Degenerative Ankle Research Articles

Ankle and Foot Arthroplasty and Prosthesis: A Review on the Current and Upcoming State of Designs and Manufacturing.

The foot and ankle serve vital roles in weight bearing, balance, and flexibility but are susceptible to many diverse ailments, making treatment difficult. More commonly, Total Ankle Arthroplasty (TAA) and Total Talus Replacement (TTR) are used for patients with ankle degeneration and avascular necrosis of the talus, respectively. Ankle prosthesis and orthosis are also indicated for use with lower limb extremity amputations or locomotor disability, leading to the development of powered exoskeletons. However, patient outcomes remain suboptimal, commonly due to the misfitting of implants to the patient-specific anatomy. Additive manufacturing (AM) is being used to create customized, patient-specific implants and porous implant cages that provide structural support while allowing for increased bony ingrowth and to develop customized, lightweight exoskeletons with multifunctional actuators. AM implants and devices have shown success in preserving stability and mobility of the joint and achieving fast recovery, as well as significant improvements in gait rehabilitation, gait assistance, and strength for patients. This review of the literature highlights various devices and technologies currently used for foot and ankle prosthesis and orthosis with deep insight into improvements from historical technologies, manufacturing methods, and future developments in the biomedical space.

Spontaneous Radiographic Improvement of a Large Cystic Osteochondral Lesion of the Talar Shoulder Following Realignment Surgery for Symptomatic Improvement

Category: Sports; Ankle Introduction/Purpose: Treating patients with a large cystic osteochondral lesion of the talar shoulder and concurrent radiographic evidence of foot and ankle malalignment is a clinical challenge. Differentiating the origin of pain in such a situation is not always straightforward, and surgical treatment for both conditions at the same time can complicate the surgery. It has been suggested that unaddressed malalignment can lead to an unfavorable result after osteochondral lesion of the talus (OLT) surgery, but the isolated effect of realignment surgery on OLT patients has not been elucidated. Therefore, the purpose of this study was to evaluate the outcomes of realignment surgery for symptomatic relief in patients with a large cystic OLT of the talar shoulder with concurrent malalignment of the foot and ankle. Methods: This retrospective study reviewed 27 patients (mean age: 34.4 years) with large cystic OLTs (>10mm in diameter) of the talar shoulder who underwent realignment surgery. Patients were excluded if they had plain radiographs suggestive of degenerative ankle arthritis, or less than 2 years of follow-up. Patients' symptoms prior to surgery were categorized by location and character. The types of realignment procedure were determined by a senior surgeon based on the patients' symptoms and radiographic findings from plain x-rays and weightbearing computed tomography. None of the included patients underwent any type of cartilage repair or replacement procedures during the realignment surgery. Clinical improvement was assessed using the foot function index (FFI) and visual analogue scale (VAS). The location of the OLTs was categorized into 9-Raikin zones, and the size of the OLTs was measured and compared pre- and postoperatively using previously described methods. Results: There were 25 patients with a medial lesion (zone 4 [n=19]; zone 7 [n=5]; zone 1 [n=1]) and two with a lateral lesion (zone 6). Despite the location of the OLT, patients' symptoms varied, with 13 experiencing diffuse medial and lateral pain, 13 experiencing lateral pain, and 1 experiencing anteromedial pain as their primary location of pain. Supramalleolar osteotomy (SMO) was performed in 18 patients (medial open-wedge [n=17] and dome-type [n=1]), while hindfoot correction without SMO was done in 9 patients. Postoperatively, both the FFI and VAS scores significantly improved. The mean preoperative size of cystic lesion was 32.9mm3 (range, 12.6-79.6), and there was a significant decrease in size to 16.3mm3 (range, 0-40.1) postoperatively. During the follow-up period, no subsequent surgery for OLT was necessary. Conclusion: We found that the main location of pain does not always match with the location of OLT in this selected cohort. Our study results suggest that realignment procedures can improve symptoms and contribute to a decrease in size of the osteochondral lesion in patients who demonstrate a large cystic OLT of the talar shoulder and malalignment of the foot and ankle at the same time. Addressing malalignment primarily in such patients can potentially minimize the risk of morbidities or complications associated with procedures involving replacement surgery for the large cystic OLTs of the talar shoulder.

