Ankle Symptoms Research Articles

Changes in coronal alignment of the ankle joint after high tibial osteotomy

The purpose of this study was to investigate changes in coronal alignment of the ankle joint after HTO. Our hypothesis was that ankle joint orientation may become more parallel or less parallel to the ground after HTO, and this change may affect ankle symptoms. Eighty-six knees were retrospectively analysed after HTO for varus osteoarthritis. Preoperative and follow-up whole-leg radiographs were taken. The hip-knee-ankle (HKA) angle and medial proximal tibial angle (MPTA) were measured to evaluate coronal alignment of the knee. Tibial plafond inclination (TPI), talar inclination (TI), talar tilt (TT), and lateral distal tibial angle (LDTA) were measured to evaluate coronal alignment of the ankle. Patients were divided into two groups: those who exhibited a decrease in the absolute value of TPI and TI after HTO (group A) and those who exhibited an increase in the absolute value of TPI or TI after HTO (group B). Clinical outcomes of the knee and ankle were evaluated pre- and postoperatively. Mean TPI and TI changed from 6.9°±3.6° and 8.0°±3.8° to 2.8°±3.1° and 3.9°±3.0° in group A (P<0.001 for both) and from -1.3°±3.7° and 0.6°±4.5° to -6.0°±4.2° and -4.6°±5.9° in group B (P=0.018 for both). VAS for ankle pain did not change significantly after HTO (n.s.) in group A, whereas those of group B increased significantly after HTO (P=0.014). Ankle joint orientation becomes more parallel or less parallel to the ground after HTO. Smaller preoperative HKA and LDTA result in a more valgus ankle joint orientation after HTO. Ankle symptoms were affected by coronal alignment changes of the ankle after HTO. III.

Arthroscopic Evaluation of Impingement and Osteochondral Lesions in Chronic Lateral Ankle Instability.

Anterolateral impingement associated with intra-articular synovitis, scarring, and fibrosis is a less recognized feature in patients with chronic lateral ankle instability. The aim of our study was to ascertain the incidence of intra-articular synovitis, osteochondral lesions (OCLs), impingement lesions (both intra- and extra-articular), and other associated pathologies in patients undergoing modified Broström-Gould ankle ligament reconstruction. We performed a retrospective review of all patients who underwent arthroscopically assisted modified Broström-Gould ankle ligament reconstruction for symptomatic recurrent ankle instability. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Ankle arthroscopy was performed prior to reconstruction in all patients. Data were obtained from clinical and radiological records including magnetic resonance imaging scans. Arthroscopic findings were recorded in detail intraoperatively. A total of 100 patients (53 females and 47 males) with an average age of 37 years (range, 15-65 years) were reviewed over a 10-year period. Sixty-three patients (63%) had intra-articular synovitis mostly in the anterior and/or anterolateral compartment, which required arthroscopic debridement. Seventeen patients (17%) were found to have OCLs, and 12 (12%) patients had anterior bony impingement lesions. This study found a high incidence of anterior/anterolateral synovitis in patients with chronic lateral ankle instability. However, there was a relatively low incidence of anterior bony impingement lesions or OCLs in our series. Level IV, retrospective case series.

Effect of medial opening wedge high tibial osteotomy on intraarticular knee and ankle contact pressures.

High tibial osteotomy (HTO) is a commonly used surgical technique for treating moderate osteoarthritis (OA) of the medial compartment of the knee by shifting the center of force towards the lateral compartment. Previous studies have documented the effects of HTO on the biomechanics of the knee. However, the effects of the procedure on the contact pressures within the ankle joint have not been as well described. Seven cadavers underwent an HTO procedure with sequential 5° valgus realignment of the leg up to 15° of correction. An axial force of up to 550 N was applied and the intraarticular pressure was recorded. Minor valgus realignment of the proximal tibia does not significantly alter the biomechanics of the ankle. However, moderate-to-large changes in proximal tibial alignment result in significantly decreased tibiotalar contact surface area and in changes in intraarticular ankle pressures. These findings are clinically relevant, as they provide a biomechanical rationale for the diagnosis and treatment of ankle symptoms in the setting of lower limb malalignment or after alignment correction procedures.

