The Classic Three-Month Post-Operative Adaptation Phase in Foot and Ankle Surgery-An Expert Perspective.

Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.

Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus.

PURPOSE: The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates. METHODS: Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5 mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy. RESULTS: Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement. CONCLUSION: The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Joint-Preserving Surgery in Varus Ankle Osteoarthritis.

Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.

Two-Staged Revision Total Ankle Arthroplasty Surgery with Primary Total Ankle Arthroplasty System: A Case Report.

CASE: Case of a 2-staged revision surgical technique for the treatment of an aseptic total ankle arthroplasty (TAA) loosening: first surgery: removal of the loosened and painful TAA Scandinavian Total Ankle Replacement, with exclusion of infection, and reconstruction of the large bone defect (bone-defect downsizing surgery); proof of successful ankle bone reconstruction by CT-scan imaging; second surgery: implantation of a primary VANTAGE TAA (ankle reconstruction with new primary TAA). CONCLUSION: The present case shows the management of a failed TAA with bone defect by performing a 2-step surgical approach: removal of loosened TAA with simultaneous bone stock restoration and then implantation of a new primary TAA. This concept is a possible alternative to a post-TAA ankle arthrodesis or to the use of a TAA revision system.

Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral defects in the talus? A systematic review and meta-analysis.

BACKGROUND: The aim of this study is to systematically review the literature on clinical outcomes of patients who have undergone autologous matrix-induced chondrogenesis (AMIC) for treatment of osteochondral lesions of the talus (OCL) and compare the studies' outcomes. METHODS: Pubmed and Embase were searched in January 2020 for articles concerning OCL surgery. Studies were included if they had a minimum 1-year follow-up and the primary measures were functional outcomes. The meta-analysis compared the Visual Analogic Score (VAS), the American Orthopedic Foot and Ankle Score (AOFAS), and the Foot Function Index (FFI) between baseline and follow-up of 1-2years, and 3-5years. A random effects model was used to evaluate outcome changes. RESULTS: The search returned 15 studies, with a total of 492 patients. The VAS improved 4.45 and 4.6 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). AOFAS improved 31.59 and 32.47 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). The FFI showed a significant improvement of 30.93 points from baseline to year 3-5 (p<0.001). A total of 6 patients with revision surgeries have been reported within the follow up period. It was not possible to correlate clinical features like lesion size, surgical approach, and bone marrow stimulation technique to the reported outcome. CONCLUSION: Surgical treatment of OCL via the AMIC procedure provided significant improvement in the functional outcome and pain scores when compared to the pre-operative values. Improvements were observed up to 5years post-operatively.

Neglected Iatrogenic Flexor Hallucis Longus Tendon Rupture After Haglund's Endoscopic Surgery: A Case Report.

Rupture of the flexor hallucis longus (FHL) tendon is a rare condition that can occur with direct or indirect trauma; most of the injuries are complete ruptures resulting from laceration. Endoscopic calcaneoplasty is used for treatment of symptomatic Haglund's deformity, and complications of this procedure are rare. Iatrogenic FHL tendon rupture occurring after endoscopic calcaneoplasty has not been reported previously. This case report presents a rare complication after endoscopic calcaneoplasty and the proper method of treatment.

Medial Ankle Instability: The Deltoid Dilemma.

Diagnosis and treatment of medial ankle instability (MAI) are still controversial and poorly discussed in literature. The purpose of this review is to highlight different clinical presentations of MAI and develop a guide for its management. The deltoid ligament complex is injured more commonly than expected, because deltoid ligament injuries may either be isolated or occur in combination with other lesions, such as lateral ankle ligament injury, posterior tibial tendon insufficiency, osteochondral lesion, and others. The presence of a pes planovalgus deformity in a patient without posterior tibial tendon insufficiency may indicate MAI.

Rehabilitation and Return to Sports: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS: A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement. CONCLUSIONS: The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle.

Digit-Like Bony Anomaly of the Hindfoot: A Case Report.

