American Orthopaedic Foot & Ankle Society Ankle-hindfoot Score Research Articles

Corrective Intra-articular Osteotomy for Malreductions of Tibial Pilon Fractures in Patients Less Than 55 Years Old.

Tibial pilon malreductions are challenging to correctively reconstruct, and the relevant literature is limited. This study aims to assess whether corrective intra-articular osteotomy is worthwhile to treat relatively younger (<55-year-old) patients with intra-articular malreductions of pilon fractures. This is a retrospective observational study with a minimum follow-up of 2 years. From 2013 to 2021, 21 patients (mean age: 39.2 ± 11.2 years) with intra-articular pilon malreductions ≥6 weeks treated with intra-articular osteotomies were analyzed. The median interval time until intra-articular osteotomy was 76 (interquartile range [IQR], 49-149) days. Plain radiographs and computed tomography were used for radiographic assessments. Clinical outcomes were evaluated with visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short-Form Health Survey (SF-36) score, and ankle range of motion (ROM). The median follow-up duration was 34.6 (IQR, 26.1-74.3) months. The median articular displacement was reduced from 12.7 mm preoperatively to 2.7 mm postoperatively (P < .05). According to the Kellgren-Lawrence grading, 16 patients were assigned to stage II, 4 to stage III, and 1 to stage IV. In the 10 patients with available preoperative assessments, substantial improvement was found in the VAS score, from 5.90 to 2.0 at the final follow-up (P < .05). Similarly, the AOFAS ankle-hindfoot score and SF-36 scores improved (P < .05). Ankle ROM did not change a clinically meaningful amount. Progressive degenerative changes were noted in 2 of 10 patients who had adequate preoperative imaging. Four patients had VAS scores ≥4 including 1 patient who is scheduled for an arthrodesis. In this small series, we found that the corrective osteotomies generally provided reasonable improvement at 3 years in patients <55 years old with intra-articular malreduction of pilon fractures. Prospective cohort studies are needed to determine if it is worthwhile in long-term outcome.

Effect of Cigarette Smoking on Postoperative Outcomes After Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

Bone marrow stimulation (BMS) is presently considered first-line surgical treatment for osteochondral lesions of the talus (OLTs); however, some patients still experience pain or dysfunction after surgery, and the reasons for success or failure remain somewhat unclear. This study aimed to investigate the effect of smoking on postoperative outcomes after arthroscopic BMS for OLTs. Consecutive patients with OLTs who underwent BMS between January 2017 and January 2020 were included. Smokers were defined as patients who actively consumed cigarettes before surgery and postoperatively, whereas nonsmokers were patients who never smoked. Visual analog scale (VAS), American Orthopaedic Foot & Ankle Society ankle hindfoot score (AOFAS), Karlsson-Peterson, and Tegner scores were assessed preoperatively and at follow-up. Additionally, a general linear model (GLM) was performed, followed by the interaction analysis to explore the potential influence of smoking. The study enrolled 104 patients with a mean follow-up of 30.91 ± 7.03 months, including 28 smokers and 76 nonsmokers. There were no significant differences in patient age (35.2 ± 10.0 years vs 37.6 ± 9.7 years, P = .282) or OLT area (63.7 ± 38.7 mm2 vs 52.8 ± 37.0 mm2, P = .782). Both univariate analysis and GLM revealed that smoking was associated with worse postoperative pain levels, Karlsson-Peterson, and AOFAS scores (P < .05). The interaction analysis showed a significant interaction between smoking and OLT area for postoperative Karlsson-Peterson scores (general ankle function) (P = .031). Simple main effects analysis revealed that the negative effect of smoking on Tegner score significantly increased among patients >32 years old or with OLT area>50 mm2 (P < .05). Smoking was associated with worse clinical outcomes following BMS of OLTs. As the size of OLTs increased, the difference in general ankle function between smokers and nonsmokers also increased. Furthermore, smokers who were older than 32 years or had larger OLTs were less likely to resume participation in high-level activities.

