Ankle Disorders Research Articles

Osteochondral autograft transfer combined with supramalleolar osteotomy for the treatment of osteochondral defect of the talus in varus ankle

Category: Ankle, Ankle Arthritis, Arthroscopy, Sports Introduction/Purpose: Osteochondral lesion of the talus (OLTs) is among the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (> 15 mm in diameter) involving posteromedial aspect of talar dome, osteochondral autograft transplantation is usually warranted. This article highlights the distal tibial double osteotomy for the management of patient with concomitant large OLTs and varus ankle malalignment. Methods: From January 2012 to July 2015, 15 patients (8 males, 7 females) received the surgery in our department. The average age was 55.4 (range, 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, following by osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight bearing X-rays were obtained for the measurement of tibial articular surface (TAS) angle and tibial lateral surface (TLS) angle. The American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) questionnaires and Visual Analog Scale (VAS) were evaluated for ankle function. In 5 cases arthroscopy was performed 12 months postoperatively and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society. Results: Thirteen patients completed the follow-up with a mean of 21.2 months. The average talar lesion was 170.0mm2, and the average depth was 11.4 mm. The mean time of bone healing was 8.5 weeks. No patient reported donor site morbidity by the last follow-up. The mean AOFAS-AH score and VAS score improved from 53 to 90 points (p < 0.05), 6.7 to 1.9 points (p < 0.05), respectively. The mean TAS angle improved from 83.1 to 90.3 degrees (p < 0.05). The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean International Cartilage Repair Society arthroscopic score from follow-up arthroscopy was (9±1) points. Conclusion: The use of osteochondral autograft transfer combined with supramalleolar osteotomy is an effective option for the treatment of osteochondral defect of the talus in varus ankle. It provides excellent visualization of the talar defect and favorable biomechanical environment for the ankle joint.

Anterior and Posterior Ankle Impingement by One-Step Arthroscopic Treatment: 10years Follow-up Prospective Study by Standard Anterior and Double Postero-Medial Portals

Simultaneous anterior and posterior ankle impingement is preferably treated by 2steps surgery. Aiming to avoid postponing further surgery in prone position, authors focused a procedure which addresses posterior ankle disorders through 2postero-medial portals, after anterior arthroscopic step without changing patient's assessment. They present this 10years follow-up prospective study. In period January 2001-January 2015 78 ankle affected with both side pathology, were submitted to arthroscopic treatment by standard anterior portals and double postero-medial approach, maintaining supine position and addressing simultaneously one-step surgery anteriorly and posteriorly. Reproducing same posterior portals of prone procedure, peroneal approach is rotated 90°medially lying 5cm superiorly to medial one along Achilles' tendon. FHL tendon landmark prevents damage to posterior tibial bundle. Patients were evaluated with pre-op and post-op x-ray scan and AOFAS scale. At final survey 71patients have been evaluated, being 7 lost. Wilcoxon test was utilized to compare score values reported at admission time, after 12months and after 10years. AOFAS scale, steady improved from preoperative mean 38.73(range21-51) to 1year postoperative=89.87 and to further 95.4 at 10years. The preop vs/postop 12months was p-value=0.00051 and postop 12months vs/10years p-value was =0.03628. Big improvement was reported in study group at 10years follow-up compared to control group (the former p-value=0.0004883, the lesser p-value=0.0009766, inferior to threshold p=0.05). None patient reported any complication, any problem to posterior tibial nerve territory or to medial talus skin sensitivity. Varicose veins caused in 3patients posterior ankle swelling and oedema for 3weeks. Four patients have been submitted to new surgical procedure for same disorder. In open surgery as in arthroscopic procedure, supine assessment made impossible to reach both the joint spaces without intra-operative patient's repositioning. Maintaining supine assessment during arthroscopy, this technique allowed to reach disorders in posterior ankle compartment after anterior treatment by standard portals. Absence of neurovascular lesions confirmed safety and reproducibility of this procedure providing anatomical landmarks respect.

