Outcomes of Total Ankle Arthroplasty in Postfracture Ankle Arthritis.

BACKGROUND: Ankle arthritis that develops after fracture accounts for a significant portion of ankle arthritis necessitating total ankle arthroplasty (TAA). It remains unknown whether TAA in postfracture patients produces equivalent outcomes to those without fracture history. The purpose of this study was to evaluate the medium-term outcomes of TAA in postfracture ankle arthritis compared to those without fracture history. METHODS: This study reviewed 178 ankles from 171 consecutive patients who underwent TAA in our institution between 2007 and 2017 and completed a minimum 5-year follow-up. Four different TAA systems were utilized by 6 surgeons. Based on fracture history, patients were divided into 2 groups: the postfracture group (n = 63; median age 65.7 years; median follow-up 5.9 years) and the nonfracture group (n = 115; median age 64.4 years; median follow-up 6.2 years). Types and rates of complications including revision and reoperation were compared. Minimum 5-year Foot and Ankle Outcome Score (FAOS) and postoperative improvement were investigated. A subgroup analysis was performed to determine whether outcomes differ between intraarticular fracture patients (n = 43) and extraarticular fracture patients (n = 20). RESULTS: Both groups exhibited comparable postoperative improvement and final FAOS scores. The postfracture group had a significantly higher reoperation rate than the nonfracture group (20 of 63, 31.7%, vs 17 of 115, 14.8%; P = .011), with gutter impingement being the most common cause. There were 3 revisions in each group. In the subgroup analysis, we found no evidence of statistical difference between the intraarticular fracture group and the extraarticular fracture group in terms of FAOS scores, revision, and reoperation rates. CONCLUSION: In this single-center, retrospective comparative study, we found total ankle arthroplasty in patients with a history of fractures around the ankle joint had no evidence of statistical difference in patient-reported outcomes and implant survivorship but led to a higher rate of nonrevision reoperation following surgery. In the much smaller subset of patients with previous fracture, we did not find that those with a history of intraarticular fracture had inferior outcomes after TAA when compared to those with a history of extraarticular fracture. LEVEL OF EVIDENCE: Level III, case-control study.

Incidence of and Functional Significance of Floating Toe After Weil Osteotomy.

BACKGROUND: The most frequent complication after Weil osteotomies is a floating toe deformity, but there are no reports about its effect on the patient. In this study, we analyzed the consequences of floating toe deformities after the performance of a modified Weil osteotomy (MWO) or a modified Weil osteotomy with interphalangeal fixation (MWOIF). METHODS: We performed a retrospective review with a prospective follow-up of 50 patients (98% women, 120 rays) who underwent MWO (65 rays) or MWOIF (55 rays), with a mean age of 54 ± 12 years and a minimum follow-up of 4 years (mean of 6 years). We analyzed the presence of floating toe deformity in MWO and MWOIF and the outcomes measured by the subjective satisfaction, Lower Extremity Functional Scale (LEFS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and quality of prehension force between patients with or without floating toe deformity. RESULTS: The mean floating toe incidence was of 57%, with no significant difference between operative techniques (48% MWO, 67% MWOIF; P = .053). Our analysis did not show differences in satisfaction, LEFS and AOFAS scores, or grip strength between the group of patients with or without floating toes. CONCLUSION: The presence of a floating toe deformity was more frequent than generally believed but did not have a meaningful impact on the patient's satisfaction or functional outcomes measured by the AOFAS and LEFS scales. There was no clear correlation between operative technique, floating toe, and quality of prehension force. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Biomechanical Cadaveric Evaluation of Partial Acute Peroneal Tendon Tears.

BACKGROUND: No clear guideline or solid evidence exists for peroneal tendon tears to determine when to repair, resect, or perform a tenodesis on the damaged tendon. The objective of this study was to analyze the mechanical behavior of cadaveric peroneal tendons artificially damaged and tested in a cyclic and failure mode. The hypothesis was that no failure would be observed in the cyclic phase. METHODS: Eight cadaveric long leg specimens were tested on a specially designed frame. A longitudinal full thickness tendon defect was created, 3 cm in length, behind the tip of the fibula, compromising 66% of the visible width of the peroneal tendons. Cyclic testing was initially performed between 50 and 200 N, followed by a load-to-failure test. Tendon elongation and load to rupture were measured. RESULTS: No tendon failed or lengthened during cyclic testing. The mean load to failure for peroneus brevis was 416 N (95% confidence interval, 351-481 N) and for the peroneus longus was 723 N (95% confidence interval, 578-868 N). All failures were at the level of the defect created. CONCLUSION: In a cadaveric model of peroneal tendon tears, 33% of remaining peroneal tendon could resist high tensile forces, above the physiologic threshold. CLINICAL RELEVANCE: Some peroneal tendon tears can be treated conservatively without risking spontaneous ruptures. When surgically treating a symptomatic peroneal tendon tear, increased efforts may be undertaken to repair tears previously considered irreparable.

Biomechanical Evaluation of Circumtibial and Transmembranous Routes for Posterior Tibial Tendon Transfer for Dropfoot.

