Subtalar Arthrodesis in Patients With Prior Tibiotalar Arthrodesis for Posttraumatic Osteoarthritis.

BACKGROUND: The tibiotalar arthrodesis for end-stage ankle osteoarthritis is a surgical procedure that leads to a modification of the kinematics of the adjacent joints and may result in the development of secondary osteoarthritic degeneration of the subtalar joint. It has previously been observed that subtalar arthrodesis in this context shows a lower fusion rate than isolated subtalar arthrodesis. This retrospective study reports the results of subtalar joint arthrodesis with previous ipsilateral tibiotalar arthrodesis and suggests some factors that may compromise the fusion of the joint. METHODS: Between September 2010 and October 2021, 15 arthrodeses of the subtalar joint with screw fixation were performed in 14 patients, with a fusion of the ipsilateral tibiotalar joint. Fourteen of 15 cases used an open sinus tarsi approach, 13 were augmented with iliac crest bone graft, and 11 had supplemental demineralized bone matrix (DBM). The outcome variables were fusion rate, time to fusion, and revision rate. Fusion was assessed by radiographs and computed tomography scan. RESULTS: Twelve of the 15 subtalar arthrodeses (80%) fused at the first attempt with an average fusion time of 4.7 months. CONCLUSION: In this limited retrospective case series, compared to the fusion rate of isolated subtalar arthrodesis reported in the literature, the rate of subtalar fusion in the presence of an ipsilateral tibiotalar arthrodesis was found to be lower. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Early-Term Results of the Cadence Total Ankle Prosthesis: An European Noninventor Study.

BACKGROUND: Although considerable literature can be found on the outcome of total ankle replacement (TAR), only a few studies have reported the results of the fixed-bearing Cadence prosthesis. This noninventor study reports a consecutive series of 60 Cadence TAR systems with a mean of 2.9 years' follow-up, focusing on clinical and radiographic outcomes and early complications. This study is the first to assess true postoperative radiographic ankle prosthesis range of motion (ROM) and to report an unanticipated serious adverse device effect. METHODS: Sixty patients who underwent primary TAR with the Cadence prosthesis between July 2016 and July 2019 were clinically and radiographically evaluated preoperatively and at last follow-up after the procedure. Revisions, additional procedures, implant failure, and complications were reported according to the classifications of Vander Griend and Glazebrook. Radiographic outcomes included radiographic TAR ROM, bone-implant interface, and alignment parameters. RESULTS: The survival rate of the prosthesis was 98.3%. The mean radiographic ankle ROM at the last follow-up was 24 degrees (9 degrees of dorsiflexion and 15 degrees of plantarflexion). The coronal and sagittal alignment of TAR was 90.8 degrees and 3.9 degrees, respectively. Bone-implant interface analysis revealed osteolysis in 9 ankles (15%) and radiolucent lines in 33 ankles (55%) occurring at both component interfaces. Intraoperative complications were 3 periprosthetic malleolar fractures (5%). Five talar implant fractures (implant failure of 8.3%) were observed, and 1 unexplained persistent pain that required a conversion from TAR to a tibiotalocalcaneal arthrodesis. CONCLUSION: Clinical, radiograph ROM, implant position outcomes, and survival rate at an early-term follow-up of 2.9 years were similar to those reported in recent Cadence studies. However, this study reports 5 unanticipated talar implant fractures and a high rate of posterior radiolucent lines. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Concomitant Triceps Surae Lengthening in Total Ankle Arthroplasty Affects the Mechanical Work at the Ankle Joint.

BACKGROUND: Previous studies have examined the effect of concomitant triceps surae lengthening on ankle dorsiflexion motion at the time of total ankle arthroplasty (TAA). As plantarflexor muscle-tendon structures are important for producing positive ankle work during the propulsive phase of gait, caution should be exercised when lengthening triceps surae, as it may decrease plantarflexion strength. In order to develop an understanding of the work of the anatomical structures crossing the ankle during propulsion, joint work must be measured. The aim of this explorative study was to assess the effect of concomitant triceps surae lengthening with TAA on the resultant ankle joint work. METHODS: Thirty-three patients were recruited to the study and divided into 3 groups of 11. The first group underwent both triceps surae lengthening (Strayer and TendoAchilles) and TAA (Achilles group), the second group underwent only TAA (Non-Achilles group), and the third group underwent only TAA, but had a greater radiographic prosthesis range of motion (Control group) compared to the first 2 groups. The 3 groups were matched in terms of demographic variables and walking speed. All patients underwent a 3D gait analysis 1 year after surgery to measure intersegmental joint work using a 4-segmented kinetic foot model. An analysis of variance (ANOVA) or Kruskal-Wallis test was used to compare the 3 groups. RESULTS: The ANOVA showed significant differences between the 3 groups. Post hoc analyses suggested that (1) the Achilles group had less positive work at the ankle joint than the Non-Achilles and Control groups; (2) the Achilles group produced less positive work performed by all foot and ankle joints than the Control group; and (3) the Achilles and Non-Achilles groups absorbed less energy across all foot and ankle joints during the stance phase than the Control group. CONCLUSION: Concomitant triceps surae lengthening in TAA may reduce the positive work at the ankle joint. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Changes in Relative Work of the Lower Extremity and Distal Foot Joints After Total Ankle Replacement: An Exploratory Study.

