Ankle Symptoms Research Articles

Ankle Microinstability

Ankle sprains are one of the most common injuries in foot and ankle, and the superior fascicle of the anterior talofibular ligament (ATFL) frequently is injured as a consequence. Patients with isolated rupture of ATFL’s superior fascicle can sustain a subtle ankle instability or ankle microinstability. Patients with symptomatic ankle microinstability may describe a subjective feeling of ankle instability, recurrent symptomatic ankle sprains, chronic anterolateral pain or a combination of any of them. When conservative management fails, anatomic all-inside ATFL’s superior fascicle repair under direct arthroscopic visualization is the preferred surgical technique.

The periosteal flap augmentation technique in chronic lateral ankle instability

Anatomic repair of the lateral ligament complex of the ankle joint and augmentation with an autologous pedicled periosteal flap of the distal fibula following identification and concomitant treatment of intra-articular pathologies. Symptomatic chronic mechanical lateral ankle instability. As amodular step in the treatment of osteochondral lesions in conjunction with lateral ankle instability. Higher degree osteoarthritis of the ankle joint (>Kellgren/Lawrence2 and 4 or Outerbridge3 and 4) and/or hindfoot deformity; mechanical incompetence of both the fibulotalar anterior ligament and the fibulocalcaneal ligament preventing anatomical reinsertion; general risk factors. Diagnostic arthroscopy for identification and treatment of intraarticular pathologies; verification and grading of ligamentous instability (medial, lateral, combined). Open exposure of the distal fibula and the ruptured components of the lateral ankle ligament complex. Anatomic reinsertion of the original ligaments and assessment of their mechanical competence. Apart from the situation in the juvenile patient with athick periosteal layer adoubled and pedicled periosteal strip of the distal fibular periosteum will suffice for the augmentation in one ligamentous component, only. Fixation in the talus or calcaneus is achieved via suture anchors, screws with awasher or transosseous fixation via interference screw. Postoperative immobilization in alower leg split cast or asplint until wound healing (5-8days), mobilization in awalker or an ankle orthosis with consecutive full weight-bearing for further 4-5weeks. Proprioceptive and pronator muscle training, optionally insole or lateral wedge at the shoe sole for 6months postoperatively. Avoidance of contact sports for 4-6months. Several studies have reported reliable restoration of ligamentous ankle stability with overall success rates >90% and good to excellent total results in >90% of patients with limited minor complications. In view of the heterogeneous data from previous studies, some recent studies have demonstrated that the outcome after periosteal augmentation is comparable to that after techniques employing free tendon graft for anatomic restoration of ligamentous ankle stability. The technique has been applied successfully in cases of poor mechanical properties of the formerly ruptured ligaments and in patients with ahigh functional demand.

All-inside arthroscopic repair of anterior talofibular ligament for chronic lateral ankle instability

Objective To evaluate the clinical efficacy and safety of all-inside arthroscopic repair of anterior talofibular ligament (ATFL) for chronic lateral ankle instability (CLAI). Methods From Oc-tober 2016 to September 2017, 19 patients with CLAI were treated with all-inside arthroscopic repair of ATFL at Department of Orthopaedic Surgery, Zhejiang Provincial People’s Hospital and Department of Foot and Ankle Surgery, Guangzhou Orthopaedic Hospital.They were 12 men and 7 women, aged from 18 to 35 years (mean, 27.3 years).Their defective ATFLs had no effective tension.After the fibular foot-print zone of ATFL was refreshed, an absorbable anchor was inserted accurately and its suture was threaded into the remnant of ATFL using the all-inside arthroscopic technique.The remnant of ATFL was fixated by the suture using Las-so-Loop method and anatomically repaired into the foot-print zone to restore the ligamentous tension.The American Orthopedic Foot and Ankle Surgery Society (AOFAS) ankle-hindfoot score, Karlsson ankle function score, Tegner activity score and visual analogue scale (VAS) were used to assess funtion of ankle before and after operation. Results All the 19 patients were followed up for a mean time of 15.6 months (from 12 to 22 months).Their ankle symptoms were all relieved after operation; their ankles recovered fine range of motion; their anterior drawer tests and varus stress tests were negative.Their preoperative AOFAS scores (64.6±11.4), Karlsson ankle function scores (63.5±11.4), Tegner activity scores (3.2±0.7) and VAS(5.8±1.7) were significantly improved at the final follow-up (92.3±3.2, 91.2±4.4, 5.7±0.6 and 1.4±1.0, respectively) (P<0.05).Complications such as incision and articular infections, superficial peroneal nerve injury, sural nerve injury and iatrogenic fracture were not demonstrated in the cohort.By the final follow-up, no patient had been found who needed a secondary revision. Conclusions The all-inside arthroscopic repair of ATFL can be used effectively and safely for CLAI, because it leads to accurate anchor insertion, anatomic repair, limited invasion, and reliable restoration of ligamentous tension.To avoid com-plications, surgeons should familiarize themselves with arthroscopic procedures. Key words: Ankle; Lateral ligament, ankle; Arthroscopy; Chronic anterolateral ankle in-stability; Anatomical ligament repair

