American Orthopaedic Foot & Ankle Society Hindfoot Score Research Articles

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis.

The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition. Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients. In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36. The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning. Level IV, case series.

Management of Failures of Total Ankle Replacement with the Agility Total Ankle Arthroplasty

Few studies have focused on treatment following failed total ankle replacement. The purpose of this study was to report the outcomes of patients undergoing revision total ankle replacement and to propose a talar component subsidence grading system that may be helpful in making decisions regarding how to revise failed total ankle replacements in the future. A retrospective review was performed of fifty-three patients who underwent revision total ankle replacement and had been followed for a minimum of two years. Patients were assessed radiographically and with outcome scores. The rates of conversion to amputation or fusion were also assessed. The mean follow-up period was 49.1 months after the revision arthroplasty. The average time from primary total ankle replacement to revision was fifty-one months. Forty-one of the fifty-three patients (77%) were available for follow-up. The revision arthroplasty had been converted to an arthrodesis in five of the forty-one patients, and two additional patients had undergone amputation. The most common indication for revision total ankle replacement was talar subsidence (63%; twenty-six of forty-one). Twenty-two patients (54%) had a subtalar arthrodesis performed at the time of the revision arthroplasty, with nineteen of those having a custom-designed long-stem talar component placed simultaneously. The mean radiographic measurements of component position did not change significantly postoperatively. The mean postoperative scores for the thirty-four patients with a retained total ankle replacement were: 4.4 of 10 possible points on a visual analog pain scale (VAS), 65 of 100 possible points on the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, 93.5 of 100 possible points on the Short-Form 12 (SF-12), 137.9 of 204 possible points on the Revised Foot Function Index (FFI-R), and 64 of 180 possible points on the Ankle Osteoarthritis Scale (AOS). The mean arc of motion radiographically was 18° preoperatively and 23° postoperatively, with all improvement occurring in plantar flexion. A lesser amount of preoperative talar subsidence was a significant predictor of a good outcome based on the AOFAS hindfoot score (p < 0.03) and the AOS (p < 0.01) score. Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant.

Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome

Background and aimOpen reduction and internal fixation (ORIF) of intra-articular calcaneal fractures through an extended lateral approach is frequently accompanied by a high complication rate. However, ORIF currently provides the best long-term clinical results. The aim of this study was twofold: (1) to evaluate both mid- to long-term clinical and radiological results of a consecutive series treated by ORIF and (2) to determine the influence of short-term complications on long-term clinical outcome. MethodsPatients with a displaced intra-articular calcaneal fracture, treated with ORIF, through an extended lateral approach, in a level-2 trauma centre between 1995 and 2008 were evaluated for the study. The long-term functional outcome (American Orthopaedic Foot & Ankle Society (AOFAS), 36-Item Short-Form Health Survey (SF-36) and Visual Analogue Scale (VAS)) and radiographic results (e.g., Böhler and Gissane angle, height, width and joint reduction) were determined. Short- and long-term complications were documented. ResultsA total of 57 patients matched the inclusion criteria, from which 39 patients agreed to participate in this study (68%). The median follow-up was 6.5 years (range 2–16 years). Based on the AOFAS hindfoot score, 74% of the patients had a good-to-excellent long-term clinical result. Radiological results were satisfying with a median postoperative Böhler angle of 26° and 25° at follow-up. Complications occurred in 32% of all patients; mainly wound-healing problems were noted. Short-term complications did not influence mid- to long-term clinical results (p>0.05). Anatomic reconstruction of the calcaneus was associated with improved long-term clinical results (p<0.05). ConclusionDespite the high complication rate following ORIF of a calcaneal fracture, complications do not affect mid- to long-term clinical outcome. Surgical treatment should focus on restoring the anatomy.Level of evidence: Therapeutic level IV.

Tibiotalocacaneal arthrodesis by lateral malleolus osteotomy and fixation with proximal humeral internal locking system