Lateral Chronic Ankle Instability: A Brief Review

Abstract Lateral ankle sprain (LAS) is considered “an acute traumatic injury to the lateral ligament complex of the ankle joint as a result of excessive inversion of the rear foot or a combined plantar flexion and adduction of the foot”. Chronic ankle instability (CAI) is characterized by a history of one significant LAS, subsequent recurrent sprains, episodes of the ankle giving way, or self-reported deficits in ankle function for >1 year following the initial sprain. If untreated, instability may lead to cartilage deterioration and end in degenerative ankle disease. The objective of this review is to provide recent scientific evidence on CAI. Through this article, we have tried to put some light upon a problem that causes significant morbidity to the patient by compilation of the available evidence-based concepts. The need for this article is as there is the absence of a generalized treatment algorithm, the presence of various treatment modalities, the presence of two schools of opinion regarding treatment, and the absence of comprehensive text. Years of research have identified numerous impairments associated with CAI such as decreases in range of motion, strength, postural control, and altered movement patterns during functional activities when compared to individuals with no LAS history. As a result, an impairment-based rehabilitation model was developed to treat the common impairments associated with CAI. The impairment-based rehabilitation model has been shown to be an effective rehabilitation strategy at improving both clinical and patient-oriented outcomes in patients with CAI. We have reviewed the current literature regarding diagnosis, imaging, conservative methods, surgical approaches, and rehabilitation protocols.

Syndesmotic Reduction Landmarks in Healthy Ankle Patients, Comparative Analysis of Weight- Bearing Computed Tomography

Category: Ankle Introduction/Purpose: Introduction: The diagnosis of low-energy syndesmotic injuries continues to be a challenge, and there is no standard for it. Being the dynamic exams, the ones with the best performance. With the development of Weight-Bearing computerized tomography (WBCT), the understanding of their lesion patterns has improved, however, there is high variability in the syndesmotic anatomy between different individuals, with asymmetry parameters in up to 89% of healthy syndesmosis. therefore the best element to evaluate them is the healthy contralateral ankle and compare these parameters. However, what are the normal values in our population, or the possible anatomical differences according to different age groups, in the morphology of the syndesmal notch of our patients, nor that there is a real symmetry between both ankles. Methods: Retrospective analysis of comparative bilateral ankle WBCT in healthy patients from March 2018 to July 2021 according to the parameters: anterior, posterior and central syndesmal distance, fibular rotation, sagittal translation and area. All patients with comparative bilateral ankle weight-bearing CT taken since January 2018 to August 2021, patients without history of ankle injuries, were included in the analysis. That have required a comparative bilateral WBCT to study another pathology. Patients with a history of acute or chronic ankle or syndesmal injuries, patients with degenerative ankle joint injuries, with severe misalignments > 10° in varus or valgus, incomplete or non-comparative study were excluded. Results: 150 patients with comparative bilateral WBCT were evaluated. Among the ankles evaluated with WB CT in a comparative manner, it is established that there were no significant differences between both ankles of subjects with healthy ankles (Wilcoxon Test) in anterior syndesmal distance (SD), posterior SD, central SD, syndesmal area (p > 0.05). While fibular rotation and sagittal translation showed significant differences between the measurements in healthy ankles, evaluated with comparative bilateral WB CT in independent evaluations (p < 0.05). Regarding the differences by age range established for the different syndesmotic reduction parameters, for the different subgroups of patients under 40 years of age, 40 and 60 years of age and over 60 years of age, no significant differences were generated between them (Wilcoxon test). Conclusion: We have established normal ranges for measurements in the syndesmal anatomy in axial slices during weight bearing CT, as well as that there are no differences between the right and left ankle in healthy ankles in anterior, posterior and central syndesmal distance, or syndesmal area. Being these parameters, the most suitable as internal control for patients with suspected syndesmotic injury regardless of the age of the patients.

Total ankle arthroplasty with the use of Zimmer prosthesis and a review of the results of previous research conducted in this field.

The aim of this article is to describe surgical technique and early results of Total Ankle Replacement (TAR) from lateral approach using Zimmer TM prosthesis. The study uses theoretical knowledge which is the result of research conducted by other authors, and practical knowledge due to the fact that our center performs that type of operation. Arthrodesis as the current standard in the treatment of advanced degenerative ankle disease, apart from its advantages, also has many disadvantages. The relative durability and reduction of the patients' pain have been achieved at the expense of the adjacent joints. Their accelerated arthrosis is the result of compensatory loads as a consequence of change in foot biomechanics. That determined implementation of solutions that will guarantee elimination of pain in the ankle joint, preserve its motor function and improve gait, while having no negative impact on the mobility of adjacent joints.

