Society Ankle-Hindfoot Scale Research Articles

Arthroscopic treatment for posterior tibial tendon lesions with a posterior approach

To evaluate clinical results of arthroscopic treatment for posterior tibial tendon (PTT) lesions using a posterior approach. Sixteen patients with PTT lesions underwent arthroscopic treatment using a posterior approach. After routine posterior arthroscopy to expose the posterior tibiotalar compartment, the posterior subtalar compartment, and the flexor hallucis longus tendon, the shaver was then moved through the flexor hallucis longus tendon to detect and treat the PTT lesion, including synovectomy, debridement, and repair of the PTT. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS) scale and visual analog scale (VAS) for subjective satisfaction were used to evaluate pre- and post-operative clinical results. Fifteen patients (94 %) (15 ankles) were followed for a mean of 26 ± 10 months. No patients experienced vascular or nerve complications during or after the operation. Mean AOFAS score improved from 49 ± 12 points preoperatively to 84 ± 8.5 points post-operatively (p = 0.000). Mean VAS improved from 6.2 ± 1.7 preoperatively to 2.4 ± 1.3 post-operatively (p = 0.000). There were three patients (20 %) with excellent outcomes, eight patients (53 %) with good outcomes, three patients (20 %) with fair outcomes, and one patient (7 %) with a poor outcome at follow-up. A posterior arthroscopic approach can provide a safe, reliable technique for detecting and treating PTT lesions and a satisfactory surgical outcome. The technique is an alternative to PTT tendoscopy.

Critical Evaluation of Outcome Scales Assessment of Lateral Ankle Ligament Reconstruction

Outcome following foot and ankle surgery can be assessed by disease- and region-specific scores. Many scoring systems exist, making comparison among studies difficult. The present study focused on outcome measures for a common foot and ankle abnormality and compared the results obtained by 2 disease-specific and 2 body region-specific scores. We reviewed 41 patients who underwent lateral ankle ligament reconstruction. Four outcome scales were administered simultaneously: the Cumberland Ankle Instability Tool (CAIT) and the Chronic Ankle Instability Scale (CAIS), which are disease specific, and the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale and the Foot and Ankle Ability Measure (FAAM), which are both body region-specific. The degree of correlation between scores was assessed by Pearson's correlation coefficient. Nonparametric tests, the Kruskal-Wallis and the Mann-Whitney test for pairwise comparison of the scores, were performed. A significant difference (P < .005) was observed between the CAIS and the AOFAS score (P = .0002), between the CAIS and the FAAM 1 (P = .0001), and between the CAIT and the AOFAS score (P = .0003). This study compared the performances of 4 disease- and body region-specific scoring systems. We demonstrated a correlation between the 4 administered scoring systems and notable differences between the results given by each of them. Disease-specific scores appeared more accurate than body region-specific scores. A strong correlation between the AOFAS score and the other scales was observed. The FAAM seemed a good compromise because it offered the possibility to evaluate the patient according to his or her own functional demand. The present study contributes to the development of more critical and accurate outcome assesment methods in foot and ankle surgery.

Intermediate Outcomes of Fresh Talar Osteochondral Allografts for Treatment of Large Osteochondral Lesions of the Talus

Large osteochondral defects of the talus present a treatment challenge. Fresh osteochondral allograft transplantation can be used for large lesions without the donor-site morbidity associated with other procedures such as autologous chondrocyte implantation or osteochondral autograft transfer. The goal of this study was to prospectively evaluate the intermediate outcomes of fresh osteochondral allografting for osteochondral lesions of the talus with use of validated outcome measures. Sixteen patients (seventeen ankles) received a fresh osteochondral allograft, and all sixteen were available for follow-up. Data were prospectively collected with use of the Ankle Osteoarthritis Scale (AOS), Short Form-36 (SF-36), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module outcome measures. Postoperative American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale scores were also collected. All sixteen patients underwent radiographic and computed tomographic (CT) analyses preoperatively, and fifteen patients had these studies postoperatively. The average duration of follow-up was 4.1 years. The latest follow-up CT evaluation identified failure of graft incorporation in two of sixteen ankles. Osteolysis, subchondral cysts, and degenerative changes were found in five, eight, and seven ankles, respectively. Five ankles were considered failures, and two required a reoperation because of ongoing symptoms. The AOS Disability and the AAOS Foot and Ankle Core Scale scores significantly improved, but there was no significant change in the AOS Pain, AAOS Foot and Ankle Shoe Comfort Scale, or SF-36 scores. Overall, ten patients had a good or excellent result; however, persistent symptoms remained in six of these patients. Only four were symptom-free. The use of a fresh osteochondral allograft is a reasonable option for the treatment of large talar osteochondral lesions. The high reoperation rate (two of seventeen) and failure rate (five of seventeen) must be taken into consideration when one is choosing this procedure for the management of these lesions.