Optimal suture anchor direction in arthroscopic lateral ankle ligament repair

In this study, the distance between the insertion point of the suture anchors and posterior surface of the fibula during arthroscopic lateral ankle ligament repair was investigated on computed tomography (CT) images. The hypothesis of this study was that there is an optimal insertional direction of the suture anchor to avoid anchor-related complications. One hundred eleven ankles of 98 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (59 males, 52 females; median age 25.5years; age range 12-78years). The shortest distance from the insertion point of the suture anchor to the deepest point of the fossa/top of the convex aspect of the fibula was measured on the axial plane, tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. The distance from the insertion point of the suture anchor to the posterior surface of the fibula was also measured in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial plane, tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in the parallel direction was 15.0±3.4mm at 90°, 17.5±3.2mm at 75°, 21.7±3.3mm at 60°, and 25.7±3.6mm at 45°. The posterior points in the parallel direction were located on the posterior fossa in 36.0% of cases at 90°, in 12.6% at 75°, and in 0.0% at 60° and 45°. The suture anchor should be directed from anterior to posterior at an angle of <45° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, to avoid passing through the fibula. Cohort study, Level III.

Chronic musculoskeletal ankle disorders in Sri Lanka

BackgroundMusculoskeletal disorders of the lower extremities are commonly affected by chronicity and disability. One of the most commonly affected areas is the ankle. Epidemiological information is limited for chronic musculoskeletal ankle disorders in the general community, particularly in the developing world. This study aimed to determine the prevalence and impact of chronic musculoskeletal ankle disorders in the Sri Lankan community.MethodsA cross-sectional stratified random sample of people (n = 1000) aged 18 to 85 years in Sri Lanka was undertaken by questionnaire in the general community setting. Of those questionnaires, 827 participants provided data.Point prevalence for no history of ankle injury or ankle disorders, history of ankle injuries without chronic ankle disorders, and chronic ankle disorders were obtained. Point prevalence of chronic musculoskeletal disorders and causes for chronicity was evaluated.ResultsThere were 448 (54.2%) participants with no ankle disorders, 164 (19.8%) with a history of ankle injury but no chronic disorders, and 215 (26.0%) with chronic ankle disorders.The major component of chronic ankle disorders was musculoskeletal disorders (n = 113, 13.7% of the total sample), most of which were due to ankle injury (n = 80, 9.7% of the total). Sprains were responsible for 17.7% of the total ankle injuries. Arthritis was the other main cause for chronicity of ankle disorders with 4% of total participants (n = 33).ConclusionsAlmost 14% of the Sri Lankan community was affected by chronic musculoskeletal ankle disorders. The majority were due to a previous ankle injury, and arthritis. Most people had to limit or change their physical activity because of the chronic ankle disorder. A very low utility of physiotherapy services was observed.

Ultrasonography of the ankle joint.

Ankle disorders are a relatively common pathological condition, and ankle injuries account for approximately 14% of sports-related orthopedic emergency visits. Various imaging modalities can be used to make a diagnosis in cases of ankle pain; however, ultrasound (US) has several benefits for the evaluation of ankle pain, especially in the tendons, ligaments, and nerves of the ankle. The purpose of this article is to review the common causes of ankle pathology, with particular reference to US features. In addition, the importance of a dynamic evaluation and a stress test with US is emphasized.