Ankle osteoarthritis does not only led to lower ankle power generation, but also results in compensatory gait mechanics at the hip and Chopart joints. Much of previous work explored the relative work distribution after total ankle replacement (TAR) either across the lower extremity joints where the foot was modelled as a single rigid unit or across the intrinsic foot joints without considering the more proximal lower limb joints. Therefore, this study aims, for the first time, to combine 3D kinetic lower limb and foot models together to assess changes in the relative joint work distribution across the foot and lower limb joints during level walking before and after patients undergo TAR. We included both patients and healthy control subjects. All patients underwent a three-dimensional gait analysis before and after surgery. Kinetic lower limb and multi-segment foot models were used to quantify all inter-segmental joint works and their relative contributions to the total lower limb work. Patients demonstrated a significant increase in the relative ankle positive joint work contribution and a significant decrease in the relative Chopart positive joint work contribution after TAR. Furthermore, there exists a large effect toward decreases in the relative contribution of the hip negative joint work after TAR. In conclusion, this study seems to corroborate the theoretical rationale that TAR reduces the compensatory strategy in the Chopart and hip joints in patients suffering from end-stage ankle osteoarthritis.

Changes in ankle and foot kinematic after fixed-bearing total ankle replacement.

Ankle osteoarthritis is a chronic debilitating disease marked by cartilage breakdown, pain and significant biomechanical impairment of the entire lower limb. Total ankle replacement (TAR) has been encouraged during the last decade as it has the potential to maintain the existing pre-operative ankle range of motion and to protect the more distally located joints of the foot. Three-dimensional gait analysis using a multi-segment foot model can provide an objective analysis of TAR for the treatment of end-stage ankle osteoarthritis. Thirty-six patients suffering from post-traumatic end-stage ankle osteoarthritis were evaluated before and after TAR. A four-segment kinematic foot model was used to calculate intrinsic foot joint kinematics during gait. Spatio-temporal parameters were also assessed. Kinematic results were compared to a control group of asymptomatic subjects. Differences in waveform patterns were mainly limited to dorsi-/plantarflexion inter-segment angles. At loading response, the Shank-Calcaneus plantarflexion angles as well as the Calcaneus-Midfoot dorsiflexion angle increased slightly in post-operative condition. During propulsion, an increase in Hallux-Metatarsus dorsiflexion angle was observed. Pain improved after surgery as supported by increased spatio-temporal parameters. While multi-segment foot and ankle kinematics were improved, they remained impaired compared to control values. This study confirms that TAR maintains the residual pre-operative range of motion after surgery from midstance to propulsion. Furthermore, the results suggest that the kinematic behavior of the foot joints distal to the affected ankle joint also improves post-operatively. The outcome of this study further emphasizes the clinical relevance of multi-segment foot modeling when assessing the outcome of TAR.

Decreased Mechanical Work Demand in the Chopart Joint After Total Ankle Replacement.