Treatment of Talocalcaneal Coalitions

The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft. A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient's outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet. Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence. A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment. Level IV-case series.

Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective

The purpose of the present study was to document the patient self-reported improvements in quality of life, function, and overall impairment scores, as well as the improvement in the clinically derived outcome scores, following a Scandinavian Total Ankle Replacement (STAR) arthroplasty performed for the treatment of end-stage ankle arthritis. All patients who underwent a Scandinavian Total Ankle Replacement arthroplasty from July 1998 through February 2008 were prospectively followed and retrospectively reviewed. All surgical procedures were performed by a single surgeon. Preoperatively and at subsequent follow-up visits, patients were assessed with (1) a visual analog scale (VAS) score for pain, (2) the Short Form-36 (SF-36) quality-of-life scale, (3) the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale and subscales, (4) the Buechel-Pappas pain and function scores, and (5) the ankle range of motion. Additional measures that were recorded included (1) concomitant surgical procedures during the initial ankle replacement, (2) revision surgery during the follow-up period, and (3) any additional surgical procedures. Revision was defined as failure of either the tibial or the talar metallic component that required removal of a metallic implant for any reason. Eighty-two consecutive patients were evaluated. The duration of follow-up ranged from twenty-four to 108 months (mean, sixty-one months; median, sixty months). During the follow-up period, three patients died and six patients moved out of the region. The latter six patients were followed by another surgeon group, and their data were included. Eight patients were lost to follow-up after twelve months. There were significant improvements in all outcome categories between the preoperative and postoperative evaluations. The most compelling finding of the present study involved the marked improvement in terms of the self-reported measures of impairments, quality of life, pain, and function. Total ankle arthroplasty with the Scandinavian Total Ankle Replacement prosthesis was associated with significant improvements in terms of pain, function, and quality of life after intermediate to long-term follow-up.

The assistant medial approach in treatment of intraarticular fractures of calcaneus

Objective To evaluate the assistant medial approach used in the surgical management of intraarticular fractures of calcaneus.Methods From January 2005 to December 2009,33 patients with intraarticular fracture of calcaneus were treated by open reduction and internal fixation through the expanded lateral L-shape approach and the assisted medial approach.They were 27 men and 6 women,aged from 18 to 62 years (average,36 years).There were 15 left sides and 18 right sides.According to Sanders' classification system,there were 27 patients with type Ⅲ displaced calcaneal fracture and 6 with type IV.Four cases were complicated with fracture of lumbar vertebra,one with pilon fracture and one with fracture of acetahulun.Fracture healing was observed and the Bǒhler and Gissane angles were measured.The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale system was used to evaluate the functional recovery.Results All patients were followed up postoperatively to assess their functional outcome.The follow-up duration was 6 to 24 months (mean,12 months).All incisions healed primarily and all fractures obtained bony union in an average of 8 weeks (from 6 to 24 months).All the Bǒhler and Gissane angles were corrected and AOFAS scores were improved.There were significant differences between preoperation and pestoperation in all indexes( P ＜ 0.05).Conclusion As the medial approach can be used to assist the expanded lateral L-shape approach in treatment of the intraarticular fractures of the calcaneus,the reduction and insertion of internal implants can be improved to achieve satisfactory functional outcome. Key words: Calcaneus; Fractures; Fracture fixation, internal; Medial approach

Total Ankle Replacement in Obese Patients: Component Stability, Weight Change, and Functional Outcome in 118 Consecutive Patients

