Anterior Distal Tibial Angle Research Articles

Mobile Anatomical Total Ankle Arthroplasty-Improvement of Talus Recentralization.

Introduction: Total ankle arthroplasty (TAA) is becoming a more frequent treatment option for end-stage ankle osteoarthritis (OA) as outcomes measures are improving. However, there is concern that malalignment of TAA can result in premature failure of the implant. One of the malalignment issues is the talar sagittal malposition. However, a consensus on the significance of the sagittal translation of the talus in TAA is yet to be established. The aim of this study was, therefore, to clarify whether talus OA subluxation is normalized after the implantation of a mobile TAA. Methods: Forty-nine consecutive patients with symptomatic end-stage ankle OA underwent 50 cementless three-component mobile-bearing VANTAGE TAA with 21 right ankles (42%) and 29 left ankles (58%). Clinical and radiographic outcomes were assessed: Clinical variables: American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score (0–100), visual analogue scale (VAS, 0–10), and ankle range of motion (ROM). Radiological variables: medial distal tibial articular angle (mDTAA), anterior distal tibial articular angle (aDTAA) and lateral talar station (LTS). Results: The clinical results showed the mean improvement in AOFAS hindfoot score from 42.12 ± SE 2.42 (Range: 9–72) preoperatively, to 96.02 ± SE 0.82 (Range: 78–100) at a mean follow-up of 12 months, with a highly statistically significant difference (p < 0.00001). Pain score (VAS) was 6.70 ± SE 0.28 (Range 0–10) preoperatively, and 0.26 ± SE 0.12 (Range: 0–3) at 12-month follow-up, with a highly statistically significant difference (p < 0.00001). ROM measurements preoperatively showed a mean of 22.55° ± SE 1.51° (Range: 0–50°), which showed a statistically significant improvement (p < 0.0001) to 45.43° ± SE 1.56° (Range: 25–60°) 12 months postoperatively. The radiological analyses revealed the following results: On the coronal view, the mDTAA preoperatively was 88.61 ± SE 0.70 (Range: 78.15–101.10), which improved to 89.46 ± SE 0.40 (Range: 81.95–95.80) at 12 months (not statistically significant—p = 0.94). On the sagittal view, the preoperative values of the aDTAA showed 82.66 ± SE 0.84 (Range: 70.35–107.47), which improved to 88.98 ± SE 0.47 (Range: 82.83–96.32) at 12 months postoperatively, with a highly statistically significant difference between preoperative and 12-months values (p < 0.00001). The mean LTS values for all patients were 3.95 mm ± SE 0.78 (Range: −11.52 to 13.89) preoperatively and 1.14 mm ± SE 0.63 (Range: −10.76 to 11.75) at 12 months, with a statistically significant difference between preoperative and 12-month follow-up (p = 0.01). The review of the radiological TAA osteointegration at 12 months showed no cases of loosening of the implanted TAAs. Two cases (4%) showed a radiolucency and one case (2%) a cyst on the tibial component; no cases had a change on the talar component. No TAA complication/revision surgeries were documented. Conclusion: In the present study, the lateral talar station of anteriorly subluxated ankles showed a significant improvement, i.e., physiological centralization of the talus, in the postoperative period when a mobile-bearing TAA was performed. The anterior/posterior congruency between the talar component and the mobile polyethylene insert of the mobile-bearing VANTAGE TAA allows the sagittal translation of the talus relative to the flat tibial component, reducing the prosthesis strain and failure.

Total Ankle Arthroplasty With Valgus Deformity.

A substantial coronal plane deformity is common in the context of end-stage ankle osteoarthritis. Recent literature shows a trend toward extending the indication of total ankle arthroplasty in increasingly severe coronal deformities, showing promising results when correct alignment is achieved. Nevertheless, the results of lateral transfibular total ankle replacement (LTTAR) in valgus has not been extensively studied. We aimed to evaluate if the outcomes of LTTAR in ankles with valgus deformity were similar to those with no major deformity at short-term follow-up. This retrospective cohort study included 228 LTTARs. Patients were classified into 2 groups according to the preoperative coronal plane tibiotalar angle (TTS): neutral (less than 10 degrees of coronal deformity, 209 patients) and valgus (above 10 degrees of valgus, 19 patients). Clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS), 12-Item Short Form Health Survey 12 (SF-12) regarding its Physical and Mental Component Summary items. The radiographic evaluation considered anteroposterior and lateral ankle radiographs. Complications were also registered and classified as major or minor. The minimum follow-up was 2 years. The average AOFAS, VAS, and SF-12 scores improved significantly postoperatively (P < .001), without differences between groups. At final radiographic follow-up, the valgus alignment group did not show significant differences with the neutral alignment group regarding TTS, lateral distal tibial angle, or anterior distal tibial angle (P > .05). LTTAR in cases with valgus deformity achieved and maintained correction at short-term follow-up, as obtained in neutral alignment ankles. Clinical outcomes improved significantly regardless of preoperative valgus deformity. Prognostic Level III, retrospective cohort study.

