Functional limitations after lateral column lengthening osteotomy of the calcaneus are associated with lower quality of life.

PURPOSE: The purpose of this study was to quantify limitations in sagittal ankle range of motion (ROM) at least two years after lateral column lengthening osteotomy of the calcaneus (LLC) and their implications regarding quality of life. METHODS: Fifteen patients with a mean follow-up of 80 ± 27 months after LLC and 15 age-matched healthy persons participated in this study. Ankle joint complex ROM in plantarflexion and dorsiflexion was measured bilaterally using a goniometer and fluoroscopy (patients only). Quality of life was assessed using the short-form health questionnaire (SF36). Differences in ROM parameters (for the tibiotalar and subtalar joint) between sides (affected vs. unaffected) and between groups (patient vs. controls) and the relationship between ROM parameters and quality of life scores were assessed. RESULTS: ROM of the ankle joint complex on the affected side in patients was smaller than on the contralateral side (goniometer and fluoroscopy) and in healthy persons (goniometer; all P < .05). Among patients, SF36 total and pain scores, respectively, correlated with ROM of the subtalar joint (fluoroscopy; R = 0.379, P = 0.039 and R = 0.537, P = 0.001). Among patients and healthy persons, those with smaller dorsiflexion (goniometer) had lower quality of life scores. CONCLUSIONS: The smaller sagittal ROM of the affected ankle joint complex compared with the contralateral foot and healthy controls was mainly explained by limitations in the tibiotalar joint. Because of its association with quality of life, ROM should be considered in the treatment and rehabilitation planning in patients who are candidates for LLC.

Intra- and inter-observer reliability of a new standardized diagnostic method using SPECT/CT in patients with osteochondral lesions of the ankle joint.

BACKGROUND: Single Photon Emission Computed Tomography-Computed Tomography (SPECT/CT) gains an important part of diagnostics in patients with osteochondral lesions (OCL). SPECT/CT is a hybrid imaging modality, which combines a 3D scintigraphy (SPECT) and computerized tomography (CT) into one single procedure and combines metabolic data, structural and mechanical information. The purpose of the study was to develop and evaluate a standardized method to anatomically localize and quantitatively analyze the bone SPECT tracer activity of the ankle joint using SPECT/CT. METHODS: OCL on the talus were diagnosed in 16 patients by 99mTc-HDP-SPECT/CT and MRI by specialized orthopedic surgeons and radiologists and retrospectively included. The articular superior surface of the talus was subdivided in six anatomical regions (T1-T6). Using customized software, absolute bone SPECT values for each anatomical area were analyzed. Relative bone tracer uptake was calculated in relation to specific reference regions representing bone SPECT tracer background activity. All measurements were performed twice by two independent observers, blinded to clinical information. Intraclass correlation coefficients (ICC) were calculated for inter- and intra-observer reliability. The intraclass correlation coefficients (ICC) showed an excellent inter- and intra-observer reliability. RESULTS: The intraclass correlation coefficients (ICC) of all six regions are between 1.00 and 0.84 which is defined as very good. Results from region T1 to T6 impair slightly due to measurement regime. All ICCs of observer 1 were nearly the same as the results of observer 2 in all regions. CONCLUSION: The presented standardized SPECT/CT algorithm is clinically feasible and showed high inter- and intra-observer reliability. It might help to better understand the complex pathology of OCL on the talar dome. The major potential benefit of SPECT/CT is the assessment of the subchondral bone plate and the subchondral bone.

Medial malleolar osteotomy for the treatment of talar osteochondral lesions: anatomical and morbidity considerations.

