HemiCAP® implantation after failed previous surgery for osteochondral lesions of the talus.

BACKGROUND: The aim of this study is to enhance data about the effectiveness of HemiCAP® implantation after failed previous surgery for osteochondral defects (OCDs). METHODS: 12 consecutive patients were retrospectively included in this study. The American Orthopedic Foot and Ankle Society Score (AOFAS), the Visual Analogue Scale (VAS) score for pain, the sub-scales Pain and Disability of the Foot Function Index (FFI-P and FFI-D) Score, and the patients' satisfaction were evaluated. RESULTS: AOFAS increased from poor to fair (p < 0.001), VAS score decreased from moderate to mild pain (p = 0.001), the final FFI-P and FFI-D were 37.50 ± 18.54 and 33.44 ± 16.24, respectively (p < 0.001). Five patients were not satisfied, three were moderately satisfied and four were highly satisfied. One implant repositioning, one ankle fusion (implant failing) and an additional surgery (double arthrodesis) were performed during the follow-up. Neither intra- nor postoperative complications were registered. CONCLUSION: Despite the clinical improvement, pain was still present at the final follow-up. Metal resurfacing might not be considered a definitely valid alternative for treatment of OCDs after failed previous surgery. LEVEL OF EVIDENCE: Level III, retrospective study.

In vivo kinematics of fixed-bearing total ankle arthroplasty.

BACKGROUND: A good recovery of the physiological mobility of the ankle is an indication of patients' satisfaction after total ankle arthroplasty, which does not generally match that of other consolidated procedures such as hip and knee replacement. The aim of this study was to investigate the kinematics of the Zimmer Total Metal Total Ankle (ZTMTA) during the different exercises. METHODS: Fifteen patients with ZTMTA were enrolled in this study. The patients performed non-weightbearing flexion-extension, stair climbing and descending, and fluoroscopic images were taken to capture the ankle movements. A combined images/three-dimensional models method was used to perform a kinematic analysis. RESULTS: Plantar-dorsiflexion resulted the main plane of movement, with the largest range of motion (ROM) of 23.3 ± 9.0° during flexion-extension. Inversion-eversion and adduction-abduction resulted lower than 10° in any trials. CONCLUSIONS: In the investigated population, the ZTMTA allowed a good recovery of the mobility, with ROMs comparable to the healthy subjects.

Early clinical and radiological evaluation in patients with total ankle replacement performed by lateral approach and peroneal osteotomy.

BACKGROUND: The Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) is a recent ankle arthroplasty approved for use in the United States and Europe. Many of the studies reporting the results of this implant are provided by surgeons involved at least in the initial design of the implant under study. The aim of this study is to describe the early clinical and radiological outcomes in patients who underwent this procedure performed by non-designer surgeons. METHODS: A total of thirty consecutive patients underwent total ankle replacement with a Zimmer TM TAR surgery between July 2013 to January 2016.All clinical assessments were collected pre- and post-operatively with minimum follow-up of 12 months for each patient using the American Orthopedic Foot and Ankle (AOFAS) score, the Foot Function Index (FFI) and a visual analogue scale (VAS) for pain. Radiographic outcomes included ankle orientation assessed with angle "α","ß" and "γ" according to Wood. Furthermore, the anteroposterior offset ratio was measured in weight-bearing lateral ankle radiographs at the last follow-up. RESULTS: The mean preoperative FFI-pain (FFI-P) value was 53.67, the FFI-disability (FFI-D) was 64.19. At the last follow-up visit, the FFI-P and FFI-D was 16.95 and 20.76 respectively (p<0.01 for the both scales). Preoperatively, the mean VAS for pain and AOFAS score was 7.81 and 40.95 respectively, and at the last follow-up 2.29 and 86.38 (p<0.01 for the both scales). The mean angle calculated using Wood and Deakin's method were "α"= 89.02°, "ß"= 85.11 and "γ"= 27.54 post-operatively. At the last follow-up the same values were respectively 89.43, 85.18 and 29.94. At the last follow-up, the mean offset ratio was 0.06 (range 0.003/-0.17). CONCLUSIONS: These early results show high levels of patient satisfaction, and we are encouraged to continue with lateral approach total ankle arthroplasty.

Clinical and imaging outcome of osteochondral lesions of the talus treated using autologous matrix-induced chondrogenesis technique with a biomimetic scaffold.

