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.

Arthrodesis of the first metatarsophalangeal joint using an intraosseous fixation device.

The complication rate for an arthrodesis of the first metatarsophalangeal joint remains high. To improve results, we used a complete intraosseous fixation device (IOFIX) with proposed biomechanical advantages. Our hypothesis is that this technique has at least an equal union rate and less hardware irritation compared to other techniques. Seventy procedures were performed in 55 patients. Average follow-up was 24.5 months. All patients returned to follow-up after 6 weeks and were evaluated for union. Fifty-nine feet (84%) completed full follow- up. Union occurred in 62 of 70 feet (88.5%). Eight feet had nonunion at 1 year follow-up. Average time to fusion was 51 days. Three of 59 feet had malunion. No hardware removal was necessary. In conclusion, an MTP1 arthrodesis using IOFIX provides consistent and good functional outcomes. Due to the low-profile design, no hardware removal was necessary. However, union rates seem slightly lower compared to other techniques.

Loss of Mechanical Ankle Function Is Not Compensated by the Distal Foot Joints in Patients with Ankle Osteoarthritis.

BACKGROUND: Patients with isolated ankle osteoarthritis (OA) often demonstrate disturbed ankle biomechanics during walking. Clinicians often believe that this triggers the distal foot joints to compensate these altered ankle biomechanics and that these foot joints are consequently subjected to degenerative joint diseases due to overuse. QUESTIONS/PURPOSES: Do patients with isolated ankle OA differ from those without ankle OA in terms of (1) ankle and foot joint kinematics and (2) ankle and foot joint kinetics as measured using three-dimensional (3-D) gait analysis? (3) Do these patients demonstrate compensatory strategies in their Chopart, Lisfranc, or first metatarsophalangeal joints in terms of increased joint kinematic and kinetic outputs? METHODS: Between 2015 and 2018, we treated 110 patients with unilateral ankle OA, and invited all of them to participate in the gait analysis laboratory. Of those, 47% (52) of patients did so, and of these, 16 patients met the inclusion criteria for this study, which were (1) diagnosis of unilateral ankle OA; (2) absence of radiographical signs of OA in the contralateral foot or lower limbs; (3) ability to walk at least 100 m without rest; and (4) being older than 18 years of age. A control group (n = 25) was recruited through intranet advertisements at the University Hospitals of Leuven. Participants were included if their age matched the age-range of the patient group and if they had no history of OA in any of the lower limb joints. Patients were slightly older (55.9 ± 11.2 years), with a slightly higher BMI (28 ± 6 kg/m2) than the control group participants (47.2 ± 4.4 years; p = 0.01 and 25 ± 3 kg/m2; p = 0.05). All participants underwent a 3-D gait analysis, during which a multisegment foot model was used to quantify the kinematic parameters (joint angles and ROM) and the kinetic parameters (rotational forces or moments), as well as power generation and absorption in the ankle, Chopart, Lisfranc, and first metatarsophalangeal joints during the stance phase of walking. Peak values were the maximum and minimum values of waveforms and the latter were time-normalized to 100% of the stance phase. RESULTS: Regarding joint kinematics, patients demonstrated a sagittal plane ankle, Chopart, Lisfranc, and first metatarsophalangeal joint ROM of 11.4 ± 3.1°, 9.7 ± 2.7°, 8.6 ± 2.3° and 34.6 ± 8.1°, respectively, compared with 18.0 ± 2.7° (p < 0.001), 13.9 ± 3.2° (p < 0.001), 7.1 ± 2.0° (p = 0.046) and 38.1 ± 6.5° (p = 0.15), respectively, in the control group during the stance phase of walking. With regard to joint kinetics in the patient group, we found a mean decrease of 1.3 W/kg (95% CI confidence interval 1.0 to 1.6) (control group mean: 2.4 ± 0.4 W/kg, patient group mean: 1.1 ± 0.5 W/kg) and 0.8 W/kg (95% CI 0.4 to 1.0) (control group mean: 1.5 ± 0.3 W/kg, patient group mean: 0.7 ± 0.5 W/kg) of ankle (p < 0.001) and Chopart (p < 0.001) joint peak power generation. No changes in kinetic parameters (joint moment or power) were observed in any of the distal foot joints. CONCLUSION: The findings of this study showed a decrease in ankle kinematics and kinetics of patients with isolated ankle OA during walking, whereas no change in kinematic or kinetic functions were observed in the distal foot joints, demonstrating that these do not compensate for the mechanical dysfunction of the ankle. CLINICAL RELEVANCE: The current findings suggest that future experimental laboratory studies should look at whether tibiotalar joint fusion or total ankle replacement influence the biomechanical functioning of these distal joints.

