Ankle Society Ankle-Hindfoot Scale Score Research Articles

Surgical Management and Outcomes of Patients with Idiopathic Peroneal Spastic Flatfoot: A Retrospective Case Series.

Although tarsal coalition represents the most common cause of peroneal spastic flatfoot, its existence cannot be verified in several cases. In some patients with rigid flatfoot, no cause can be detected after clinical, laboratory, and radiologic examination, and the condition is called idiopathic peroneal spastic flatfoot (IPSF). This study aimed to present our experience with surgical management and outcomes in patients with IPSF. Seven patients with IPSF, who were operated on between 2016 and 2019, and followed for at least 12 months were included, whereas those with known causes, such as tarsal coalition or other causes (eg, traumatic) were excluded. All patients were followed up for 3 months with botulinum toxin injection and cast immobilization as a routine protocol, and clinical improvement was not achieved. The Evans procedure and grafting with tricortical iliac crest bone graft in five patients and subtalar arthrodesis in two patients were performed. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores and Foot and Ankle Disability Index scores were obtained preoperatively and postoperatively from all patients. On physical examination, all feet manifested rigid pes planus with varying degrees of hindfoot valgus and limited subtalar motion. Overall, the mean American Orthopaedic Foot and Ankle Society and Foot and Ankle Disability Index scores significantly increased from 42 (range, 20-76) and 45 (range, 19-68) preoperatively (P = .018) to 85 (range, 67-97) and 84 (range, 67-99) (P = .043) at the final follow-up, respectively. No major intraoperative or postoperative complications were observed in any of the patients. All computed tomographic and magnetic resonance imaging scans revealed no evidence of tarsal coalitions in any of the feet. All radiologic workups failed to demonstrate secondary signs of fibrous or cartilaginous coalitions. Operative treatment seems to be a good option in the treatment of patients with IPSF who do not benefit from conservative treatment. In the future, it is recommended to investigate the ideal treatment options for this group of patients.

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients.

Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk. We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months. A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications. In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot. Level II, prospective comparative study.

Clinical Outcomes of Posterior Hindfoot Endoscopic Surgery using 1.9-mm Diameter Needle Arthroscopy for Posterior Ankle Impingement in Athletes

Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Posterior hindfoot endoscopy is a safe and effective treatment for posterior ankle impingement syndrome (PAIS). However, wound-healing problems following hindfoot endoscopy have been still reported. Recently, a novel 1.9- mm diameter needle-arthroscopic system has been introduced. Its small features can help reduce the risk of wound complications and can have the potential to make it earlier to return to play sports due to its minimally invasiveness. To our knowledge, no studies have been reported regarding PAIS treatment using a 1.9-mm diameter needle-arthroscopy. The purpose of this study was to report the clinical outcomes including return to sports following hindfoot endoscopic surgery using 1.9-mm diameter needle- arthroscopy for PAIS. Methods: Six patients who engaged in athletic activity (mean age 21.7 [range 16-34] years) and were treated by a hindfoot endoscopic surgery using a 1.9-mm diameter arthroscopic system (NanoScopeTM, Arthrex) for PAIS were included. In all patients, os trigonum was resected and flexor hallucis longus (FHL) tenosynovitis was debrided. American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score was evaluated and Visual analog scale (VAS) at 1 day and 2 weeks after surgery were recorded. Time to return to sports activity at preinjury level was also evaluated. Engaged sports included soccer (3 patients), ballet (2 patients), and lacrosse (1 patient). Results: The mean AOFAS score improved significantly from 77.7 to 100 after surgery (p<0.001). Mean VAS score at 1 day and 2 weeks were 1.5 (range 0-3) and 0.3 (range 0-1). respectively. All patients were able to return to full sports activities and the mean time to return to sports activities at preinjury level was 4.8 weeks (range 3-7 weeks). No complications were reported. Conclusion: Posterior hindfoot endoscopy using a 1.9-mm diameter needle-arthroscopy provided excellent clinical outcomes in the treatment of PAIS with relatively earlier return to play sports compared to conventional arthroscopy surgery, although this is not a comparative study. Minimum invasiveness with less postoperative pain using needle-arthroscopy may contribute to its early recovery. Further studies are required to support our results.

Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus.

The treatment for severe hallux valgus deformity presents a challenge with high risk of complications. Third generation MIS techniques have increased their publications in recent years. The aim was to compare clinical and radiologic outcomes in moderate and severe cases and report minor and major complications. Retrospective series of cases with prospective data collection of 156 consecutive feet that underwent percutaneous double first metatarsal osteotomy (PEDO) and first phalanx osteotomy between 2008 and 2019 for moderate (hallux valgus angle [HVA] between ≥20 and <40 degrees and/or intermetatarsal angle [IMA] <16 degrees) and severe (HVA ≥40 degrees and/or IMA ≥16 degrees) hallux valgus deformities. Primary outcomes included radiographic and clinical parameters. Secondary outcomes included minor and major complications. A total of 156 procedures were performed in 128 patients. Mean age was 54.3 years (SD 14.3) (range, 19-82 years), median follow-up was 22.6 months (range, 12-96 months). Radiographic changes pre- to postoperation were as follows: HVA changed from 38.2 (SD 10.1) degrees to 11.2 (SD 8.3) degrees (P < .001), IMA from 14.7 (SD 3.2) degrees to 7.9 (SD 3.7) degrees (P < .001), and distal articular metatarsal angle from 19.7 (SD 6.3) degrees to 8.8 (SD 5.7) degrees (P < .001) after PEDO technique. Clinical changes pre- to postoperation were as follows: American Orthopaedic Foot & Ankle Society ankle-hindfoot scale scores improved from 47.3 (SD 16.5) to 87 (SD 11.6) (P < .001) and visual analog scale scores from 5 (2.7) to 0.9 (1.3) (P < .001). The satisfaction rate was 97% in the total sample. Recurrence rate (HVA ≥20 degrees) was 7.7%. Hallux varus (HVA <0 degrees) occurred in 5.8%, acute osteomyelitis in 1.3%, partial avascular necrosis in 0.6%, screw removal in 0.6%, and reoperation in 1.9%. No nonunion was observed. Clinical and radiographic parameters improved significantly, with a minimum of 12 months of follow-up in moderate and severe hallux valgus. Long experience in percutaneous surgery and specific instruments are needed for this technique. Recurrence was linked to preoperative HVA ≥40 degrees and postoperative tibial sesamoid position; Hallux varus was linked to lateral soft tissue release. Level IV, case series.

Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up.

Few studies have investigated long-term clinical outcomes of a mobile-bearing total ankle arthroplasty (TAA) system. This study analyzed long-term outcomes of TAA using the HINTEGRA prosthesis at a single, non-developer center. Primary TAAs were performed on 213 ankles in 194 patients, and 151 consecutive ankles [71%] in 136 patients with a minimum follow-up of 10 years after the primary TAA were included in this study. Clinical results were assessed using a visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale score, the Ankle Osteoarthritis Scale (AOS) pain and disability subscores, and ankle range of motion. Prosthesis survivorship, reoperations, and risk factors were also evaluated. The mean follow-up was 135.5 months (range, 120.0 to 204.0 months). All clinical scores and ankle range of motion improved significantly from preoperatively to 2 years, 4 to 6 years, and ≥10 years after TAA (p < 0.001). A total of 43 ankles (28.5%) required revision procedures, with the most common reason being periprosthetic osteolysis (32 ankles [21.2%]). The overall implant survivorship was 93.5% in Kaplan-Meier survival analysis at the mean follow-up of 11.3 years after the TAA. TAA using the HINTEGRA prosthesis with careful follow-up observation and appropriate adjunct procedures for the treatment of end-stage ankle arthritis produced satisfactory clinical results, which were maintained at a follow-up of ≥10 years, and resulted in 93.5% of implant survivorship. Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture

Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon total rupture score and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The preinjury median TAS score was 4 point and unchanged at the last follow-up. The mean Achilles tendon Total Rupture Scores and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score 1 point lower than that at preinjury and with less favorable clinical outcomes.

Minimally-Invasive Plate or Intramedullar Nail in the Management of Distal Extra-Articular Tibial Fracture, What Is Better?