PURPOSE: Osteochondral lesions of the talus are often located posteromedially requiring open surgery to facilitate solid and complete osteochondral reconstruction. The aim of the study was to identify the optimal anatomical site for medial malleolar osteotomy based on the criteria of minimal cartilage damage (Study I) and to report on the morbidity in patients receiving osteotomy performed at the previously identified site (Study II). METHODS: For Study I, cartilage coverage of the tibiofibular ankle joint facet was measured in 40 cadaveric ankles (20 cadaver specimens). In Study II, we assessed clinical (VAS pain score, AOFAS score, range of motion) and radiological outcome measures (SPECT-CT) in 17 patients (mean age, 36.8 ± 10.8 years) undergoing medial malleolar osteotomy. RESULTS: The medial edge in the transition zone of the tibial plafond to the medial malleolus showed less than 75 % of cartilage coverage in 62.5 % of cadavers (Study I). Surgery resulted in lower pain levels (2.4 ± 2.6 compared with 6.3 ± 1.8 points; p < 0.001) and greater AOFAS scores (82.9 ± 14.1 compared with 43.5 ± 10.8 to points; p < 0.001) compared with baseline (Study II). No signs of intra-operative damage or mal- or non-union were found. Long-term morbidity was found in one patient. Implant removal was necessary in 12 of 17 patients (71 %). CONCLUSION: Anatomically, there is an optimal location for the medial malleolar osteotomy at the medial ankle edge involving minimal cartilage damage. Clinical results using this location showed no short- or mid-term morbidity and little long-term morbidity. However, many patients required re-intervention for implant removal. LEVEL OF EVIDENCE: IV.

Mineral density and penetration strength of the subchondral bone plate of the talar dome: high correlation and specific distribution patterns.

The subchondral bone plate plays an important role in stabilizing the osteochondral joint unit and in the pathomechanism of osteochondral lesions and osteoarthritis. The objective of the present study was to measure the mineral density distribution and subchondral bone plate penetration strength of the talar dome joint facet to display and compare the specific distribution patterns. Ten cadaver specimens were used for computed tomography (CT) scans, from which densitograms were derived using CT-osteoabsorptiometry, and for mechanical indentation testing from which the penetration strength was obtained. Our results showed 2 different distribution patterns for mineral density and penetration strength. Of the 10 specimens, 6 (60%) showed bicentric maxima (anteromedially and anterolaterally), and 4 (40%) showed a monocentric maximum (either anteromedially or anterolaterally). A highly significant correlation (p < .0001) for both methods confirmed that the mineral density relied on local load characteristics. In conclusion, the biomechanical properties of the subchondral bone plate of the talar dome joint facet showed specific distribution patterns. CT-osteoabsorptiometry is a reliable method to display the mineral density distribution noninvasively. We recommend CT-osteoabsorptiometry for noninvasive analysis of the biomechanical properties of the subchondral bone plate in osteochondral joint reconstruction and the prevention and treatment of osteoarthritis and osteochondral lesions.

Tibiofemoral loss of contact area but no changes in peak pressures after meniscectomy in a Lapine in vivo quadriceps force transfer model.

PURPOSE: The menisci are thought to modulate load transfer and to absorb shocks in the knee joint. No study has experimentally measured the meniscal functions in the intact, in vivo joint loaded by physiologically relevant muscular contractions. METHODS: Right knee joints of seven New Zealand white rabbits were loaded using isometric contractions of the quadriceps femoris muscles controlled by femoral nerve stimulation. Isometric knee extensor torques at the maximal and two submaximal force levels were performed at knee angles of 70°, 90°, 110°, and 130°. Patellofemoral and tibiofemoral contact areas and pressure distributions were measured using Fuji Presensor film inserted above and below the menisci and also with the menisci removed. RESULTS: Meniscectomy was associated with a decrease in tibiofemoral contact area ranging from 30 to 70% and a corresponding increase in average contact pressures. Contact areas measured below the menisci were consistently larger than those measured on top of the menisci. Contact areas in the patellofemoral joint (PFJ), and peak pressures in tibiofemoral and PFJs, were not affected by meniscectomy. Contact areas and peak pressures in all joints depended crucially on knee joint angle and quadriceps force: The more flexed the knee joint was, the larger were the contact areas and the higher were the peak pressures. CONCLUSIONS: In agreement with the literature, removal of the menisci was associated with significant decreases in tibiofemoral contact area and corresponding increases in average contact pressures, but surprisingly, peak pressures remained unaffected, indicating that the function of the menisci is to distribute loads across a greater contact area.