We report the case of an asymptomatic digit-like bony anomaly located on the plantar aspect of the calcaneus, which was incidentally found on radiographs of a 50-year-old male with a tibial shaft fracture. To the best of our knowledge, this is the first description of such an anomaly in the foot. The differential diagnosis includes accessory ossicles, polydactyly, heel spur, heterotopic ossification, osteochondroma, and pelvic digits.

How To Diagnose and Treat Infection in Total Ankle Arthroplasty.

Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.

All-Arthroscopic Autologous Matrix-Induced Chondrogenesis-Aided Repair of a Patellar Cartilage Defect Using Dry Arthroscopy and a Retraction System.

The technique of all-arthroscopic autologous matrix-induced chondrogenesis (AMIC)-aided repair of patellar cartilage lesions using a retraction system and dry arthroscopy has been recently described. We report the first clinical and radiological data at a short-term follow-up. Twelve patients underwent AMIC-aided cartilage repair for a patellar lesion. All steps of the procedure were performed arthroscopically, which include the use of an intra-articularly placed retraction plate for distraction of the patellofemoral joint and evacuation of saline solution for collagen matrix insertion and fixation. Clinical assessment performed before surgery and at a mean follow-up time of 38 months (range: 24-70) included the following scores: Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and visual analog scale (VAS). Magnetic resonance imaging was performed at the follow-up examination, including the magnetic resonance observation of cartilage repair tissue (MOCART) score. The mean KOOS and IKDC scores increased significantly (p < 0.01) from 50.3 and 37.4 points preoperatively to 90.1 and 79.4 postoperatively. The VAS score decreased from 7.8 to 2.3 points. Mean MOCART score at follow-up was 58.3 points. Cartilage repair of patellar lesions aided by a retraction system in a dry arthroscopy setup is a promising approach. Further studies are needed to evaluate this procedure and compare it to existing matrix implantation techniques. The level of evidence for the study is 4 (case series).

Contrast-enhanced CT imaging as a non-destructive tool for ex vivo examination of the biochemical content and structure of the human meniscus.

The biochemical and histopathological techniques used to investigate meniscal content and structure are destructive and time-consuming. Therefore, this study evaluated whether contrast-enhanced computed tomography (CECT) attenuation and contrast agent flux using the iodinated contrast agents CA4+ and ioxaglate correlate with the glycosaminoglycan (GAG) content/distribution and water content in human menisci. The optimal ioxaglate and CA4+ contrast agent concentrations for mapping meniscal GAG distribution were qualitatively determined by comparison of CECT color maps with Safranin-O stained histological sections. The associations between CECT attenuation and GAG content, CECT attenuation and water content, and flux and water content at various time points were determined using both contrast agents. Depth-wise analyses were also performed through each of the native surfaces to examine differences in contrast agent diffusion kinetics and equilibrium partitioning. The optimal concentrations for GAG depiction for ioxaglate and CA4+ were ≥80 and 12 mgI/ml, respectively. Using these concentrations, weak to moderate associations were found between ioxaglate attenuation and GAG content at all diffusion time points (1-48 h), while strong and significant associations were observed between CA4+ attenuation and GAG content as early as 7 h (R2 ≥ 0.67), being strongest at the equilibrium time point (48 h, R2 = 0.81). CECT attenuation for both agents did not significantly correlate with water content, but CA4+ flux correlated with water content (R2 = 0.56-0.64). CECT is a promising, non-destructive imaging technique for ex vivo assessment of meniscal GAG concentration and water content compared to traditional biochemical and histopathological methods. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1018-1028, 2017.

Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity.

Management of diabetic Charcot midfoot deformity is one of the most demanding aspects of foot and ankle surgery. Its treatment should aim at reducing the rate of complications, including foot and ankle amputations or limb loss. Attempting reconstruction at Eichenholtz stages I and II carries the risk of infection and loss of fixation. It is advisable to limit surgical reconstruction to Eichenholtz stage III in the absence of any evidence of infection or vascular insufficiency. Achilles lengthening or gastrocnemius-soleus release is an essential initial step in surgery. Addressing the medial foot column first is a key to a successful reconstruction.