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.

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.

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.

Charcot neuroarthropathy after simultaneous pancreas-kidney transplantation: risk factors, prevalence, and outcome.

We retrospectively analyzed outcome and risk factors of developing Charcot foot (CF) in 100 patients with type 1 diabetes mellitus who underwent a simultaneous pancreas-kidney (SPK) transplantation. Patients who developed CF after SPK transplantation had significantly higher mortality (56% vs. 18%) and more frequently graft failure (44% vs. 13%). Recipients with CF also experienced acute rejections more frequently (78% vs. 41%). They furthermore had higher pre-transplant values of HbA1c , received cyclosporine and azathioprine more often, and had significantly higher cumulative corticosteroid use. Patients transplanted in an earlier era (1992-1998) received cyclosporine and azathioprine more often and had a significantly higher cumulative corticosteroid use with the higher prevalence of CF. Conversely, patients with diabetes transplanted more recently (1999-2012) received lower doses of corticosteroids as part of their tacrolimus-based immunosuppressive therapy, resulting in fewer CF attacks. In conclusion, development of CF after SPK is associated with poor patient and graft outcome. Poor pre-transplant diabetic control and the use of high-dose corticosteroids are risk factors for the development of CF. We recommend reduction in or even total avoidance of corticosteroids after SPK transplantation. Given the importance of the diagnosis of CF on outcome, a systematic examination of SPK patients' feet is recommended.

Implementation of a quality improvement initiative in Belgian diabetic foot clinics: feasibility and initial results.

BACKGROUND: This article aims to describe the implementation and initial results of an audit-feedback quality improvement initiative in Belgian diabetic foot clinics. METHODS: Using self-developed software and questionnaires, diabetic foot clinics collected data in 2005, 2008 and 2011, covering characteristics, history and ulcer severity, management and outcome of the first 52 patients presenting with a Wagner grade ≥ 2 diabetic foot ulcer or acute neuropathic osteoarthropathy that year. Quality improvement was encouraged by meetings and by anonymous benchmarking of diabetic foot clinics. RESULTS: The first audit-feedback cycle was a pilot study. Subsequent audits, with a modified methodology, had increasing rates of participation and data completeness. Over 85% of diabetic foot clinics participated and 3372 unique patients were sampled between 2005 and 2011 (3312 with a diabetic foot ulcer and 111 with acute neuropathic osteoarthropathy). Median age was 70 years, median diabetes duration was 14 years and 64% were men. Of all diabetic foot ulcers, 51% were plantar and 29% were both ischaemic and deeply infected. Ulcer healing rate at 6 months significantly increased from 49% to 54% between 2008 and 2011. Management of diabetic foot ulcers varied between diabetic foot clinics: 88% of plantar mid-foot ulcers were off-loaded (P10-P90: 64-100%), and 42% of ischaemic limbs were revascularized (P10-P90: 22-69%) in 2011. CONCLUSIONS: A unique, nationwide quality improvement initiative was established among diabetic foot clinics, covering ulcer healing, lower limb amputation and many other aspects of diabetic foot care. Data completeness increased, thanks in part to questionnaire revision. Benchmarking remains challenging, given the many possible indicators and limited sample size. The optimized questionnaire allows future quality of care monitoring in diabetic foot clinics.