Ankle instability: presentation and management

Abstract The ankle joint is akin to a mortise. Damage to this mortise joint with injury to either the medial, lateral or syndesmotic complex can result in chronic ankle instability. In this article we discuss the management of ankle instability, most commonly arising from injuries to the lateral ligament complex. Chronic ankle instability may develop from an inversion-type ankle sprain, usually affecting the anterior talo-fibular ligament (ATFL). Most affected patients improve with conservative management following this injury, but up to 30% of patients can develop debilitating chronic ankle symptoms. In assessing ankle instability it is important to differentiate between patients with functional instability and those with mechanical instability. Clinical assessment is the cornerstone of diagnosis, although stress views performed under anaesthesia (including the contralateral ankle for comparison) are useful. MRI is helpful in the assessment of soft tissue and cartilage injury. Short periods of immobilisation and physiotherapy are the mainstay of acute treatment. Patients with functional instability may benefit from peroneal strengthening and proprioceptive rehabilitation. Surgery is recommended for patients with mechanical instability who fail conservative treatment. Anatomical ligament repair has the best results. Non-anatomic ligament reconstruction is reserved for revision cases although primary ligament reconstruction may have a role in selected cases.

Neurologic injuries after primary total ankle arthroplasty: prevalence and effect on outcomes.

BackgroundNeurologic injuries are complications that can arise after total joint arthroplasty. However, no comprehensive study has been conducted on peripheral nerve injuries after total ankle arthroplasty. The purpose of the present study was to identify the prevalence of neurologic injury following primary total ankle arthroplasty, the predisposing factors, and evaluate the effect on clinical outcomes.MethodsWe retrospectively analyzed 150 consecutive primary total ankle arthroplasty using the mobile-bearing prosthesis between January 2005 and December 2011, in 150 patients with symptomatic ankle end-stage arthritis. All the patients were divided into groups according to whether they had postoperative peripheral neuropathy (23 patients) or not (127 patients). We investigated the prevalence, predisposing factors, and effect on clinical outcomes of neurologic injuries. The mean age was 61.3 years, and the mean follow-up period was 41.8 months.ResultsThere were 23 nerve injuries (15.3 %), including nine in posterior tibial nerves, six superficial peroneal nerves, six deep peroneal nerves, one saphenous nerve, and one sural nerve. Neurologic injury was significantly associated with the development of posttraumatic osteoarthritis, but it was not significantly associated with other predisposing factors, such as age, gender, body mass index, and symptom duration. Of the 23 nerve injuries, 13 (56.5 %) presented a complete, spontaneous recovery, 9 (39.1 %) presented an incomplete recovery, and 1 (4.3 %) presented no recovery. The patients with neurologic injury had significantly lower American Orthopaedic Foot and Ankle Society scores and lower levels of patient satisfaction.ConclusionsThe results of this study suggest that the prevalence of neurologic injury after total ankle arthroplasty is considerable, and that neurologic injury is associated with low levels of patient satisfaction and poor clinical outcomes at mean of 3 years, postoperatively. Care is needed to reduce the occurrence of neurologic injuries.

Validity and reliability of a Dutch version of the Foot and Ankle Ability Measure.

The aim of the study was to develop a Dutch language version of the Foot and Ankle Ability Measure (FAAM) and evaluate its measurement properties according to the consensus-based standards for the selection of health measurement instruments (COSMIN) definitions. A forward-backward translation procedure was performed and subsequently the Dutch version of the FAAM was evaluated for its reliability and validity in 369 patients with a variety of foot and ankle complaints. The reliability was assessed by calculating the intraclass correlation coefficients (ICC, test-retest reliability), Cronbach's alpha (internal consistency), the standard error of measurement and the minimal detectable change (MDC). Additionally, this was done for athletes. The construct validity was assessed by the use of Spearman's correlation coefficient between FAAM domains and similar and contradictory domains of the Foot and Ankle Outcome Score, Short Form 36 and the Numeric Rating Scale for pain. The ICC of the subscales ranged from 0.62 to 0.86. Cronbach's alpha's minimum was 0.97. At individual level, the MDC ranged from 23.9 to 44.7 and at group level from 2.77 to 4.32. In the subgroup of athletes, the reliability was higher. The hypothesized correlations of the construct validity were supported by an 80% confirmation rate. The Dutch version of the FAAM met adequate measurement properties, although the reliability is not optimal. The FAAM-Sport subscale is more useful in athletes and the FAAM-Sport % seems not to contribute. In athletes with various foot and ankle symptoms, the FAAM can be used for functional assessment and follow-up at group level. For the general population, the FAAM is less appropriate. Diagnostic study, Level I.