Posterior malleous fixation in trimalleolar ankle fractures using anterior to posterior screw versus posterolateral plate

Introduction: Posterior malleolar fractures are observed in approximately 7%-44% of all ankle fractures. Due to the important biomechanical function of the posterior tibial margin in weight-bearing and ankle stability, the affected ankle is prone to degenerative ankle arthritis. In ankle fractures involving the posterior malleolus, the issue of which type of fractures require posterior malleolus fixation is still controversial, suggesting that a trans-syndesmotic fixation may be adequate instead of posterior malleolar fixation. Objective: This study compares the anterior to posterior screw versus posterolateral plate for posterior malleous fixation in trimalleolar ankle fractures. Material and Methods: This study was conducted in patients with trimalleolar ankle fracture admitted in a tertiary level health care centre.It is a Prospective, randomized comparative study. Patients were randomized into two groups by using computerized random no. table and subsequent pt. was allocated in alternative groups /In group A fixed with anterior to posterior screw was done by an identified orthopedic surgeon. In group open reduction internal fixation with posterolateral plate fixation. Patients were examined for clinical and radiological, union, bone strength, weight bearing, deformity and range of motion at 2wks, 6wks, till 6 months. Results: Forty six patients were evaluated in this study and were divided in two groups accordingly. Group A = Anterior to posterior leg screw and Group B = Postero-lateral Plate. Evidence of union in X-ray seen after 18.80±1.92 weeks of operation in group-A and 20.16±2.01 weeks in group-B. In terms of functional result, 28.00% patients were excellent, 58.00% patients were good and 14.00% patients were poor in group-A. 40.00% patients treatment results were excellent, 50.00% patients treatment results were good and 10.00% patients treatment results were poor in group-B. Conclusion: These results demonstrate that posterior malleolar fracture fixation is closely related to successful radiological and functional outcomes after trimalleolar fractures. Transyndesmal screw fixation may not be needed in the cases where the posterior malleolar fracture fixated. For these reasons, we recommend that all posterior malleolar fractures have to be fixed regardless of size.

Coronal Plane Deformity and Total Ankle Replacement: When to Stage with Cement Spacer Ankle Arthroplasty for Deformity Correction

Category:Ankle ArthritisIntroduction/Purpose:Degenerative ankle joint disease is a debilitating condition that causes significant pain, adversely affects function and quality of life. Though primary arthritis of the ankle can occur without deformity, frequently soft tissue imbalances or joint deformities complicate the clinical picture. Often, additional procedures are required to balance the foot and ankle during the index total ankle replacement procedure. When large deformities exist a staged approach to first, align the ankle joint to neutral as stage one and then implantation of the TAR as stage two can be deployed. This paper will further popularize the cement spacer staged TAR technique in correction of coronal deformities, share a clinical algorithm on approach, and depict a case series demonstrating its application.Methods:A case series was performed of 7 patients and 8 ankles, who underwent staged primary TAR utilizing a cement spacer to assist with deformity correction, between the years 2016-2019.Results:Patients' mean age 58.5 yrs., preoperative varus coronal plane deformity mean 19.1 degrees, preoperative valgus coronal plane mean 10.25 degrees. Mean time from stage 1 till 2 was 163.5, +-140.2 days. Stage 1 soft tissue procedures: Chrisman-Snook procedure with synthetic ligament graft, Brostrum-Gould with synthetic graft, Brostrum-Gould without graft, FDL transfer, and isolated medial release/peel. Osteotomies performed during stage one: Dwyer, MDCO, Cotton, and MDCO with medial malleolus osteotomy. Fusions performed during stage one consisted: Subtalar joint, talonavicular joint (TNJ), and STJ with 1st Metatarsophalangeal joint (MTPJ). Seven ankles were replaced with Cadence Total Ankle System (Integra), and one with INBONE II (Wright Medical Technology). Average follow-up time for included patients was 290.75 days (9.7 months). One revision was performed following index TAR procedure.Conclusion:This paper describes a cement wedge spacer staged total ankle arthroplasty technique for correction and stabilization of deforming forces at the ankle joint. While not all ankle deformities necessitate a staged approach, the complexity of the malalignment and the extent of tissue disruption needed to achieve a neutral ankle should be considered when correcting a given deformity with a staged or non-staged approach.

Effects Of Toe-in/ Out Toe-in Gait And Lateral Wedge Orthoses On Lower Extremity Joint Kinetics.