Profiling patients with foot and ankle symptoms and osteoarthritis at other joints: a cluster analysis

Profiling patients with foot and ankle symptoms and osteoarthritis at other joints: a cluster analysis

Relationship of Joint Hypermobility with Ankle and Foot Radiographic Osteoarthritis and Symptoms in a Community-Based Cohort.

To explore associations of joint hypermobility (a condition where range of motion is greater than normal) with ankle and foot radiographic osteoarthritis (OA) and symptoms in a large community-based cohort of African American and white adults ages 55-94 years old. Ankle and foot radiographs and joint hypermobility data (Beighton score for joint hypermobility criteria) were available for 848 participants (from 2003 to 2010) in this cross-sectional study. General joint hypermobility was defined as a Beighton score ≥4 (range 0-9); knee hypermobility was defined as hyperextension of at least 1 knee. Standing anteroposterior and lateral foot radiographs were read with standard atlases for Kellgren-Lawrence grade, osteophytes, and joint space narrowing (JSN) at the tibiotalar joint, and for osteophytes and JSN to define OA at 5 foot joints. Ankle or foot symptoms were self-reported. Separate person-based logistic regression models were used to estimate associations of ankle and foot OA and symptom outcomes with hypermobility measures, adjusting for age, sex, race, body mass index, and history of ankle/foot injury. This sample cohort included 577 women (68%) and 280 African Americans (33%). The mean age of the participants was 71 years, with a mean body mass index of 31 kg/m2 . The general joint hypermobility of the participants was 7% and knee hypermobility was 4%. Having a history of ankle injury was 11.5%, and foot injury was 3.8%. Although general joint hypermobility was not associated with ankle and foot outcomes, knee hypermobility was associated with ankle symptoms, foot symptoms, and talonavicular OA (adjusted odds ratios of 4.4, 2.4, and 3.0, respectively). Knee joint hypermobility may be related to talonavicular OA and to ankle and foot symptoms.

Arthroscopic repair of chronic lateral ankle instability

Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies. Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability. Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome. Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using asuture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex. Partial weight-bearing and short leg cast for 2weeks, then 4weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months. Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to asignificant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported asignificantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.

Foot Alignment in Symptomatic National Basketball Association Players Using Weightbearing Cone Beam Computed Tomography.

