Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis.

PURPOSE: Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes. METHODS: A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications. RESULTS: The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections. CONCLUSION: Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications). LEVEL OF EVIDENCE: Level IV, Systematic Review and Meta-Analysis.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis.

BACKGROUND: Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis. PURPOSE: To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks. RESULTS: Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures. CONCLUSION: For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections. REGISTRATION: NTR7261 (Netherlands Trial Register).

The completely patient-reported version of the American Orthopaedic Foot and Ankle Society (AOFAS) score: A valid and reliable measurement for ankle osteoarthritis.

BACKGROUND: The American Orthopaedic Foot and Ankle score (AOFAS) is an outcome measure for ankle and hindfoot conditions, which requires scoring from both the patients and the physician. A completely patient-reported version has been developed and used before, but its measurements properties are unknown. Our goal was to determine the measurement properties and the minimally important change (MIC) of a completely patient-reported AOFAS (PR-AOFAS) in patients with ankle osteoarthritis. Additionally, the MIC of both the PR-AOFAS and the AOFAS was estimated, which had not previously been done. MATERIALS AND METHODS: The PR-AOFAS of 112 patients was evaluated for reliability, construct validity (using the AOFAS, Foot and Ankle Outcome Score, Ankle Osteoarthritis Score, Visual Analogue Scale, and Short Form-36), and responsiveness. The MIC was estimated using the optimal cut-off point of the receiver operating characteristic curve. This was a substudy of a randomized clinical trial on the efficacy of platelet-rich plasma injections for ankle osteoarthritis (OA). RESULTS: The PR-AOFAS had sufficient construct validity, internal consistency, test-retest reliability, and responsiveness. The smallest detectable change at group level was 2.34. The MIC was 6.5 points (95% confidence interval: 0.6-14.4). CONCLUSIONS: The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. The minimally important change of the PR-AOFAS is smaller than its smallest detectable change, making it more suitable for use in groups of patients, such as a research setting. LEVEL OF CLINICAL EVIDENCE: 1.

What Is the Efficacy of Intra-articular Injections in the Treatment of Ankle Osteoarthritis? A Systematic Review.

BACKGROUND: Ankle osteoarthritis (OA) is painful and can impact a patient's physical and mental quality of life. Although intra-articular injections are commonly used to alleviate symptoms, there is conflicting evidence concerning their efficacy. Therefore, an updated systematic review would be informative. QUESTION/PURPOSE: In this systematic review, we asked: Are there clinically important benefits or harms associated with the use of intra-articular injections in the treatment of ankle OA? METHODS: We used PubMed, Embase, and the Cochrane Library to search for randomized controlled trials on intra-articular injections for the treatment of ankle OA in June 2021, and updated the search in January 2022; eligible dates were from the date of inception of each database through January 2022. Reference lists of eligible studies and previous reviews were manually screened. Two reviewers independently assessed studies for eligibility. We included seven studies. Three compared hyaluronic acid (HA) with saline, one compared HA with exercise, one compared four different regimens of HA [ 34 ], one compared platelet-rich plasma (PRP) with saline, and one compared botulinum toxin Type A (BoNT-A) with HA. A total of 340 patients were included: 141 in the HA arms, 48 in the PRP arm, 38 in the BoNT-A arm, and 113 in the saline arms. Across all studies, the mean age was 52 ± 21 years, and 35% were women (119 of 340 patients). Methodologic quality was assessed using the Cochrane Risk of Bias 2.0 tool. Of the included studies, the risk of bias was low in two studies, presented some concerns in one study, and was high in four studies. According to the Grading of Recommendations Assessment, Development, and Evaluation methodology, the level of evidence was very low for HA, moderate for PRP, and very low for BoNT-A. The level of heterogeneity was high, and we opted to perform a systematic review rather than a meta-analysis. A clinically relevant difference was based on whether the between-group difference surpassed the cutoff point determined as the minimum clinically important difference. RESULTS: No clinically relevant differences were found among HA, PRP, and BoNT-A and their control groups at 3, 6, or 12 months. No studies reported any serious adverse events in any treatment group. CONCLUSION: Given the lack of observed efficacy in this systematic review, these treatments should not be used in practice until or unless future high-quality studies find evidence of efficacy. LEVEL OF EVIDENCE: Level III, therapeutic study.

Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial.

Importance: Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis. Objective: To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis. Design, Setting, and Participants: A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020. Interventions: Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52). Main Outcomes and Measures: The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks. Results: Among 100 randomized patients (mean age, 56 years; 45 [45%] women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points [95% CI, 6-14]; P < .001) and 11 points in the placebo group (from 64 to 75 points [95% CI, 7-15]; P < .001). The adjusted between-group difference over 26 weeks was -1 ([95% CI, -6 to 3]; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group. Conclusions and Relevance: Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis. Trial Registration: Netherlands Trial Register: NTR7261.

