Ankle Joint Line Research Articles

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Radiological, functional, and anatomical outcome in patients with osteoarthritic knee undergoing high tibial osteotomy.

Objective: To determine the radiological, functional, and anatomical outcome in patients with osteoarthritic knee undergoing high tibial osteotomy (HTO).Design of study: Descriptive case series.Study duration and settings: The present study was a descriptive case series carried out at the Orthopedic Departments of District Head Quarter Hospital Faisalabad affiliated with Faisalabad Medical University, Faisalabad from Jan 2014 to March 2018.Methodology: This study involved 40 patients of both genders, aged between 40 and 65 years having advanced degenerative disease of knee limited to medial compartment of joint. These patients were treated by medial open wedge high tibial osteotomy (OWHTO) and outcome was evaluated after 5 years of surgery in terms of radiological knee mechanics, functional outcome scores, and arthroscopic evidence of cartilage regeneration in the medial compartment. A signed written consent was taken from every patient.Findings: There was a female predominance with a male-to-female ratio of 1:4. The mean age of the patients was 53.2 ± 6.9 years. The values of the radiographic parameters significantly changed from pre-operative condition after HTO; mechanical tibiofemoral angle [MTFA, (−8.1 ± 1.2° vs. 2.5 ± 1.2°; p-value < 0.0001)], tibial plateau inclination [TPI, (5.3 ± 1.1° vs. 3.4 ± 1.1°; p-value < 0.0001)], knee joint line orientation relative to the ground [G-KJLO, (0.3 ± 0.1° vs. 4.6 ± 1.5°; p-value < 0.0001)], and ankle joint line orientation relative to the ground [G-AJLO (8.3 ± 3.2° vs. 2.3 ± 1.7°; p-value < 0.0001)]. There was significant improvement in patient’s functional status; KOOS-ADL score (45.5 ± 7.8 vs. 73.7 ± 8.6; p-value < 0.0001), International Knee Documentation Committee (IKDC) score (42.4 ± 6.9 vs. 68.5 ± 12.7; p-value < 0.0001), International Knee Society (IKS) score (149.4 ± 11.9 vs. 179.4 ± 10.2; p-value < 0.0001), Knee Society Score [KSS, (54.2 ± 5.6 vs. 69.7 ± 12.7; p-value < 0.0001)], and Hospital for Special Surgery [HSS, (50.8 ± 3.3 vs. 64.8 ± 10.7; p-value < 0.0001)]. 42.5% patients showed excellent regeneration of femoral and 30.0% patients showed excellent regeneration of tibial cartilage in the medial compartment.Conclusion: By significantly alternating the knee biomechanics, HTO was found to unload the medial compartment leading to regeneration of the articular cartilage and significant improvement in patient’s symptoms and quality of life. It is therefore recommended in the management of patients with arthritic changes limited to medial compartment only.

The effects of residual hip deformity on coronal alignment of the lower extremity in patients with unilateral slipped capital femoral epiphysis.

PurposeThe aim of our explorative study was to compare the differences in the coronal alignments of the hip, knee and ankle on the slip side and non-slip sides in patients with slipped capital femoral epiphysis (SCFE).MethodsThe study group consisted of 28 patients. On the full-length standing radiographs, measurements of articulo-trochanteric distance (ATD), neck-shaft angle (NSA), femoral offset, hip-knee-ankle axis, femur-tibial angle, mechanical axis deviation ratio (MAD-r), anatomical medial proximal femoral angle (aMPFA), mechanical lateral proximal femoral angle (mLPFA), anatomical lateral distal femoral angle (aLDFA), mechanical lateral distal femoral angle (mLDFA), knee joint line congruency angle, mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal tibial angle (mLDTA), ankle joint line orientation angle (AJOA), and leg length discrepancy (LLD) were performed. The data from the slip side were compared with those from the non-slip side.ResultsAt skeletal maturity, there were significant differences between the slip side and non-slip side in ATD (p <0.001), NSA (p <0.001), MAD-r (p <0.001), aMPFA (p <0.001), aLDFA (p = 0.03), mLDFA (p = 0.04), mLDTA (p = 0.02), AJOA (p <0.001) and LLD (p<0.001).ConclusionResidual deformity in the proximal femur after epiphyseal slip and premature epiphysiodesis could cause changes in the coronal alignment of the lower extremity. We can add lower extremity alignment examination to follow-up protocol to rule out secondary problems in patients with SCFE.Level of EvidenceLevel III, retrospective comparative study