BACKGROUND: The purpose of our study was to assess the clinical and imaging outcome of autologous matrix-induced chondrogenesis (AMIC) technique consisting of microfractures followed by the filling of osteochondral lesions of the talus (OLTs) with a cell-free biphasic collagen-hydroxyapatite osteochondral scaffold (MaioRegen). METHODS: Sixteen patients (eight males, age: 42.6 ± 18.4, range 14-74) with OLT repaired using AMIC technique, with implantation of MaioRegen, were clinically evaluated through the American Orthopedic Foot and Ankle Society Score (AOFAS) and a 10-point Visual Analogue Scale (VAS) pain score after a mean follow-up of 30 ± 16.9 months. The MRI examinations were performed 12 and 24 months after surgery. A paired t-test was applied to compare pre- and post-operative clinical findings (VAS and AOFAS) and Magnetic resonance observation of cartilage repair tissue (MOCART) score changes in the follow-up. To assess the correlation between variation of AOFAS and MOCART scores, the Pearson's correlation coefficient was calculated. RESULTS: No complications after surgery were encountered. From pre-operative to post-operative values, there was a significant (P < 0.001) reduction of mean VAS pain score (6.3 ± 0.9,range: 4-8 and 2.9 ± 1.8,range: 0-6, respectively) and increase of AOFAS score (60.2 ± 7.8,range: 50-74 and 77.4 ± 16.2,range: 50-100, respectively). Among 16 patients, six (37%) were not satisfied at the end of follow-up, six (37%) were moderately satisfied and four (25%) were highly satisfied. The treatment was considered failed in five out of 16 patients (31%). Among them, four (25%) required re-interventions with implantation of ankle prostheses, whereas one patient was treated with a further AMIC technique combined with autologous bone graft and platelet-rich plasma. The mean MOCART score was 41.9 ± 14.6 (25-70) 12 months after surgery and 51.9 ± 11.6 (30-70) after 24 months, with a statistically significant increase (P = 0.012). However, no correlation was seen between AOFAS and MOCART changes (r = 0.215, p = 0.609). CONCLUSION: The high rates of treatment failure encountered in our study using MaioRegen need to be confirmed by larger studies and should induce the scientific community questioning the reliability of this biomimetic scaffold for the treatment of OLTs.

Validation of the Italian version of the Oxford Ankle Foot Questionnaire for children.

PURPOSE: The purpose of this study was to translate the Oxford Ankle Foot Questionnaire (OAFQ) into Italian, to perform a cross-cultural adaptation and to evaluate its psychometric properties. METHODS: The Italian OAFQ was developed according to the recommended forward/backward translation protocol and evaluated in pediatric patients treated for symptomatic flatfoot deformity. Feasibility, reliability, internal consistency, construct validity [comparing OAFQ domains with Child Health Questionnaire (CHQ) domains] and responsiveness to surgical treatment were assessed. RESULTS: A total of 61 children and their parents were enrolled in the study. Results showed satisfactory levels of internal consistency for both children and parent forms. The test-retest reliability was confirmed by high ICC values for both child and parents subscales. Good construct validity was showed by patterns of relationships consistent with theoretically related domains of the CHQ. After surgery, the mean OAFQ scores improved in all the domains after treatment with the subtalar arthroereisis, for both children and parent scales (p < 0.01). Effect size ranged from small to moderate for almost all domains. CONCLUSIONS: The Italian version of the OAFQ might be a reliable and valid instrument in order to evaluate interventions used to treat children's foot or ankle problem, but needs further study on different clinical settings.

Recreational Sports Activities After Calcaneal Fractures and Subsequent Subtalar Joint Arthrodesis.

Subtalar joint arthrodesis is a common treatment for the management of hindfoot pathologic entities. Despite pain reduction, hindfoot stiffness is a common concern of active patients, who wish to continue or start exercising for fitness. The purpose of the present retrospective observational clinical study was to assess the rate and type of recreational sports activities in patients before and after subtalar joint arthrodesis and to correlate the clinical outcome and the level of sports activities. In 33 patients (22 males, 11 females) treated with subtalar joint arthrodesis, the pre- and postoperative participation in sports and recreational activities was evaluated. The American Orthopaedic Foot and Ankle Society hindfoot scale score, 36-item Short Form Health Survey, and a visual analog scale for pain were used as clinical outcome measures. The weekly session number, session time, and interval to activity recovery after surgery were registered. Patients with a subtalar joint arthrodesis returned to a satisfactory level of activity postoperatively. The sports participation almost reached levels similar to those preoperatively but with a shift from high- to low-impact activities.