Pigmented villonodular synovitis

Pigmented villonodular synovitis

The use of MRI in pre-operative evaluation of anterior talofibular ligament in chronic ankle instability.

ObjectivesTo evaluate the applicability of MRI for the quantitative assessment of anterior talofibular ligaments (ATFLs) in symptomatic chronic ankle instability (CAI).MethodsBetween 1997 and 2010, 39 patients with symptomatic CAI underwent surgical treatment (22 male, 17 female, mean age 25.4 years (15 to 40)). In all patients, the maximum diameters of the ATFLs were measured on pre-operative T2-weighted MR images in planes parallel to the path of the ATFL. They were classified into three groups based on a previously published method with modifications: ‘normal’, diameter = 1.0 - 3.2 mm; ‘thickened’, diameter > 3.2 mm; ‘thin or absent’, diameter < 1.0 mm. Stress radiography was performed with the maximum manual force in inversion under general anaesthesia immediately prior to surgery. In surgery, ATFLs were macroscopically divided into two categories: ‘thickened’, an obvious thickened ligament and ‘thin or absent’. The imaging results were compared with the macroscopic results that are considered to be of a gold standard.ResultsAgreement was reached when comparison was made between groups, based on MRI and macroscopic findings. ATFLs were abnormal in all 39 cases and classified as ten ‘thickened’ and 29 ‘thin or absent’. As to talar tilt stress radiography, a clear cut-off angle, which would allow discrimination between ‘thickened’ and ‘thin or absent’ patients, was not identified.ConclusionMRI is valuable as a pre-operative assessment tool that can provide the quantitative information of ATFLs in patients with CAI.Cite this article Bone Joint Res 2014;3:241–5.

The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement

The purpose of the current study was to clinically evaluate the diagnostic value of the new posterior impingement (PIM) view in the detection of an os trigonum, compared with the standard lateral view, using computed tomography (CT) as a reference standard. Three observers, 2 experienced (orthopaedic surgeon and radiologist) and one inexperienced (resident), independently scored 142 radiographic images for the presence of an os trigonum. The diagnostic performance was assessed using the computed tomographic scan as the reference standard. Accuracy, sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated. The PIM view had significantly superior accuracy compared with the lateral view for each observer: orthopaedic surgeon, PIM view= 90 versus lateral view= 75 (P= .013); radiologist, PIM view= 80 versus lateral view= 64 (P=.019); resident, PIM view= 90 versus lateral view= 79 (P= .039). The mean sensitivity and specificity of the lateral view for all observers was 50% and 81%, respectively. For the PIM view, this was 78% and 89%, respectively. The PPV was 50% for the lateral view and 70% for the PIM view. The NPV was 84% for the lateral view and 93% for the PIM view. The PIM view has significantly superior diagnostic accuracy compared with the conventional lateral view in the detection of an os trigonum. In cases of symptomatic posterior ankle impingement, we advise that a PIM view beusedinstead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions. LEVELOF Level II, development of diagnostic criteria on basis of consecutive patients with universally applied reference gold standard.