Musculoskeletal modelling of human ankle complex: Estimation of ankle joint moments

BackgroundA musculoskeletal model for the ankle complex is vital in order to enhance the understanding of neuro-mechanical control of ankle motions, diagnose ankle disorders and assess subsequent treatments. Motions at the human ankle and foot, however, are complex due to simultaneous movements at the two joints namely, the ankle joint and the subtalar joint. The musculoskeletal elements at the ankle complex, such as ligaments, muscles and tendons, have intricate arrangements and exhibit transient and nonlinear behaviour. MethodsThis paper develops a musculoskeletal model of the ankle complex considering the biaxial ankle structure. The model provides estimates of overall mechanical characteristics (motion and moments) of ankle complex through consideration of forces applied along ligaments and muscle-tendon units. The dynamics of the ankle complex and its surrounding ligaments and muscle-tendon units is modelled and formulated into a state space model to facilitate simulations. A graphical user interface is also developed during this research in order to include the visual anatomical information by converting it to quantitative information on coordinates. FindingsValidation of the ankle model was carried out by comparing its outputs with those published in literature as well as with experimental data obtained from an existing parallel ankle rehabilitation robot. InterpretationQualitative agreement was observed between the model and measured data for both, the passive and active ankle motions during trials in terms of displacements and moments.

Large variation in use of patient-reported outcome measures: A survey of 188 foot and ankle surgeons

BackgroundThere is an increasing interest in the use of patient reported outcome measures (PROMs). However, there is a large variety of PROMs and a lack of consensus regarding preference for their use. Aim of this study is to determine how often PROMS are used for foot and ankle disorders, for what purpose PROMs are used, and what the preferences of the foot and ankle surgeons are, when choosing a PROM to use. MethodsMembers of the Ankleplatform Study Group—Science of Variation Collaborative were invited to participate in this survey by email. The online survey consisted of six questions on the use and preferences regarding foot and ankle PROMs. Results188 participants completed the questionnaire. Of the respondents 17% reported not to use PROMs, 72% stated to use PROMS for research, 39% routinely for patient care and 34% for registration or quality assessment. The respondents were familiar with 30 different outcome measures, of which 20 were PROMs. One of the excluded outcome measures, the AOFAS Hindfoot scale was most commonly reported as preferred outcome measure. FAOS and MOXFQ were the preferred PROMs, reported by 9.7% of the surgeons. Subsequently followed by the FFI (4.3%), the FAAM (3.7%) and the VAS-FA (3.7%). ConclusionsA large majority of the foot and ankle surgeons uses PROMs. The AOFAS hindfoot scale is mentioned as the most preferred outcome measure, while in fact this is not a PROM. Of the twenty different PROMs mentioned in this study, most reported were the FAOS and MOXFQ both supported by only 9.7% of the surgeons. For proper comparison between patients in clinical practice and research, consensus is needed on which easy-to-use PROM with adequate clinimetric properties should be used. Therefore more evidence in the field of clinimetrics of foot and ankle outcome measures is needed.

Tibiotalocalcaneal Arthrodesis Using a Soft Tissue-Preserved Fibular Graft for Treatment of Large Bone Defects in the Ankle.

Pathogenesis of ankle disorders with a large bone defect is varied and treatment for those problems is challenging for orthopaedic surgeons. The aims of this study were to present an operative technique of arthrodesis for the reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue-preserved fibular strut graft and to report outcomes of consecutively treated patients. Twelve feet from 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening, were treated. Bone defects were filled using iliac bone and/or resected fibula and tibiotalocalcaneal arthrodesis was performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint while preserving the lateral to posterior skin and soft tissues on the fibula. The periods of bony fusion and outcomes were radiographically and clinically evaluated. The mean follow-up period was 33.4 months. Bony fusion was achieved within 3 months in all cases. Coronal and sagittal alignments were acceptable, and the mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded their results of treatment as "satisfied." This procedure did not require special techniques and it should be applicable to complicated cases with large bone defects. High fusion rates that we believe are due to preserving blood supply to the fibular graft can be expected with preservation of the hindfoot height. Level IV, case series.