Background:Weightbearing cone beam computed tomography (WB CBCT) allows detailed 3-dimensional imaging of the foot and ankle in a weightbearing state and provides improved accuracy and reliability of foot alignment measures, especially when compared with conventional radiographic views.Purpose:To describe the foot alignment in National Basketball Association (NBA) players with different symptomatic foot and ankle injuries using WB CBCT and to determine if any predominant morphotype would be identified.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 45 active NBA players (mean age, 24.4 years [range, 20-34 years]; N = 54 feet [29 right, 25 left]) were assessed using WB CBCT. Measurements included the following: (1) foot and ankle offset (FAO), (2) calcaneal offset (CO), (3) hindfoot alignment angle (HAA), (4) angle between the inferior and superior facets of the talus (Inftal-Suptal), (5) angle between the inferior facet of the talus and the horizontal floor line (Inftal-Hor), (6) forefoot arch angle (FAA), (7) navicular-to-floor distance, and (8) medial cuneiform–to-floor distance. Measurements were then compared with values available in the literature for a “normal” foot morphotype.Results:Among the 54 feet, the mean FAO was 0.48% (95% CI, –0.25% to 1.21%), the mean CO was 1.18 mm (95% CI, –0.50 to 2.87 mm), and the mean HAA was 1.42° (95% CI, –0.80° to 3.65°). The mean Inftal-Suptal angle was 5.31° (95% CI, 3.50°-7.12°), while the mean Inftal-Hor angle was 4.04° (95% CI, 2.56°-5.51°). The mean FAA was 15.84° (95% CI, 14.73°-16.92°), the mean navicular-to-floor distance was 38.30 mm (95% CI, 36.19-40.42 mm), and the mean medial cuneiform–to-floor distance was 26.79 mm (95% CI, 25.30-28.28 mm). None of these values were found to be significantly different when comparing forwards, guards, and centers.Conclusion:NBA players presenting with symptomatic foot and ankle injuries had a fairly “normal” foot morphology, with a tendency toward a varus hindfoot and a high-arched morphotype. No significant differences were found between players based on their position on the court. WB CBCT may help to shed light on anatomic risk factors for common injuries in professional players and may aid in the planning of specific prevention programs.

Effects of Cryopreserved Amniotic Membrane-Umbilical Cord Allograft on Total Ankle Arthroplasty Wound Healing

Relatively high rates of wound healing complications continue to be reported with a total ankle arthroplasty (TAA) anterior incision. The amniotic membrane-umbilical cord (AM-UC) allograft is a regenerative orthobiologic adjunct that modulates wound healing by down-regulating inflammation, enhancing local healing and antimicrobial factors, and reducing scar formation. The purpose of this study was to determine whether local application of a cryopreserved AM-UC allograft enhances soft tissue healing after TAA. A total of 104 patients with symptomatic ankle arthritis who failed conservative management underwent standard TAA. At skin closure, patients were allocated to either the treatment (local application of AM-UC) or control (no allograft) group. Demographic data, patient comorbidities, and radiographic findings were collected. The primary outcome was a major complication necessitating reoperation. Secondary outcomes were time to healing, minor complications (i.e., skin dehiscence, local wound care, use of antibiotics), and patient scar assessment. Local application of an AM-UC allograft significantly decreased the overall time to skin healing (28.5 days vs 40 days; p = .03). Two patients required a reoperation for soft tissue wound complications, with no difference (p = 1.00) between the groups. No statistically significant difference was detected in terms of skin dehiscence, local wound care, or antibiotic prescriptions in the 2 groups. Regenerative technology using local application of a cryopreserved AM-UC allograft may enhance TAA outcomes by decreasing the time to healing. Larger randomized controlled trials are needed to determine whether an AM-UC allograft enhances soft tissue wound healing and ultimately reduces the incidence of devastating soft tissue complications.

Lateral ankle ligament anatomic reconstruction for chronic ankle instability: Allograft or autograft? A systematic review