Health-Related Quality of Life in Ankle Osteoarthritis: A Case-Control Study.

OBJECTIVE: Ankle osteoarthritis (OA) has a prevalence of 3.4% in the general population of which 70% to 78% is posttraumatic, affecting younger patients with a longer projected life span compared with hip and knee OA. The current literature reports the physical and mental quality of life (QoL) of patients with ankle OA, to be similar to end-stage hip OA, end-stage kidney disease and digestive heart failure. However, the QoL of ankle OA patients has not yet been determined compared with a matched control group representing the general population. Our aim is to determine the physical and mental QoL compared with a matched control group. DESIGN: The Physical and Mental Component Summaries of the Short Form-36 of 100 patients with ankle OA were compared with 91 age- and gender-matched controls. This case-control study is a substudy of the PRIMA trial, in which the efficacy of platelet-rich plasma injections for ankle OA is determined. RESULTS: A clinically relevant difference was found for both the Physical (P=0.003; 95% CI -6.7 to -1.3) and Mental Component Summary scores (P < 0.001; 95% CI -10 to -6). Patients with ankle OA had a median of 45 points (matched controls 52 points) and 43 points (matched controls 53 points) for the Physical and Mental Component summary scores, respectively. CONCLUSIONS: Patients with ankle OA had a clinically relevant poorer mental and physical QoL compared with matched controls from the general population. Furthermore, the physical QoL of patients with ankle OA from younger age categories was affected more than those in older age categories.

Assessment of Isometric Knee Flexor Strength Using Hand-Held Dynamometry in High-Level Rugby Players Is Intertester Reliable.

OBJECTIVE: To assess intertester reliability of isometric knee flexor strength testing in high-level rugby players with testers of different physical capacity and different methods of dynamometer fixation. DESIGN: Reliability study. PATIENTS: Thirty noninjured high-level (Tegner Activity Score ≥9) rugby players, free from hamstring injury in the previous 2 months. ASSESSMENT: Isometric knee flexor strength (in N) in prone 0/15 degrees (hip/knee flexion) and supine 90/90 degrees position. Tests were performed by 1 female and 2 male testers whose upper-body strength was measured with a 6-repetition maximum bench press test. The prone 0/15 degrees measurement was performed with manual and external belt fixation of the dynamometer. MAIN OUTCOME MEASURES: Absolute and relative intertester reliability were calculated using intraclass correlation coefficient (ICC) and minimal detectable change. Paired t-tests were used to identify systematic measurement error between testers and to test for a difference in recorded knee flexor strength between methods of dynamometer fixation. METHODS: Isometric knee flexor strength was measured in prone 0/15 degrees (hip/knee flexion) and supine 90/90 degrees position. RESULTS: Good intertester reliability was found for all pairwise comparisons (ICC 0.80-0.87). MDCs (as percentage of mean strength) ranged from 15.2% to 25.4%. For tester couples where systematic error was identified, Bland-Altman plots and Pearson correlation coefficients demonstrated no statistically significant correlation between mean knee flexor strength and between-tester difference. There was no significant difference in isometric knee flexor strength between manual and belt fixation of the dynamometer. CONCLUSIONS: In strong high-level rugby players, hand-held dynamometry for isometric knee flexor strength assessment in prone 0/15 degrees and supine 90/90 degrees position is intertester reliable.

Ankle osteoarthritis and its association with severe ankle injuries, ankle surgeries and health-related quality of life in recently retired professional male football and rugby players: a cross-sectional observational study.

OBJECTIVES: To determine (1) the prevalence of ankle osteoarthritis (OA) among former professional football and rugby players, (2) assess the association between ankle injuries or ankle surgeries with ankle OA, and (3) compare the mental and physical quality of life (QoL) between former professional football and rugby players with and without OA. METHODS: We conducted a questionnaire-based observational study with a cross-sectional design. Former professional football and rugby players were recruited by the Football Players Worldwide and the International Rugby Players. Information concerning ankle OA, sustained ankle injuries and ankle surgeries was gathered (medical record or most recent medical professional). Health-related QoL was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical and mental health scores. RESULTS: Overall, 553 former professional football (n=401) and rugby (n=152) players were enrolled in the study (response rate of 56%). Ankle OA prevalence among former professional football and rugby players was 9.2% and 4.6%, respectively. Football players were more likely to suffer from ankle OA following every ankle injury and/or surgery. Football and rugby players with ankle OA had similar PROMIS physical and mental health scores to the norm for the general population. CONCLUSION: Former professional football and rugby players had higher ankle OA prevalence than the general population (3.4%). Football players are more likely to suffer from ankle OA following every ankle injury and/or surgery. No clinically relevant difference was seen for physical or mental health-related QoL among football and rugby players. Preventive measures for ankle injuries are recommended.