Tibiotalocalcaneal Arthrodesis: Comparison of Ipsilateral Distal Fibular Autograft as an Intramedullary Strut and Lateral Tibia Plating Versus Intramedullary Nail.

What's New in Foot and Ankle Surgery.

To systematically review the clinical efficacy of total ankle arthroplasty (TAA) and ankle arthrodesis (AA) in the treatment of end-stage ankle arthritis. The PubMed, EMBASE and Cochrane Library databases were searched for articles published in the treatment of end-stage ankle arthritis with AA or TAA from the establishment of the database to June 2021. Bias risk tool was used to evaluate the quality of the literature. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale(AOFAS), visual analog scale (VAS), ankle osteoarthritis scale(AOS), gait analysis (pace, frequency, stride), range of motion (ROM), satisfaction, complications and reoperation rate were analyzed by meta-analysis between AA and TAA groups by RevMan 5.3 software. A total of 12 articles were included, including 1 050 patients in the AA group and 3 760 patients in the TAA group, totaling 4 810 patients. Meta-analysis showed that the total score of AOFAS[MD=-3.12, 95%CI(-9.02, 2.96), P=0.31], pain score [MD=1.60, 95%CI(-1.35, 4.54), P=0.29], alignmentl score[MD=-0.04, 95%CI(-0.52, 0.44), P=0.88], VAS[MD=0.10, 95%CI(-0.49, 0.68), P=0.74], and AOS total score [MD=-4.01, 95%CI(-8.28, 0.25), P=0.06], the difference was not statistically significant (P>0.05). The score of AOFAS functional in TAA group was significantly higher than that in TAA group[MD=44.22, 95%CI(-8.01, -0.43), P=0.03]. There was no significant difference in gait analysis between the two groups (P>0.05). Postoperative ROM [MD=-4.93, 95%CI(-6.35, -3.52), P<0.000 01] and change in ROM from preoperative to follow-up[MD=-5.74, 95%CI(-8.88, -2.61), P=0.0003] between two groups, the difference was statistically significant. There was no significant difference in satisfaction between the two groups [OR=1.011, 95%CI(0.46, 2.23), P=0.98]. Complications [OR=1.61, 95%CI(1.26, 2.06), P=0.0002] and non-revision reoperation [OR=1.61, 95%CI(1.17, 2.21), P=0.003] were significantly lower in the TAA group than in the AA group. There was no significant difference in the rate of revision and reoperation(P>0.05) between the two groups [OR=1.02, 95%CI(0.37, 2.78), P=0.97]. The clinical efficacy of AA is similar to that of TAA, but the non revision reoperation rate and main surgical complications of TAA are significantly reduced. Therefore, further high-quality methodological research and long-term follow-up are needed to confirm this conclusion.

Translation, Cross-Cultural Adaptation, Reliability, and Validity of Turkish Version of the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale.

To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of fiveyears. Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed. The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection. The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.