Obesity is a growing problem in Europe and the United States. While obesity has been linked to poor outcomes after total knee or hip replacement, there are no data addressing outcomes in obese patients who underwent total ankle replacement (TAR). This retrospective chart review included 118 patients (123 ankles) with a minimum body mass index (BMI) of 30 kg/m2 who underwent TAR between May 2000 and June 2008. There were 61 male (51.7%) and 57 female (48.3%) patients with a mean age of 59.8 +/- 11.6 years (range, 25.4 to 85.0). All patients were evaluated pre- and postoperatively (mean followup 67.7 +/- 27.0 months; range, 29 to 126). Radiological outcomes were assessed using standardized weightbearing radiographs. Clinical outcomes were assessed using the visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale. There were nine intraoperative complications. All patients experienced significant pain relief (VAS change from 7.0 +/- 1.7 to 1.4 +/- 1.1, p < 0.001) and functional improvement (AOFAS score change from 35.4 +/- 14.9 to 75.4 +/- 9.6, p < 0.001; total ROM change from 26.9 +/- 13.7 to 35.3 +/- 8.1 degrees, p < 0.001). BMI measured preoperatively, and at 1 and 2 years postoperatively was 32.9 +/- 2.5 (range, 30.0 to 40.0) kg/m2, 32.4 +/- 2.4 (range, 28.6 to 41.0) kg/m2, and 32.2 +/- 2.4 (range, 28.6 to 40.5) kg/m2, respectively. Gender had a significant effect on weight loss, but not age or postoperative sports activity. Revision surgery was performed in six patients, resulting in a 6-year survivorship of 93%. Our findings confirm that TAR gives significant pain relief and functional improvement. In this study, the survivorship of the prosthesis components was comparable to the results obtained in non-obese patients.

Functional Outcome of Matrix-Associated Autologous Chondrocyte Implantation in the Ankle

The technique of Matrix-associated autologous chondrocyte implantation (MACI) is well established with satisfactory outcomes up to 5 years in the knee. Fewer series describe the outcomes of this technique in the ankle. We present the functional outcomes of the technique for a single surgeon series in a general hospital setting. Twenty-seven patients, mean age 41, were reviewed at 3.7 (range, 1 to 5) years. Patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, Tegener activity score and University of California lower extremity activity scale. MRI findings were also reviewed. While most patients report a significant improvement in symptoms with full return to activities of daily living, 36% of those under 40 and 78% of those over 40 reported restricted recreational activity. Of the patients under 40 years of age, 86% were able to run compared with 23% of those over 40. Of patients over 40, 64% continued to have moderate or severe pain. Careful preoperative counseling is required for patients of all ages regarding likely outcomes. In patients over 40, the procedure is unlikely to give good pain relief and alternative options should be considered.

Experimental model in cadavera of arthroscopic resection of calcaneonavicular coalition and its first in-vivo application: preliminary communication

Open surgical resection of calcaneonavicular coalition is indicated after the failure of conservative treatment. Our objectives are to develop the arthroscopic surgical technique and to check the feasibility of the arthroscopic resection of the calcaneonavicular coalition. We designed and performed endoscopic resection of the calcaneonavicular ligament and part of the anterior process of calcaneus as a simulation of the coalition resection on four cadaver specimens. After this procedure, we successfully performed the first resection in a 12-year-old girl, without any soft tissue interposition. American Orthopaedic Foot and Ankle Society Hindfoot Scale was 55 before surgery, 98 after 10 weeks, and 100 after 2 years without recurrence.

Minimally invasive tibiotalocalcaneal arthrodesis with a retrograde locking nail

Objective To discuss the therapeutic effect of tibiotalocalcaneal arthrodesis for severe painful ankle diseases using a locked retrograde intramednllary nail. Methods From January 2003 to November 2007, 12 patients with severe painful ankle diseases underwent tibiotalocalcaneal arthrodesis with a retrograde locking nail in our department. Their mean age was 47.2 (range, 25 to 68) years. The preoper-ative diagnoses of the 9 male and 3 female patients included posttraumatic osteoarthritis (n=7), rheumatoid arthritis (n=3) and eqninovarus (n=2). The mean interval between the primary disease and the operation was 13.6 (range, 5 to 25) years. All patients were evaluated clinically and radiographically by means of clinical examination, questionnaire, weight-bearing radiographic assessment and the American Foot and Ankle Society(AOFAS) ankle-hindfoot scale. Results All patients were available for the follow-up with an average duration of 18.3 (range, 10 to 36) months. Complications, such as damage to neurovascular struc-tures, non-union and infection, were not seen. Solid fusion was achieved in all ankles after a mean time of 17 (range, 12 to 21) weeks. At the latest follow-up, 8 patients reported no pain and 4 mild pain; 7 patients had no limitation in recreational or daily activities while 5 had limitation in recreational but not in daily activities; 7 patients experienced no difficult walking on any surface but 5 did on uneven terrain and stairs. No patient showed obvious limp. The preoperative mean AOFAS score was 47.3 (range, 40 to 57), and the postoperative one 74.2 (range, 50 to 87) . Conclusion Locked retrograde intramedullary nailing is a minimally in-vasive, effective and safe technique in tibiotalocalcaneal arthrodesis for severe painful ankle diseases. Key words: Arthrodesis; Bone nails; Osteoarthritis

Displaced intra-articular calcaneal fractures: 15-Year follow-up of a randomised controlled trial of conservative versus operative treatment