PURPOSE: The aim of the current investigation was to examine the effects of both lateral orthoses and toe-in/ toe-out foot progression angles on lower extremity joint loading during walking using a musculoskeletal simulation approach. METHODS: The current investigation examined 15 healthy males, walking in six different conditions (neutral, lateral orthoses, toe-in, lateral toe-in, toe-out and lateral toe-out). Walking kinematics were collected using an eight-camera motion capture system, and kinetics via an embedded piezoelectric force plate. Lower extremity joint loading was explored using a musculoskeletal simulation approach. RESULTS: This investigation showed that peak patellofemoral joint stress was greater in the neutral (3.96 KPa/BW) and lateral orthoses (4.20 KPa/BW) conditions compared to toe-in (3.33 KPa/BW), lateral toe-in (3.43 KPa/BW), toe-out (3.35 KPa/BW) and lateral toe-out (3.53 KPa/BW) and ankle joint impulse larger in the toe-in (1.65BW·s) and toe-out (1.62BW·s) foot progression angle modalities compared to neutral (1.51BW·s) and lateral orthoses (1.53BW·s). Furthermore, it was also shown that medial tibiofemoral impulse was statistically greater in the toe-in (1.20BW·s) and lateral toe-in (1.15BW·s) conditions compared to neutral (1.07BW·s), lateral orthoses (1.07BW·s), toe-out (1.09BW·s) and lateral toe-out (1.05BW·s). CONCLUSIONS: Therefore, the current investigation provides evidence that altering the foot progression angle may attenuate the risk from patellofemoral disorders whilst simultaneously enhancing the risk from degenerative ankle pathologies. Similarly, adopting a toe-in foot progression angle may also increase the risk from medial tibiofemoral degeneration.

Effects of toe-in/ out toe-in gait and lateral wedge orthoses on lower extremity joint kinetics; an exploration using musculoskeletal simulation and Bayesian contrasts

IntroductionThe aim of the current investigation was to examine the effects of both lateral orthoses and toe-in/ toe-out foot progression angles on lower extremity joint loading during walking using a musculoskeletal simulation approach.MethodsThe current investigation examined 15 healthy males, walking in 6 different conditions (neutral, lateral orthoses, toe-in, lateral toe-in, toe-out and lateral toe-out). Walking kinematics were collected using an eight-camera motion capture system, and kinetics via an embedded piezoelectric force plate. Lower extremity joint loading was explored using a musculoskeletal simulation approach.ResultsThis investigation showed that peak patellofemoral joint stress was greater in the neutral (3.96 kPa/BW) and lateral orthoses (4.20 kPa/BW) conditions compared to toe-in (3.33 kPa/BW), lateral toe-in (3.43 kPa/BW), toe-out (3.35 kPa/BW) and lateral toe-out (3.53 kPa/BW) and ankle joint impulse larger in the toe-in (1.65BW·s) and toe-out (1.62BW·s) foot progression angle modalities compared to neutral (1.51BW·s) and lateral orthoses (1.53BW·s). Furthermore, it was also shown that medial tibiofemoral impulse was statistically greater in the toe-in (1.20BW·s) and lateral toe-in (1.15BW·s) conditions compared to neutral (1.07BW·s), lateral orthoses (1.07BW·s), toe-out (1.09BW·s) and lateral toe-out (1.05BW·s).Conclusions Therefore, the current investigation provides evidence that altering the foot progression angle may attenuate the risk from patellofemoral disorders whilst simultaneously enhancing the risk from degenerative ankle pathologies. Similarly, adopting a toe-in foot progression angle may also increase the risk from medial tibiofemoral degeneration.

Clinical-radiological outcomes and complications after total ankle replacement through a lateral transfibular approach: a retrospective evaluation at a mid-term follow-up.

Degenerative ankle arthropathy is a debilitating and increasingly widespread condition with worsening of quality of life. In last years, total ankle replacement has increased indications, thanks to advances in surgical technique, materials and design that provided new solutions for surgeons. The purpose of this study is to evaluate the effectiveness of total ankle replacement (TAR), implanted using a trans-fibular lateral approach in patients with high-grade degenerative arthropathy, in terms of clinical, functional and radiological outcomes and possible complications. This retrospective study included 73 patients, aged between 47 and 79years (mean age 61.7 ± 14.2years), who underwent trans-fibular total ankle arthroplasty. All patients were followed up for at least two years post-operatively with mean follow-up 31.2 ± 8.1months and have been evaluated clinically and radiographically both pre-operatively and post-operatively. Patients demonstrated a significant improvement in average AOFAS score, SF-36 score and VAS scale. Average plantarflexion improved from 9.9° ± 4.2 to 18.4° ± 6.3 and dorsiflexion from pre-operative mean value of 6.8° ± 5.8 to 17.2° ± 3.1 post-operative. Complications recorded in our series were 16 (21.9%), specifically 2 major complications and 14 minor complications. This study found that trans-fibular total ankle replacement is a safe and effective option for patients with ankle osteoarthritis, resulting in improvement of patient-reported outcomes, range of motion, and radiographic parameters. However, further studies are required to determine long-term performance of these implants.