Midterm Results of AAA Ankle Arthroplasty.

Outcome reports for Alpha Ankle Arthroplasty (AAA), a third-generation implant relying on a mobile bearing design for total ankle replacement, are sparse. This retrospective study evaluated the midterm survivorship, clinical, and radiologic outcomes after implantation of this implant. For 64 patients who received 65 Triple A ankle implants between 2009 and 2020, implant survival was calculated using the Kaplan-Meier curve. Clinical outcomes were evaluated by measuring the range of motion, stability, Western Ontario and McMaster Universities Osteoarthritis Questionnaire score (WOMAC), and American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The average pain level and satisfaction with the postoperative result were rated on a numeric rating scale (0-10). Additionally, radiologic analysis was performed using anteroposterior and lateral radiographs and tibiotalar alignment was assessed. The implant-survival rate was 61.5% at a mean follow-up of 8.2 years. Twenty-five patients (38.5%) required revision surgery (average time to revision, 3.1 years, 95% CI 2.1-4.1 years). For patients without revisions, the average range of motion in dorsiflexion and plantarflexion were 3.6 ± 4.2 degrees and 21.9 ± 7.8 degrees, respectively. The mean WOMAC and AOFAS scores were 44.7 ± 47.5 and 75.1 ± 14.0, respectively. The average pain and subjective satisfaction scores were 2.0 ± 1.7 and 8.5 ± 1.9, respectively. Mean alignment values did not differ significantly for patients who required revision surgery. We found a high revision rate with use of the AAA. However, patients who did not require revision surgery had, on average, high satisfaction and good functional outcomes. Level IV, case series.

Posterior pilon fracture treated by opening the fibula fracture gap

BackgroundPosterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL).MethodsA retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS).ResultsThe overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05).ConclusionThe trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome.Trial registration: Retrospective registration.

Prognostic value of the Haraguchi classification in posterior malleolar fractures in A0 44-C type ankle fractures

Background and purposeIncidence of posterior malleolar fractures (PMFs) associated with ankle fractures is historically based on plain radiographs. Several classification systems for PMF are currently in use, but the reliability of the Haraguchi classification is not reported.The aim of this diagnostic cohort study was to assess incidence of PMF in patients with AO 44-C fractures, and test the reliability of the Haraguchi fracture classification based on CT. In addition, to evaluate the clinical outcome in patients with PMF. Methods210 patients with an AO 44-C type fracture treated with syndesmotic fixation between 2011 and 2017 were included. Presence of PMF was registered, morphology was assessed and classified according to the Haraguchi classification. Interobserver agreement for the Haraguchi classification was evaluated. Patient assessment was conducted at 6 weeks, 6 months, 1 and 2 years. The American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) was the primary outcome measure. Secondary outcome measures included presence of osteoarthritis. Results125 of 210 patients (60%) had a PMF. 34% of the PMFs were missed on plain radiographs compared to CT. The interobserver agreement was 0.797, (95% CI: 0.705 to 0.889, p < 0.001), for the Haraguchi classification. The 2-year follow-up rate was 86%. Haraguchi type II fractures had a lower AOFAS compared with the no-fracture group at 6 weeks (mean difference -7.5 (95% CI; -15.0 to -0.2), p = 0.04) and 6 months (mean difference -8.4 (95% CI; -15.3 to -1.5), p = 0.01). Presence of osteoarthritis was higher in patients with Haraguchi type II PMF compared to the no PMF group, this finding was not significant (relative risk (RR) 1.6(95% CI 1.1 to 2.4, p = 0.059)). ConclusionsPlain radiographs underestimated PMF. Patients with a Haraguchi type II fracture had a poorer outcome measured by the AOFAS score compared to no PMF up until 6 months. Classification of PMF according to the Haraguchi classification was reliable.