BACKGROUND: Tibialis posterior tendon transfer is performed when loss of dorsiflexion has to be compensated. We evaluated the circumtibial (CT), above-retinaculum transmembranous (TMAR), and under-retinaculum transmembranous (TMUR) transfer gliding resistance and foot kinematics in a cadaveric foot model during ankle range of motion (ROM). METHODS: Eight cadaveric foot-ankle distal tibia specimens were dissected free of soft tissues on the proximal end, applying an equivalent force to 50% of the stance phase to every tendon, except for the Achilles tendon. Dorsiflexion was tested with all of the tibialis posterior tendon transfer methods (CT, TMAR, and TMUR) using a tension tensile machine. A 10-repetition cycle of dorsiflexion and plantarflexion was performed for each transfer. Foot motion and the force needed to achieve dorsiflexion were recorded. RESULTS: The CT transfer showed the highest gliding resistance ( P < .01). Regarding kinematics, all transfers decreased ankle ROM, with the CT transfer being the condition with less dorsiflexion compared with the control group (6.8 vs 15 degrees, P < .05). TMUR transfer did perform better than TMAR with regard to ankle dorsiflexion, but no difference was shown in gliding resistance. The CT produced a supination moment on the forefoot. CONCLUSION: The CT transfer had the highest tendon gliding resistance, achieved less dorsiflexion and had a supination moment. Clinical Relevance We suggest that the transmembranous tibialis posterior tendon transfer should be the transfer of choice. The potential bowstringing effect when performing a tibialis posterior tendon transfer subcutaneously (TMAR) could be avoided if the transfer is routed under the retinaculum, without significant compromise of the final function and even with a possible better ankle range of motion.

Astragalectomía. Evaluaciones funcional y radiográfica / Talectomy. Functional and radiological evaluation

Analizar las indicaciones de la astragalectomía y evaluar sus resultados radiográficos y funcionales en cuatro pacientes. Materiales y Métodos: Se evaluaron los resultados funcionales (puntaje de la AOFAS) y radiológicos de cinco astragalectomías en cuatro pacientes con diferentes etiologías: Casos 1 y 4, osteonecrosis infectada secundaria a fracturas expuestas de astrágalo; Caso 2, osteonecrosis asociada a equino varo y retropié rígido, secuela de fractura expuesta grave de tibia; y Caso 3, equino varo y retropié rígido neurológico bilateral. Todos los pacientes eran hombres, con una edad promedio de 32.5 años (rango 19-56). Se utilizaron los siguientes procedimientos: abordaje anteroexterno en pie y tobillo, astragalectomía y fijación en posición de corrección con dos clavos de Steinmann de 3 mm, tenotomía del Aquiles u otros, según necesidad. Resultados: Seguimiento de 38 meses (rango 15-84), sin signos de osteoartrosis, o signos leves y sin dolor. Puntaje de la AOFAS 81,4 (puntaje prequirúrgico 17), una discrepancia de longitud del miembro <2 cm y un rango de flexo-extensión de 18° en promedio (variancia entre 10° y 45°). Dos varos leves del retropié y tres alineaciones neutras asintomáticos. Conclusiones: Se observa una buena correlación entre la sintomatología de los pacientes, la alineación adecuada y los escasos signos por imágenes de artrosis tibiocalcánea o en el resto del pie. Si es imposible realizar la técnica de artrodesis o artroplastia de tobillo, la astragalectomía es un método de rescate para pacientes con deformidades muy graves o déficit de stock óseo e infecciones recalcitrantes de la articulación del tobillo. Nivel de Evidencia: IV...

Objectives: To analyze the indications for talectomy and evaluate the radiographic and functional results in four patients. Methods: Functional (AOFAS score) and radiological (X-rays and MR) of five talectomies in four patients with different etiologies: Cases 1 and 4, septic osteonecrosis secondary to open fractures of the talus; Case 2, osteonecrosis associated with rigid equinovarus hindfoot, sequelae of severe open tibia fracture, and Case 3, neurological rigid equinovarus hindfoot, bilateral. All patients were men, with an average age of 32.5 years (range 19-56). We performed the following procedures as needed: anterolateral approach for the foot and ankle, talectomy and fixation in corrected position with two 3 mm Steinmann’s pins, Achilles tenotomy or others.Results: At 38-month follow-up (range 15-84) there were no signs of osteoarthritis, or mild signs and absence of pain. AOFAS score of 81.4 points (preoperative score 17), a length discrepancy of lower limb <2 cm, and a range of flexion and extension of 18° on average (variance between 10° and 45°). Two mild varus hindfoot and three asymptomatic and neutral alignments. Conclusions: There is a good correlation among the patient’s symptoms, proper alignment and few imaging signs of osteoarthritis in the ankle or other joints in the foot. If treatmet with an arthrodesis or an ankle replacement is not possible, the talectomy is an acceptable salvage procedure for patients with severe deformities, bone stock deficiency and recalcitrant infections in the ankle. Level of Evidence: IV...