The early functional results after total ankle replacement

Cilj: Totalna endoproteza (TEP) gležnja ugrađuje se kod uznapredovalog stadija osteoartritisa gležnja s ciljem održavanja bezbolnog, stabilnog i pokretljivog zgloba. Cilj je ovog istraživanja bio analizirati rane funkcionalne rezultate nakon ugradnje TEP-a gležnja. Ispitanici i metode: Ispitana je skupina od 18 pacijenata s ugrađenim TEP-om gležnja. Prosječna dob pacijenata bila je 62 godine. Kod 12 pacijenata radilo se o sekundarnom obliku osteoartritisa gležnja na osnovi prethodne ozljede, a kod 6 o primarnom osteoartritisu gležnja. Svi su pacijenti kirurški liječeni u Klinici za ortopediju Lovran u razdoblju od 2013. do 2016. godine, a ispitivanje je provedeno uz pomoć anketnog lista institucije American Academy of Orthopedic Surgeons (AAOS), vizualne analogne ljestvice (VAS) bola i goniometra. Rezultati: Dobiveni rezultati pokazali su značajno poboljšanje u funkcionalnom stanju gležnja, kao i u njegovoj pokretljivosti. Prijeoperacijski rezultati AAOS-ova anketnog lista iznosili su 30,34, dok su poslijeoperacijski iznosili 70,01 bodova. Prosječni je opseg pokreta gležnja prije operacije bio 16,11°, a poslijeoperacijski 30,26°. Također se pokazalo da je intenzitet bola nakon ugradnje endoproteze gležnja značajno manji. Prijeoperacijski je prosječna razina VAS-a bola bila 7,83, a poslijeoperacijski 3,5. Zaključak: Rezultati ove studije potvrđuju uspješnost ugradnje TEP-a gležnja u pacijenata s uznapredovalim osteoartritisom gležnja.

Hindfoot endoscopic release of the posterior ankle capsuloligamentous structures improves ankle dorsiflexion range, function and pain in patients with painful limitation of ankle dorsiflexion

ObjectiveTo evaluate the effect of arthroscopic release of the posterior capsuloligamentous structures on ankle dorsiflexion and function in patients with painful limitation of ankle dorsiflexion.MethodsA prospective consecutive case series of 13 adult patients with painful limitation of ankle dorsiflexion were included. None had clinically relevant gastrocnemius, soleus or Achilles contracture. Patients with anterior bony impingement or ankle degeneration on CT scan were excluded. All patients underwent combined anterior and posterior ankle arthroscopies with resection of posterior capsuloligamentous structures and the posterior fibulotalocalcaneal ligament. Ankle range of motion was assessed 2 years postoperatively. Foot and Ankle Outcome Scores (FAOS) were used to assess functional outcome.ResultsThe median patient age at surgery was 26 years (range 19–44). At 2 years postsurgery, the ankle dorsiflexion range had increased by 15 degrees (range 0–25, p<0.0001). FAOSs completed at a median of 44 months postsurgery (range 26–72) significantly improved. Median improvements were 19 points for pain (range 6–67, p=0.0004), 14 points for symptoms (range 0–36, p=0.0005), 15 points for activities of daily living (range 6–35, p<0.0001), 45 points for sport (range 20–55, p<0.0001) and 50 points for quality of life (range 13–62, p<0.0001).ConclusionsHindfoot endoscopic release of the posterior ankle structures, including the posterior fibulotalocalcaneal ligament, is an effective technique for improving ankle dorsiflexion range in patients with painful limitation of ankle dorsiflexion.Level of evidenceIV.