American Orthopaedic Foot and Ankle Society ankle–hindfoot scale: A cross-cultural adaptation and validation study from Iran

BackgroundThe use of valid and reliable outcome rating scales is essential for evaluating the result of different treatments and interventions. The purposes of this study were to translate and culturally adapt the American Orthopaedic Foot and Ankle Society ankle–hindfoot scale (AOFAS-AHFS) into Persian languages and evaluate its psychometric properties. MethodsForward–backward translation and cultural adaptation method were used to develop Persian version of AOFAS-AHFS. From March to July 2016, one hundred consecutive patients with ankle and hindfoot injuries were included. Internal consistency and reproducibility were evaluated using Cronbach’s alpha, Spearman’s rank correlation coefficient and Intraclass correlation coefficient (ICC) respectively. Construct validity reported which compare the outcome rating scale measurements with Short Form-36 (SF-36), also convergent and discriminant validity evaluated using Spearman’s rank correlation coefficient. ResultsMean age (SD) of the patients was 41.95±13.45years. Cronbach’s α coefficient, Spearman’s rho and ICC values were 0.71, 0.89 and 0.90 respectively. Total score of AOFAS-AHFS and SF-36 domains has a correlation ranged between 0.17–0.55. Spearman’s rank correlation coefficient of 0.4 was exceeded by all items with the exception of stability. The Spearman’s rank correlation between each item in functional subscales with its own subscales was higher than the correlation between these items and other subscales. ConclusionsPersian version of AOFAS-AHFS provides additional reliable and valid instrument which can be used to assess broad range of patients with foot and ankle disorders that speaking in Persian. However, it seems that the original version of AOFAS-AHFS needs some revisions.

Osteochondral autograft transplantation with biplanar distal tibial osteotomy for patients with concomitant large osteochondral lesion of the talus and varus ankle malalignment

BackgroundOsteochondral lesions of the talus (OLTs) are amongst the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (>10 mm), Osteochondral autograft transplantation is usually recommended. This article highlights biplanar distal tibial osteotomy as an approach and management for patients with concomitant large OLTs and varus ankle malalignment.MethodsFrom January 2012 to July 2014, 13 patients (6 male and 7 female) underwent surgery in our faculty and their average age was 55.4 (ranging from 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, followed by an osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight-bearing X-rays were conducted and used for the measurement of radiographic parameters such as the tibial articular surface (TAS) and tibial lateral surface (TLS) angles. Ankle function of the subjects was evaluated according to the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot score (AOFAS-AH) questionnaires and Visual Analog Scale (VAS).Results11 patients completed the follow-up over a mean period of 21.2 months. The average area of talar lesion was 135.9 mm2 while the average depth was 11.4 mm. The mean time for osseous union was 8.5 weeks. Donor site morbidity was not recorded in any of the cases. The mean AOFAS-AH and VAS improved from 53 to 90 points (p < 0.05) and 6.7 to 1.9 points (p < 0.05) respectively. The mean TAS angle improved from 83.1 to 90.3° (p < 0.05).ConclusionsBiplanar distal tibial osteotomy with the combination of osteochondral autograft transplantation could be used to address patients with concomitant large OLTs and varus ankle malalignment as this technique provides excellent visualization of the talar defect, favorable biomechanical environment for the ankle joint with high rate of good and excellent results.

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

We sought to translate and culturally adapt the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (AOFAS-AHFS) into Turkish and determine the selected psychometric properties of the translated version. The AOFAS-AHFS is widely used to evaluate disability associated with foot and ankle injuries but has not yet been translated or culturally adapted for Turkish-speaking individuals. The AOFAS-AHFS was translated into Turkish using the Beaton guidelines. The measurement properties of the Turkish AOFAS-AHFS (internal consistency, construct validity, and floor and ceiling effects) were tested in 72 patients (94 feet, 50 [69.4%] females; average±SD age 44.88±16.30years) with a variety of foot and ankle pathologic features. Construct validity was analyzed using the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Medical Outcomes Study short-form 12-item survey (SF-12). The Turkish version of the AOFAS-AHFS showed excellent test-retest reliability (intraclass correlation coefficient0.91). The correlation coefficients between the AOFAS-AHFS and the FAAM activities of daily living and FAAM sport were r=0.41, p=.01 and r=0.37, p=.03, respectively. The correlation coefficients between the AOFAS-AHFS and the SF-12 physical component scale was r=0.27, p=.08. The weakest correlation was found between the AOFAS-AHFS and the SF-12 mental component scale (r=-0.03, p=.73). The Turkish version of the AOFAS-AHFS has sufficient reliability and validity to measure patient-reported outcomes for Turkish-speaking individuals with a variety of foot and ankle disorders.