BackgroundTo investigate if there is any evidence in favour of autograft or allograft use for anatomic reconstruction of lateral ankle ligaments in patients with symptomatic chronic ankle instability. MethodsA literature search was performed in PubMed MEDLINE, Cochrane Library, EMBASE and Google Scholar databases, over the years 1994–2017, to identify the studies presenting clinical results of anatomic lateral ankle ligaments reconstruction using various combinations of the keywords “lateral ankle ligaments reconstruction”, “anatomic reconstruction”, “chronic ankle instability”, “allograft”, “autograft”. The surgical procedure was considered anatomic if consistent with the description of lateral ankle ligaments made by Burks and Morgan in 1994. ResultsAmong the 89 papers matching the search terms, only 12 could be included in which 357 anatomic lateral ankle ligaments reconstructions were performed. One was a comparative case series (level of evidence III — LOE III) while other papers were retrospective case series (LOE IV), the mean Modified Coleman Methodology Score (MCMS) was fair: 56.7 (SD±5.2). Due to the low level of evidence of the available literature only a qualitative analysis was performed. The limited evidence from the studies analysed suggests that there is no difference in graft survivorship, graft-dependent variables, patient’s satisfaction, clinical outcome measures and radiographic results between allograft and autograft. ConclusionsGiven the low number of studies, their poor methodology score and their low level of evidence it is not possible to determine if allograft is better or safer than autograft.Level of evidence: Level IV, review paper of level III and level IV studies.

A new arthroscopic BrostrÖm procedure for chronic lateral ankle instability

Category: Arthroscopy Introduction/Purpose: Chronic lateral ankle instability is usually progressed from previous lateral ankle sprain which is not treated properly. Although patients with acute lateral ankle ligament injury are often managed successfully with conservative treatment, approximately 20%-40% will go on developing symptomatic chronic recurrent lateral ankle instability. Several procedures have been introduced to address these patients including open or arthroscopic techniques, the most common of which is the BrostrÖm procedure. The aim of this study was to describe a new outside-in arthroscopic BrostrÖm procedure and its results for treating patients with chronic lateral ankle instability. Methods: Of the 32 patients that were treated, 18 males and 14 females, and aged from 15~57 years (mean 27.8 years). All patients were symptomatic with a combination of recurrent ankle sprains, giving way and avoidance of sports, as well as presented positive anterior drawer test in the physical examination. The history of all patients was over 6 months and conservative treatments were not enough to relieve the symptoms. Standard anteromedial and anterolateral portal was established. Using a suture anchor (2.9 mm Lupine BR, preloaded with double orthocord sutures, DePuy Synthes) and a cannulated needle as a suture passer, anterior talofibular ligament repair was achieved with an outside-in technique. Follow-up was 6~14 months (mean 8.7). Results: Subjective instability and mechanical instability were all significantly improved. No recurrences of ankle instability were reported. The mean AOFAS Ankle-Hindfoot score increased from 74 preoperatively to 95 at final follow-up. 2 patients reported superficial peroneal nerve (SPN) irritation symptom postoperatively but only 1 persisted. 2 patients complained mild pain anteroinferior to the lateral ankle. Conclusion: The arthroscopic outside-in BrostrÖm procedure with a single suture anchor was a safe, effective and reproducible technique for chronic lateral ankle instability. The ankle stability resumed with high clinical success rate. The main complication of this procedure was injury to SPN, which crossed the area of repair. The transient neurologic symptom may be related to stretch injury when establishing the anterolateral portal, while the persistent one may be due to nerve entrapment.

Chronic Symptomatic Ankle Avulsion Fracture

Category: Ankle Introduction/Purpose: Persistent pain and instability following inversion or eversion injuries of the ankle is not rare. Besides injury of lateral or medial ligaments, avulsion fracture of lateral or medial malleolus could be found in some cases. The avulsion fracture may result in nonunion and/or ligamentous laxity which could lead to chronic ankle pain. The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients of symptomatic ankle avulsion fracture. Methods: 23 patients of ankle avulsion fracture along with chronic ankle pain and instability were studied. Tenderness and swollen at lateral and/or medial gutter were found and radiographic images were taken for the diagnosis. After at least 6 months of unsuccessful non-operative treatment, all patients underwent surgery of osseous fragments excision and anatomic ankle ligaments reconstruction. AOFAS-AH and VAS Score were given to assess the outcomes of surgery. Results: There were 21 males and 9 females among the patients. The average age of the patients was 24.6 years (range, 18-45 years) at the time of injury and 27.3 years (range, 18-46) at the time of surgery, indicating a mean delay in diagnosis and/or treatment of 2.7 years. At a mean follow-up of 2.6 years (range, 1 to 5.2 years), the average AOFAS-AH Score increased from 72.5 to 93.2 out of 100 (P&lt;0.05), the average VAS score decreased from 6.2 to 1.2 (P&lt;0.05). Conclusion: For those patients of ankle avulsion fracture presenting with chronic ankle pain and instability, surgical excision of the bony fragment combined with reconstruction of ankle ligaments were effective in eliminating pain, restoring ankle stability, and helping return to the pre-injury functional level.