Retrograde synovial biopsy of the knee joint using a novel biopsy forceps.

Synovial biopsies of the knee joint are commonly performed arthroscopically with the patient under full or regional anesthesia. To overcome the effort, costs, and potential risks of surgery, we developed an office-based technique for retrograde synovial biopsy using a designated novel biopsy forceps. Using this technique, no arthroscopic or radiologic control is needed to perform rapid synovial biopsies of the knee joint. Concomitant aspiration of synovial fluid can be performed. A technical description of the procedure is given.

Bony periosteum-covered iliac crest plug transplantation for severe osteochondral lesions of the talus: a modified mosaicplasty procedure.

PURPOSE: This study reports first evidence of a modified procedure for osteochondral autologous transplantation where bony periosteum-covered plugs are harvested at the iliac crest and transplanted into the talar osteochondral lesion. METHODS: Thirteen out of 14 patients, average age 39.6 (SD 14.4) years, were followed clinically and radiographically for a median of 25 (24-28) months (minimal follow-up, 24 months). RESULTS: For these 13 patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 47 (SD 11) points pre-operatively, to 81 (SD 14) points postoperatively (p < 0.0001). The average pain score decreased from 6.6 (SD 1.3) points pre-operatively, to 1.4 (SD 1.9) points postoperatively (p < 0.0001). Seven patients returned to sports activity. Radiographically good plug osteointegration was observed in nine out of 11 ankles. Follow-up arthroscopy showed fibrous cartilage in four ankles, periosteum hypertrophy in five ankles, and partial or total missing of coverage of the bone in three ankles. Three revision surgeries had to be performed. CONCLUSIONS: This modified mosaicplasty might be recommended for severe and recurrent osteochondral lesions of the talus and may lead to restoration of the subchondral bone stock, formation of fibro-cartilage, and stable joint function. LEVEL OF EVIDENCE: IV.

Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis.

BACKGROUND: Osteochondral lesions (OCLs) of the talus are a common entity in sports orthopaedics. There are several operative techniques with a good outcome on follow-up examinations. However, limitations such as sacrificing healthy cartilage (osteochondral autograft transfer system [OATS], mosaicplasty), multiple-stage operative procedures (matrix-induced autologous chondrocyte transplantation [MACI], autologous chondrocyte implantation [ACI]), high costs (ACI, allograft), and limited availability (allograft) do remain and reflect potential drawbacks of the currently used techniques. PURPOSE: To describe a novel operative technique for the treatment of OCLs of the talus in the form of an economically efficient, 1-step procedure combining OCL debridement, spongiosaplasty, and sealing of the OCL area with a collagen matrix. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-six patients underwent surgery receiving a modified autologous matrix-induced chondrogenesis (AMIC)-aided repair of OCLs of the talus consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold. Ligament repair was performed in 17 of 26 cases. A corrective calcaneal osteotomy was performed in 16 of 26 cases. Clinical and radiological assessment was performed before and a minimum of 24 months after surgery (mean, 31 months; range, 24-54 months). Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. Radiological imaging included single-photon emission computed tomography-computed tomography (SPECT-CT) and magnetic resonance imaging (MRI). The magnetic resonance observation of cartilage repair tissue (MOCART) score was applied, and sport activity was documented. RESULTS: The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17-79 points) to 89 points (range, 61-100 points) postoperatively (P < .01). The preoperative pain score averaged 5 (range, 2-8), improving to an average of 1.6 (range, 0-7) postoperatively (P < .01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 62 points (range, 20-95 points). Complete filling of the defect at the level of the surrounding cartilage was found in 35%, and complete filling with a hypertrophic cartilage layer was found in 50% of the patients. Normal signal intensity of the repair tissue compared with the adjacent native cartilage was seen in 15%, with nearly normal activity in 69%. Nineteen patients (73%) participated in sports before the onset of symptoms compared with 3 (12%) at the time of surgery. The number increased to 16 patients (62%) at postoperative follow-up. CONCLUSION: The modified AMIC procedure is safe for the treatment of OCLs in the ankle with overall good clinical and MRI results.