BACKGROUND: The success of total ankle replacement (TAR) must be based on restoring reasonable mechanical balance with anatomical structures that can produce mechanical joint work through elastic (eg, tendons, fascia) or viscoelastic (eg, heel pad) mechanisms, or by active muscle contractions. Yet, quantifying the work distribution across the affected joint and the neighboring foot joints after TAR is lacking. Therefore, the objective of this study was to investigate if there is a change in the joint work distribution across the Ankle, Chopart, Lisfranc and Metatarsophalangeal joints during level walking before and after patients undergo TAR. METHODS: Fifteen patients with end-stage ankle osteoarthritis scheduled for primary TAR for pain relief were recruited and peer-matched with a sample of 15 control subjects. All patients underwent a 3D gait analysis before and after surgery, during which a kinetic multisegment foot model was used to quantify intersegmental joint work. RESULTS: The contribution of the Ankle joint (P = .007) to the total foot and ankle positive work increased significantly after TAR. In contrast, a significant decrease in the contribution to the total foot and ankle joint positive work (P < .001) were found at the Chopart joint after TAR. The foot joints combined produced a significant increase in a net mechanical work from +0.01 J/kg before surgery to +0.05 J/kg after TAR (P = .006). CONCLUSION: The findings of this study corroborate the theoretical rationale that TAR reduces significantly the compensatory strategy in the Chopart joint in patients with end-stage ankle osteoarthritis after TAR. However, the findings also showed that the contribution of the ankle joint of patients after TAR to the total foot and ankle joint positive work remained impaired compared to the control group.

Patients' point of view on the long-term results of total ankle arthroplasty, tibiotalar and tibiotalocalcaneal arthrodeses.

INTRODUCTION: Total ankle arthroplasty (TAA), tibiotalar (TT) arthrodesis and tibiotalocalcaneal (TTC) arthrodesis are common surgical procedures that are sometimes concurrent. The functional results of TTC are deemed to be inferior because of the double joint sacrifice. Patient-Reported Outcome Measures (PROMs), as well as satisfaction scores, are commonly used to assess the outcome of these surgeries, but lack at capturing patients' ability to cope with potential functional limitations. The objective of our study was to compare the results of TAA, TT and TTC arthrodeses according to patients' point of view. We proposed two hypotheses: 1) TAA confer better results than TT arthrodeses, 2) and TT arthrodeses confer better results than TTC arthrodeses, on this specific criterion. MATERIAL AND METHODS: We carried out a retrospective study integrating all TAA, TT and TTC arthrodeses performed in our center from 2010 to 2017. These surgeries were compared using PROMs (Foot Function Index (FFI), Foot and Ankle Outcome Scale (FAOS) and 12-Item Short Form Survey (SF-12)), a satisfaction rating and self-reported perceived recovery state. RESULTS: Fifty-one patients were included in the TAA group, 50 in the TT group and 51 in the TTC group. The mean duration of follow-up was 46±20.8 months. The TAA group had better results than the TT group regarding the FFI score and satisfaction, thus confirming our primary hypothesis. On the other hand, no significant difference was found between the TT group and the TTC group, which invalidated our secondary hypothesis. No significant difference between the groups was found regarding the distribution of patients' perceived recovery state. CONCLUSION: Our hypothesis was not confirmed. In fact, TAAs, TT and TTC arthrodeses presented substantially similar results. Although it is difficult to compare surgeries with different indications, it is surprising to find that the patients' perceived recovery state, deviating from the usual clinical and radiological results, are relatively similar. LEVEL OF EVIDENCE: IV; Retrospective study.

Impact of foot modeling on the quantification of the effect of total ankle replacement: A pilot study.

BACKGROUND: Kinematic and kinetic foot models showed that computing ankle joint angles, moments and power with a one-segment foot modeling approach alters kinematics and tends to overestimate ankle joint power. Nevertheless, gait studies continue to implement one-segment foot models to assess the effect of total ankle replacement. RESEARCH QUESTION: The objective of this pilot study was to investigate the effect of the foot modeling approach (one-segment versus multi-segment) on how total ankle replacement is estimated to benefit or degrade the patient's biomechanical performance. METHODS: Ten subjects with post-traumatic ankle osteoarthritis scheduled for total ankle replacement and 10 asymptomatic subjects were recruited. A one-segment and a multi-segment foot model were used to calculate intrinsic foot joints kinematics and kinetics during gait. A linear mixed model was used to investigate the effect of the foot model on ankle joint kinematic and kinetic analysis and the effect of total ankle replacement. RESULTS: Differences in range of motion due to the foot model effect were significant for all the gait subphases of interest except for midstance. Peak power generation was significantly overestimated when computed with the one-segment foot model. Ankle and shank-calcaneus joint dorsi-/plantarflexion range of motion did not increase post-operatively except during the loading response phase. A significant 'group' effect was found for stance and pre-swing phase range of motion, with total ankle replacement patients showing lower range of motion values than controls for dorsi/plantarflexion. SIGNIFICANCE: The outcome of this study showed that the 'foot model' had a significant effect on estimates of range of motion and power generation. The findings in our study therefore emphasize the clinical interest of multi-segment foot modeling when assessing the outcome of a therapeutic intervention.