Sports Activity After Reconstruction of Osteochondral Lesions of the Talus With Autologous Spongiosa Grafts and Autologous Matrix-Induced Chondrogenesis.

BACKGROUND: For the treatment of osteochondral lesions of the talus (OCLTs), autologous matrix-induced chondrogenesis (AMIC) is a safe 1-step procedure with good clinical and radiological results. However, data regarding postoperative sports activity after AMIC are limited. PURPOSE: To identify significant factors influencing the rate of postoperative sports and recreational activities. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The sports and recreational activities of 60 patients (mean age, 34.9 ± 11.5 years) undergoing the AMIC procedure were retrospectively analyzed at a mean of 46.9 ± 17.8 months (range, 24.5-87.0 months) postoperatively. The visual analog scale (VAS) for pain score, Tegner activity scale score, activity rating scale (ARS) score, and satisfaction with surgery outcomes were assessed. RESULTS: Corrective calcaneal osteotomy was performed in 38 of 60 (63.3%) patients. Ligament repair was performed in 41 of 60 (68.3%) patients. The mean VAS score improved significantly from 6.9 ± 1.6 points (range, 5-10 points) preoperatively to 2.3 ± 1.9 points (range, 0-6 points) at latest follow-up (P < .001). No significant change in the mean Tegner activity scale score (3.3 ± 2.0 preoperatively to 3.4 ± 2.2 postoperatively; P = .526) and the mean ARS score (2.6 ± 4.3 preoperatively to 2.3 ± 3.4 postoperatively; P = .874) was noted. The percentage of patients involved in sports activity before the onset of symptoms became significantly lower at the time of surgery (from 95.0% to 53.3%; P < .001); no significant difference was noted postoperatively (from 53.3% to 58.3%; P = .663). No significant difference of the weekly sports frequency and the duration of sports activity was found postoperatively. CONCLUSION: Patients undergoing AMIC repair of an OCLT participate at a similar low postoperative sports and recreational activity level compared with the preoperative level.

Computed Tomographic Evaluation of Joint Geometry in Patients With End-Stage Ankle Osteoarthritis.

BACKGROUND: Deformation of the talus and the distal tibia can be frequently observed during ankle joint osteoarthritis (OA). The aim of this study was to objectify these morphologic changes. We hypothesized that a flattening of the talus and a broadening of the distal tibia surface occurs in end-stage OA of the ankle joint. METHODS: Twenty-seven computed tomography (CT) ankle joint examinations of unilateral ankle OA were matched by sex and age with 27 CT examinations of healthy ankle joints. Three-dimensional reformatting and measurements were performed with geometry analysis software. The following parameters were assessed: sagittal radius of the talus, talus height, and mediolateral and anteroposterior width of the distal tibial joint surface. RESULTS: Medial, midsagittal, and lateral sagittal arc radii of osteoarthritic tali were significantly larger compared to tali of controls. There was a statistically significant difference in the height of the osteoarthritic talar dome in the medial and in the lateral frontal segment and in the medial central segment compared to tali of controls. The anteroposterior width and the sagittal curvature of the distal tibia was significantly larger in OA ankles than in the control group. The mediolateral measurements were comparable across both groups. CONCLUSION: Flattening of the talus appears to be more pronounced in the frontal aspect of the talus. The distal tibia broadens anteroposteriorly. These findings may contribute to better understanding of ankle OA development. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

Ankle Joint Fusion With an Anatomically Preshaped Anterior Locking Plate.

We present a novel fixation plate for primary ankle joint fusion. A single anatomically preshaped angular stable plate was used with an anterior approach. An excellent result with good bone consolidation was present at the 1-year follow-up examination.

Transcutaneous pleural biopsy with a retrograde forceps: a novel approach.