Foot and ankle ability measure to measure functional limitations in patients with foot and ankle disorders: a Chinese cross-cultural adaptation and validation

Purpose: To perform a cultural adaptation and validation study (internal and external) of the FAAM questionnaire to create the Chinese version of the questionnaire (FAAM-Ch).Materials and methods: Two independent professional native translators performed a translation from English to Chinese and reverse translation. Psychometric properties analysis: Internal consistency of measure was analysed through the Cronbach’s α coefficients. After extraction by maximum likelihood (EML), the structure factor and construct validity was analysed; to extract a factor, it was necessary to complete the following three requirements: ≥10% of variance, Eigenvalue >1.0 and scree plot inflection point. Standard error measurement (SEM) and minimal detectable change 90 (MDC90) were calculated. FFI-Taiwan version, SF12v2, and EuroQol5D were used for criterion validity analysis.Results: The internal consistency (Cronbach’s α) for specific FAAM-Ch subscales was 0.879 (ADL) and 0.901 (Sport); test–retest analysis (interclass correlation) item ranging between 0.758 and 0.970 (ADL: 0758–0946; Sport: 0.911–0.970). Measures error: 3.449% (MDC90) and 1.478% (SEM). Chi-squared value =15228.74 and gl 406) (p < 0.001) and the Kaiser–Meyer–Oklin values (0.919). The correlation level with the FFI is strong, with SF12v2 is between poor and strong and with EuroQoL5d is between moderate and strongConclusions: FAAM-Chinese version has satisfactory “transversal” psychometric properties, facilitating the inclusion of FAAM-Chinese into research and clinical practice.Implications for RehabilitationCross-cultural adaptation of the FAAM-Ch has been performed from the original version.The psychometric properties of the FAAM-Ch indicate satisfactory and consistent results (particularly in the internal consistence, reliability and criterion validity) with the original version.FAAM-Ch can be used by Chinese speaking clinicians and researches.

Optimum Insertional Direction of the Suture Anchor in Arthroscopic Lateral Ankle Ligament Repair

Category: Arthroscopy Introduction/Purpose: The gold standard for chronic lateral ankle ligament injury is ligament repair via the modified Broström- Gould procedure. Recently, lateral ankle ligament repair has been performed arthroscopically. This requires the insertion of one to three suture anchors in the fibula from anterior to posterior via the accessory portal. It is important to insert the suture anchors completely into the fibula bone. Because the distal fibula is tapered and has a fossa on the posterior surface, unfavorable insertional direction of the suture anchor can lead to complications such as inadequate suture anchor stability or friction between the suture anchor and the peroneus tendons. This study aimed to investigate the distance between the insertion point of the suture anchors and the posterior surface of the fibula on computed tomography (CT) images. Methods: Twenty ankles from 16 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (10 male, 10 female; mean age, 32 years; age range, 12–78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of fossa/the top of the convex of fibula was measured on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. We also measured the distance from the insertion point of the suture anchor to the posterior surface of the fibula, in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. Results: The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in a parallel direction was 15.6 mm at 90°, 18.0 mm at 75°, 21.5 mm at 60°, and 24.8 mm at 45°. The posterior points in a parallel direction were located on the posterior fossa in 40% of cases at 90°, in 10% at 75°, and in 0% at 60° and 45°. Conclusion: We suggest that the suture anchor should be directed from anterior to posterior at an angle of less than 60° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, in order to avoid passing through the fibula.