Category:Ankle, Ankle Arthritis, Basic Sciences/Biologics, HindfootIntroduction/Purpose:Ankle arthrodesis has traditionally been the treatment of choice for ankle arthritis. However, loss of range of motion, chronic pain, risk of nonunion, and potential risk of adjacent arthritis are ongoing concerns after this procedure. Most of surgeons state that subtalar fusion is an alternative to treat a painful and dysfunctional ankle fusion, but successful ankle arthrodesis take down using Total Ankle Arthroplasty (TAA) has been reported in the literature. The paucity of literature comparing these two treatment methods hinders the ability to make an informed decision on the best therapy. The purpose of the study was to compare patient-reported outcomes; gait mechanics and complications in patients with ankle arthrodesis take down using TAA to those who underwent subtalar fusion in a previously fused ankle.Methods:This is a comparative study of patients who underwent tibiotalar arthrodesis take down with total ankle arthroplasty and subtalar arthrodesis in previously arthrodesed ankles. Patients who were willing to take the gait mechanics test were included. They were distributed in two groups according to the undergone procedure. Postoperative outcomes consisted of patient- reported functional measures, and complications rate. Patient-reported functional measures included the American Orthopaedic Foot & Ankle Society Score (AOFAS) hindfoot scale, Visual Analogue Scale (VAS) for pain, and the Short Form 36 Health Survey (SF-36). Three-dimensional joint mechanics and ground reaction forces were measured during level walking at least one-year post surgery. Gait mechanics included spatiotemporal parameters, and the peak plantar and dorsiflexion moment. Data were analyzed using analysis of variance (ANOVA) to determine significant differences between the two groups. (a = 0.05).Results:Ten patients were included in the ankle arthrodesis taken down (AATD) group, and seven patients were included in the subtalar fusion (STF) group. The average follow-up time in the AATD and SFT group was 70.4 and 46 months, respectively P=0.14. There were no statistically significant differences in the demographics of both groups. The peak plantar flexion was 4.6 degrees and 1.3 degrees in the AATD and STF group, respectively; P=0.04. The range of motion in the sagittal plane was 11.5 degrees and 7.8 degrees in patients with AATD and STF groups, respectively; P=0.13. The complication rate was higher in the AATD group (7 patients, 70% vs 1 patient, 14%; P=0.02). There were no statistically significant differences in the patient-reported outcomes between the two groups.Conclusion:Patients with ankle arthrodesis taken down using total ankle arthroplasty as compared with patients with tibiotalocalcaneal arthrodesis have better range of motion of the hindfoot and improved gait mechanics. The improved cadence and mobility decreased the imbalance in the midfoot and forefoot during the gait. Nevertheless, due to the complexity of the procedure the complication rate is considerably higher. Further research with a larger sample of both groups may demonstrate greater differences in patient-reported outcomes.

Background. Developed in 1994 by H. Kitaoka et al. the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS-AHS) allows to assess pain, function, deformity and alignment of the foot and ankle. There is no Russian-language AOFAS-AHS questionnaire adapted according to current standards in the scientific literature. The aim of this paper is to perform the cross-cultural adaptation and to assess the validity of the Russian-language version of the AOFAS-AHS scale, including the evaluation of its psychometric properties. Methods. The original English version of the AOFAS-AHS scale was translated from English into Russian by a native Russian speaker. Then the questionnaire was back-translated into English by another translator whose native language is English. The next stage was the comparison of the original and back-translated versions, followed by the presentation of a pre-final cross-culturally adapted version, which was tested on 10 patients to ensure that the questions were comprehensible. The next step was the approval of the final version and its completion by patients to be operated on the hindfoot or ankle. The printed copy of the final version of the questionnaire was completed by the patients with an interval of 3 days. Total of 44 consecutive patients were enrolled, including 18 women (41%) and 26 men (59%), with a mean age of 61.7 (32-78) years. The psychometric properties of the Russian-language version of the AOFAS-AHS questionnaire (internal consistency, retest reliability, measurement error, responsiveness, and construct validity) were assessed based on the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) principles. Results. The mean score according to the AOFAS-AHS scale was 49.6 (min 2; max 82) out of a possible 100. The average time to complete the questionnaire was 4.2 minutes. All hypotheses formulated showed correlations of varying moderate to strong degrees. The Cronbach’s alpha coefficient was 0.76, which indicates a high level of internal consistency of the elements of the validated questionnaire. A good intra-class consistency of 0.83 was obtained, which shows a high degree of reliability of the questionnaire’s reproducibility. The ceiling and floor effects for the primary results of the questionnaires did not exceed 15%. The mean value of the Russian-language version of the AOFAS-AHS increased to 86.6 after surgical treatment. The values of standardized effect size (ES) and standardized response mean (SRM) were 5.56 and 4.83, respectively. Conclusion. The adapted Russian-language version of the AOFAS-AHS scale showed good psychometric properties and can be recommended for assessment of the physical activity in patients with ankle and hindfoot-related pathology and can also be used for monitoring the changes during the treatment.

