Changes in clinical outcomes and alignment of the ipsilateral knee and ankle after supramalleolar osteotomy in patients with varus osteoarthritis of the ankle: a short-term follow-up study.

PURPOSE: The purpose of this study was to investigate the changes in clinical outcomes and alignment of the ipsilateral knee and ankle in patients with varus ankle osteoarthritis after supramalleolar osteotomy (SMO). METHODS: We retrospectively reviewed 23 patients (24 ankles) with Takakura II, IIIa and IIIb ankle osteoarthritis treated with SMO between May 2017 and March 2022. The radiologic parameters of ankles contained medial distal tibial angle (TAS), tibiotalar angle (TT), tibial lateral surface (TLS), tibial plafond inclination (TPI) and talar inclination (TI). The radiologic parameters of knees contained medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), the knee joint line orientation relative to ground (G-KJLO) and WBL. Hip-knee-ankle angle (HKA) was also collected. The Takakura system was used for evaluating the ankle osteoarthritis and the Kellgren-Lawrence (KL) system was used for evaluating the knee osteoarthritis. Clinical evaluation of the ankle joints contained American Orthopedic Foot and Ankle Society (AOFAS), range of motion (ROM) and visual analogue scale (VAS). Clinical evaluation of the knee joints contained Japanese Orthopaedic Association Scores (JOA), ROM, VAS. RESULTS: The mean follow-up times were 20.3 ± 7.3 months (range 12-38). According to the radiologic evaluation, the TAS increased from preoperative 84.7° ± 2.0° to 91.2° ± 1.8° at the last follow-up (P < 0.001). The TPI and TI decreased from 4.4° ± 4.2° and 11.0° ± 5.2° to 0.1° ± 4.7° and 4.1° ± 4.8° (P < 0.001 for both). The TT angel improved from 9.5° ± 4.1° to 4.9° ± 3.3° (P < 0.001). No significant differences were found regarding MPTA, JLCA, G-KJLO, knee WBL and HKA (P > 0.05 for all). The Takakura stage improved after SMO (P < 0.001) whilst the KL stage maintains the similar lever (P > 0.05). According to the clinical evaluation, the AOFAS significantly increased from 67.5 ± 10.6 to 88.5 ± 9.3 and the VAS of the ankle decreased from 4.7 ± 1.6 to 1.2 ± 1.1, whilst there were no changes on VAS and even the JOA and knee ROM after SMO (P > 0.05 for all). CONCLUSIONS: SMO can alleviate the symptoms of varus ankle osteoarthritis and delay the time for ankle replacement or arthrodesis by redistributing the abnormal stress of the ankle and restoring the congruence of the tibiotalar joint. In addition, it did not induce the clinical symptoms of knee without compromising lower limb alignment or knee joint line orientation in the short term. LEVEL OF EVIDENCE: Level IV case series.

A novel distractor-assisted reduction combined with the sinus tarsi approach for joint depression-type calcaneal fractures.

PURPOSE: A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures. METHODS: Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler's angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded. RESULTS: Fifty-two patients achieved an average follow-up of 24.3 months (range 18 to 34 months), and two patients were lost to follow-up six months post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler's angle; and Gissane angle (p < 0.01), but no significant difference was detected between the post-operative and normal side Bohler's angle (p > 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after seven months post-operatively; and two developed transient ankle stiffness. CONCLUSION: The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.

Absorbable suture anchor and knotless anchor techniques produced similar outcomes in arthroscopic anterior talofibular ligament repair.