Post-sprain versus post-fracture post-traumatic ankle osteoarthritis: Impact on foot and ankle kinematics and kinetics.

BACKGROUND: Common etiologies for post-traumatic ankle osteoarthritis are ankle fractures and chronic ankle instability. As the nature of trauma is different for these two etiologies, it might be expected that the two subtypes of post-traumatic ankle osteoarthritis would display different foot mechanics during gait. RESEARCH QUESTION: The objective of this exploratory cross-sectional study was to compare the foot kinematics and kinetics of patients suffering from post-fracture ankle osteoarthritis with those of patients suffering from post-sprain ankle osteoarthritis. METHODS: Twenty-nine subjects with end-stage post-traumatic ankle osteoarthritis and fifteen asymptomatic control subjects participated in this study. All patients suffered from post-traumatic ankle osteoarthritis secondary to ankle-related fracture (Group 1; n = 15) or to chronic ankle instability (Group 2; n = 14). A four-segment kinematic and kinetic foot model was used to calculate intrinsic foot joint kinematics and kinetics during gait. Vector field statistical analysis MANOVA was used to assess differences between groups for the entire three-component intrinsic foot joint angles and moments. RESULTS: MANOVA showed significant differences between the groups. Post-hoc analyses suggested that the differences between post-fracture ankle osteoarthritis group and controls were caused by a combination of less adducted Shank-Calcaneus position and less plantarflexion at this joint. Post-hoc analyses also suggested that both pathological groups exhibited a decreased plantarflexion moment for Shank-Calcaneus, Chopart, Lisfranc joints compared to controls. Analyses of both pathological groups versus controls for power suggested lower Shank-Calcaneus and Lisfranc power generation during pre-swing phase. SIGNIFICANCE: No significant differences were found between the two pathological groups in this exploratory study. Alterations in foot kinematics and kinetics were mainly found about the dorsi-/plantarflexion axis during the pre-swing phase of the stance phase for both pathological groups compared to controls. Observed differences were not limited to the painful ankle joint, but seem also to have affected the kinetics of the neighbouring foot joints.

Cortical thickness of the second metatarsal after correction of hallux valgus.

BACKGROUND: Hallux valgus is a functional deformity of the first ray. When incorrectly aligned, the first ray is less effective as a support structure, and the stresses then theoretically transfer to the second metatarsal which could lead to increased cortical density. The aim of this study was to evaluate if surgical correction of hallux valgus lead to changes in the cortical density of the second metatarsal. MATERIALS AND METHODS: This was a retrospective study involving 13 patients who had surgery for isolated hallux valgus. The average postoperative followup was 16 (range, 11 to 24) months. We analyzed pre- and postoperative radiographs of the feet. We assessed the variations in the medial and lateral cortical thickness, the medullary thickness and the shaft thickness (ST) of the second and fourth metatarsals. RESULTS: A significant reduction of the medial cortical bone thickness of the second metatarsal (MT2) (p < 0.001) and a significant medullary increase of MT2 (p < 0.001) were observed postoperatively. However, no significant difference in the lateral cortical thickness or shaft thickness of the metatarsal was found. A significant reduction of the MCT/ST ratio (p < 0.001) was also observed. Regarding the fourth metatarsal, which was used as a control, no significant change was observed. CONCLUSION: The isolated cortical variations of the second metatarsal suggests that isolated hallux valgus correction led to a redistribution of the stresses on to the first ray.

Reliability of the Maestro radiographic measuring tool.

INTRODUCTION: Maestro et al. presented a detailed preoperative measuring and classification technique for the forefoot. The purpose of this paper was to determine if the PACS system will allow the Maestro measuring technique and classification system to be reliable and precise. MATERIALS AND METHODS: This radiographic study was conducted on 73 subjects (36 females, 37 males, age 30.4 ± 9.9) who had given informed consent. The geometrical progression was measured for each foot of each subject by the two observers according to the measuring methodology of Maestro. The intraclass correlation coefficient (ICC), and the 95% lower confidence limit (95% LCL) were calculated for the geometrical progression variables of the lesser metatarsals. Once the feet were classified by each observer, the accordance in classification of the feet was analyzed between the two observers. RESULTS: The radiographic measuring technique of Maestro was a reliable method for analyzing the mathematical progression of the lesser metatarsals through the use of the PACS system. A 92.6% concordance in the classification of the radiological forefoot morphotypes was found between the two observers. CONCLUSION: We found Maestro et al.'s measuring technique and classification system precise and reproducible using PACS digital radiographs. It is hoped that utilization of this technique will lead to better forefoot outcomes and patient satisfaction.