Surgical Anatomy of a Novel Medial Gastrocnemius Recession versus the Proximal Medial Gastrocnemius Recession

Category: Hindfoot Introduction/Purpose: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Decreased power and endurance with plantar flexion activities have been reported in patients after the Strayer procedure. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective surgical treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. The aim of this study was to describe an anatomic basis for a novel medial gastrocnemius recession (MGR) at the mid-level of the gastrocnemius muscle and to investigate the anatomical structures at risk in comparison to PMGR. Methods: Ten fresh frozen cadaveric lower leg specimens were employed for the study. The standard PMGR and the novel MGR were performed on each specimen. For the MGR procedure, we made a 2 cm incision over the mid-level of the medial gastrocnemius muscle region and performed complete release of the medial gastroncnemius fascia. After completion of the two procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve and popliteal artery. These distances were recorded and compared statistically. Results: Proximities of anatomic structures to surgically released gastrocnemius fascia were significantly different between the two techniques. Major neurovascular structures were closer to the surgical margin than anticipated and at greater risk with the PMGR. In particular, popliteal artery (average distance 6.62 mm) and the tibial nerve (8.04 mm) were in close proximity with the PMGR margin, whereas these structures were deeply embedded and farther away from the MGR margin. For the PMGR, the semimembranosus tendon (average distance of 4.16 mm), small saphenous vein (6.71 mm), medial sural cutaneous nerve (3.66 mm), were also in close proximity to the surgical margin. For the MGR, the structures closer to the surgical margin and thus at greater risk of injury were the greater saphenous vein (12.22 mm) and saphenous nerve (11.87 mm). Conclusion: Medial gastrocnemius recession (MGR) at the central level of the gastrocnemius muscle may be an attractive surgical option and method when addressing IGC associated with various foot and ankle disorders. It can easily be performed in either the supine or prone position and may allow for less risk of injury to major surrounding neurovascular structures than a more proximal release. The biomechanical and clinical efficacies of the proposed MGR warrant further investigation.

How Reliable is Clinical Evaluation in Hindfoot Coronal Alignment?

Category: Hindfoot Introduction/Purpose: Hindfoot alignment in the coronal plane is an extremely important aspect to consider in order to make a comprehensive evaluation of different foot and ankle disorders. To the authors knowledge the evidence concerning the precision of clinical hindfoot alignment assessment is scarce. The aim of this study is to evaluate correlation and reproducibility between clinical and radiographical hindfoot alignment. Methods: Intra and interobserver reliability of clinical and radiographical hindfoot assessment was performed in 85 patients. Clinical alignment was evaluated on photographs taken at the time of presentation and hindfoot alignment was quantified on long axial view radiographs in neutral rotation position. Photographs were classified into three categories (valgus, neutral and varus) and radiographs were measured taking standardized parameters. Each observer made measurements independently and was blinded to both patient identification and the others’ measurements. All measurements were made on two separate occasions with the order of images randomized. Results: We did not observe a significant correlation between clinical and radiographical assessment (k1a 0,072 - p=0,24; k1b 0,167 - p=0,029; k2a 0,23 - p&lt; 0,001; k2b 0,137 - p=0,021). We did find a good clinical and radiographical intraobserver agreement (K1= 0,789; K2=0,783; Pearson1= 0,956; Pearson2= 0,990). Clinical interobserver agreement was moderate (K1= 0,584; K2=0,566) while radiographical interobserver agreement was statical significant (Pearson1= 0,926; Pearson2= 0,953). Conclusion: Due to a poor clinical-radiographical correlation we should not rely on clinical evaluation to guide the decision making in different foot and ankle conditions. We strongly recommend the use of the long axial view in order to assess the magnitude of the hindfoot deformity.