Ankle arthroscopy to manage sequelae after ankle fractures

The role of ankle arthroscopy in managing the consequences of ankle fractures is yet to be fully established. This study aims to assess this procedure in terms of the accuracy of preoperative diagnosis, re-operation rate and patient-reported outcomes. Sixty-six patients were identified [mean age 40 years (SD 13 years)] who had undergone ankle arthroscopy following a fracture of the distal tibia or fibula. Medical case notes were reviewed to ascertain details of the index injury, intra-operative findings and identify any further procedures. Patients were then contacted using a standardized questionnaire to assess satisfaction and return to normal function. Injury occurred in a mean of 2 years 10 months before arthroscopy (SD 13 months, min 6 months). Forty-nine of 66 fractures (74 %) had been managed operatively. The commonest indication for arthroscopy was anterior impingement (45 %) followed by degenerative change (30 %) and osteochondral lesions (OCL) (18 %). Intra-operative findings revealed an unexpected OCL or frank degenerative change in 20 % of patients. Using a Kaplan-Meier estimate 1 year after arthroscopy, 10 % of patients had undergone further surgery. This had increased to 34 % by 4 years after arthroscopy. Four patients underwent ankle fusion. Questionnaires were completed by 55/66 patients (84 %). Only 28 patients (50 %) felt surgery allowed them to return to normal activity. Thirty-nine patients reported a benefit from surgery (75 %) whilst 43 were satisfied (77 %) and 48 (86 %) would recommend the procedure to a friend. Intra-articular pathology was significantly underestimated preoperatively for one patient in five. Arthroscopy improved symptoms in 75 % of patients who complain of ankle symptoms after fracture of the ankle or distal tibia. However, further procedures were required in 34 % of patients. The findings of this study help guide patient counselling and operative decision-making in this challenging group of patients. IV.

AB1006 Evaluation of Clinical and Ultrasound Findings in Subtalar and Midfoot Disease in Rheumatoid Arthritis in Hong Kong: A Pilot Study

BackgroundApproximately 90% of Rheumatoid Arthritis (RA) patients report foot-related complaints within 10 years of disease onset. More than one-third of patients have significant disease in the feet. Athritis of the...

FRI0211 Usability of the Modified Swindon Foot and Ankle Questionnaire

BackgroundFoot and ankle problems are common but often neglected in Rheumatology patients. We developed a self-administered, rapid screening questionnaire with unique feature of diagrams for patients to indicate their problems...

SAT0169 Ultrasound Evaluation of Ankle Joint in Rheumatoid Arthritis Patients with Clinical Remission and Low Disease Activity

BackgroundPatients with rheumatoid arthritis (RA) who have achieved clinical remission (CR) or low disease activity (LDA) may have synovitis detectable by ultrasound (US) and continue to get joint distruction. Despite...

Validation of the Dutch language version of the Foot and Ankle Outcome Score.

The aim of this study was to develop a Dutch language version of the Foot and Ankle Outcome Score (FAOS-DLV) and evaluate its measurement properties according to the definitions of the COnsensus-based Standards for the selection of health Measurement INstruments(COSMIN). After a standard forward-backward translation procedure, the Dutch version of the FAOS was evaluated for reliability and validity in 110 patients with various hind foot and ankle complaints. Reliability was evaluated by calculation of intraclass correlation coefficients (ICC), Cronbach's alpha for internal consistency, and the smallest detectable change (SDC). Construct validity of the FAOS was assessed by calculation of Spearman's correlation coefficients with similar and dissimilar domains of the SF-36 health survey, American Orthopedic Foot and Ankle Society Ankle and Hindfoot Scale, and visual analogue scales for pain and disability. Dimensionality was tested with confirmatory factor analysis. Reliability of the FAOS-DLV was good. TheICC of the subscales ranged from 0.83 to 0.88. The minimal value of Cronbach's alpha was 0.76. The SDC at individual level ranged from 18 to 21 and at group level between 2.1 and 2.5. Construct validity was supported by confirmation of 85% of the hypothesized correlations. Unidimensionality of the FAOS-DLV domains was moderate. The Dutch version of the FAOS seems to have acceptable measurement properties. The questionnaire can be used for functional assessment of patients with varying hindfoot and ankle symptoms. It is, however, more suitable for clinical evaluation at group level than for monitoring a specific patient. Diagnostic study, Level I.