Significantly Better Efficacy for Acute Ankle Gouty Arthritis Through Arthroscopic Debridement Compared With Simple Drug Therapy: A Longitudinal Study With 1-Year Follow-up.

The aim of this study was to compare the clinical feasibility, efficacy, and cost economics of simple drug therapy with a combination therapy of arthroscopic debridement and drug treatment of ankle acute gout arthritis. Patients with acute ankle gout arthritis hospitalized in our department from January 2017 to August 2019 were included. Among them, 32 patients who received arthroscopic debridement in a special floating position and drug therapy were included into the observation group, and 24 patients who received drug treatment alone were included into the control group. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the effective rate, the recurrent rate, stay of hospital, complications, and cost economics were compared between these 2 groups at postoperative 48 hours, discharge time, and 1 year. The basic data and AOFAS ankle-hindfoot score before treatment showed no significant difference (p > 0.05) between these 2 groups. Compared with the control group, the observation group showed significantly higher AOFAS score at postoperative 48 hours (80.73 ± 9.15 vs 71.09 ± 8.54, p = 0.000), discharge time (87.73 ± 9.92 vs 77.71 ± 10.26, p = 0.000), and postoperative 1 year (85.92 ± 10.39 vs 76.36 ± 8.72, p = 0.000); lower recurrence rate (15.63% vs 25%, p = 0.382); significantly shorter length of hospitalization (4.92 ± 0.88 days vs 8.90 ± 0.73 days, p = 0.000); and significantly higher cost (¥8981.2 ± ¥740.2 vs ¥3558.3 ± ¥270.1, p = 0.000) during the discharge time. Ankle gout arthritis could be systematically and safely managed with ankle arthroscopic technique in special floating position. In addition, compared with conservative drug therapy alone, ankle arthroscopic debridement combined with conservative drug therapy improved clinical efficacy, lowered recurrence rate, and shortened length of hospitalization.

A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture

The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.

Addressing Hindfoot Arthritis with Concomitant Tibial Malunion or Nonunion with Retrograde Tibiotalocalcaneal Nailing

Tibial malunions and nonunions are associated with degenerative changes about the ankle. A comprehensive literature review revealed no articles discussing treatment options for patients with tibial shaft malunion and ipsilateral ankle arthritis. The aim of our study was to evaluate a series of patients in whom tibial osteotomy and retrograde tibiotalocalcaneal nailing were used to treat both tibial deformity and ankle osteoarthritis. Twenty-five patients underwent retrograde tibiotalocalcaneal nailing with concomitant realignment tibial osteotomy with takedown of the nonunion or malunion in a single procedure. All surgical procedures were performed by a single surgeon at a single institution. Baseline patient characteristics (age, sex, body mass index [BMI], preoperative diagnosis, and prior surgical procedures) were recorded. Data including visual analog scale (VAS) pain scores (0 to 10, with 0 indicating no pain and 10 indicating worst pain) and American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores were prospectively collected at the preoperative evaluation and the time of final follow-up, and patients were asked about their final satisfaction. Preoperative VAS scores averaged 8.3 (range, 7 to 10) of 10, which improved to an average of 2.8 (range, 0 to 6) at the time of final follow-up (p < 0.01). The preoperative AOFAS-AH scores averaged 43 (range, 18 to 62) of 100 and improved to 76 (range, 57 to 84) at the time of follow-up (p = 0.022). Twenty-one patients (84%) stated that they were extremely satisfied with the result of the procedure, three patients (12%) were satisfied, and one patient (4%) with a poor result was unsatisfied. Tibial malunion or nonunion with concomitant hindfoot arthritis can be addressed with a single-stage procedure consisting of tibial osteotomy and retrograde intramedullary nailing for correction of the angular deformity and hindfoot fusion. This procedure provides a viable alternative to multiplanar external fixation or a staged procedure addressing the nonunion or angular deformity and the hindfoot arthritis separately.