The translating Weil osteotomy in the treatment of an overriding second toe: a report of 25 cases.

We present a retrospective study of 25 feet operated for an overriding second toe deformity, whether or not associated with hallux valgus deformity and metatarsalgia. The surgical technique of a medial sliding and decompressive Weil osteotomy is described. All patients, operated between January 2002 and December 2007 for this condition in our institution, were reviewed clinically and radiologically. The mean AOFAS score improved with 47.6 points from 45.9 to 93.5. The theoretical advantages of such a translation Weil osteotomy are discussed trying to clarify the previously described pathologic anatomy of this condition.

Medium term follow-up of the AES ankle prosthesis: High rate of asymptomatic osteolysis.

BACKGROUND: The AES (Ankle Evolutive System) is a cobalt-chromium three-component ankle prosthesis with a hydroxyapatite coating, similar to the Buechel-Pappas ankle prosthesis, but with some modifications. Our objective was to assess its medium term follow-up results as well as its complications. METHODS: 21 patients (mean age of 57.6 years) were operated by a total ankle arthroplasty (TAA), using the AES implant, according to the standard technique. Only 18 patients were included. The other three patients were excluded from the study: two had been revised for avascular talar necrosis and one patient was happy with her outcome but could not present for logistic reasons at the last follow-up. Indications for surgery included posttraumatic osteoarthritis, primary osteoarthritis, hemochromatosis, rheumatic arthritis and osteoarthritis as a sequel of ankle instability. All patients were analyzed clinically and radiologically. Special attention was given to the presence or not of areas of osteolysis around the implants as well on conventional radiography as on CT-scan imaging, according to a specific protocol. RESULTS: The mean follow-up was 39.4 months. Average American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 52.2 preoperatively to 86.6 postoperatively. No intra-operative complications or early complications have been noted. Delayed complications were the following: one valgus malalignment, one recurrent painful anterior heterotrophic bone formation. Above all, we noted on conventional X-ray the presence of osteolysis in 77% (14) of our patients, with a size of 0.5-1cm or greater on conventional X-ray. The most vulnerable area seemed to be the posterior tibial plafond. The four remaining patients did not show any cyst formation on X-ray but did also, just as the other 14 patients, on the CT-scan. CT-scan, on the contrary, found more osteolysis in the body of the talus, underneath the implant, an area masked on conventional X-ray. Only one patient was revised with allograft bone filling of a symptomatic osteolysis, without the need for implant removal. CONCLUSIONS: This retrospective study shows a high frequency of delayed appearance of osteolysis (77%) in 18 AES total ankle arthroplasties. Fortunately at this moment and considering one revision, this considerable amount of asymptomatic osteolysis could not warrant a durable uncomplicated outcome.

Intrinsic foot joints adapt a stabilized-resistive configuration during the stance phase.

BACKGROUND: This study evaluated the 3D angle between the joint moment and the joint angular velocity vectors at the intrinsic foot joints, and investigated if these joints are predominantly driven or stabilized during gait. METHODS: The participants were 20 asymptomatic subjects. A four-segment kinetic foot model was used to calculate and estimate intrinsic foot joint moments, powers and angular velocities during gait. 3D angles between the joint moment and the joint angular velocity vectors were calculated for the intrinsic foot joints defined as follows: ankle joint motion described between the foot and the shank for the one-segment foot model (hereafter referred as Ankle), and between the calcaneus and the shank for the multi-segment foot model (hereafter referred as Shank-Calcaneus); joint motion described between calcaneus and midfoot segments (hereafter referred as Chopart joint); joint motion described between midfoot and metatarsus segments (hereafter referred as Lisfranc joint); joint motion described between first phalanx and first metatarsal (hereafter referred as First Metatarso-Phalangeal joint). When the vectors were approximately aligned, the moment was considered to result in propulsion (3D angle <60o) or resistance (3D angle >120o) at the joint. When the vectors are approximately orthogonal (3D angle close to 90°), the moment was considered to stabilize the joint. RESULTS: The results showed that the four intrinsic joints of the foot are never fully propelling, resisting or being stabilized, but are instead subject to a combination of stabilization with propulsion or resistance during the majority of the stance phase of gait. However, the results also show that during pre-swing all four the joints are subject to moments that result purely in propulsion. At heel off, the propulsive configuration appears for the Lisfranc joint first at terminal stance, then for the other foot joints at pre-swing in the following order: Ankle, Chopart joint and First Metatarso-Phalangeal joint. CONCLUSIONS: Intrinsic foot joints adopt a stabilized-resistive configuration during the majority of the stance phase, with the exception of pre-swing during which all joints were found to adopt a propulsive configuration. The notion of stabilization, resistance and propulsion should be further investigated in subjects with foot and ankle disorders.