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 valid diagnostic parameters in static bilateral CT scan to predict unstable syndesmotic injury with ankle fracture

Category: Trauma Introduction/Purpose: The purpose of this study is to evaluate valid and reasonable parameters to predict syndesmotic injury in ankle fracture. Methods: Seventy patients who underwent preoperative bilateral CT scans were enrolled retrospectively. On preoperative x-ray, tibiofibular overlap (TFO) and tibiofibular clear space (TFCS) were measured. On preoperative CT scan, anterior fibular distance (AFD), posterior fibular distance (PFD), anterior translation distance (AT), fibular diastasis (FD), anterior-posterior translation (APT), fibular length (FL), surface area of syndesmosis (SAS), surface area of syndesmosis of 1.5 cm above the ankle joint line (SAS1.5) were measured. Those measured values were divided with those of uninjured side, in order to minimize the differences among the individuals. Results: Statistically significant differences has been shown between The measurements of ratio (Injured/Uninjured) of TFO, PFD, APT, Diastasis, and SAS of groups which required transfixation have shown statistically significant difference, compared to those of groups which did not require transfixation. Other measurements were not showing significant difference. Furthermore, using ROC curve analysis, a ratio of measurement which is the most reasonable to predict transfixation was SAS (95% confidence interval = 0.598 – 0.869, cut of value = 1.555) Conclusion: Measuring TFO, PFD, APT, Diastasis, and SAS from CT scans and comparing with uninjured side preoperatively can provide surgeon an reasonable evidence to perform transfixation intraoperatively

Concomitant Ankle Osteoarthritis Is Related to Increased Ankle Pain and a Worse Clinical Outcome Following Total Knee Arthroplasty.

Occasionally, patients experience new or increased ankle pain following total knee arthroplasty (TKA). The aims of this study were to determine (1) how the correction of varus malalignment of the lower limb following TKA affected changes in alignment of the ankle and hindfoot, (2) the difference in changes in alignment of the ankle and hindfoot between patients with and without ankle osteoarthritis (OA), and (3) whether the rate of ankle pain and the clinical outcome following TKA differed between the 2 groups. We retrospectively reviewed prospectively collected data of 56 patients (99 knees) treated with TKA. Among these cases, concomitant ankle OA was found in 24 ankles. Radiographic parameters of lower-limb, ankle, and hindfoot alignment were measured preoperatively and 2 years postoperatively. In addition, ankle pain and clinical outcome 2 years after TKA were compared between patients with and without ankle OA. The orientation of the ankle joint line relative to the ground improved from 9.4° of varus to 3.4° of varus, and the valgus compensation of the hindfoot for the varus tilt of the ankle joint showed a 2.2° decrease following TKA. Patients in the group with ankle OA showed decreased flexibility of the hindfoot resulting in less preoperative valgus compensation (p = 0.022) compared with the group without ankle OA. The postoperative hindfoot alignment was similar between the 2 groups because of the smaller amount of change in patients with ankle OA. The group with ankle OA had a higher rate of increased ankle pain (38% compared with 16%) as well as a worse Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (mean of 22.2 compared with 14.2) following TKA. A considerable proportion of patients who underwent TKA had concomitant ankle OA with reduced flexibility of the hindfoot. These patients experienced increased ankle pain following TKA and a worse clinical outcome. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Examination of the Origin and Branching Direction of the Anterior Medial Malleolar Artery From the Anterior Tibial Artery: A Cadaveric Study.

This study characterized the anterior medial malleolar artery (AMMA) branching from the anterior tibial artery (ATA) to identify problems in anterior ankle arthroscopy possibly contributing to injury to the AMMA. Barium was injected into 12 adult cadaveric feet via the external iliac artery and the origin and branching direction of the AMMA were identified on computed tomography. The AMMA originated from the level of the ankle joint and below and above the ankle joint line (AJL) in 4 (33.3%), 6 (50.0%), and 1 (8.3%) specimen, respectively. Mean distance from the AJL to the branching point of the AMMA on the sagittal plane was 2.5 mm distal to the AJL. Mean angle between the distal longitudinal axis of the ATA and AMMA was 83.2°. This study established the origin and branching of the AMMA from the ATA. The AMMA should be examined carefully during ankle arthroscopy. Level IV: Cadaveric study.