Degenerative Pathology of the Ankle, Hindfoot, and Midfoot is as Limiting to Patient Mobility as Congestive Heart Failure

Category:Ankle, Ankle Arthritis, Hindfoot, Midfoot/ForefootIntroduction/Purpose:Degenerative conditions of the ankle, hindfoot, and midfoot can markedly limit mobility. The Life-Space Assessment (LSA) is a questionnaire quantifying how patients mobilize after a medical event as they return to their previous daily settings. Current outcome measures do not accurately assess mobility in the geriatric foot and ankle population. In contrast, the effect of congestive heart failure (CHF) on patient mobility is routinely assessed via the New York Heart Association (NYHA) functional classification. The NYHA classification is stratified by limitation of physical activity: I (no limitation), II (some limitation), III (marked limitation), and IV (unable to carry out without discomfort). We hypothesized that degenerative conditions of the foot and ankle would be as mobility limiting as CHF.Methods:Patients over the age of 50 were included in this study. LSA data was prospectively collected from patients with degenerative ankle, hindfoot, and midfoot diagnoses at their preoperative visit and NYHA-classified CHF patients at a cardiology clinic. The degenerative foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and comorbidities were recorded from the electronic medical record. Mean LSA data was analyzed and compared using a Student’s t-test.Results:28 degenerative foot and ankle patients and 44 CHF patients met inclusion criteria for the study. Patient demographics, including age, gender, and BMI, were not significantly different between the two groups. The foot and ankle cohort had a mean LSA score of 68. Mobility of the foot and ankle group was significantly less compared to NYHA class I patients, who had a LSA score of 103 (p=0.008). There was no significant difference in mobility compared to class II or III congestive heart failure patients, who recorded a mean LSA score of 62 (p=0.60). There was insufficient data available on NYHA class IV patients to make comparisons to this group.Conclusion:Degenerative ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III congestive heart failure.

Mobility Limitation is Greater After Surgery for Degenerative Pathology of the Ankle, Hindfoot, and Midfoot than Total Hip Arthroplasty

Category:Ankle, Ankle Arthritis, Hindfoot, Midfoot/ForefootIntroduction/Purpose:Degenerative conditions of the ankle, hindfoot, and midfoot can markedly limit mobility. Surgery often results in lengthy postoperative recoveries with requisite weight-bearing restrictions. In contrast, total hip arthroplasty (THA) is associated with fewer postoperative restrictions and quicker recovery of mobility. In this study, we utilized the Life-Space Assessment (LSA), a questionnaire quantifying how patients mobilize after a medical event as they return to previous daily settings. The LSA has never previously been utilized to describe the perioperative mobility of patients undergoing THA or elective foot and ankle surgery. Current outcome measures do not accurately assess patient mobility in the geriatric foot and ankle or THA populations. We hypothesize that patients undergoing elective foot and ankle surgery will have greater postoperative mobility limitation than THA patients.Methods:Preoperative, 3-month postoperative, and 6-month postoperative LSA data was collected from both the THA and foot and ankle cohorts. 12-month postoperative data was obtained for the foot and ankle group but was unavailable for the THA cohort. The degenerative foot and ankle cohort included patients undergoing surgery for Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and comorbidities were recorded from the electronic medical record. Data was analyzed using a Student’s t-test.Results:28 foot and ankle and 35 THA patients met inclusion criteria. Demographics were not significantly different between the groups. Mean preoperative foot and ankle LSA (62) was lower than the THA score (72.2), although not a significant difference (p=0.246). THA LSA scores improved 3-months postoperatively (85) compared to preoperative (p=0.09). At 3-months, foot and ankle scores were less (45.1) compared to both preoperative baseline and 3-month THA (p=0.22, p=0.0013). At 6-months, the THA group improved to 91, whereas the foot and ankle group increased to 65.5 (p=0.0281). THA patients showed an increase from preoperatively (72) to 6-months postoperative (91) (p=0.008); however, foot and ankle patients showed no difference (62 to 65.5, p=0.82). 12-months postoperatively, foot and ankle patients showed improvement (85.7) compared to preoperative (p=0.09).Conclusion:Degenerative conditions of the ankle, hindfoot, and midfoot may have greater limitation on mobility compared to hip osteoarthritis. Recovery of mobility after surgery for degenerative foot and ankle conditions is slower with lower mobility at 3 months and likely 6 months postoperatively compared to total hip arthroplasty. At 6 months postoperatively, total hip arthroplasty patients exhibit improved mobility compared to their preoperative state, whereas patients undergoing surgery for degenerative ankle, hindfoot, and midfoot diagnoses do not show improved mobility until 12-months postoperatively.