PURPOSE: The purpose of this study is to compare absorbable suture anchor with knotless anchor techniques for arthroscopic anterior talofibular ligament (ATFL) repair. METHOD: A multicenter retrospective study was performed with 185 patients, who had undergone an arthroscopic ATFL repair procedure using absorbable suture anchor or knotless anchor between May 2017 and October 2019. The follow-up time was a minimum of 18 months. Karlsson-Peterson score, visual analogue scale (VAS), and Cumberland ankle instability tool (CAIT) were evaluated. The complications were also recorded. RESULTS: One hundred and seven patients underwent one absorbable suture anchor repair procedure (Group A [A]), and the other seventy-eight patients underwent one knotless anchor repair procedure (Group B [B]). At the final follow-up, both Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs post 93.5 ± 5.3, P < 0.001; B, pre 59.5 ± 8.2 vs post 92.4 ± 6.3, P < 0.001), VAS score (A, pre 5.0 ± 1.3 vs post 0.5 ± 0.7, P < 0.001; B, pre 5.5 ± 1.2 vs post 0.9 ± 1.0, P < 0.001), and CAIT score (A, pre 53.1 ± 12.0 vs post 93.1 ± 6.6, P < 0.001; B, pre 51.6 ± 12.0 vs post 93.1 ± 6.5, P < 0.001) improved significantly in both groups. There was no significant difference between the two groups regarding the Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs B, pre 59.5 ± 8.2, n.s; A, post 93.5 ± 5.3 vs B, post 92.4 ± 6.3, n.s), CAIT score (A, pre 53.1 ± 12.0 vs B, pre 51.6 ± 12.0, n.s; A, post 93.1 ± 6.6 vs B, post 93.1 ± 6.5, n.s) and the change ranges of VAS (A, 4.5 ± 1.0 vs B, 4.6 ± 1.2, n.s). Anchor complications were easier to occur in Group B (0/107 vs 6/78, P = 0.007). Knot irritation slightly increased in Group A (10/107 vs 0/78, P = 0.006). No significant difference was found regarding total complication rates (A, 10/107 vs B, 6/78, n.s). CONCLUSION: Absorbable suture anchor and knotless anchor for arthroscopic ATFL repair produced similar clinical outcomes. The ankle stability scores increased significantly in both groups. However, the knotless anchor has a higher risk to loosen, deviated direction or break, while the absorbable suture anchor still has a slim chance of knot irritation. LEVEL OF EVIDENCE: III.

Müller-Weiss Disease: Midfoot Arthrodesis in Reduction vs Malreduction.

BACKGROUND: Midfoot arthrodesis is regarded as the main surgical approach for treating Müller-Weiss disease (MWD). This study aimed to investigate the incidence of postoperative pain during MWD treatment through midfoot reduction or malreduction during arthrodesis and to explore the factors influencing postoperative pain in patients with MWD. METHODS: A total of 67 patients with MWD were recruited and divided into two groups according to whether midfoot alignment was reduced: reduction group (n = 38) and malreduction group (n = 29). Demographic characteristics before the operation and at the last follow-up, as well as clinical and radiographic parameters, were compared between the two groups. Clinical parameters included the American Orthopaedic Foot & Ankle Society score and visual analog scale score, whereas radiographic parameters included the calcaneal pitch angle, lateral Meary's angle, talometatarsal-1 angle dorsoplantar (TMT1dp), talocalcaneal angle dorsoplantar (Kite angle), talonavicular coverage angle, and medial navicular pole extrusion. Postoperative complications and incidence of midfoot pain were evaluated at the last follow-up visit. RESULTS: The reduction group exhibited better clinical and radiological parameters, including the TMT1dp and medial navicular pole extrusion, than the malreduction group at the last follow-up (all P < .05). However, the calcaneal pitch angle, lateral Meary's angle, Kite angle, and talonavicular coverage angle did not significantly differ between the two groups (all P > .05). The overall incidence of midfoot pain was 26.4%. The reduction group showed a lower incidence of medial pain than the malreduction group (15.7% vs. 40.0%, P < .05). Regression analysis revealed that midfoot abduction, represented by the TMT1dp, was a critical factor for midfoot arthrodesis failure and that medial navicular pole extrusion was not correlated with postoperative midfoot pain. CONCLUSION: Midfoot reduction arthrodesis yields better clinical outcomes than malreduction arthrodesis. The TMT1dp, representing midfoot abduction, is a key factor for midfoot arthrodesis failure. The extruded medial navicular bone may not affect postoperative medial midfoot pain. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

[Influence and risk factors of lateral hinge fracture on early effectiveness of supramalleolar osteotomy].

Objective: To evaluate the influence of lateral hinge fracture (LHF) on the early effectiveness of supramalleolar osteotomy (SMO) and to explore the related risk factors for LHF. Methods: A total of 39 patients (39 feet) with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively. There were 10 males and 29 females, aged from 41 to 71 years (mean, 57.7 years). According to Takakura stage, there were 6 feet in stage Ⅱ, 19 feet in stage Ⅲa, and 14 feet in stage Ⅲb. The LHF was recognized by the immediate postoperative X-ray film. The osteotomy healing time and the changes of pain visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and tibiotalar angle (TT) before and after operation were compared between patients with and without LHF. The age, gender, affected side, body mass index, Takakura stage, preoperative VAS score, preoperative AOFAS score, preoperative TAS, preoperative TLS, preoperative TT, SMO correction angle, osteotomy distraction, distance from medial osteotomy to ankle joint line (MD), and distance from lateral osteotomy to ankle joint line (LD) were compared between with and without LHF patients, and further logistic regression analysis was used to screen the risk factors of LHF during SMO. Results: All patients were followed up 12-54 months (mean, 27.1 months). During operation, 13 feet developed LHF (group A) and 26 feet did not develop LHF (group B). X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation; the osteotomy of other patients healed, and there was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, there were significant differences in VAS score, AOFAS score, TAS, TLS, and TT of the two groups when compared with preoperative ones ( P<0.05), but there was no significant difference in the changes of above indicators before and after operation between the two groups ( P>0.05). The differences in SMO correction angle, osteotomy distraction, and LD between with and without LHF patients were significant ( P<0.05), and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO ( P<0.05). Conclusion: Too high or too low lateral hinge position during SMO may lead to LHF, but as long as appropriate treatment and rehabilitation measurements are taken, the early effectiveness is similar to that of patients without LHF.