Associations between MRI Findings and Symptoms in Patients with Chronic Ankle Sprain

Magnetic resonance imaging (MRI) provides an accurate method of observing and diagnosing injuries of the ligament complex of the ankle. However, the association between ankle symptoms and MRI findings has been unclear. The purpose of the present study was to evaluate the relationship between ankle pain and MRI findings. This prospective study included 40 patients with ankle pain after inversion injury and 10 healthy volunteers. Correlations among the ankle symptoms (tenderness on the anterior talofibular ligament, pain during varus stress in a neutral and plantarflexed ankle), and MRI findings were analyzed. A complete tear of the anterior talofibular ligament correlated with ankle pain during varus stress in the neutral position (r = 0.365, p = .031) and tenderness at the anterior talofibular ligament (r = 0.362, p = .032). The results of our study suggest that a complete tear of the anterior talofibular ligament will correlate with lateral ankle pain.

Psychometric Properties of the Foot and Ankle Outcome Score in a Community‐Based Study of Adults With and Without Osteoarthritis

Foot and ankle problems are common in adults, and large observational studies are needed to advance our understanding of the etiology and impact of these conditions. Valid and reliable measures of foot and ankle symptoms and physical function are necessary for this research. This study examined psychometric properties of the Foot and Ankle Outcome Score (FAOS) subscales (pain, other symptoms, activities of daily living [ADL], sport and recreational function [sport/recreation], and foot- and ankle-related quality of life [QOL]) in a large, community-based sample of African American and white men and women ages ≥50 years. Johnston County Osteoarthritis Project participants (n = 1,670) completed the 42-item FAOS (mean age 69 years, 68% women, 31% African American, mean body mass index [BMI] 31.5 kg/m(2) ). Internal consistency, test-retest reliability, convergent validity, and structural validity of each subscale were examined for the sample and for subgroups according to race, sex, age, BMI, presence of knee or hip osteoarthritis, and presence of knee, hip, or low back symptoms. For the sample and each subgroup, Cronbach's alpha coefficients ranged from 0.95-0.97 (pain), 0.97-0.98 (ADL), 0.94-0.96 (sport/recreation), 0.89-0.92 (QOL), and 0.72-0.82 (symptoms). Correlation coefficients ranged from 0.24-0.52 for pain and symptoms subscales with foot and ankle symptoms and from 0.30-0.55 for ADL and sport/recreation subscales with the Western Ontario and McMaster Universities Osteoarthritis Index function subscale. Intraclass correlation coefficients for test-retest reliability ranged from 0.63-0.81. Items loaded on a single factor for each subscale except symptoms (2 factors). The FAOS exhibited sufficient reliability and validity in this large cohort study.

The HINTEGRA® Ankle Arthroplasty: Intermediate Term Results of 16 consecutive Ankles and a Review on the Current Literature

Purpose: Total ankle arthroplasty provides an alternative to arthrodesis for management of ankle osteoarthritis. The results of the third generation total ankle replacements have been promising. The purpose of the present study was to investigate the clinical and radiographical outcome and implant survival of 16 consecutive patients suffering from symptomatic ankle osteoarthritis treated with the HINTEGRA® (Newdeal SA, Lyon, France) prosthesis. Methods: The first 16 implanted HINTEGRA® total ankle replacements (between 2001 and 2006) by a fellowship-trained foot and ankle surgeon were assessed clinically and radiographically after a mean of 61,8 months (range, 7–116). Eight female and eight male patients were operated at a mean age of 55 years (range, 34–77). Diagnosis was post-traumatic osteoarthritis in 10 (62,5%), primary osteoarthritis in 3 (18,7%) and arthritis secondary to infection in 3 (18,7%) patients. Results: The mean AOFAS score at final follow-up was 77 (range, 49–91). Mean ankle ROM as determined clinically and fluoroscopically was 23,72 degrees (range, 12,0–47,5). Six patients required revisional surgery (37,5%). The mean follow up period until revisional surgery occured was 50,6 months (range, 24–116). In total, implant survival in all followed ankles was 66,7%. Discussion: Our study demonstrated that the functional results of the HINTEGRA® ankle were comparable to most high volume centres but the implant survival was lower. With regards to the steep learning curve of total ankle arthroplasty these results seem compatible.