Functional and clinical assessment of two ankle arthrodesis techniques.

Isolated tibiotalar fusion is the preferred choice for isolated end-stage arthritis, joint destruction after infection, talar avascular necrosis, Charcot neuroarthropathy, and joint replacement failure. Combined tibiotalar and subtalar joint fusion with an intramedullary nail can achieve better alignment and save patients from prolonged non-weightbearing. The purpose of the present study was to functionally assess using instrumental gait analysis and clinically assess the effect of these 2 surgical techniques. Twelve patients with a mean follow-up duration of 70 (range 55 to 89) months after successful ankle fusion were analyzed, 6 isolated and 6 combined. The main outcome measure was the functional assessment performed using a stereophotogrammetric system and an established multisegment foot kinematics protocol. Standard clinical, imaging, and score systems were also assessed in the 2 groups, including radiographic-based classification of arthritic degeneration at the neighboring foot joints. No significant differences were found between the 2 groups using the scoring systems. Severe arthritic degeneration was found at the subtalar joint in the isolated fusion group and at the talonavicular and Lisfranc joints in the combined fusion group. From the gait analysis, no differences were found in the time-distance parameters; however, significant differences were observed in several joint rotations and planar angles. Isolated tibiotalar fusion allows for motion, however small, at the subtalar joint but can result in severe degeneration. Good clinical and functional results can also be obtained with combined tibiotalar and subtalar fusion, although this can result in degeneration of the adjacent joints of the foot.

Reliability, validity and responsiveness of the Italian version of the Foot Function Index in patients with foot and ankle diseases.

PURPOSE: The purpose of this study was to translate the Foot Function Index (FFI) into Italian, to perform a cross-cultural adaptation and to evaluate the psychometric properties of the Italian version of FFI. METHODS: The Italian FFI was developed according to the recommended forward/backward translation protocol and evaluated in patients with foot and ankle diseases. Feasibility, reliability [intraclass correlation coefficient (ICC)], internal consistency [Cronbach's alpha (CA)], construct validity (correlation with the SF-36 and a visual analogue scale (VAS) assessing for pain), responsiveness to surgery were assessed. The standardized effect size and standardized response mean were also evaluated. RESULTS: A total of 89 patients were recruited (mean age 51.8 ± 13.9 years, range 21-83). The Italian version of the FFI consisted in 18 items separated into a pain and disability subscales. CA value was 0.95 for both the subscales. The reproducibility was good with an ICC of 0.94 and 0.91 for pain and disability subscales, respectively. A strong correlation was found between the FFI and the scales of the SF-36 and the VAS with related content, particularly in the areas of physical function and pain was observed indicating good construct validity. After surgery, the mean FFI improved from 55.9 ± 24.8 to 32.4 ± 26.3 for the pain subscale and from 48.8 ± 28.8 to 24.9 ± 23.7 for the disability subscale (P < 0.01). CONCLUSIONS: The Italian version of the FFI showed satisfactory psychometric properties in Italian patients with foot and ankle diseases. Further testing in different and larger samples is required in order to ensure the validity and reliability of this score.

Radiographic considerations of hallux valgus versus hallux rigidus.

BACKGROUND: Metatarsus primus elevatus (MPE) has long been suggested as a primary causative factor in the pathogenesis of hallux rigidus (HR). The purpose of this investigation was to more clearly define this relationship by comparison of first ray position in patients with hallux rigidus, hallux valgus, and a control population with no known foot pathology. MATERIALS AND METHODS: Clinical and radiographical data were retrospectively collected from 297 patients (394 feet) between the periods of January 2007 and September 2008. Patients were stratified into those having isolated HR (110 patients, 145 feet), isolated hallux valgus (HV) (118 patients, 159 feet), and control group (C) of asymptomatic volunteers (69 patients, 90 feet). Any patient with a previous history of foot trauma, surgery, or other foot or ankle pathology was excluded from the study. Standing lateral weightbearing X-rays were obtained for measurement of first to second metatarsal head elevation (Horton Index), Seiberg Index, and Sagittal Intermetatarsal Angle (IMA). RESULTS: A significant difference in first ray elevation in HR population was identified by all the three measurements. Horton Index (mm) was 6.4 +/- 2.5 for HR population, as compared to 4.0 +/- 2.5 and 3.4 +/- 1.9 for the HV and C populations (p < or = 0.05). Seiberg Index (mm) measured 2.5 +/- 1.8 for the HR group, versus 1.0 < or = 1.6 and 0.24 +/- 0.9 for the HV and C groups respectively (p < or = 0.05). The sagittal IMA (degrees) were 4.5 +/- 2.5 versus 2.7 +/- 2.2 and 1.8 +/- 1.2 (p < or = 0.05). CONCLUSION: This investigation does not show any etiological relation between MPE and HR, but identified a correlation between them.