Changes in Hip, Knee, and Ankle Coronal Alignments After Total Hip Arthroplasty With Transverse Femoral Shortening Osteotomy for Unilateral Crowe Type IV Developmental Dysplasia of the Hip

BackgroundTo investigate changes in lower extremity coronal alignment in patients with unilateral Crowe type IV developmental dysplasia of the hip who underwent total hip arthroplasty with transverse femoral shortening osteotomy. MethodsWe reviewed the preoperative and 1-year postoperative full-length lower extremity radiographs of 25 patients. Femoral offset (FO), mechanical hip-knee-ankle angle, anatomical axis, mechanical axis deviation (MAD), mechanical lateral proximal femoral angle, anatomical medial proximal femoral angle, mechanical lateral distal femoral angle, anatomical lateral distal femoral angle, knee joint line congruency angle, mechanical medial proximal tibial angle, mechanical lateral distal tibial angle, ankle joint line orientation angle, tibial plafond talus angle, extremity length, and pelvic obliquity were measured on both the operative and nonoperative sides. ResultsPostoperatively, there were significant changes in FO (P = .001), hip-knee-ankle angle (P = .004), MAD (P = .016), mechanical lateral proximal femoral angle (P = .001), anatomical medial proximal femoral angle (P = .012), mechanical lateral distal femoral angle (P = .043), and ankle joint line orientation angle (P = .012) on the operative side. Only MAD (P = .035) changed significantly on the nonoperative side. ConclusionModification of FO and reconstruction of hip joint anatomy led to neutralization of knee and ankle valgus alignment. Effects on the nonoperative side were minimal.

Changes of ankle inclinations after total knee arthroplasty

Aim:To evaluate the changes in ankle joint line inclination in patients who had total knee arthroplasty due to degenerative osteoarthritis.Material/Method:Sixty-two knees (with a mean age of 71,66±6,78 years, follow-up 52,34±27,42 months) which had undergone total knee arthroplasty between November 1996 and May 2014 were included in this retrospective study. The knee joint line orientations (KJLO) of the prosthesis and ankle joint line inclination (AJLI) relative to the floor were evaluated on postoperative standard standing long-leg X-rays. The AJLI relative to the floor was defined as the angle between the tangent to the subchondral plate of the talus and the horizontal grid line on radiographs. In order to determine the effects of KJLO and high varus on AJLI, patients were divided into two each groups that were pre-operative mechanical axes (MA) as <20° (n=35, group1) and >=20° (n=27, group2) and post-operative MA <3° (n=32, group a) and >=3° (n=30, group b). In addition, the changes in AJLI were compared between each group. The patients were regrouped as either <=3° (n=28, group i) or >3° (n=34, group ii), in terms of the postoperative KJLO. Inclination angles of the prosthesis were compared between each groups. Statistical analysis was performed with SPSS v18.Results:Mean MA of pre-operative and post-operative were 16,35±6,56° and 3,92±3,35°, respectively. All ankle inclinations were lateralized. AJLI, were significantly decreased from pre-operative mean 7,37°±3,19° to post-operative mean 3,71°±2,22° (p<0,0001). The mean of change was 3,65°±3,03°. However, pre-operative AJLIs were significantly increased in high varus group (group1: 6,34°±2,54°, group2: 8,70°±3,48°, p=0,003); post-operative AJLIs did not differ significantly (group1: 3,55°±2,36°, group2: 3,92°±2,05°, p=0,516) with respect to the MA. The changes in preop-postop AJLI’s were significantly higher in high varus group again (p=0,009). When the KJLO groups were compared, pre-operative AJLIs were significantly different (group i: 6,25°±2,33°, group ii: 8,29°±3,53°, p=0,004) while post-operative AJLIs did not differ significantly (group i: 3,46°±2,38°, group ii: 3,92°±2,08°, p=0,489).Conclusion:Pre-operatively high varus knees also had high ankle varus, hence ankle deformity was corrected by the restoration of the optimal lower limb aligment. Obtaining parallel orientation of the components relative to the ground, restored the AJLI. Pre-operative planning and convenient implantation of the components lead to achieve optimum knee orientation which restored the ankle joint line orientation independent from mechanical axes. Not only the goal of optimum mechanical axes but also optimum knee joint line orientation’s importance was demonsrated.