Efficacy of intraarticular botulinum toxin A and intraarticular hyaluronate plus rehabilitation exercise in patients with unilateral ankle osteoarthritis: a randomized controlled trial

BackgroundThere was an increasing requirement for novel treatments of osteoarthritis (OA). The aim was to compare the efficacy of intraarticular Botulinum toxin type A (BoNT-A) and intraarticular hyaluronate plus rehabilitation exercise in patients with ankle OA.MethodsThis was a prospective, randomized, assessor-blinded study with a 6-month follow-up period, conducted in the outpatient rehabilitation department at a university-affiliated tertiary care medical center. Seventy-five patients with symptomatic ankle OA (Kellgren-Lawrence grade 2) were randomized to receive either a single 100-unit BoNT-A injection into the target ankle (n = 38) or a single hyaluronate injection plus 12 sessions of rehabilitation exercise (30 minutes/day, 3 times/week for 4 weeks) (n = 37). The primary outcome measure was the Ankle Osteoarthritis Scale (AOS). Secondary outcome measures included American Orthopedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score, visual analog scale (VAS) for ankle pain, single leg stance test (SLS), Timed “Up-and-Go” test (TUG), consumption of rescue analgesics and global patient satisfaction.ResultsThere were no significant between-group differences in total AOS scores, pain subscale and disability subscale scores (adjusted mean difference AMD = -0.2, 95% CI = (-0.5, 0.2), p = 0.39; AMD = -0.1, 95% CI = (-0.5, 0.3), p = 0.57; AMD = -0.2, 95% CI = (-0.6, 0.2), p = 0.36). The 2 groups showed no significant differences in AOFAS, VAS, SLS, TUG scores and consumption of rescue analgesics at each follow-up visit, except that the hyaluronate group improved more in SLS than the BoNT-A group at 1-month follow-up. Patients’ satisfaction rate was high, with no serious adverse events. There was no difference in adverse events between the two groups (p = 1.00).ConclusionsTreatment with intraarticular BoNT-A or hyaluronate injection plus rehabilitation exercise was associated with improvements in pain, physical function and balance in patients with ankle OA. These effects were rapid at 2 weeks and might last for at least 6 months. There was no difference in effectiveness between the two interventions.Trial registrationThe trial was registered at clinical trials.gov (Registry number NCT01760577).

The Incidence of Ankle Symptoms Following Hip Arthroscopy

The Incidence of Ankle Symptoms Following Hip Arthroscopy

Peroneal tendon abnormalities in subjects with an enlarged peroneal tubercle

To examine the association between inframalleolar peroneal tendon abnormalities and an enlarged peroneal tubercle. Two independent readers evaluated consecutive ankle MR imaging studies to classify inframalleolar peroneal tendon findings as normal, tenosynovitis, partial tear or complete tear. The size and morphology of the peroneal tubercle was also recorded. We performed statistical analyses for inter-observer agreement and to assess differences in peroneal tubercle size between groups with and without peroneal tendon abnormalities. The study group comprised 121 subjects (mean age, 45.5 years) of whom 28% (34 out of 121) had lateral ankle symptoms. The peroneal tubercle was absent in 56% of subjects (68 out of 121). In subjects with a peroneal tubercle (>0 mm), the mean size was 3.5 mm (37% triangular and 7% plateau-shaped). Male subjects had significantly larger mean peroneal tubercle size than female subjects (2.1 ± 2.5 vs 1.2 ± 1.9 mm, P = 0.04). Overall, 26% (32 out of 121) of subjects had some peroneal tendon abnormality: 17% (20 out of 121) had tenosynovitis and 17 % (20 out of 121) had partial thickness tears. The peroneal tubercle size was significantly larger in subjects with peroneal tendon partial tears (P = 0.036), tenosynovitis (P < 0.001), and when both abnormalities were present (P = 0.007). ROC statistic showed 73% sensitivity and 74% specificity for detection of partial tears for peroneal tubercle size ≥4.3 mm. Our study shows a significantly larger peroneal tubercle in subjects with inframalleolar peroneal tendon abnormalities. A cut-off of 4.3 mm showed good sensitivity and specificity for the presence of partial tears of the peroneal tendon.