Objective To discuss the clinical outcome of tibiotalocalcaneal arthrodesis using lateral malleolus osteotomy and fixation with proximal humeral internal locking system (PHILOS). Methods From December 2008 to March 2010,11 patients with ankle arthritis were treated by tibiotalocalcaneal arthrodesis.They were 7 men and 4 women with an average age of 48.1 years (from 33 to 67 years).There were 6 cases of post-traumatic arthritis,3 cases of osteoarthritis and 2 cases of avascular necrosis of talus.The average disease duration was 2 years (from 1 to 3 years).Three patients were complicated with ankle varus and one patient with ankle valgus.According to the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system,the preoperative ankle and hindfoot scores averaged 45.5 ± 11.1 points(from 30 to 64 points).Lateral malleolus osteotomy and internal fixation with PHILOS were performed in all patients. Results Superficial wound infection occurred in one patient which was cured after dressing changes.The other incisions healed by first intention without complications.Ten patients were followed up for 24 months on average (from 12 to 36months).The X-ray films showed that hone fusion was obtained at 12 weeks postoperation (from 10 to 16weeks) on average. The symptoms were relieved completely,without complications of implant failure,nonunion or malunion,in all patients at the last follow-up.The postoperative AOFAS ankle and hindfoot score at the last follow-up was 80.1 ± 7.4 points,significantly higher than the preoperative one ( t =27.101,P =0.000). Conclusion Tibiotalocalcaneal arthrodesis with lateral malleolus osteotomy and PHILOS fixation is technically simple and easy to handle,but it can provide rigid fixation and result in a high fusion rate and a good clinical outcome. Key words: Arthrodesis; Osteoarthritis, ankle; Ankle injuries

Arthroscopic Treatment of Osteochondral Lesions of the Ankle With Matrix-Associated Chondrocyte Implantation

Background: Conventional autologous chondrocyte transplantation in the ankle often requires tibial or fibular osteotomies with potential morbidity for the patient. Advances in biotechnology and surgical techniques have resulted in the development of matrix-associated chondrocyte implantation (MACI). As the chondrocyte-loaded scaffold can be applied arthroscopically, this procedure is especially useful for the treatment of osteochondral defects in the ankle. Hypothesis: Arthroscopic MACI is a safe procedure in the ankle with good clinical and magnetic resonance imaging results. Study Design: Case series; Level of evidence, 4. Methods: The authors reviewed all patients (n = 18) who had arthroscopic MACI for osteochondral lesions of the ankle (n = 19) between February 2006 and May 2008 clinically and with magnetic resonance imaging. The pain and disability module of the Foot Function Index (FFI), the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating system, the Core Scale of the Foot and Ankle Module of the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Outcomes Assessment Instruments, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score were used. The clinical results up to 3 years after MACI (mean follow-up, 24.5 months) were compared with preoperative data for 14 cases and the magnetic resonance imaging data for all 19. Results: A significant improvement (50.3% ± 13.2%) in all clinical scores was noted (FFI pain before MACI: 5.5 ± 2.0, after MACI: 2.8 ± 2.2; FFI disability before MACI: 5.0 ± 2.3, after MACI: 2.6 ± 2.2; AOFAS before MACI: 58.6 ± 16.1, after MACI: 80.4 ± 14.1; AAOS standardized mean before MACI: 59.9 ± 16.0, after MACI: 83.5 ± 13.2; AAOS normative score before MACI: 23.0 ± 13.0, after MACI: 42.2 ± 10.7). According to the AOFAS Hindfoot score, 64% were rated as excellent and good, whereas 36% were rated fair and poor. The results correlated with the age of the patient and the duration of symptoms, but not with the size of the lesion. Sixteen patients (89%) reported regular sports activities before the onset of symptoms; 13 of them (81%) returned to sports after the MACI, 56% (n = 9) to the same level. The mean MOCART score was 62.4 ± 15.8 points. In general, there was no relation between MOCART score and clinical outcome, although the filling of the defect showed some correlation with the AAOS score. Conclusion: Arthroscopic MACI is a safe procedure for the treatment of osteochondral lesions in the ankle with overall good clinical and magnetic resonance imaging results.

Surgical treatment for malunion of intra-articular calcaneal fractures

Objective To report the techniques and clinical results of surgical treatment of malunion of intra-articular calcaneal fractures. Methods From February 2003 to December 2007, 49 cases of malunited intra-articular caleaneal fractures were treated and followed up. The patients underwent lateral wall exostosectomy or subtalar arthrodesis according to their complaints and their types of deformity. The subtalar joint was either fused in situ or with bone graft following distraction depending on the severity of deformity. Osteotomy in the calcaneal body was done simultaneously to correct the residual deformity, if any. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Scores were used to evaluate the clinical outcome. Results All the patients were followed up for a mean time of 18.4 months. The average healing time for subtalar fusion was 12.8 weeks. Postoperatively, the average talocalcaneal height, talar declination angle, talocalcaneal angle, and calcaneal pitch angle improved significantly compared with the preoperative values. The mean AOFAS Hindfoot Score increased from 25.7±4.3 points preoperatively to 74.9±4.8 at the final follow-up. Conclusions The surgical treatment of malunion of intra-articular calcaneal fracture should be based on the preoperative clinical and radiographic evaluations while individual scheme made ac-cording to the foot deformity and the patient' s expectation. Lateral wall decompression, subtalar arthrodesis and correction of the hindfoot varus/valgus deformity are keys to successful surgical treatment. Key words: Calcaneus; Fracture; Fracture healing; Abnormalities; Surgical treatment