Preoperative determination of tibial nail length: An anthropometric study

ObjectiveTo assess the correlation between five anthropometric parameters and the distance from tibial tuberosity to medial malleolus in 100 volunteers. MethodsSix anthropometric parameters were measured in 50 male and 50 female medical students using a metallic scale: medial knee joint line to ankle joint line (K-A), medial knee joint line to medial malleolus (K-MM), tibial tuberosity to ankle joint (TT-A), tibial tuberosity to medial malleolus (TT- MM), olecranon to 5th metacarpal head (O-MH) and body height (BH). Nail size predicted based upon TT-MM measurement was chosen as ideal nail size. A constant was derived for each of the six anthropometric parameters which was either added or subtracted to each measurement to derive nail size. A regression equation was applied to BH measurements. Nail sizes calculated were compared with that obtained from TT-MM measurement and accuracy was evaluated. Accuracy of O-MH and BH regression equations recommended by other authors were calculated in our data. ResultsAdding 11 mm to TT-A distance had highest accuracy (81%) and correlation (0.966) in predicting nails correctly. Subtracting 33 mm from K-MM measurement and 25 mm from K-A distance derived accurate sizes in 69% and 76% respectively. Adding 6 mm to O-MH distance had a poor accuracy of 51%. Nail size prediction based upon body height regression equation derived correct nail sizes in only 34% of the cases. Regression equation analysis by other authors based on O-MH and BH distances yielded correct sizes in 11% and 5% of the cases respectively. ConclusionTT-A, K-A and K-MM measurements can be used simultaneously to increase accuracy of nail size prediction. This method would be helpful in determining nail size preoperatively especially when one anatomic landmark is difficult to palpate.

Effects of total knee arthroplasty on ankle alignment in patients with varus gonarthrosis: Do we sacrifice ankle to the knee?

Total knee arthroplasty is one of the most commonly preferred surgical methods in the treatment of patients with varus gonarthrosis. In this study, we aimed to evaluate the radiological changes observed in the ankles after total knee arthroplasty. Between May 2012 and June 2013, 80 knees of 78 patients with varus deformity over 10° underwent total knee arthroplasty. For each patient, full-leg standing radiographs were obtained pre- and post-operatively. Mechanical and anatomical axes (HKA and AA), lateral distal femoral angle, medial proximal tibial angle, lateral distal tibial angle (LDTA), ankle joint line orientation angle (AJOA), tibial plafond talus angle (PTA) and talar shift were measured for each patient both pre- and post-operatively. Pre-operatively, the mean HKA was 16.6° and the mean AA was 10.41°, both in favour of varus alignment. Post-operatively, the mean HKA decreased to 3.6° and the mean AA to -2.1. The mean LDTA was 87.3°. Before the operation, the mean AJOA was -7.6°, opening to the medial aspect of the ankle, and it was 0.04° after the operation and opening to the lateral aspect (p<0.05). Our study reveals the changes occurring in the ankle after acute correction of long-standing varus deformity of the knee using total knee arthroplasty. In cases undergoing knee arthroplasty, effect of the acute change in the alignment of the knee on the ankle should be taken into consideration and the amount of correction should be calculated carefully in order not to damage the alignment of the ankle. IV.

Changes of knee joint and ankle joint orientations after high tibial osteotomy

We sought to determine (1) whether change in the tibial plateau inclination (TPI) after high tibial osteotomy (HTO) is different from change in the knee joint line orientation (KJLO) relative to the ground; (2) whether, in varus knee OA patients before and after HTO, these radiographic measures are different from those in normal control; and (3) whether the postoperative values of the TPI and KJLO relative to the ground are associated with short term clinical outcome scores after HTO. Fifty patients who underwent HTO and 75 normal controls were assessed with four radiographic measures. We compared the measures before HTO with those after HTO and with those of the normal controls, then examined associations between the postoperative radiographic measures and clinical outcome scores 1-year after HTO. After HTO, TPI increased 9.0°, whereas KJLO relative to the ground only increased 4.1°, with a compensatory change of the ankle joint line orientation. However, the postoperative KJLO relative to the ground in the HTO group was significantly different from that of the normal controls (mean difference, 4.9°; P < 0.001). In the multiple regression analyses, the postoperative radiographic measures were not associated with outcome clinical scores 1 year after HTO. After HTO the relative KJLO changed significantly less than did the anatomical geometry of the proximal tibia. Although the KJLO after the HTO was still significantly different from that of normal knees, its value did not adversely affect clinical outcome scores 1 year after HTO.