Osteochondral Lesions of the Talus – A Biomechanical Explanation for Larger OLT Shoulder Lesions Leading to Increased Patient Risk

Category:Ankle, TraumaIntroduction/Purpose:Osteochondral lesions of the talus (OLT) are a common injury that can result in pain, disability, and risk ankle degeneration, with poor outcomes when not managed properly. Unconstrained ‘shoulder’ lesions on the medial edge of the talar dome present a particular challenge. The objective of this study was to assess the effect of increasing size of a medial OLT shoulder lesion on ankle joint contact mechanics and to determine a threshold size that would warrant bulk grafting of the defect. Our hypothesis is that larger defects will demonstrate increased pressure applied over a lesser surface area, with peak pressure progressing towards the rim of the defect, resulting in an increased risk for tissue damage and need for treatment.Methods:Nine cadaver ankle joints were dissected without disrupting the medial and lateral stabilizing ligaments. A Tekscan pressure sensor was inserted into the ankle joint. Intact specimens were axially compressed up to 800 N with the foot in neutral and again at 20° inversion, simulating ankle position during inversion injury. The specimens were then tested with progressively larger semicircular osteochondral lesions at diameters of 8, 10, 12, 14, and 16 mm that were centered on the edge of the medial talar dome, followed by a final ovoid lesion of 16x20 mm. After each lesion was created the specimens were retested. Linear mixed models adjusted for donor characteristics and assessed changes in peak pressure (MPa), contact area (mm2), peak pressure location (mm), and distance from peak pressure location to the lateral rim of the defect (mm) by defect size and ankle position.Results:For all defect sizes, mean peak pressures were significantly higher in inversion compared to neutral. Mean peak pressure magnitude progressively increased with defect size in both ankle positions. Donor characteristics did not significantly affect mean peak pressure. Contact area decreased in both positions as defect size increased, but inversion led to significantly lower contact areas than in neutral. In neutral positions, the location of peak pressure moved laterally on the talar dome but also moved closer to the defect rim as the size of the defect increased. The rim-peak pressure distance stabilized for defect sizes of 10 mm and above. In inversion, however, the rim-peak pressure distance remained unchanged at about 8 mm for all defect sizes.Conclusion:As OLT defect sizes increased, we observed an increase in peak pressure, a decrease in contact surface area, and a lateral translation of peak pressure location relative to the defect rim. Distance between location of peak pressure and defect rim decreased with neutral loading until a 10 mm defect but remained consistent in inversion loading. These findings suggest a biomechanical explanation for secondary injuries and treatment failures in larger OLT shoulder lesions due to maladaptive cartilage tissue on the dome of the talus. Larger defects (=10 mm) remain a critical point of interest with predictive clinical value for OLT outcomes.

Total ankle arthroplasty and ankle arthrodesis affect the biomechanics of the inner foot differently

Ankle arthrodesis and total ankle arthroplasty are the two primary surgeries for treatment of end-stage degenerative ankle arthritis. The biomechanical effects of them on the inner foot are insufficient to identify which is superior. This study compared biomechanical parameters among a foot treated by ankle arthrodesis, a foot treated by total ankle arthroplasty, and an intact foot using computational analysis. Validated finite element models of the three feet were developed and used to simulate the stance phase of gait. The results showed total ankle arthroplasty provides a more stable plantar pressure distribution than ankle arthrodesis. The highest contact pressure, 3.17 MPa, occurred in the medial cuneonavicular joint in the total ankle arthroplasty foot. Neither of the surgeries resulted in contact pressure increase in the subtalar joint. The peak stress in the metatarsal bones was increased in both surgical models, especially the second and third metatarsals. This study enables us to get visual to the biomechanics inside of an intact foot, and feet treated by total ankle arthroplasty and ankle arthrodesis during walking.

The Munich Ankle Questionnaire (MAQ): a self-assessment tool for a comprehensive evaluation of ankle disorders

BackgroundThere are many approved patient-related outcome measurement tools regarding ankle pathologies. However, there is none incorporating the range of motion (ROM) as an objective parameter. Most instruments focus on subjective parameters such as pain and impairment at work or daily living. Furthermore, the majority is only applicable to a specific pathology. Therefore, the objective of our study was to develop and validate the Munich Ankle Questionnaire (MAQ) as a universal self-assessment score including subjective and objective items.MethodsThe established McGuire Score, Bray Score, Ankle Hindfoot Score (AOFAS) and Olerud and Molander Score were analyzed for relevant items and subscales. Items of interest were then condensed and allocated to the respective subscales of the MAQ. The final MAQ consists of 6 items addressing general and demographic data and 12 items addressing three domains: pain (3 items), work and daily living (5 items), movement and ROM (4 items). The evaluation of validity, reliability and responsiveness of the MAQ was performed in a prospective clinical study including traumatic as well as degenerative ankle pathologies.ResultsIn total, 148 patients (79 female, 69 male, median age 45 years) were included in the validation study. With intra-class correlation coefficients of at least 0.77, test–retest reliability was proven. Construct validity with a correlation coefficient of 0.82 and responsiveness with a correlation coefficient ranging from 0.42 to 0.47 were confirmed.ConclusionThe MAQ is a reliable and valid self-assessment measurement tool for the follow-up examination regarding subjective and objective parameters of traumatic and degenerative ankle pathologies. The MAQ has no limitation to specific disorders and allows a broad application.