Histomorphometric, CT arthrographic, and biomechanical mapping of the human ankle.

BACKGROUND: The specific morphological and biomechanical characteristics of the osteochondral unit of the ankle joint are not yet fully understood. This anatomical study aimed to map regional thickness of the articular hyaline uncalcified cartilage and its adjacent layers of mineralized cartilage and subchondral bone as well as to measure the regional indentation stiffness of human ankle joint cartilage. MATERIALS AND METHODS: A total of 20 pairs of human cadaver ankle joints (median age: 78 years) were evaluated by histomorphometry and multidetector row double-contrast CT arthrography for cartilage thickness in 17 distinct anatomical regions. In addition, regional distribution of the subchondral bone plate and of the mineralized cartilage was scrutinized histologically. Cartilage indentation stiffness was measured using an arthroscopic handheld device (Artscan200), especially validated for use in thin cartilage. The correlation between the thickness of different components of the osteochondral unit and the cartilage indentation stiffness was evaluated. RESULTS: The thinnest uncalcified cartilage was measured at the anterior talar dome and the distal fibula. The thickest uncalcified cartilage was found in the mid and posterior talar dome, as well as in the tibial plafond. Mineralized cartilage and subchondral bone showed highest values at the anteromedial talar dome. Cartilage indentation stiffness showed a bicentric distribution pattern in 14/20 ankle pairs and was highest in regions with thin cartilage. Positive correlation between the thickness of the mineralized cartilage and the subchondral bone plate was found. No correlation between the thickness of the uncalcified and the mineralized cartilage could be identified. CONCLUSION: This anatomical study provides a comprehensive mapping of the osteochondral unit of the human ankle joint in elderly people. Articular hyaline uncalcified cartilage and the subchondral bone plate showed clear regional differences and were reciprocally distributed. Cartilage indentation stiffness was inversely correlated to cartilage thickness in elderly people. CLINICAL RELEVANCE: Thorough understanding of the osteochondral unit of the ankle joint could be helpful for clinicians and researchers in the development of improved operative repair techniques for osteochondral defects in the ankle joint, for example, in constructing specific tissue-engineered osteochondral plugs.

Dynamic in-vivo force transfer in the lapine knee loaded by quadriceps muscle contraction.

BACKGROUND: The rabbit knee is a frequently used model for experimental osteoarthritis (OA). Despite the acknowledged importance of joint loading in the onset and progression of OA, the load transfer in the three compartments of the intact rabbit knee remains unknown. Therefore, this study was aimed at determining load transfer in the three compartments for isometric, concentric, and eccentric knee extensor contractions. METHODS: Maximal and sub-maximal isometric, concentric, and eccentric knee extensor contractions were produced by electrical stimulation of the femoral nerve in 13 rabbits. Knee extensor forces were measured using a custom-built servomotor. Contact areas and pressure distributions were measured in the patello-femoral, and the medial and lateral tibio-femoral joints using Fuji Presensor film. FINDINGS: Contact areas and peak pressures increased with increasing quadriceps forces for all compartments. Maximal knee extensor forces, joint moments, and contact pressures reached values of 504 N, 5.5 Nm and 60 MPa, respectively. Force transfer in the patello-femoral joint was about twice that observed in the individual tibio-femoral joints. During isometric contractions, force transfer was higher in the medial compared to the lateral tibio-femoral joint, while this trend was reversed for dynamic contractions. INTERPRETATION: The results of this study suggest that the increasing muscular forces are transferred through an increased contact area, thereby limiting the increase in average contact pressure. These results may be used as reference data for contact pressures in the intact rabbit knee and may form the foundation for studies using the lapine knee as an experimental model of osteoarthritis.

Micro CT analysis of the subarticular bone structure in the area of the talar trochlea.