Biomechanical Evaluation of Syndesmotic Screw Position

To evaluate the stresses in syndesmotic screws and widening of syndesmosis under loading after placement of the screws at different levels from the ankle joint line and to determine the optimal level. From a set of computed tomographic data of an ankle, a 3-dimensional finite-element model was reconstructed. Six fixation configurations of the syndesmosis with placement of 3.5 or 4.5 mm single tricortical screws at 20-45 mm from the tibiotalar joint were performed on this model. Physiological loads approximating those during both midstance and heel-off states of stance phase of normal walking were applied to evaluate the stress in the screw and widening of the syndesmosis. Among the 6 fixation configurations, the lowest von Mises stress was found in the screws placed 30-40 mm above the joint line (373.31-380.17 MPa for 3.5 mm cortical screw and 284.06-327.31 MPa for 4.5 mm cortical screw in midstance phases), whereas the least syndesmosis widening was determined when the screw was placed 30 mm above the tibial plafond (0.005 mm) for 3.5 mm cortical screw and 20, 25, and 30 mm above the tibial plafond (0.004 mm for each, respectively) for 4.5 mm cortical screw during midstance phases. This study showed that syndesmosis fixation at the level of 30-40 mm above the tibiotalar joint has advantages with regard to stress in screws in comparison with the other evaluated levels.

Dynamic control of knee axial deformities

The authors have evaluated the clinical examination of the patients with axial malalignments in the knee by the original method and device which was named varovalgometer. The measurements were conducted by tension of the cord through the spina iliaca anterior superior and the middle of the lower pole of patella. The deviation of the center of the ankle estimated by metal ruler which was positioned perpendicular to the lower leg axis on the level of the ankle joint line. The results of comparison of our method and computer navigation in 53 patients during the TKA show no statistically significant varieties but they differ by average 5° of valgus in clinical examination in comparison with mechanical axis which was identified by computer navigation. The dynamic control of axial malalignment can be used in clinical practice for estimation of the results of treatment of pathology with axial deformities in the knee; for the control of reduction and secondary displacement of the fractures around the knee; for assessment of instability; in planning of correctional osteotomies and intraoperative control of deformity correction; for estimation of Q angle in subluxation and recurrent dislocation of patella; in planning of TKA; during the growth of child it allows to assess the progression of deformity.

Preoperative estimation of tibial nail length—Because size does matter

IntroductionSelecting the correct tibial nail length is essential for satisfactory outcomes. Nails that are inserted and are found to be of inappropriate length should be removed. Accurate preoperative nail estimation has the potential to reduce intra-operative errors, operative time and radiation exposure. MethodsWe compared the most commonly used radiological, anthropometric and intra-operative techniques to determine ideal nail lengths for 16 paired cadaveric tibiae. Five different anthropometric measurements were taken from each intact cadaver including: knee joint line to ankle joint line distance (JJD), medial knee joint line to medial malleolus distance (MMD), tibial tuberosity to medial malleolus distance (TMD), olecranon to 5th metacarpal head distance (OMD) and body height (BHR). Each tibia also underwent antero–posterior (AP) and lateral scanograms. Computerised tomography was used to determine the ideal nail length for each tibia. Each anthropometric and radiological measurement was recorded by two orthopaedic surgeons independently. An expert tibial nail was then inserted after nail length estimation was performed using a guidewire technique and an intra-operative radiographic ruler. ResultsThe AP scanogram was found to be 100% accurate in selecting ideal nail length. The lateral scanogram was also found to be reasonably accurate but in 19% (3/16) of cases it led to a nail being too long. The intra-operative radiographic ruler was found to give a good indication of the ideal nail size, as did the guidewire technique, with only 6% (1/16) of cases producing an incorrect nail size. In general, the anatomical measurements gave a poor indication of ideal nail size compared with the other techniques. The following accuracies were noted: JJD 56%, MMD 50%, TMD 38%, BHR 13% and OMD 56%. ConclusionsWe found that radiological methods such as using an AP radiograph with known magnification and intra-operative radiographic ruler were able to predict nail length very accurately and we suggest that these measurements should be performed routinely. The guidewire technique was also effective but we recommend that it not be used in isolation as errors can occur. We found that anatomical measurements are not accurate for predicting tibial nail length.