Objective: The aim of this study was to compare the clinical and functional outcomes of patients with distal tibia extraarticular fractures treated with Intramedullary nailing (IMN) or Minimally invasive plate osteosynthesis (MIPO). Materials and Methods: This retrospective study included 47 patients treated with IMN and 41 patients with MIPO. Clinical and radiographic results were evaluated at last follow-up. Anterior knee pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score and Lysholm knee scoring scale were used as clinical measurement. Results: Although the union time and operation time were significantly higher in the IMN group compared to the MIPO group (p&amp;lt;0.001), the full weight bearing time and the hospital time were higher in the MIPO group (p&amp;lt;0.001). There were no statistical differences between wound problem, malposition, infection and grafting rates in both groups (p&amp;gt;0.05). Although the AOFAS score was statistically higher in the IMN group (p=0.031), the Lysholm knee score was higher in the MIPO group (p&amp;lt;0.001). Conclusion: While MIPO is advantageous with low union time, low operating time and no damage to the knee joint, IMN allows earlier full weight bearing, lower hospitalization and has better ankle functional results. Keywords:

Ankle Arthrodesis Combined With Mosaic Bone Autograft Transplantation for End-Stage Ankle Osteoarthritis With Large Cysts of Talar Dome

End-stage ankle osteoarthritis with large cysts of talar dome can be challenging to treat. Twenty patients diagnosed as end-stage ankle arthritis with large talar cysts between 04/2010 and 02/2016 were randomly divided into experimental group (10 cases) and conventional group (10 cases) by random number method. Patients in the experimental group were treated with ankle arthrodesis combined with a concomitant procedure of mosaic bone autograft transplantation, the conventional group under the ankle arthrodesis. The operation time, intraoperative blood loss, postoperative hospital stay, the time of bone union, and postoperative height of the talus between the 2 groups were compared. The preoperative and postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score were also recorded and compared. There was no significant difference in the operation time, intraoperative blood loss, and postoperative hospital stay between the 2 groups. The postoperative height of the talus body and the time of bone union were better in the experimental group than that in the conventional group (p < .05). The results of follow-up showed that the American Orthopaedic Foot and Ankle Society scores of the conventional group were lower than those in the experimental group (p < .001). And the incidence of complication (10%) in the experimental group was significantly lower than that in the conventional group (40%). The use of tibiotalar arthrodesis combined with mosaic bone autograft transfer may be potentially an effective option for the treatment of end-stage ankle arthritis with large talar cysts.

Calcaneal lengthening using ipsilateral fibula autograft in the treatment of symptomatic pes valgus in adolescents

BackgroundEvans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.MethodsWe retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.ResultsThe calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p < 0.001), and from 14.5 to 4.6 (p < 0.001) and 13.5 to 8.5 (p < 0.001), respectively. The mean distance of the lengthening site showed no significant change (p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p < 0.001).ConclusionsEvans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.

Modified arthroscopic Broström procedure using a soft anchor for chronic lateral ankle instability: Short-term follow-up results.

Objectives This study aims to examine the clinical outcomes and complications of lateral ligament reconstruction performed using soft anchors according to the arthroscopic modified Broström technique (MBT) for the treatment of chronic ankle instability (CAI) and to evaluate the frequency of return to sports.Patients and methods A total of 14 patients with CAI (9 males, 5 females; mean age: 30.1±4.6 years; range, 22 to 38 years) who underwent the MBT with soft anchors between January 2015 and December 2019 were retrospectively analyzed. Ankle function was evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale and Karlsson Ankle Function Score (Karlsson/Peterson, K/D score), while pain was evaluated using the Visual Analog Scale (VAS) after a minimum follow-up of 12 months.Results The mean follow-up was 23.6±7.7 months. The mean overall AOFAS score was 74.0±2.6 preoperatively, which improved to 96.2±1.9 in the postoperative period (p=0.001). The mean pre- and postoperative K/P scores were 72.4±3.1 (range, 68 to 78) and 95.3±2.2 (range, 92 to 98), respectively (p=0.001). The mean preoperative VAS score was 2.4±0.9 (range, 1 to 4) and showed a significant improvement to 0.6±0.5 (range, 0 to 1) in the postoperative period (p=0.001). Nine (64.3%) patients returned to sports activities after surgery at a mean period of 9±2.1 months.Conclusion In the treatment of CAI, arthroscopic MBT performed with soft anchors provides successful outcomes in short-term follow-up. In addition to being a minimally invasive technique, MBT is a reliable and safe approach with low complication rates and significant functional improvement. However, the low ratio of return to sports should be considered as a failure of this technique.