Arthroplasty or Arthrodesis in the CJR Era

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis can be a debilitating disease that results in decreased daily activity and chronic morbidity. Many patients elect for surgical intervention to minimize pain and improve function. To curb costs associated with the increasing demand for total joint arthroplasty (TJA) in the growing elderly Medicare population, CMS announced the Comprehensive Care for Joint Replacement (CJR) model, which included total ankle arthroplasty. To provide continued quality care and cost containment, it is necessary to determine the optimal surgical intervention for patients that could fall within the CJR program. Therefore, we sought to determine the impact of surgical fixation on functional outcomes, systemic utilization, and medical expenditures for patients with ankle arthritis. Methods: We reviewed a prospectively collected and maintained database to identify all patients who underwent a total joint replacement from April 2016 to September 2017. Patients were identified based on DRG codes for primary arthritis of a lower extremity joint, then specifically for foot and ankle, as well as CPT codes for ankle arthroplasty (27702) or ankle arthrodesis (27870/28725). Functional outcomes were assessed based on insurance type. The cohorts were matched for age, comorbidities, and gender. Statistical analysis was performed using chi-squared and paired t-test to assess for differences in patient reported outcomes. Descriptive statistical analysis was used to assess for differences in cost between the cohorts. Results: A total of 573 patients were included.There were 48 replacements and 47 fusions. Arthrodesis procedures costs approximately $6,500 less per case than the system costs for patients who underwent arthroplasty procedures. The average length of stay for patients who underwent total ankle arthroplasty was 1.6 days compared to outpatient surgical centers utilized for most arthrodesis patients. Overall, patients reported improved pain and a 30.96 increase in FAAM scores. Most patients had a global rate of change that was “very much better” or “much better” (68%). Based on insurance type, patients who underwent a total ankle replacement in the CJR program had improved outcomes and lower cost than patients commercially insured. Conclusion: With the CJR, there is greater emphasis on the optimal intervention for elective operations. There should be coordinated efforts to optimize quality care, while minimizing financial waste within the healthcare system. The price differential suggests an annual potential for financial savings as high as $325,000 for a system that supports intervention for ~50 cases per year. As such, these results suggest that arthroplasty may be optimal for patients with severe symptomatic ankle arthritis, while most patients have adequate relief with an ankle fusion. More importantly, quality improvement efforts should focus on the impact of surgical intervention on functional activity.

Changes in health-related quality of life (EQ-5D) dimensions associated with community-based musculoskeletal physiotherapy: a multi-centre analysis

PurposeTo determine the changes in each of the five dimensions of the EuroQol 5-dimension index associated with community-based physiotherapy.MethodsFour thousand one hundred and thirty-six patients that received community-based musculoskeletal physiotherapy across five NHS centres completed the EQ-5D on entry into the service and upon discharge. Patients were categorised on symptom location and response to treatment based on their EQ-5D index improving by at least 0.1 (“EQ-5D responders”). For each symptom location, and for responders and non-responders to treatment, the mean (± SD) were calculated for each dimension pre- and post-treatment as well as the size of effect.ResultsThe mobility dimension improved (p < 0.05) in all symptom locations for EQ-5D responders (d = 0.26–1.58) and in ankle, knee, hip and lumbar symptoms for EQ-5D non-responders (d = 0.17–0.45). The self-care dimension improved (p < 0.05) in all symptom locations for EQ-5D responders (d = 0.49–1.16). The usual activities dimension improved (p < 0.05) across all symptom locations for EQ-5D responders (d = 1.00–1.75) and EQ-5D non-responders (d = 0.14–0.60). Despite the pain/discomfort dimension improving (p < 0.05) across all symptom locations for both EQ-5D responders (d = 1.07–1.43) and EQ-5D non-responders (d = 0.29–0.66), the anxiety/depression dimension improved (p < 0.05) from higher starting levels in EQ-5D responders (d = 0.76–1.05) with no change seen for EQ-5D non-responders (d = − 0.16 to 0.06).ConclusionsClinicians should not assume that a patient presenting with pain but expressing high anxiety/depression is unlikely to respond to treatment, as they may show the best HRQoL outcomes. For patients presenting with pain/discomfort and low levels of anxiety/depression, the EQ-5D index is perhaps not a suitable tool for sole use in patient management and service evaluation.

Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study.

ObjectivesTo identify by systematic review published prevalence estimates of radiographic ankle osteoarthritis (OA) and to subsequently estimate the prevalence of ankle pain and symptomatic, radiographic ankle OA within community-dwelling older adults from North Staffordshire, UK.MethodsElectronic databases were searched using terms for ankle, osteoarthritis and radiography. Data regarding population, radiographic methods, definitions and prevalence estimates of ankle OA were extracted from papers meeting predetermined selection criteria. Adults aged ≥50 years and registered with four general practices in North Staffordshire were mailed a health questionnaire. Ankle pain in the previous month was determined using a foot and ankle pain manikin. Respondents reporting pain in or around the foot in the last 12 months were invited to attend a research clinic where weight-bearing, antero-posterior and lateral ankle radiographs were obtained and scored for OA using a standardised atlas. Prevalence estimates for ankle pain and symptomatic, radiographic ankle OA were calculated using multiple imputation and weighted logistic regression, and stratified by age, gender and socioeconomic status.ResultsEighteen studies were included in the systematic review. The methods of radiographic classification of ankle OA were poorly reported and showed heterogeneity. No true general population prevalence estimates of radiographic ankle OA were found, estimates in select sporting and medical community-dwelling populations ranged from 0.0–97.1%. 5109 participants responded to the health survey questionnaire (adjusted response 56%). Radiographs were obtained in 557 participants. The prevalence of ankle pain was 11.7% (10.8,12.6) and symptomatic, radiographic ankle OA grade≥2 was 3.4% (2.3, 4.5) (grade≥1: 8.8% (7.9,9.8); grade = 3: 1.9% (1.0,2.7). Prevalence was higher in females, younger adults (50–64 years) and those with routine/manual occupations.ConclusionNo general population prevalence estimates of radiographic ankle OA were identified in the published literature. Our prevalence study found that ankle pain was common in community-dwelling older adults, whereas moderate to severe symptomatic, radiographic ankle OA occurred less frequently. Further investigations of the prevalence of ankle OA using more sensitive imaging modalities are warranted.

The Salto total ankle arthroplasty — Clinical and radiological outcomes at five years

BackgroundModern designs of total ankle arthroplasty (TAA) have the potential to treat symptomatic ankle OA without adversely affecting ankle biomechanics. We present the mid-term results of a modern, mobile-bearing TAA design. MethodsTAA was performed in 50 consecutive patients (55 ankles) in an independent, prospective, single-centre series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of five years (range 2–10.5years). ResultsA total of three patients (four ankles) died and two (two ankles) were lost to follow-up. Three TAAs were revised for aseptic loosening (in two cases) or infection. Two further patients underwent reoperations, one for arthroscopic debridement of anterolateral synovitis and one for grafting of an asymptomatic tibial cyst. With all-cause revision as an endpoint, implant survival was 93.3% at five to ten years (95% CI 80.5%–97.8%). If reoperations are included this falls to 90.2% (95% CI 75.6%–96.3%) at five years. No other patient demonstrated radiographic evidence of loosening or subsidence. PROMs and satisfaction were excellent at latest follow-up. ConclusionAt five years, the outcomes for this design of TAA in this series were excellent, and were similar to those of previously published series from the designer centre.