Effect of foot deformity on conventional mechanical axis deviation and ground mechanical axis deviation during single leg stance and two leg stance in genu varum

We assessed the effect of foot deformity on the loading axis of lower limbs in 33 patients with genu varum (25 bilateral and eigth unilateral) caused by varying etiologies including achondroplasia, cerebral palsy, prior trauma, rickets, metaphyseal chondrodysplasia and primary osteoarthritis using single leg stance and both leg stance radiographs. Deviation at the knee from the hip ankle line (conventional) and hip foot line (centre of hip to centre of heel) was calculated. A comparison was made between single leg stance and two leg stance for tibiocalcaneal angle, mechanical axis angle, knee and ankle joint line convergence angle, conventional mechanical axis deviation (MADC) and ground mechanical axis deviation (MADG). In addition comparisons were also made among three groups formed depending on the tibiocalcaneal angle and MADC–MADG difference for all the above measurements. Mechanical axis deviation (calculated using the two methods) varied with the talocalcaneal angle and single leg stance. Patients with a fixed subtalar varus and with severe genu varum, where the normal compensatory subtalar eversion could not compensate showed that conventional mechanical axis deviation was significantly higher by 3.4 ± 2.4 mm and ground mechanical axis deviation degrees was significantly higher by 3.8 ± 3.2 mm in single leg stance when compared to two leg stance ( p < .0001). Foot deformity should be included during preoperative evaluation and planning for knee deformity correction.

Analyse segmentaire de la déformation frontale dans les gonarthroses fémoro-tibiales latéralisées

Purpose of the study We conducted a retrospective radiographic study to identify and quantify medial and lateral misalignments in candidates for total knee arthroplasty. Material and methods We studied a discontinuous series of 101 patients (164 knees) among candidates for total knee arthroplasty seen between 1990 and 2002. We selected a random sample for study. Exclusion criteria were any history of fracture, surgical treatment, rheumatoid disease, or congenital disorder. A first group of 136 genu varum knees was identified in 82 patients (mean age 72 years, mean weight 79 kg). A second group of 28 genu valgum knees was identified in 19 patients (mean age 67 years, mean weight 71 kg). The standard radiograms were digitalized for semi-automatic measurements using the Metros™ software. We recorded overall deformation, femoral valgus, tibial varus, HKA angle, HKS angle (mechanical/anatomic axis of the femur) and angle C (horizontal inclination of the ankle to the ground). All measures were compared between each other for each patient to search for relations. Results In the genu varum group (136 knees), mean overall deformation was 9̊, mainly due to tibial misalignment (5.5̊) with a 1̊ femoral valgus component. The HKS angle was 6.3̊, and lateral joint gap 4.3̊; the C angle was 4̊. Overall varus followed tibial varus (p<0.01). Ankle inclination followed tibial varus (p<0.01). In the genu valgum group (28 knees), overall deformation was 4.2̊, mainly due to femoral misalignment (5.6̊) with 1̊ tibial varus and a medial joint gap of 2̊. The HKS angle was 4.7̊ and the mean C angle -4̊. Overall valgus was related to femoral valgus (p<0.001). Tibial varus was greater with greater femoral valgus (p<0.01). In both groups, the HKS angle was smaller with greater femoral valgus. Discussion Semi-automatic measurements on digitalized films enabled excellent reproducibility. Causes of error were related to limb rotation at acquisition. This study showed that genu varum worsens because of tibial wear followed by ligament distension, while for genu valgum, worsening predominantly results from femoral wear. The ankle joint line was nearly horizontal in one-third of the limbs, even when there was a major misalignment of the lower limb. The HKS angle was quite variable in both morphotypes, but was smaller with greater femoral valgus in both groups. Conclusion Measuring all components involved in medial and lateral knee misalignment is very useful for understanding the morphotype of each individual knee before performing osteotomy or implanting a knee prosthesis.

