANCE: A safe biopsy site for cartilage in the ankle eliminates donor-site morbidity in the knee and may improve the suitability and biology of the obtained chondrocytes for successful repair of symptomatic joint surface defects of the ankle.