To report the 15-year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment published in 1993. Of the initial study, 46 patients (82%) were still alive at a mean of 15 years post injury and 26 patients (57%) agreed to review. The patients had been randomly allocated to either conservative or operative treatment in the original study. Clinical [American orthopaedic foot and ankle society hindfoot scale (AOFAS), foot function index (FFI) and calcaneal fracture score] and radiological (Böhler's angle and calcaneum height) outcome measures were used. The grade of osteoarthritis was also assessed at long-term follow-up. At long-term follow-up, the clinical outcomes were not different between conservative versus operative treatment. AOFAS hindfoot scale: conservative=78.5 and operative=70, p=0.11; FFI: conservative=24.4 and operative=26.9, p=0.66; calcaneal fracture score: conservative=70.1 and operative=63.5, p=0.41. The radiological outcomes were also not different between both groups. Böhler's angle: conservative=10.4 degrees and operative 16.9 degrees , p=0.07; height of calcaneum: conservative=37.2mm and operative=38.2mm, p=0.57; grade of osteoarthritis of the sub-talar joint: p=0.54. There was no correlation between Böhler's angle and the outcome measures in either group. The results of this 15-year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment and demonstrate similar findings to those at one year follow-up.

A Surgical Approach for Flexible Flatfeet in Adults Including a Subtalar Arthroereisis with the MBA Sinus Tarsi Implant

The purpose of this study was to determine the functional outcomes and radiographic results of adult patients who had an operation for flexible flatfeet without any hindfoot osteotomies or fusions. Twenty-eight feet in 23 patients with problems caused by their flexible flatfoot deformities had reconstructive foot and ankle surgery that included a subtalar arthroereisis (the restriction of the range of motion of a joint) with the Maxwell-Brancheau Arthroereisis (MBA) sinus tarsi implant. The American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot Scale and a patient assessment questionnaire were obtained from all patients before surgery and at final follow-up. Preoperative and postoperative standing radiographs were analyzed to determine radiographic correction of the deformities. The average followup was 44 months. The MBA implant was surgically removed in 11 of 28 feet (39%) because of sinus tarsi pain. The average preoperative AOFAS score was 52 and had improved to 87 (p<0.00001) at final followup. The average response to four of five questions in the patient assessment had significantly improved (p<0.05). On a 10-point scale, average patient satisfaction was 8.3 points; 78% said that they would have the surgery again. Correction after surgery was significant (p<0.0001) in each of the three radiographic parameters evaluated for 'correction with MBA' and 'final correction.' With the numbers available, no significant differences could be detected after the MBA was removed. Complications included sinus tarsi pain in 46% (13) of the 28 feet in this study; after implant removal, 73% (8) of 11 feet had less discomfort than before surgery with AOFAS scores 80 or better. Reconstructive foot and ankle surgery that included a subtalar arthroereisis with the MBA sinus tarsi implant resulted in favorable clinical outcomes and patient satisfaction in 78% (18) of 23 patients. In spite of the high incidence of temporary sinus tarsi pain until the implant was removed, this operative approach compares favorably with other operations for flexible flatfoot deformities in adults.

Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy.

To assess the efficacy of surgical correction of stage II tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular, the authors retrospectively reviewed results of treatment of stage II posterior tibial tendon deficiency in 129 patients for whom surgery was performed between 1990 and 1997. The indication for surgery included tendon weakness, flexible deformity, and foot pain refractory to nonsurgical treatment. All patients had a painful flexible flatfoot without fixed forefoot supination deformity (stage II). A medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular were done. The patients were examined, radiographs were obtained, and isokinetic evaluation of both feet was performed at a mean of 5.2 years postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form Health Surgery (SF-36) were used to evaluate patients postoperatively. The mean AOFAS score at follow-up was 79 points (range, 54-93). There were seven significant complications in six patients. Isokinetic inversion and plantarflexion power and strength were symmetric with the contralateral limb in 95 patients, mildly weak in 18 patients, and moderately weak in eight patients. Subtalar joint motion was normal in 56 (44%), slightly decreased in 66 (51%), and moderately decreased in seven patients (5%). Correction was significant (p < .05) in all four radiographic parameters evaluated. Patients were entirely satisfied (118 patients), partially satisfied (seven patients), or dissatisfied (four patients). Further, 125 (97%) experienced pain relief, 121 (94%) showed improvement of function, 112 (87%) experienced improvement in the arch of the foot, and 108 (84%) were able to wear shoes comfortably without shoe modifications or orthotic arch support. The surgical correction of stage II posterior tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications and a high patient satisfaction rate.