The importance of early arthroscopy in athletes with painful cartilage lesions of the ankle: a prospective study of 61 consecutive cases

BackgroundAnkle sprains are common in sports and can sometimes result in a persistent pain condition.PurposePrimarily to evaluate clinical symptoms, signs, diagnostics and outcomes of surgery for symptomatic chondral injuries of the talo crural joint in athletes. Secondly, in applicable cases, to evaluate the accuracy of MRI in detecting these injuries. Type of study: Prospective consecutive series.MethodsOver around 4 years we studied 61 consecutive athletes with symptomatic chondral lesions to the talocrural joint causing persistent exertion ankle pain.Results43% were professional full time athletes and 67% were semi-professional, elite or amateur athletes, main sports being soccer (49%) and rugby (14%). The main subjective complaint was exertion ankle pain (93%). Effusion (75%) and joint line tenderness on palpation (92%) were the most common clinical findings. The duration from injury to arthroscopy for 58/61 cases was 7 months (5.7–7.9). 3/61 cases were referred within 3 weeks from injury. There were in total 75 cartilage lesions. Of these, 52 were located on the Talus dome, 17 on the medial malleolus and 6 on the Tibia plafond. Of the Talus dome injuries 18 were anteromedial, 14 anterolateral, 9 posteromedial, 3 posterolateral and 8 affecting mid talus. 50% were grade 4 lesions, 13.3% grade 3, 16.7% grade 2 and 20% grade 1. MRI had been performed pre operatively in 26/61 (39%) and 59% of these had been interpreted as normal. Detection rate of cartilage lesions was only 19%, but subchondral oedema was present in 55%. At clinical follow up average 24 months after surgery (10–48 months), 73% were playing at pre-injury level. The average return to that level of sports after surgery was 16 weeks (3–32 weeks). However 43% still suffered minor symptoms.ConclusionArthroscopy should be considered early when an athlete presents with exertion ankle pain, effusion and joint line tenderness on palpation after a previous sprain. Conventional MRI is not reliable for detecting isolated cartilage lesions, but the presence of subchondral oedema should raise such suspicion.

Effectiveness of physical examination of the hind and mid foot by orthopaedic surgeons and accident and emergency clinicians

Background: Precise physical examination by a clinician with a sound knowledge of surface anatomy plays an important part in the accurate diagnosis of hind and mid foot pathology. Objective: To assess knowledge of hind and mid foot surface anatomy among orthopaedic surgeons and accident and emergency (A&E) clinicians. Methods: Sixty-two doctors (34 orthopaedic and 28 A&E) were asked to palpate 12 frequently symptomatic regions of the hind and mid foot. Results: Twelve subjects declined to participate. Three subjects correctly palpated all 12 points while one subject failed to correctly palpate a single point. Thirty-eight subjects correctly palpated the ankle joint line and 11 subjects the retrocalcaneal protuberance. The mean and median scores (orthopaedic and A&E combined) were 6.4 and 6. Conclusion: The majority of orthopaedic and A&E doctors do not perform a precise physical examination of the hind and mid foot. Undergraduate teaching programmes should address this deficiency and aim to improve anatomical teaching.

Interlocking nails for displaced metaphyseal fractures of the distal tibia

Metaphyseal fractures of the distal tibia near the ankle joint are difficult to manage. Poor soft tissue coverage and comminution of the fracture complicate open reduction. This prospective study aims to evaluate the practicability of using interlocking nails to treat such fractures. Using the method of closed reduction and internal fixation with a shortened tibial interlocking nail, 20 consecutive cases of distal tibial metaphyseal fractures within 4 cm of the ankle joint line were enrolled from 1997 to 2001. All patients received regular post-operative radiographic check-up and the ankle function was evaluated with the Iowa Ankle-Evaluation rating system. Our result was satisfactory and all of the fractures united solidly with a mean union time of 17.2 weeks. No major complication occurred. We conclude that tibial interlocking nailing is a reliable and safe method for managing metaphyseal fractures of the distal tibia near the ankle joint.