The Protective Effect of Ginsenoside Rg1 on Apoptosis in Human Ankle Joint Traumatic Arthritis Chondrocytes.

The ankle biomechanics is easily changed due to the acute injury of the tissue around the ankle joint and the damage of the ankle joint structure, such as ankle instability and joint surface imbalance. When the mechanical load of the ankle changes, it can cause ankle regeneration and remodeling processes such as cartilage loss, bone remodeling, and degenerative changes. The aim of this study was to investigate the effect and mechanism of ginsenoside Rg1 against interleukin-1ß (IL-1ß)-induced apoptosis in human articular chondrocytes (HACs). The apoptosis model of HAC cells was established by IL-1ß induction, and then the HAC cells were cultured with different concentrations of Rg1. The protective effect of Rg1 on HAC cell apoptosis was investigated by detecting the changes of apoptosis and activity of PI3K/Akt/mitochondrial signaling pathway. The results showed that a specific concentration of Rg1 could promote the proliferation of IL-1ß-induced HAC cells and inhibit apoptosis. At the same time, Rg1 treatment with specific concentration can reduce the content of reactive oxygen species (ROS) and malondialdehyde (MDA) in HACs and improve the related expression of mitochondrial membrane potential (MMP). Furthermore, qRT-PCR and western blot results showed that Rg1 could improve the low expression of Bcl-2 and inhibit the high expression of Bax, caspase-3, caspase-8, caspase-9, FasL, AIF, and Cyto c in IL-1ß-induced cells. In summary, Rg1 can inhibit IL-1ß-induced apoptosis of HAC cells by decreasing the activity of PI3K/Akt/mitochondrial signaling pathway, and Rg1 has a protective effect on apoptosis of HAC cells.

Endoscopically Assisted, Minimally Invasive Reconstruction for Chronic Achilles Tendon Rupture With a Double-Bundle Flexor Hallucis Longus.

BACKGROUND: High morbidity has been reported regarding Achilles tendon (AT) injuries, and the upward trend has accelerated since the mid-1990s. A chronic Achilles tendon rupture usually results from a neglected or misdiagnosed acute rupture, and about one-fifth of acute AT ruptures are missed and lead to chronic AT rupture. Although many techniques have been described, there is no gold standard in the treatment of chronic AT ruptures. HYPOTHESIS: Endoscopically assisted, minimally invasive reconstruction for chronic AT rupture using a double-bundle flexor hallucis longus (FHL) tendon would result in improvement of the overall function, with a low rate of wound complications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between May 2015 and November 2016, a total of 19 consecutive patients were enrolled and treated using endoscopically assisted, minimally invasive reconstruction for chronic AT rupture using a double-bundle FHL. The operative assessment comprised the Achilles Tendon Total Rupture Score, the American Orthopaedic Foot & Ankle Society score, the Victorian Institute of Sports Assessment-Achilles score, and a postoperative questionnaire. All postoperative complications were recorded. RESULTS: The mean follow-up time for all patients was 31 months (range, 20-42 months). According to the postoperative questionnaire, the result of surgery was excellent in 8 (42%) of 19 patients, good in 10 (53%), and fair in 1 (5%). All clinical outcome scores (mean ± SD) improved significantly after surgery: Achilles Tendon Total Rupture Score, 23.3 ± 10.3 vs 98.3 ± 9.2 (postoperatively vs preoperatively); American Orthopaedic Foot & Ankle Society, 52.1 ± 12.4 vs 97.5 ± 18.9; and Victorian Institute of Sports Assessment-Achilles, 23.4 ± 11.2 vs 95.7 ± 17.1 (P < .05). No complications with regard to wound healing or infection were noted. Twelve relatively young patients returned to preinjury activity levels, such as playing basketball or badminton, and the older patients were able to meet their daily needs, such as walking up stairs and jogging. CONCLUSION: Chronic AT ruptures were successfully treated via minimally invasive reconstruction using a double-bundle FHL, which provided excellent functional improvement. It is best suited for patients with complex requirements who are at high risk for wound complications.