Orthopaedic Foot and Ankle Patient Comprehension

Category: Other Introduction/Purpose: Individuals with inadequate health literacy and limited comprehension may lack the skills needed to make informed decisions about their health. They are also at risk for inferior treatment outcomes and are more likely to express dissatisfaction with their care. Unfortunately, the Institute of Medicine has declared low health literacy a “silent epidemic”, as approximately 50% of Americans are afflicted. Because foot and ankle disorders are common, often disabling, and at times utilize a variety of diagnostic and therapeutic modalities unfamiliar to patients, it is critical that we gain insight into patients’ foot and ankle comprehension. As such, we developed a novel questionnaire, the Foot and Ankle Literacy Survey (FALS), to evaluate this and the relationship between demographic factors and foot and ankle specific comprehension. Methods: The 14 question FALS (Figure 1A) was developed by our study group and was distributed to a consecutive series of 206 English-speaking adults presenting for first visits, immediate pre-operative evaluations, or one of a number of post-operative or follow-up visits in the foot and ankle practices of our senior authors and the ambulatory care clinic of an academic, urban medical center. The questionnaire’s content was based on the following four categories: 1) terminology, 2) anatomy, 3) conditions and treatment, and 4) perioperative considerations. These categories were chosen following our group’s review of the most commonly emphasized themes within the American Orthopaedic Foot and Ankle Society’s internet-based patient education website, FootCareMD.org. Participants completed the FALS and a demographic survey. Both overall and categorical performance were evaluated as a function of demographic characteristics via Wilcox Rank Sum, Kruskal-Wallis and McNemar’s testing. The level of significance for all tests was set at P &lt; 0.05. Results: Participants’ demographic characteristics are presented in Figure 1B. The mean FALS score was 9.88 ± 2.67 out of a possible 14 points. Participants performed significantly worse on the conditions and treatment subsection as compared to the others (P &lt; 0.05). Significantly better FALS performance correlated with race (Caucasian, P &lt; 0.001), higher levels of education (College degree or higher, P &lt; 0.001), visit type (Pre-operative evaluation, P &lt; 0.002), and a current or previous healthcare occupation (P=0.008) (Figure 1B). Additionally, of those patients who had previously seen a provider (orthopaedic surgeon, podiatrist, orthopaedic surgeon and podiatrist, other provider) for a foot and ankle complaint, a significantly higher score was observed in patients who saw an orthopaedic surgeon versus other types of providers. Age, gender and anatomic region did not correlate with FALS scores. Conclusion: Patient comprehension of foot and ankle related terminology, anatomy, conditions, treatment, and perioperative issues is critical for successful encounters between orthopaedic foot and ankle surgeons and patients. This study has identified race, education, occupation, prior evaluation by an orthopaedic surgeon, and visit type as factors that significantly correlate with comprehension. With such knowledge, patient education can be focused on those most in need, an approach that we hope will improve health literacy and optimize outcomes. Admittedly, future research is pivotal and must identify the most effective means of educating patients and objectively evaluate the relationship between outcomes and patient comprehension.

Proposed Sonographic Criteria for the Diagnosis of Idiopathic Tarsal Tunnel Syndrome

ObjectiveTo propose new sonographic criteria for the diagnosis of idiopathic tarsal tunnel syndrome (TTS). DesignProspective case-control study. SettingAcademic referral center. ParticipantsAdult healthy volunteers (n=17) and adult patients (n=14) with electrodiagnostically proven idiopathic TTS (mean age, 43.4±8.7y; height, 161.4±7.0cm; weight, 90.6±13.9kg) (N=31). The exclusion criteria were patients with diabetes, neurological disorders, associated ankle and/or foot disorders, electrodiagnostic evidence of a widespread lesion, or feet that were electrophysiologically negative for TTS or with structural abnormalities detected via ultrasound imaging. InterventionsNot applicable. Main Outcome MeasuresTibial nerve CSA at the proximal tarsal tunnel, tibial nerve CSA within the tunnel, within tunnel-to-proximal tunnel CSA ratio. ResultsThere was a significant difference in the within tunnel CSA and within tunnel-to-proximal tunnel CSA ratio between the TTS group and controls (P=.002 and P=.001, respectively). The optimum cutoff value was 19mm2 for the within tunnel CSA and 1 for the within tunnel-to-proximal tunnel CSA ratio. Sensitivities were 61% and 74%, respectively. ConclusionsThe within tunnel-to-proximal tunnel CSA ratio and the within tunnel CSA are the most accurate sonographic parameters and can be helpful in the assessment of idiopathic TTS.