Early clinical results of the BOX ankle replacement are satisfactory: a multicenter feasibility study of 158 ankles.

A new design for a 3-part ankle replacement was developed in an effort to achieve compatibility with the naturally occurring ligaments of the ankle by allowing certain fibers to remain isometric during passive motion. In order to test the design concept clinically, 158 prostheses were implanted in 156 patients within a 9-center trial and were followed up for a mean of 17 (range 6 to 48) months. The mean age at the time of surgery was 60.5 (range 29.7 to 82.5) years. Outcome measures included the American Orthopaedic Foot & Ankle Surgery hindfoot-ankle score and range of motion measured on lateral radiographs of the ankle. The preoperative American Orthopaedic Foot & Ankle Surgery score of 36.3 rose to 74.6, 78.6, 76.4, and 79.0, respectively, at 12, 24, 36, and 48 months. A significant correlation between meniscal bearing movement on the tibial component (mean 3.3 mm; range 2 to 11 mm) and range of flexion at the replaced ankle (mean 26.5°; range 14° to 53°) was observed in radiograms at extreme flexions. Two (1.3%) revisions in the second and third postoperative years necessitated component removal (neither were for implant failure), and 7 (4.4%) further secondary operations were required. The results of this investigation demonstrated that non-anatomic-shaped talar and tibial components, with a fully conforming interposed meniscal bearing, can provide safety and efficacy in the short term, although a longer follow-up period is required to more thoroughly evaluate this ankle implant.

Total ankle replacement compatible with ligament function produces mobility, good clinical scores, and low complication rates: an early clinical assessment.

BACKGROUND: A three-part ankle replacement was developed to achieve compatibility with the natural ligaments by allowing fibers on the medial and lateral sides to remain isometric during passive motion. Unlike all current prostheses, the new design uses nonanatomically shaped components on the tibia and talus and a fully conforming interposed meniscal bearing. QUESTIONS/PURPOSES: Does this new design restore ankle mobility, improve clinical score, and result in low complication and early revision rates? PATIENTS AND METHODS: We reviewed 51 patients in whom 51 prostheses were implanted in a seven-center trial from July 2003 to July 2006. The mean age of the patients at surgery was 61.5 years (range, 35.1-82.5 years). We used the AOFAS score to assess clinical outcome. We used lateral radiographs to assess function. The minimum followup was 24 months (mean, 30 months; range, 24-48 months). RESULTS: The mean preoperative AOFAS score of 38.5 increased to 76.9, 79.1, 76.4, and 79.0 at 12, 24, 36, and 48 months, respectively. We observed a correlation between meniscal bearing movement on the tibial component (mean, 3.4 mm; range, 2-12 mm) and range of flexion at the replaced ankle (mean, 27.4º; range, 16º-53º). We revised one arthroplasty in the second postoperative year for lateral impingement, providing a 3-year cumulative survival rate of 97% and performed one other secondary operation for hindfoot pain. CONCLUSIONS: These data suggest the new prosthesis can provide short-term restoration of ankle mobility, a good clinical score, and low complication and failure rates. Longer followup with larger numbers is required. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Medial Cuneiform Opening Wedge Osteotomy for Correction of Flexible Flatfoot Deformity: Trabecular Titanium vs. Bone Allograft Wedges.

Adult flatfoot is a common pathology characterized by multiplanar deformity involving hindfoot, midfoot, and forefoot. Various surgical techniques have been described for the treatment but may not adequately correct the fixed forefoot varus component. Residual forefoot supination can be addressed by a plantar flexing opening wedge osteotomy of the medial cuneiform, also known as a Cotton osteotomy. Thus, the aims of this study were to compare clinical, radiological, and functional outcome after Cotton osteotomy, in patients treated with bone allograft or metallic implant. Consequently, 36 patients treated with opening wedge osteotomy of the medial cuneiform for forefoot varus were studied retrospectively. Patients were divided into two groups: the bone allograft group (HBG) (n=18) and the metallic implant group with BIOFOAM® Cotton Wedges (TTW) (n=18). Radiographic assessment and clinical scores including American Orthopaedic Foot and Ankle Society score, Foot Function Index, and visual analogue scale for pain were collected before operation and the last follow-up. The difference between baseline and follow-up for both groups was statistically significant for all the clinical scores and radiographic angles (p < 0.05). Most participants (92%) were very satisfied after surgery. Our results showed that Cotton osteotomy with a metallic implant provided both good clinical and radiographic outcomes comparable with bone allograft.