Change in gait biomechanics after total ankle replacement and ankle arthrodesis: a systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review with meta-analysis was to determine the change in gait biomechanics after total ankle replacement and ankle arthrodesis for end-stage osteoarthritis. METHODS: Electronic databases were searched up until May 2019. Peer-reviewed journal studies including adult participants suffering from end-stage ankle osteoarthritis and reporting pre- and post-operative kinematics, kinetics and spatio-temporal effects of total ankle replacement and ankle arthrodesis during walking were included with a minimum of 12 months follow-up. Seventeen suitable studies were identified and assessed according to methodological and biomechanical qualities. Meta-analysis was performed by calculating the effect size using standard mean differences between pre- and post-operative gait status. FINDINGS: Seventeen studies with a total of 883 patients were included. Meta-analysis revealed moderate evidence of an improvement in lower limb kinematics, kinetics and spatio-temporal parameters after total ankle replacement. Moderate evidence indicated an increase in ankle moment, hip range of motion and walking speed after ankle arthrodesis. INTERPRETATION: The currently available evidence base of research papers evaluating changes in gait biomechanics after total ankle replacement and ankle arthrodesis is limited by a lack of prospective research, low sample sizes and heterogeneity in the patho-etiology of ankle osteoarthritis. Following total ankle replacement, improvements were demonstrated for spatio-temporal, kinematic and kinetic gait patterns compared to the pre-operative measures. Improvements in gait mechanics after ankle arthrodesis were limited to walking speed and ankle moment. Increased hip range of motion after ankle arthrodesis could represent a sign of compensation for the lack of ankle motion.

Long-Term Effects of Whole-Body Vibration on Human Gait: A Systematic Review and Meta-Analysis.

Background: Whole-body vibration is commonly used in physical medicine and neuro-rehabilitation as a clinical prevention and rehabilitation tool. The goal of this systematic review is to assess the long-term effects of whole-body vibration training on gait in different populations of patients. Methods: We conducted a literature search in PubMed, Science Direct, Springer, Sage and in study references for articles published prior to 7 December 2018. We used the keywords "vibration," "gait" and "walk" in combination with their Medical Subject Headings (MeSH) terms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used. Only randomized controlled trials (RCT) published in English peer-reviewed journals were included. All patient categories were selected. The duration of Whole-Body Vibration (WBV) training had to be at least 4 weeks. The outcomes accepted could be clinical or biomechanical analysis. The selection procedure was conducted by two rehabilitation experts and disagreements were resolved by a third expert. Descriptive data regarding subjects, interventions, types of vibration, training parameters and main results on gait variables were collected and summarized in a descriptive table. The quality of selected studies was assessed using the PEDro scale. Statistical analysis was conducted to evaluate intergroup differences and changes after the WBV intervention compared to the pre-intervention status. The level of evidence was determined based on the results of meta-analysis (effect size), statistical heterogeneity (I 2) and methodological quality (PEDro scale). Results: A total of 859 studies were initially identified through databases with 46 articles meeting all of the inclusion criteria and thus selected for qualitative assessment. Twenty-five studies were included in meta-analysis for quantitative synthesis. In elderly subjects, small but significant improvements in the TUG test (SMD = -0.18; 95% CI: -0.32, -0.04) and the 10MWT (SMD = -0.28; 95% CI: -0.56, -0.01) were found in the WBV groups with a strong level of evidence (I 2 = 7%, p = 0.38 and I 2 = 22%, p = 0.28, respectively; PEDro scores ≥5/10). However, WBV failed to improve the 6MWT (SMD = 0.37; 95% CI: -0.03, 0.78) and the Tinetti gait scores (SMD = 0.04; 95% CI: -0.23, 0.31) in older adults. In stroke patients, significant improvement in the 6MWT (SMD = 0.33; 95% CI: 0.06, 0.59) was found after WBV interventions, with a strong level of evidence (I 2 = 0%, p = 0.58; PEDro score ≥5/10). On the other hand, there was no significant change in the TUG test despite a tendency toward improvement (SMD = -0.29; 95% CI: -0.60, 0.01). Results were inconsistent in COPD patients (I 2 = 66%, p = 0.03), leading to a conflicting level of evidence despite a significant improvement with a large effect size (SMD = 0.92; 95% CI: 0.32, 1.51) after WBV treatment. Similarly, the heterogeneous results in the TUG test (I 2 = 97%, p < 0.00001) in patients with knee osteoarthrosis make it impossible to draw a conclusion. Still, adding WBV treatment was effective in significantly improving the 6 MWT (SMD = 1.28; 95% CI: 0.57, 1.99), with a strong level of evidence (I 2 = 64%, p = 0.06; PEDro score ≥5/10). As in stroke, WBV failed to improve the results of the TUG test in multiple sclerosis patients (SMD = -0.11; 95% CI: -0.64, 0.43). Other outcomes presented moderate or even limited levels of evidence due to the lack of data in some studies or because only one RCT was identified in the review. Conclusions: WBV training can be effective for improving balance and gait speed in the elderly. The intervention is also effective in improving walking performance following stroke and in patients with knee osteoarthrosis. However, no effect was found on gait quality in the elderly or on balance in stroke and multiple sclerosis patients. The results are too heterogenous in COPD to conclude on the effect of the treatment. The results must be taken with caution due to the lack of data in some studies and the methodological heterogeneity in the interventions. Further research is needed to explore the possibility of establishing a standardized protocol targeting gait ability in a wide range of populations.