PURPOSE: Certain regions of the talar trochlea are recognized as exhibiting varying cartilage thickness and degrees of subchondral bone mineralization. These changes have been attributed to the long-term loading history. For the current study, we accepted the hypothesis that stress-induced alterations of the joint surface include not only varying degrees of subchondral lamellar mineralization, but also structural changes of the subarticular cancellous bone. METHODS: In order to examine the structure of the subarticular cancellous bone, ten formalin-fixed talar trochleae were analyzed using micro CT. Sixteen measurement zones were defined and then evaluated in five layers each of 1-mm thickness, enabling assessment of the cancellous architecture extending 5 mm below the trochlear surface using numerical and structural parameters. RESULTS: As with mineralization patterns in the subchondral lamella, large variation was observed regarding bone volume, trabecular quantity, thickness, and spacing, as well as for structure model index and degree of anisotropy, depending on localization. In addition, like previous reports examining mineralization of the subchondral lamella, two distinct groups could be identified as "bicentric" or "monocentric". CONCLUSIONS: These results show that structural tissue adaptation probably due to loading history is also evident within the subarticular cancellous bone.

Treatment of the arthritic valgus ankle.

The ankle joint is part of a biomechanical hindfoot complex. Approximately 1% of the world's adult population is affected by ankle osteoarthritis (AO). Trauma is the primary cause of ankle OA, often resulting in varus or valgus deformities. Only 50% of patients with end-stage ankle OA have a normal hindfoot alignment. The biomechanics and morphology of the arthritic valgus ankle is reviewed in this article and therapeutic strategies, including joint preserving and nonpreserving modalities are presented. Pitfalls are discussed and the literature is reviewed regarding outcomes in patients with valgus deformity who underwent total ankle replacement.

Open lateral patellar retinacular lengthening versus open retinacular release in lateral patellar hypercompression syndrome: a prospective double-blinded comparative study on complications and outcome.

PURPOSE: To compare complication rates and outcome of open lateral retinacular (LR) lengthening and open LR release in the treatment of lateral patellar hypercompression syndrome (LPHS). METHODS: In a prospective double-blinded study, 28 patients (mean age, 48 years; 21 women and 7 men) received either LR release (14 patients) or LR lengthening (14 patients) in alternating fashion over the same lateral parapatellar skin incision for LPHS (blinding of patients to surgical procedure [i.e., single blinding]). Strict inclusion criteria (retinacular pain, tight retinaculum, decreased patellar mobility) were used to exclude other reasons for anterior knee pain (patellar instability, leg malalignment or maltorsion, trochlear dysplasia, patella alta). The surgeon and postsurgical rehabilitation were the same. Preoperatively and at 3, 6, 12, and 24 months postoperatively, complications, muscle atrophy, and Kujala patellofemoral outcome score were documented by examiners blinded to the surgical procedure (double blinding). All patients completed 2 years of follow-up. RESULTS: The results of 2 years of follow-up showed that recurrence of LPHS, as indicated by the patellar tilt test and decreased medial patellar glide test, developed in 2 cases after LR release and 1 case after LR lengthening (P > .999). Medial patellar subluxation, as indicated by the gravitation-subluxation test and increased medial patellar glide test, developed in 5 cases after LR release and no case after LR lengthening (P = .041). Quadriceps atrophy, as indicated by the mean circumference difference compared with the healthy contralateral side, was significantly higher (P = .001) in the LR release group (1.8 cm) than in the LR lengthening group (0.2 cm). The mean Kujala score was significantly lower (P = .035) in the LR release group (77.2 points) than in the LR lengthening group (88.4 points). CONCLUSIONS: In this prospective double-blinded study, retinacular lengthening showed less medial instability, less quadriceps atrophy, and a better clinical outcome at 2 years compared with retinacular release. We believe that this may be explained by the controlled preservation of the lateral patellar muscle-capsuloligamentous continuity after retinacular lengthening. LEVEL OF EVIDENCE: Level II, prospective double-blinded comparative study.

Computer tomographic evaluation of talar edge configuration for osteochondral graft transplantation.