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.

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.

Evidence for symmetrically reduced foot mechanics and energetics in patients after trimalleolar fracture repair: A cross-sectional study.

BACKGROUND: Trimalleolar fractures osteosynthesis is associated with a suboptimal outcome. It is hypothesized that patients with trimalleolar fractures face different ankle joint kinetics at mid- and long-term causing compensations at the distal foot joints. RESEARCH QUESTION: Do patients with a history of a trimalleolar fracture demonstrate different foot joint mechanics and energetics (1) between their affected side and their matched controls? (2) between their unaffected side and their matched controls? (3) between their affected side and their unaffected side? METHODS: Fifteen patients who sustained a trimalleolar fracture and underwent osteosynthesis for both the lateral, medial and posterior malleolus were compared to a asymptomatic control group which was matched for sex, age and walking speed. Three-dimensional gait analysis was used to quantify kinetic parameters in the Ankle, Chopart, Lisfranc and first metatarsophalangeal joint through a multi-segment kinetic foot model. Statistical analysis was performed using a Univariate Analysis of Covariance and/or a paired t-test. RESULTS: The peak internal ankle moment was significantly lower in patients when compared to the control group (p < 0.001). Mean peak power generation and total positive work were significantly lower for the Chopart joint when comparing the patients to the control group (p < 0.001). These results were observed for both the affected and unaffected side of the patients compared to the control group, showing symmetrical changes in the patient group. SIGNIFICANCE: Despite adequate radiographic quality of reduction and the fact that all patients were treated according to a fixed postoperative protocol, this study indicates that patients with a history of a trimalleolar fracture demonstrate reduced foot joint kinetics. It is hypothesized that these findings originate from extrinsic and intrinsic foot muscle strength, stiffness and pain. Future research is needed to validate this hypothesis.

Preliminary Evidence That Taping Does Not Optimize Joint Coupling of the Foot and Ankle Joints in Patients with Chronic Ankle Instability.

BACKGROUND: Foot-ankle motion is affected by chronic ankle instability (CAI) in terms of altered kinematics. This study focuses on multisegmental foot-ankle motion and joint coupling in barefoot and taped CAI patients during the three subphases of stance at running. METHODS: Foot segmental motion data of 12 controls and 15 CAI participants during running with a heel strike pattern were collected through gait analysis. CAI participants performed running trials in three conditions: barefoot running, and running with high-dye and low-dye taping. Dependent variables were the range of motion (RoM) occurring at the different inter-segment angles as well as the cross-correlation coefficients between predetermined segments. RESULTS: There were no significant RoM differences for barefoot running between CAI patients and controls. In taped conditions, the first two subphases only showed RoM changes at the midfoot without apparent RoM reduction compared to the barefoot CAI condition. In the last subphase there was limited RoM reduction at the mid- and rearfoot. Cross-correlation coefficients highlighted a tendency towards weaker joint coupling in the barefoot CAI condition compared to the controls. Joint coupling within the taped CAI conditions did not show optimization compared to the barefoot CAI condition. CONCLUSIONS: RoM was not significantly changed for barefoot running between CAI patients and controls. In taped conditions, there was no distinct tendency towards lower mean RoM values due to the mechanical restraints of taping. Joint coupling in CAI patients was not optimized by taping.

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.

Clinical Applicability of an Existing Proportionality Scheme in Three-Segment Kinetic Foot Models.

An important methodological challenge in multi-segment kinetic foot models is to partition the total ground reaction force across different foot segments. Several studies applied a proportionality scheme based on the combination of a pressure- and force platform. A recent study highlighted distinct errors in the partitioning of shear forces when using this proportionality scheme. To date, the impact of this shear force partitioning error analysis on joint moment calculations using inverse dynamic calculations in pathological gait is not known. Hence, the goal of this study was to investigate the clinical applicability of an existing proportionality scheme by extending the shear force partitioning error analysis towards joint moment calculations. Both healthy (n = 10) and pathological gait (n = 10) was assessed using (I) an adjacent force plate method and (II) the estimation method based on an existing proportionality scheme. A correction factor matrix was developed to compensate for the shear force partitioning errors in the estimation method. Extending the shear force partitioning error analysis towards joint moments using inverse dynamic calculations, did not reveal significant differences when comparing corrected joint moments with the estimated joint moments in both healthy and pathological gait.