Distal oblique first metatarsal osteotomy in grade 3 hallux rigidus: a long-term followup.

BACKGROUND: While some studies have demonstrated that metatarsus primus elevatus in hallux rigidus is an uncommon secondary change rather than a causative factor, we believe it is, in fact, more common. We advocate surgical treatment if the first ray is elevated beyond normal range, thereby acting as a decompression realignment osteotomy. MATERIALS AND METHODS: We analyzed patients operated between June 1994 and December 1996. Oblique distal osteotomy of the first metatarsal was performed in 20 patients. A retrospective review of clinical and radiological outcomes was performed including an AOFAS score and patient satisfaction scale. The postoperative ROM was evaluated with lateral radiographs in maximum plantar/dorsiflexion. The average followup was 11.1 (range, 8.7 to 13.6) years. RESULTS: One case of metatarsalgia was the only postoperative complication. The average AOFAS score increased from 44 (range, 14 to 68) to 82 (range, 80 to 100). Good to excellent results were achieved in 19 patients. The mean passive dorsiflexion of the first MTP joint improved from 8 degrees (range, 5 degrees to 10 degrees) to 44 degrees (range, 15 degrees to 55 degrees). No patient underwent subsequent surgery. CONCLUSION: The oblique osteotomy is a safe and reliable procedure for treatment of painful hallux rigidus. In our experience, it yields good and excellent results with high patient satisfaction and low complication rates.

Return to sport activities after subtalar arthroereisis for correction of pediatric flexible flatfoot.

The aim of this study was to establish whether children treated with subtalar arthroereisis for flexible flatfoot were able to return to sport activities. We reviewed 49 patients with a mean age at the time of surgery of 10.7 years. The type of sport activities, the number of sessions per week, the time dedicated to each session, and the level achieved were assessed preoperatively and at the last follow-up. Overall, 45 patients returned to sports after surgery. Surgery did not alter the duration, frequency, and type of sporting activities, but the participation in physical activities as well as the emotional status and footwear issues improved.

Calcaneal osteotomies.

The current trend is to preserve the hindfoot joints to allow for more normal biomechanics and avoid arthritic changes in adjacent joints. Calcaneal osteotomies are effective in the treatment of hindfoot and foot malalignment with an acceptable rate of complications at medium-term follow-up. An important prerequisite should be flexibility and the absence of joint arthritis.

Treatment of bone marrow edema of the talus with pulsed electromagnetic fields: outcomes in six patients.

BACKGROUND: Bone marrow edema (BME) of the talus is a rare, mostly self-limiting cause of foot and ankle pain. We sought to investigate in patients with idiopathic BME of the talus the effectiveness of pulsed electromagnetic fields and to determine the effect of this therapy on magnetic resonance imaging findings. METHODS: Six patients with BME of the talus confirmed by magnetic resonance imaging were enrolled. Pain was quantified with a visual analog scale from 0 (no pain) to 10 (the worst pain imaginable). The clinical outcome was assessed using the American Orthopaedic Foot and Ankle Society scoring system. Treatment consisted of pulsed electromagnetic field stimulation 8 h/d for 30 days. The device used generated pulses 1.3 milliseconds in duration, with a frequency of 75 Hz and a mean ± SD induced electric field of 3.5 ± 0.5 mV. RESULTS: The mean American Orthopaedic Foot and Ankle Society score improved from 59.4 (range, 40-66) before treatment to 94 (range, 80-100) at the last follow-up. The visual analog scale score decreased significantly from 5.6 (range, 4-7) before treatment to 1 (range, 0-2) at the last follow-up. Magnetic resonance imaging showed that BME improved after 1 month of treatment and resolved completely within 3 months in 5 patients, with normal signal intensity and no signs of progression to avascular necrosis. CONCLUSIONS: A significant reduction in BME area was associated with a significant decrease in pain within 3 months of beginning treatment.