Ankle and Hindfoot Symptoms after Medial Open Wedge High Tibial Osteotomy.

Medial open wedge high tibial osteotomy (MOWHTO) is a commonly performed procedure for symptomatic medial compartment osteoarthritis (OA). However, little is known about its effects on ipsilateral ankle or hindfoot. The aim of our study was to determine the incidence of ankle or hindfoot problems after MOWHTO and examine its association with radiological indices. Thirty-five knees (32 patients) undergoing navigated MOWHTO were evaluated for the presence of new-onset ankle or hindfoot symptoms after surgery. Pre- and postoperative hip-knee-ankle (HKA) angle, medial proximal tibial angle (MPTA), and tibial plafond inclination (TPI) were measured and compared on standing lower limb alignment radiographs. The mean postoperative change in HKA angle, MPTA, and TPI was 8.8°, 7.0°, and 8.4°, respectively. New-onset unexplained ankle or hindfoot symptoms were seen in 20% of the cases after surgery. Postoperative change in TPI was significantly greater in symptomatic patients as compared with asymptomatic ones (12.8° ± 4.9° vs. 8.1° ± 4.8°, p = 0.03). The odds ratio (OR) for developing ankle or hindfoot symptoms in cases with ≥ 10° change in TPI postoperatively was 10.8 (p = 0.04). Ankle or hindfoot symptoms were successfully managed with conservative treatment in all cases.

Intraoperative Findings of Lateral Ligament Avulsion Fractures and Outcome After Refixation to the Fibula.

An acute ankle sprain can result in a bony avulsion of the lateral ankle ligaments. The extent of concomitant lesions and subsequent instability patterns are not clearly understood. The high incidence of old avulsion fractures found in symptomatic chronic ankle instability may indicate the need for primary fixation. Ten patients (5 male, 5 female; mean age, 34 years; range, 15-64 years) with bony avulsion fractures of the fibula after acute ankle sprains were included. All patients were treated after a mean of 7.7 days (range, 2-17 days) with screw fixation of the fragment to the fibula. Clinical and radiographic assessments were performed, and the extent of ligament injury was documented. The anterior talofibular ligament and calcaneofibular ligament were found to be attached to the avulsion fragment. The average size was 6.3 mm (range, 4-9 mm) in width from anterior to posterior and 5.2 mm (range, 4-7 mm) in length from superior to inferior. The displacement of the fragment increased under varus stress. Two patients had cartilage lesions in the lateral talus. After a mean follow-up period of 2.4 years (range, 2-4 years), all were clinically and radiographically stable, and patients were satisfied. It was observed arthroscopically that the anterior talofibular ligament and calcaneofibular ligament were attached to the fragment. This is critical because motion between the fragment and the fibula may prevent spontaneous healing. Primary fixation of the fragment prevented rotational instability and was efficient to restore function and stability. Level IV, retrospective case series.

Functional Outcomes of Symptomatic Implant Removal Following Ankle Fracture Open Reduction and Internal Fixation.

Orthopedic implant removal following open reduction internal fixation of a fracture is a common procedure, especially in the foot and ankle. The purpose of this study was to evaluate functional change after the removal of symptomatic implants following ankle fracture open reduction internal fixation (ORIF) using the Short Musculoskeletal Function Assessment (SMFA) outcome score. We hypothesized that implant removal after ankle fracture would result in improved functional outcomes. Retrospective review of prospectively collected data on patients with a closed ankle fracture between 2013 and 2016 was performed. Inclusion criteria were skeletal maturity, symptomatic ankle implants and completion of the SMFA questionnaire prior to and 6 months after removal. Exclusion criteria were development of a nonunion, prior or current infection, peripheral neuropathy or ongoing litigation surrounding the surgery. The primary outcome was change in SMFA score from baseline to follow-up using Wilcoxon signed-rank test. Additional logistic regression models evaluated the effects of age, sex, body mass index, smoking status, and patient American Society of Anesthesiologists scores. The study population consisted of 43 patients. There was a statistically significant improvement in function, represented by a decrease in SMFA scores from baseline to the 6-month follow-up period (∆ = -4.1 [95% confidence interval, -7.0, -1.3]; P = .003). Secondary outcome measures of the bother index and daily activities domain also demonstrated significant improvements ( P = .005 and P = .002, respectively). Additional logistical regression models identified no significant effects by assessed covariates for change in SMFA scores. Patients with symptomatic implants following ankle fracture ORIF had a statistically significant improvement in function following implant removal. There appears to be value in removing implants from the ankle in patients who report discomfort during daily activities. Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted. Level IV, case series.