To successfully surgically reconstruct osteochondral lesions of the talus, the exact three-dimensional (3D) configuration of the upper articular surface of the talus has to be respected. We assessed the talar geometry by measuring the coronal and sagittal talar edge radius and the frontal talar profile in multiplanar reconstructions of computer tomographic (CT) studies of 79 patients (83 feet) with a healthy ankle joint. An image visualization software designated for coordinate measurement was used to perform the measurement. In the coronal plane, the mean lateral talar edge radius was 4.0 mm and the medial 4.5 mm. In the sagittal planes the mean lateral talar edge radius was 20.3 mm, the radius of the sulcus 20.7 mm and the medial talar edge radius 20.4 mm. The talus showed a concave shape in coronal cuts. These results show a significant difference between medial and lateral talar edge configuration in coronal planes. The measurements of the lateral and medial sagittal radius and the mid-sagittal radius in the sulcus tali show no statistically significant difference. The depth of the talar sulcus shows no correlation to age or sex. Different sizes of custom-made tissue-engineered grafts according to the location of the osteochondral lesion at the talus are needed for exact surgical reconstruction of the anatomy. Osteochondral lesions are three dimensional; therefore, a 3D preoperative planning tool by CT scan or MRI is mandatory.

A novel imaging method for osteochondral lesions of the talus--comparison of SPECT-CT with MRI.

BACKGROUND: Magnetic resonance imaging (MRI) is the current standard in noninvasive diagnostics of osteochondral lesions (OCLs) of the talus. Single-photon emission computed tomography-computed tomography (SPECT-CT) is a new technique that displays different imaging qualities. The influence of the aforementioned diagnostic information on treatment decision making in talar OCLs is not known. PURPOSE: The aim of the study was to evaluate SPECT-CT in comparison with MRI for image interpretation and decision making in OCLs of the talus. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Magnetic resonance imaging and SPECT-CT of 25 patients (average age, 32 years; range, 18-69 years) were analyzed by 3 independent orthopaedic surgeons blinded to the study. Raters had to analyze images for predefined criteria of cartilage, subchondral bone plate, and subchondral bone, including bone marrow edema on MRI and scintigraphic activity on SPECT-CT. For MRI alone, SPECT-CT alone, and their combination, the treatment decision had to be defined. RESULTS: In comparison with MRI alone, treatment decision making changed in 48% of the cases with SPECT-CT alone and 52% with SPECT-CT and MRI combined. While cartilage showed good correlation for interpretation between MRI and SPECT-CT, the subchondral bone plate and subchondral bone showed substantial differences. Poor intrarater correlation highlighted the different information provided by the 2 imaging techniques. Poor interrater correlation showed a high heterogeneity in the treatment decision making of OCLs. CONCLUSION: Compared with MRI, SPECT-CT provides additional information and influences the decision making of OCL treatment. For thorough diagnostic evaluation in OCLs, performing both MRI and SPECT-CT is recommended. Further clinical investigation is needed to see if SPECT-CT in addition to MRI results in improved treatment outcomes.

Distinctive pain course during first year after total ankle arthroplasty: a prospective, observational study.

BACKGROUND: Patients and health care professionals alike are often surprised by the course of pain after total ankle arthroplasty (TAA). The current study aimed to determine the baseline patterns of postoperative symptoms during the first year following uncomplicated TAA. MATERIALS AND METHODS: In a prospective observational study 28 patients with unilateral posttraumatic osteoarthritis were tested for pain with a visual analogue scale, swelling (min grade, 0; max grade, 4), ankle range of motion, and AOFAS ankle score. Assessments were performed preoperatively and 6 weeks, 3, 6, 9, and 12 months after TAA. RESULTS: At 6 weeks all variables had improved significantly. However, at 3 months a relapse with deterioration of mean variables was found. These improved asymptotically during assessments at 6, 9, and 12 months. CONCLUSION: Our data suggest patients undergoing uncomplicated TAA have to overpass what we believe is an adaptive inflammatory phase with increased periarticular pain and swelling about 3 months after surgery. This distinctive course may influence patient education and increase confidence of healthcare professionals involved in the rehabilitation of TAA patients.