Long-term Patient-Reported Outcome Measures Following Particulated Juvenile Allograft Cartilage Implantation for Treatment of Difficult Osteochondral Lesions of the Talus.

Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes. Thirteen patients with difficult-to-treat OCLTs underwent arthroscopy-assisted implantation of particulated juvenile articular cartilage graft into defects from 2010 to 2012 by the same surgeon. "Difficult to treat" was defined as having at least 3 of the following features or 2 if both variables described lesion characteristics: (1) lesions size of 107 mm2 or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI) >25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery. Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form-36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741). These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation. Level II, prospective cohort study.

Open Curettage With Bone Augmentation for Symptomatic Tumors and Tumor-like Lesions of Calcaneus: A Comparison of Bioactive Glass Versus Allogeneic Bone

Few studies have characterized the clinical outcomes of 45S5 Bioglass® applied as a bone graft to that of allogeneic bone applied in calcaneal open curettage. Therefore, the purpose of the present investigation was to compare the outcomes of patients with calcaneal tumors and tumor-like lesions treated by open curettage with 45S5 Bioglass® or allogeneic bone. Of the 31 patients who underwent open curettage (18 cases of unicameral bone cysts, 7 cases of aneurysmal bone cysts, and 6 cases of intraosseous lipoma), 16 (52%) received grafts with 45S5 Bioglass® and 15 (48%) with allogeneic bone. All the feet achieved bone fusion according to the modified Neer radiographic classification system at the last follow-up examination. The mean bone ingrowth time for the grafts with 45S5 Bioglass® versus allogeneic bone was 3.71 ± 0.86 versus 4.46 ± 1.04 months (p = .038), the mean bone healing time was 4.86 ± 0.93 versus 5.73 ± 1.07 months (p = .021), and the mean incision drying time was 7.2 ± 1.8 versus 8.2 ± 1.5 days (p = .047), respectively. No differences were found in the postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores between the 2 groups (p = .213). These results show that 45S5 Bioglass® can better facilitate the formation of new bone with a faster drying time of the incision than allogeneic bone. Although both materials can benefit the clinical outcomes of calcaneal tumors and tumor-like lesions, further studies are needed to observe the long-term complications and lesion recurrence rates.

A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond

BackgroundAlthough efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes.MethodsTwenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.ResultsAll surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up.ConclusionsThe fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon.

Background:The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture.Methods:A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up.Results:Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up (P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively (P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery.Conclusion:The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery.Level of Evidence:Level IV, retrospective case series.

Achilles Tendon Region Defects: Delayed Composite Anterolateral Thigh Flap With Stripping of Fascia Lata: A Case Series

The purpose of this study was to evaluate the functional and physical functioning score out-comes of patients following microsurgical reconstruction of the yarrow region, using a combination of objective, subjective, and semi-subjective measurements. Between 2007 and 2018, 15 patients underwent delayed Achilles tendon region reconstruction with different anterolateral thigh flap types. Seven (7) patients underwent tendon and soft tissue re-construction with a chimeric anterolateral thigh flap (ALT) and rolled-up fascia lata, and 8 patients underwent soft tissue reconstruction and only tendon coverage with fascia lata. Follow-up assessments included maximal range of motion (MROM) (plantarflexion and dorsiflexion), the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale score, and the Med-ical Outcomes Study 36-item Short-Form Health Survey physical functioning subscore. A total of 15 patients (11 males and 4 females with a mean age of 39.86 years) were evaluated during a mean follow-up time of 23 months (SD = 7.12). The MROM for plantarflexion and dorsiflexion was 42.71 degrees (SD = 2.9) and 24.8 degrees (SD = 4.29), respectively, in patients who underwent composite ALT with a rolled-up fascia lata. The MROM for plantarflexion and dorsiflexion was 43 degrees (SD = 5.37) and 27.37 degrees (SD = 3.2), respectively, in patients who underwent fasciocutaneous ALT. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 82 for the first group and 86.87 for the second, whereas the mean Medical Outcomes Study 36-item Short-Form Health Survey scores were 82.57 and 81.5, respectively, for the 2 groups. Statistical analysis showed no significant difference between the 2 groups. The results of this case series suggest that the single-stage composite reconstruction with a fasciocutaneous flap with or without a strip of fascia lata is a safe and reliable strategy for composite reconstruction of the Achilles tendon region. Additional studies to evaluate these outcomes and instruments to evaluate functioning are necessary.