How Accurate Is Clinical Evaluation in Hindfoot Coronal Alignment?

Background: Hindfoot coronal alignment is an important factor in the assessment of patients with many different foot and ankle complaints. A number of clinical and radiographic techniques have been described to measure hindfoot coronal alignment, but none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of each. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was measured from photographs. Each patient was placed at a distance of 1 m from the observer, with both feet placed parallel. Four photographs were taken, at a height of 40 cm: a posterior view of both lower limbs including knees, a posterior view focalized on the studied hindfoot, an anterior view of the foot, and the last view of the medial aspect of the foot. Radiographic alignment was quantified on long axial view radiographs. Patients were lying over the film cassette with a focus distance of 1 m and the beam pointed to the ankle joint. The inclination angle of the beam was 45 degrees to the floor. Measurements were independently made by 2 observers, who were asked to classify pictures into 3 categories: varus, neutral, and valgus. Radiographic measurements were made using the angle measurement tool on the radiograph viewer. The intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) of the ICC were used to quantify the inter- and intraobserver reliability for clinical assessment. Radiographic parameters were correlated by calculating the Pearson correlation coefficient (r). Results: The intraobserver ICC for clinical analysis was good for both observers, while the interobserver ICC was moderate for both measurements. Regarding radiographic assessment, there was significant intra- and interobserver reliability. The correlation between both methods was weak for both observers. Conclusions: We found only weak intra- and interobserver correlations between the clinical and radiographic assessment of hindfoot coronal alignment. It is therefore necessary to complement the clinical evaluation of hindfoot alignment with an objective measurement method such as a long axial view radiograph. Further studies comparing different measurement methods need to be performed to establish the most objective evaluation. Level of Evidence: Level III, diagnostic study.

Is Magnetic Resonance Imaging (MRI) Reliable in the Diagnosis of Ankle Instability

Category: Ankle, Sports, Trauma Introduction/Purpose: MRI is the preferred modality for the diagnosis of ankle joint pathology. The aim of this study was to specifically analyse the reliability of MRI reported lateral ligament findings in relation to examination under anaesthesia and stress X-rays in patients with symptomatic ankle instability. Methods: A single centre, single surgeon consecutive series of patients who had undergone examination under anaesthesia and stress X-rays preceded by an MRI scan for symptomatic ankle pathology were included in this retrospective clinical study. All MRI scans were reported by a musculoskeletal radiologist. MRI reports and procedure findings were extracted and analysed. Results: Between April 2012 and December 2016, 49 patients who fulfilled the above criteria were included. There were 25 male and 24 female patients, the average age was 43.1. The average time interval between MRI scan and examination under anaesthesia was 9.7 months (2-49 months). There is a significant association between MRI reported lateral ligament findings and status of ankle stability detected on examination under anaesthesia and stress views, p=0.003 (Chi-square analysis for association). In 34 patients who had abnormal lateral ligament findings on MRI, 20 patients (58.8%) had stable findings and 14 (41.2%) had unstable findings on stress views. There was, however, a 100% concordance between MRI reported normal lateral ligament findings and stability on examination under anaesthesia and stress views (N=15). Conclusion: MRI is accurate in diagnosing the status of ankle ligaments and in particular, in predicting true stability.