Correction to: Clinical Applicability of an Existing Proportionality Scheme in Three-Segment Kinetic Foot Models.

This article was updated to correct Giovanni A. Matricali's name.

Quantifying clinical misinterpretations associated to one-segment kinetic foot modelling in both a healthy and patient population.

BACKGROUND: Rigid foot modelling approaches are still widely used to assess ankle joint kinetics in clinical biomechanical research. Yet, studies on healthy subjects using multi-segment kinetic foot models indicated that one-segment kinetic foot models tend to overestimate ankle joint kinetic data. Our aim was to compare ankle joint kinetics computed with a one-segment versus a multi-segment kinetic foot model in both asymptomatic and pathological gait. We also assessed whether differences between models can lead to different interpretations in clinical decision-making. METHODS: A two-factor repeated measure analysis of variance was performed to investigate differences in ankle joint kinetics, with the first factor being group effect (control vs. patients) and second factor being foot model effect (one-segment vs. multi-segment). Minimal detectable change was calculated to assess the clinical relevance of the observed differences in ankle joint kinetics. FINDINGS: Ankle joint peak kinematic, angular velocity and kinetic variables were all significantly overestimated (P < 0.05) when computed with the one-segment kinetic foot model. Kinetic differences in peak plantarflexion angular velocity and peak power generation were higher than their MDC-values. INTERPRETATION: Ankle joint kinetics are significantly overestimated when computed with a rigid foot modelling approach in both asymptomatic and pathological gait. This overestimation leads to clinical misinterpretations as MDC-values were less than the observed overestimation. In future studies, it is of clinical relevance to assess ankle joint kinetics with a multi-segment foot modelling approach.

Fracture of the posterior medial tubercle of the talus: a case report and review of the literature.

Isolated fracture of the posterior medial tubercle of the talus is a rare injury. To our knowledge the fracture has only been described by five different authors. We diagnosed lately a fracture after a direct trauma. Non-operative treatment with custom made insoles and counselling lead to a acceptable outcome.

Effect of taping on multi-segmental foot kinematic patterns during walking in persons with chronic ankle instability.

OBJECTIVES: To evaluate multi-segmental foot kinematic patterns in chronic ankle instability (CAI) participants during walking, and to investigate the influence of high-Dye and low-Dye taping on these kinematic patterns. DESIGN: Cross-sectional study. METHODS: Kinematic data of 12 non-injured controls and 15 CAI participants were measured with a three-dimensional motion analysis system during barefoot walking. In addition, the CAI participants walked with high-Dye and low-Dye taping. A rigid Plug-in gait model and the Rizzoli 3D Multi-Segment Foot Model were used to measure multi-segmental foot kinematic patterns. One-dimensional statistical parametric mapping was used to compare barefoot walking of the control and CAI group, and to evaluate differences between walking barefoot and walking with high-Dye and low-Dye taping within the CAI group. RESULTS: Compared to the control group, CAI participants showed a decreased ankle dorsiflexion during loading response (p=0.025) and a more inverted calcaneus in relation to the shank during the initial swing phase (p=0.024). A more inverted position of the metatarsus in relation to the midfoot was observed after low-Dye taping during almost the entire stance phase (p=0.017). No significant differences were found for high-Dye taping. CONCLUSIONS: Significant differences in kinematic patterns were found in the ankle joint and rearfoot, but not in the mid- and forefoot in CAI participants. The application of low-Dye taping resulted in a significantly increased inverted position of the forefoot, which can be considered as a less desirable effect for patients with CAI. No other effects of high-Dye and low-Dye taping on kinematic patterns were revealed.

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.

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.