Arthroscopic Debridement After Total Ankle Arthroplasty.

BACKGROUND: Residual pain due to impingement after ankle arthroplasty can be addressed with arthroscopic debridement. Literature focusing on the effectiveness of arthroscopic debridement after total ankle arthroplasty (TAA) is scarce. The authors report a case series of 12 patients complaining of anterior or posterior impingement pain, 11 of which were in the absence of malalignment which were treated by arthroscopy. METHODS: Of the 106 TAAs performed between 2003 and 2012, a total of 12 subjects reported postoperative pain resulting from anterior or anteromedial impingement, medial and/or lateral gutter impingement, posterior impingement, and/or ankylosis. All patients were reviewed on a regular basis through chart review, clinical examination, and radiologic evaluation. The average time to final follow-up was 58.8 months. The average period from the original TAA to the arthroscopic debridement was 38.2 months. RESULTS: The median AOFAS hindfoot score was significantly (P < .05) improved from 64.6 preoperatively to 73.5 postoperatively. Eight subjects reported good pain relief after the arthroscopic debridement, and partial pain relief was reported by 4 subjects. Three patients with painful ankylosis had no improvement in the total range of motion of the TAA implant after the arthroscopic debridement. CONCLUSION: The results suggest that arthroscopic debridement in patients with residual pain due to impingement syndromes after TAA was effective in 8 of the 12 cases at 2 years' follow-up. However, the results suggest that arthroscopic debridement in the presence of painful ankylosis associated with or without impingement syndromes results only in partial pain relief and does not improve the range of motion. LEVEL OF EVIDENCE: Level IV, case series.

Posterior Arthroscopic Subtalar Arthrodesis.