Knotless All-Inside Arthroscopic Modified Broström Procedure for Lateral Ankle Instability

One reported complication of the arthroscopic modified Broström operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Broström operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Broström operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

Modified Bunnell suture repair versus bundle-to-bundle suture repair for acute Achilles tendon rupture: a prospective comparative study of patients aged

BackgroundThis study aimed to compare the operative outcome of percutaneous repair (modified Bunnell suture technique) versus open repair (bundle-to-bundle suture technique) of acute Achilles tendon rupture.MethodsSeventy-two consecutive patients who underwent surgical treatment of Achilles tendon rupture were evaluated in this prospective study. Thirty-six patients were treated using the bundle-to-bundle suture technique (group A), and 36 patients were treated using the modified Bunnell suture technique (group B). All patients underwent functional examination comprising measurement of the calf muscle circumference and performance of the single-leg heel-rise test. The length and diameter of the Achilles tendon were compared between the injured and uninjured sides on magnetic resonance imaging. The number of single-leg heel rises (height > 5 cm) performed within 15 s was compared between the injured and uninjured sides. The ankle range of motion was also recorded. The Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, and visual analog scale (VAS) pain score were used to evaluate the clinical outcome at 12 months postoperatively.ResultsA total of 61 patients were followed up. The mean follow-up duration did not significantly differ between group A (23.73 ± 2.81 months) and group B (22.61 ± 3.96 months). However, there were significant differences between groups in the heel-rise test (group A, 1.74 ± 0.96; group B, 2.37 ± 1.42) and length of the Achilles tendon (group A, 11.98 ± 1.64 cm; group B, 11.11 ± 1.74 cm). The calf circumference of the injured side was significantly larger in group A than in group B (p = 0.043). The cross-sectional diameter of the Achilles tendon was significantly smaller in group A than group B. At final follow-up, there were no significant differences between the two groups in the ATRS, AOFAS score, or VAS score. One patient in group A had delayed wound healing, which resolved in 40 days.ConclusionsPatients with acute Achilles tendon rupture treated with open repair (bundle-to-bundle suture technique) achieved a better clinical outcome regarding the heel-rise test and calf circumference compared with those treated with percutaneous repair (modified Bunnell suture technique).Trial registrationChinese Clinical Trial Registry, ChiCTR2000035229, 8/4/2020, Retrospectively registered.

Medium-term results of calcaneus lengthening in idiopathic symptomatic flat foot in children and adolescents.

Purpose Calcaneus lengthening can be used in symptomatic flat foot in children, but few details on its medium-term results and complementary procedures are available.MethodsA total of 20 flexible, symptomatic, idiopathic valgus flat feet (in 15 children; mean age 13.9 years (10 to 17)) were operated on. Complementary procedures were based on preoperative and intraoperative analyses. Radiographic measurements were obtained preoperatively and with at least four years follow-up.ResultsAt a mean of 8.3 years (4 to 15) postoperatively, 13 feet had good clinical and radiological results, with significant improvement in American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale scores and radiological measurements. Seven feet had residual pain. Six of them had no osteotomy of the first cuneiform.ConclusionCalcaneus lengthening with adequate complementary musculo-tendinous and/or bone procedures according to preoperative and intraoperative foot deformation leads to good medium-term results. Forefoot supination is the most frequent residual defect. If present intraoperatively, first cuneiform pronation-flexion osteotomy is indicated.Level of evidenceIV

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare.

To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare. A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined. 31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks. Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.