Failure investigation of a tibiotalocalcaneal arthrodesis system

Ankle disorders such as arthritis and trauma are treated with Arthrodesis where an intramedullary (IM) nail is inserted in the ankle to fuse the joints. Fusion reduces pain and has been proposed as gold standard. Nailing is used in a variety of situations, particularly to treat fractures in long bones. This paper describes failure analysis of an ankle intramedullary nailing system implanted in a 49-year old male patient. The failure location was proximal of the two distal interlocking screw holes laterally. The medical devices are regulated in the United States, the material of the nail conformed to the ISO specification requirements. Optical and scanning electron microscopes were used to identify the fracture origin. Finite element analysis (FEA) was performed to determine maximum Von Mises stresses from torsion and translation movements. Axial load to failure of the implant was determined by conducting numerical analysis. The implant failed due to multiple factors involving clinical and biomechanical parameters exceeding the nail strength. Lack of proper bone purchase while inserting the screw and interference with the IM nail wall initiated the crack. The force and torque developed during the gait propagated the crack to a length of 0.4–0.6mm, upon subsequent use the cracked device was unable to load-bear resulting in premature failure.

Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery.

The Manchester-Oxford Foot Questionnaire (MOXFQ) has been validated in Spanish for use in patients undergoing foot and ankle surgery. 120 patients completed the MOXFQ and the SF-36 before surgery and 6 and 12 months postoperative. Surgeons completed the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating System. Psychometric properties were assessed for all three MOXFQ dimensions, and for the MOXFQ Index. The Spanish MOXFQ demonstrated consistency with Cronbach's alpha values between 0.65 and 0.90, and reliability ([ICCs] >0.95). It shows a moderate to strong correlation between the Walking/standing dimension and the related domains of the SF-36 (|r|>0.6), the AOFAS Ankle-Hindfoot Scale (|r|>0.47) and Hallux-MTP-IP Scale (|r|>0.64). Responsiveness was excellent, (effect sizes >2.1). The respective minimal detectable change (MDC90) was 14.18 for the MOXFQ Index. The Spanish version of the MOXFQ showed good psychometric properties in patients with foot and ankle disorders.

Real-time sonoelastography and ultrasound evaluation of the Achilles tendon in patients with diabetes with or without foot ulcers: a cross sectional study

BackgroundDiabetes mellitus (DM) is an endocrine disease characterized by metabolic abnormalities and long-term complications. The Achilles tendon (AT) plays an important role in foot biomechanics. We aimed to investigate the effect of DM on the Achilles tendon, which may contribute to long-term complications in the foot–ankle complex. MethodsSeventy-eight patients with diabetes, with (35 patients, group I) or without (43 patients, group II) foot ulcers were recruited from the endocrinology clinic. Thirty-three age-, gender-, and BMI-matched healthy individuals were selected as controls. All participants underwent ultrasonography and sonoelastography of their AT in order to evaluate Achilles tendon thickness (ATT) and stiffness (ATS). Each patient was also tested for fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1C) as a measure of diabetes control. Other chronic complications were also evaluated in all patients with diabetes. ResultsThe AT was significantly thicker in group I compared to group II and the controls. HbA1C, FPG, and duration of diabetes were higher in group I. We observed that ATT was positively correlated with neuropathy, retinopathy, nephropathy, peripheral arterial disease and coronary arterial disease in group II while this correlation was not detected in group I. ATS was reduced in group I more than group II and control groups. ConclusionChanges in the structure of the AT may precede foot ankle disorders in patients with diabetes. This is the first study that reported the results of sonoelastosonography of AT in patients with diabetes and revealed the correlation between ATT and other chronic complications of diabetes.