INTRODUCTION: Although subtalar joint arthrodesis may be achieved through open or arthroscopic approaches, we have found that posterior arthroscopic subtalar arthrodesis has technical advantages compared with other approaches. STEP 1 PREOPERATIVE ASSESSMENT AND PLANNING: Clinically assess the foot and ankle with regard to remaining motion, previous scarring, and associated deformities, ensuring that no concomitant procedure will be needed in the supine position. STEP 2 POSITIONING OF THE PATIENT: Use spinal or general anesthesia. STEP 3 PLACEMENT OF THE POSTEROLATERAL PORTAL LATERAL TO THE ACHILLES TENDON: Place the posterolateral portal lateral to the Achilles tendon at the level of the tip of the lateral malleolus, according to the original technique described by van Dijk et al. STEP 4 PLACEMENT OF THE POSTEROMEDIAL PORTAL MEDIAL TO THE ACHILLES TENDON: Place the posteromedial portal medial to the Achilles tendon at the level of the tip of the lateral malleolus. STEP 5 EXPOSURE OF THE SUBTALAR JOINT BY REMOVING THE FATTY TISSUE AND PART OF THE POSTERIOR JOINT CAPSULE: With the help of the shaver, look for the landmarks of the posterior arthroscopy, going from the posterolateral part of the subtalar joint toward the flexor hallucis longus tendon, which is medially located, while exposing the tibiotalar joint. STEP 6 DEBRIDEMENT AND MICROFRACTURING OF THE POSTERIOR FACET OF THE SUBTALAR JOINT: Sometimes an accessory portal, just anterior to the tip of the external malleolus, may be needed to achieve a distraction of the anterior part of the subtalar posterior facet. STEP 7 USE OF BONE GRAFT: To perform this concomitant step, which generally is not necessary, use an arthroscopic forceps to insert a 5 by 20-mm autograft or allograft in the subtalar joint. STEP 8 FIXATION OF THE SUBTALAR JOINT USING TWO CANNULATED SCREWS AND FLUOROSCOPY: Use two cannulated screws with a 7.3-mm diameter; we prefer stabilization screws to compression screws. STEP 9 ADDITIONAL SURGICAL PROCEDURES: Always clean out the posterior compartment of the ankle during the PASTA procedure, as is done during surgical treatment for posterior impingement syndrome, and note that both posterior impingement syndrome and subtalar degenerative changes may thereby be easily addressed through this procedure. STEP 10 POSTOPERATIVE CARE: A short posterior leg splint is worn for three to ten days, followed by another non-weight-bearing cast for another three weeks. RESULTS: Since the appearance of the original article, a total of forty-one unilateral subtalar joints in twenty-five men and sixteen women, seen between May 2007 and December 2012, with isolated subtalar arthritis or talocalcaneal coalition without any other major hindfoot arthritis were treated by posterior arthroscopic subtalar arthrodesis, and all subtalar joints except for two were considered radiographically fused at the first attempt after an average of 6.7 weeks (range, six to ten weeks).IndicationsContraindicationsPitfalls & Challenges.

Intermediate-term Results of Mobile-bearing Total Ankle Replacement.

BACKGROUND: The literature analyzing total ankle replacement (TAR) results should be critically interpreted because studies made by the design surgeons are potentially subject to bias. European nondesigner surgeon studies reviewing the HINTEGRA TAR system are scarce in the literature. The present study is a European nondesigner surgeon study reviewing a consecutive series of 50 HINTEGRA TAR systems with a minimum follow-up of 2 years, focusing on clinical and radiographic outcomes. METHODS: Fifty primary TAR procedures were performed between February 2008 and January 2012 by a single surgeon. Every patient underwent a standardized clinical and radiographic follow-up at 6 weeks, 3 and 6 months, and 1 year postoperatively and annually thereafter. The mean time to final follow-up was 45 months. RESULTS: The mean American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score significantly increased from 43.5 preoperatively to 83.8 postoperatively. Clinical range of motion of the ankle also improved from 23.3 degrees preoperatively to 28.3 degrees postoperatively. In 70% of the TAR procedures, the talar component was positioned anteriorly with respect to the tibial axis. Radiological evidence of osteolysis was identified in 24 ankles. The failure rate in the present series was 10%, which was defined as having major revision surgery within 4 years. CONCLUSION: The survival of the first 50 HINTEGRA TAR systems in this series was satisfactory from clinical and radiological points of view. However, the incidence of asymptomatic periprosthetic osteolytic lesions was quite high (24 ankles). LEVEL OF EVIDENCE: Level IV, retrospective case series.

Anatomical characteristics of the flexor digitorum accessorius longus muscle and their relevance to tarsal tunnel syndrome a systematic review.

BACKGROUND: Clinical and cadaver studies have reported that supernumerary muscles could be the etiology of a variety of pathologic disorders, such as posterior impingement syndrome, tarsal tunnel syndrome (TTS), and flexor hallucis longus tenosynovitis. We describe a unique variant of the flexor digitorum accessorius longus (FDAL) muscle as an apparent cause of TTS, functioning as an independent flexor of the second toe, which has not been described in the literature. In addition to this case report, a systematic review was performed of TTS caused by the FDAL muscle. METHODS: A targeted search of PubMed, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and Web of Science identified full-text papers that fulfilled the inclusion and exclusion criteria. RESULTS: Twenty-nine papers were identified for inclusion in the systematic review: 12 clinical papers of TTS caused by the FDAL muscle and 17 cadaver-based papers. CONCLUSIONS: Clinicians often do not include the FDAL muscle in the differential diagnosis of TTS. This literature review suggests that the FDAL is an important muscle in terms of its functional and clinical significance. Knowledge of this muscle, its anatomical location and variations, and its magnetic resonance imaging characteristics may help clinicians make an accurate differential diagnosis.