PURPOSE: Pleural biopsies are commonly performed to investigate the cause of exudative pleural effusion. Biopsy needles (e.g. Abrams needle, Cope needle) are traditionally used to perform the biopsy. However, certain complications such as pneumothorax and haemothorax have been described. We present a technique utilizing a novel retrograde forceps, which could improve the simplicity and lower the complication rate of performing closed pleural biopsies. DESCRIPTION: A retrograde forceps (Retroforceps, Karl Storz, Tuttlingen, Germany) was used to perform 20 transcutaneous pleural biopsies in a cadaver thorax under thoracoscopical control. Video documentation of the procedure from outside and inside the thorax was performed. The surgeon performing the biopsy was blinded to the thoracoscopical view. After the removal of the forceps, it was checked whether biopsy material was retrieved. The video material was retrospectively used to confirm whether the biopsy was taken from the pleura parietalis. EVALUATION: Biopsy material was retrieved in 19 out of 20 biopsy attempts. Video material confirmed that the biopsy was taken from the pleura parietalis in all cases. CONCLUSIONS: Using a retrograde biopsy forceps is a simple and practicable procedure suitable for clinical application. This technique could potentially reduce the incidence of pneumothorax.

A cationic gadolinium contrast agent for magnetic resonance imaging of cartilage.

A new cationic gadolinium contrast agent is reported for delayed gadolinium enhanced magnetic resonance imaging of cartilage (dGEMRIC). The agent partitions into the glycosaminoglycan rich matrix of articular cartilage, based on Donnan equilibrium theory, and its use enables imaging of the human cadaveric metacarpal phalangeal joint.

Total ankle replacement.

BACKGROUND: About 1% of adults suffer from painful osteoarthritis of the ankle. The current literature contains no information on the percentage of such patients who derive long-term relief of symptoms from conservative treatment. Advanced ankle osteoarthritis can be treated with non-joint-preserving measures, such as total ankle replacement and ankle fusion. METHODS: This review is based on selected relevant publications, guidelines from Germany and abroad, and the authors' personal experience. RESULTS: Before surgery is considered, conservative measures such as physiotherapy and orthopedic aids should be used to the fullest possible extent. No randomized trials have yet been published comparing total ankle replacement with ankle fusion. Total ankle replacement with newer types of prosthesis yields good to very good intermediate-term and long-term results, with mean success rates of up to 90% at 10 years (range, 68-100%). Independent risk factors for the failure of ankle replacement are age over 70 years (odds ratio [OR] 3.84), primary osteoarthritis (OR 7.19), post-traumatic osteoarthritis (OR 6.2), and type of prosthesis (e.g., single hydroxyapatite coating: OR 15.04). The average range of motion of the replaced ankle joint is 25° to 30°, with values as high as 60°. CONCLUSION: Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. It can restore joint function and make the patient mobile with little or no pain. There are, however, many contraindications to be taken into account. There is a need for further studies of the biomechanics of arthritic and replaced ankle joints and for long-term follow-up studies of total ankle replacement.

Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery.

BACKGROUND: The aim of this study was to quantify the incidence of postoperative wound complications in elective foot and ankle surgery as well as the risk factors for postoperative wound complications. METHODS: Two hundred ninety-five elective orthopaedic foot and ankle operative procedures were performed in 290 patients between January 2006 and June 2010. A logistic multiple regression model was used to identify independent risk factors for postoperative wound healing complications/infection. RESULTS: The overall prevalence of postoperative wound complications within our cohort was 16.9%. In 4 patients (1.4%) deep infection was diagnosed requiring operative irrigation and debridement. Using a logistic multiple regression model we identified the following statistically independent risk factors: age ≥ 60 years (OR = 8.98, 95% CI = 3.55 to 25.02), tobacco use (OR = 48.77, 95% CI = 15.55 to 139.71), and tourniquet time ≥ 90 minutes (OR = 7.02, 95% CI = 2.77 to 19.32). CONCLUSION: Patients at risk for postoperative wound healing complications following elective orthopaedic foot and ankle surgery include those with higher age, tobacco use, and prolonged use of tourniquet. LEVEL OF EVIDENCE: Prognostic Level III, comparative study.