Association Between Knee Malalignment and Ankle Degeneration in Patients With End-Stage Knee Osteoarthritis

BackgroundThe association between knee malalignment and ankle degeneration has not been well established. This study aimed at determining whether knee malalignment and compensatory ankle morphology to knee malalignment are associated with the development and progression of ankle osteoarthritis (OA) in patients with end-stage knee OA. MethodsWe retrospectively reviewed 96 patients (106 knees) who underwent total knee arthroplasty. The progression of ankle OA, knee alignment, and ankle morphology were evaluated based on digital radiographs. Alignment deformity of the lower extremity was evaluated with hip-knee-ankle angle and medial proximal tibial angle (MPTA). Ankle morphology was evaluated by the lateral distal tibial angle, talar tilt, tibial plafond inclination angle, and ankle joint line orientation angle. ResultsThe incidence of radiological ankle OA was observed in 39 of 106 cases. The MPTA (odds ratio = 0.72, P = .0009) and hip-knee-ankle angle (odds ratio = 1.13, P = .0169) were significantly associated with ankle OA. Among patients with tibial varus deformity, 26 of 49 had ankle OA. Among patients with neutral tibial alignment, 13 of 57 had radiological findings of ankle OA. MPTA was the only parameter associated with the progression of ankle OA. No association was observed between compensatory change in ankle morphology and the severity of ankle OA. ConclusionTibial varus deformity is associated with the development and progression of ankle OA; however, it is unclear whether it causes ankle OA. Due to the high incidence of ankle OA in total knee arthroplasty patients, it is reasonable to consider routine evaluation of the ankle.

The regenerative therapies of the ankle degeneration: a focus on multipotential mesenchymal stromal cells.

The ankle degeneration ranging from focal osteochondral lesions to osteoarthritis can cause a total joint function loss. With rising life expectancy and activity of the patients, various regenerative therapies were introduced aiming to preserve the joint function via the induction of cartilage and bone repair. Here, biological events and mechanical changes of the ankle degeneration were discussed. The regenerative therapies were reviewed versus the standard surgical treatment. We especially focused on the use of mesenchymal (multipotential) stromal cells (MSCs) highlighting their dual functions of regeneration and cell modulation with an emphasis on the emerging MSC-based clinical studies. Being at an early step, more basic and clinical research is needed to optimize the applications of all ankle regenerative therapies including MSC-based methods.

Arthroscopic Ankle Arthrodesis: A 2-15 Year Follow-up Study

The purpose of our study was to determine the results of arthroscopic ankle arthrodesis (AAA) and how the procedure affects adjoining joints and functional scores. Between 1993 and 2013, 116 patients (120 ankles) underwent AAA. Nineteen ankles were lost to follow-up due to death, insufficient radiographic studies, or inability to contact, resulting in 97 patients (101 ankles). Mean age at surgery was 61.1years (range, 35.8-79.6years); mean follow-up was 86months (range, 24-247months). Patients were assessed according to the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Ankle Osteoarthritis Scale (AOS), and Foot and Ankle Outcome Score (FAOS) and underwent comprehensive clinical and radiographic examinations. A total of 94.6% of patients achieved ankle fusion on radiographs. Mean AOFAS score was 83.3 (standard deviation [SD], 13.2). Mean modified FAOS score was 87.4 (SD, 10.4). The AOS scoring system showed 75% good/excellent results. According to the Kellgren-Lawrence score and van Dijk osteoarthritis grading scale, 85% and 69% of patients had no change in talonavicular or subtalar grade of osteoarthritis, respectively. There were no cases of deep infection or other serious adverse events. All but 4 patients were able to return to work following AAA. AAA is an effective operation for treating degenerative ankle disease, even in cases of moderate tibiotalar coronal deformity. At a mean of 86months postop, nearly three quarters of our patients had good/excellent functional outcomes. Arthritis found in the adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change and not directly caused by the tibiotalar fusion. Level IV, therapeutic case series.