To describe anterior fibrous bundle as an intra-articular residual disorder following ankle sprain. Between January 1998 and January 2009, we performed arthroscopy on 10 patients (7 males, 3 females; median age, 25 years; age range, 17-43 years) who had the uncommon problem of anterior ankle pain accompanied by restriction of plantar flexion following an ankle sprain. Pre-operative magnetic resonance imaging revealed osteochondral lesions (OCLs) of the talar dome in 3 patients, but no other findings that could explain restricted plantar flexion. All patients underwent arthroscopy for investigation and treatment of the cause of symptoms, and the 3 patients with OCL underwent additional arthroscopic drilling. Outcome was measured using the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score, Visual Analogue Scale (VAS) for pain and active plantar flexion angle. In all patients, an anterior fibrous bundle was confirmed under arthroscopic investigation as the cause of symptoms and was resected arthroscopically. Median AOFAS and VAS scores improved significantly from 65 (range 61-82) and 70 (range 50-85) pre-operatively to 95 (range 84-100) and 4 (range 0-15) at final follow-up, respectively (p < 0.001). In addition, median active plantar flexion angle improved significantly from 40° (range 35-40) pre-operatively to 55° (range 45-55), (p < 0.01). An anterior fibrous bundle is one of the intra-articular residual disorders after ankle sprain that can cause restriction of plantar flexion.

Medial vs. Anterior Malleolar Osteotomy in Osteochondral Autologous Transplantation for Hepple V Talar Lesions: A Retrospective Study.

There are still controversies on the effect of grafting during open reduction and internal fixation of calcaneal fractures. The aim of this study was to compare the radiological and functional outcomes in patients with or without intraoperative grafting. In a comparative retrospective study, among 442 operatively-treated calcaneal fractures, 60 patients with unilateral closed sanders type II intraarticular calcaneal fracture who underwent ORIF via lateral extensile approach using locking anatomical plates with at least 1year follow-up without any postoperative wound complication were enrolled. The patients were separated into 2 groups: with bone allograft and without bone allograft. The functional outcome of the patients was assessed using visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, foot function index (FFI), and short-form (SF-36) health survey. Radiographic variables included Böhler angle, Gissane angle, calcaneal width, calcaneal height, and talar declination angle. Also, the differences (delta) of these values in comparison to the uninjured foot were calculated. The mean age was 39.1 ± 12.7 (range, 13-67) years with 54 males, 90.0%. No statistically significant differences were detected in age, gender, affected side, and subtypes of calcaneal fractures between the two groups (p > 0.05). The average follow-up was 25.1 (range, 12-48) months. The differences for all radiographic measurements and also, the delta values between the groups were not statistically significant, except talar declination angle which was more in cases without grafting (p = 0.007). Although the differences between the two groups regarding AOFAS ankle-hindfoot scale (p = 0.257), VAS for pain (p = 0.645), and FFI (p = 0.261) were not statistically significant; the group with bone graft experienced less pain (19.7 ± 22.0) than the other group (26.7 ± 22.8). The difference between the groups was not statistically significant (p = 0.87) according to the SF-36 questionnaire. Incorporating allografts into the void defects during ORIF of displaced intraarticular calcaneal fractures may not improve functional outcomes and recover postoperative radiological parameters. Therefore, routine use of allograft to fill the defects during ORIF of calcaneus may not be recommended. Of note, that these findings solely relate to the treatment of Sanders type II fractures. Comparative retrospective study.

Severe septic destruction of the ankle joint poses a therapeutic challenge but lacks a consensus optimal treatment. Tibiotalocalcaneal arthrodesis (TTCA) is considered a valuable salvage procedure, but the literature remains scarce. Conventional treatment approaches, including 2-stage procedures, have been associated with prolonged recovery times and varying success rates. Many authors prefer classical external fixation in these scenarios, citing concerns that internal implants might pose a risk for recurrent infection. To date, no study has investigated the outcomes of 1-stage surgery using a retrograde intramedullary (IM) nail. The main purpose was to assess the rate of recurrent infection at 2 years following 1-stage TTCA using a retrograde IM nail in severe septic destruction of the ankle joint. Fusion rates and functional outcomes were evaluated as secondary purposes. The clinical and radiologic data of patients who underwent 1-stage TTCA with retrograde IM nail following severe septic destruction of the ankle joint with a minimal follow-up of 2 years were retrospectively analyzed. Reinfection rate, fusion rate, functional outcomes, and complications were evaluated. A total of 25 patients were included with a mean follow-up of 42 months (24-92 months). The mean age was 55 ± 18 years old. At the last follow-up, reinfection occurred in 6 patients (24%) and fusion was obtained in 19 patients (83%). Eight patients (32%) required revision surgery. The mean postoperative modified American Orthopaedic Foot & Ankle Society (AOFAS) score, 12-Item Short Form Health Survey physical and mental component summary scores were respectively 53 ± 19.5, 35.5 ± 11.4, and 46.7 ± 13.5 points. One-stage TTCA with retrograde IM nail appears to be an acceptable alternative in severe septic destruction of the ankle joint, with a high eradication rate of infection and ankle fusion.

Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail

The purpose of this study was to report the results of 52 combined subtalar and ankle arthrodesis using an intramedullary nail. Retrospective review identified 49 patients who had 52 combined ankle and subtalar arthrodeses with an ACE retrograde locked intramedullary humeral nail (DePuy-Ace), Warsaw, IN). Most procedures included bone grafts from the fibula, proximal tibia, or iliac crest or femoral head allograft. Intraoperative complications included one fractured tibia and one fractured medial malleolus. The procedure was done mainly for the treatment of combined ankle and subtalar arthritis (31) or complex hindfoot deformities (12). Outcome was assessed by a combination of chart review, clinical examination, and telephone questionnaire. Followup averaged 34 (8 to 73) months. At followup 82% of patients were satisfied with the results of surgery, 82% reported improvements in pain levels, and 67% reported improved foot function. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 63. Postoperative complications included deep infection, amputation, stress fracture, nonunion, and prominent hardware. Hindfoot arthrodesis with intramedullary nailing is an effective technique for treating complex foot deformities and often is the only alternative to amputation. Patient satisfaction is high, but the procedure is demanding and complications are frequent.

Introduction: The use of outcome assessment scales in scientific studies is necessary so that different treatment forms can be compared among individuals with the same diagnosis. Objectives: This study targeted the translation and validation of the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale into Arabic. Materials and methods: The scale was applied to 93 patients with ankle-hindfoot joint conditions. The patients were also assessed using the SF-36 (Short Form questionnaire-36 items) quality-of-life generic questionnaire and the visual analogue scale (VAS). Results: Pearson’ s correlation coefficient (PCC) was 0.77 (P <0.001). The functional capacity, pain and energy components of SF-36 had the highest correlations (0.71, 0.62 and 0.63, respectively; P <0.001) with the AOFAS Ankle-Hindfoot scale. The PCC between VAS and AOFAS Ankle-Hindfoot scale was inversely proportional (– 0.681; P <0.001). Conclusions: We conclude that the version of AOFAS Ankle-Hindfoot scale for the Arabic language was successfully translated and culturally adapted for application to Arabic patients, with satisfactory reliability and construct validity.

Although intramedullary nailing is a popular method for tibiotalocalcaneal arthrodesis, nonunion is one of the most commonly reported complications. This study aimed to evaluate the fusion rate, improvement in functional outcomes, and occurrence of complications in tibiotalocalcaneal arthrodesis using retrograde intramedullary nailing with partial fibulectomy and onlay bone graft technique. Twenty-six consecutive patients using the proposed technique were retrospectively reviewed. For radiographic outcomes, the union rate, alignment, and any related complications were assessed. Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society hindfoot scale, Foot and Ankle Outcome Score, and visual analog scale, preoperatively and at the final follow-up. The mean follow-up period was 38.2months. The tibiotalar joint achieved complete union in 80.8% at six months postoperatively, while all the cases achieved complete union at 12months postoperatively. However, the subtalar joint achieved complete union in 26.9% at six months postoperatively, which gradually increased to 73.1% at 12months postoperatively, and 80.8% at the final follow-up without revision surgery. A subgroup analysis showed there was a trend of higher subtalar fusion rate when an additional screw for the subtalar joint fixation was placed (86.7% vs. 54.5%). The functional outcomes significantly improved at the final follow-up. A few minor complications occurred, including surgical site infection, irritational symptoms, and metal failure; however, they eventually resolved. Our technique of tibiotalocalcaneal arthrodesis with partial fibulectomy and onlay bone grafting could be a good option where both the tibiotalar and subtalar joints need to be fused.

Danish Language Version of the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) in Patients with Ankle-Related Fractures