Eccentric ankle arthritis in the sagittal plane: a novel description of anterior and posterior ankle arthritis

BackgroundTo report radiographic characteristics of anterior and posterior ankle arthritis, which demonstrates the eccentric narrowing of either aspect of the tibiotalar joint in the sagittal plane. MethodsRadiographic analysis of 19 ankles with anterior arthritis and 16 ankles with posterior arthritis was performed, which were defined as having both (1) eccentric narrowing of the anterior or posterior tibiotalar joint space on lateral radiographs and (2) talar tilt angle less than 4 degrees on anteroposterior radiographs. Measured radiographic parameters were: Talar tilt angle, medial distal tibial angle (MDTA), talar center migration (TCM), anterior distal tibial angle (ADTA), tibial axis-to-talus ratio (TT ratio), talo-first metatarsal (Meary) angle, hindfoot alignment angle (HAA), hindfoot moment arm, and mechanical axis deviation (MAD). An Intergroup comparison analysis, including a normal control group, was also performed. ResultsThe TT ratio was significantly different between each group, indicating a distinct talus position in the sagittal plane. The anterior group had a significantly larger TCM than the control group and lower ADTA compared to other groups, indicating medial translation of the talus and anterior opening of the tibial plafond. The posterior group demonstrated a significantly higher Meary angle and lower HAA compared to other groups and lower MDTA compared to the control group, indicating lower medial longitudinal arch, valgus heel alignment, and varus tibial plafond. The MAD was significantly higher in both the anterior and posterior groups than the control group, indicating varus lower limb alignment. ConclusionAnterior ankle arthritis demonstrated anteromedial translation of the talus and anterior opening of the tibial plafond. Posterior ankle arthritis was associated with the lower medial longitudinal arch and hindfoot valgus, indicating an association with flatfoot deformity. Both anterior and posterior ankle arthritis were associated with varus lower limb alignment.

A Staged Approach to Combined Extra-articular Limb Deformity Correction and Total Ankle Arthroplasty for End-Stage Ankle Arthritis.

Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation. Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity-Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function). Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), P = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), P = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), P < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), P = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), P = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), P = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), P = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), P = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), P = .007. There was one incidence of pin site infection and one reoperation. Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction. Level IV, retrospective case series.

Total Ankle Arthroplasty in Valgus Deformity

Category:Ankle ArthritisIntroduction/Purpose:Total ankle replacement use has increased among patients with end-stage ankle arthritis. Substantial coronal plane deformity is usual in that context. In addition, recent literature shows a trend towards the extension of the indication of total ankle arthroplasty in increasingly severe coronal deformities, showing good results when correct alignment is achieved. Nevertheless, the results of lateral transfibular total ankle replacement (LTTAR) in valgus has not been extensively studied. We aimed to evaluate if the outcomes of LTTAR in ankles with valgus deformity are similar with those with no major deformity.Methods:This retrospective cohort study included 228 LTTAR. Patients were classified into 2 groups according to the preoperative coronal plane tibiotalar angle (TTS): neutral (less than 10° of coronal deformity, 209 patients) and valgus (above 10° of valgus, 19 patients). Clinical evaluation was performed using American Orthopaedic Foot & Ankle Society Score (AOFAS), Visual analogue scale (VAS), short Form 12 Quality of Life (SF-12) regarding its physical (PCS) and mental (MCS) items. Radiographic evaluation considered anteroposterior and lateral ankle radiographs. Surgical times were recorded in all the cases. There were no differences between groups regarding mean age, mean body mass index and follow up. The minimum follow up was 24 months.Results:The average AOFAS, VAS and SF-12 scores improved significantly postoperatively (p-value<0.01), without differences between groups. At final radiographic follow up, the valgus alignment group did not show significant differences with the neutral alignment group regarding TTS, lateral distal tibial angle or anterior distal tibial angle (p-value>0.05). Surgical time was longer in the valgus group (152.84 +- 40.86 mins vs 129.51 +- 52.13), but the difference was not statistically significant.Conclusion:Lateral transfibular total ankle replacement in ankles with valgus deformity achieved and maintained correction of coronal alignment in a short term follow up, as obtained in neutral alignment ankles. Clinical outcomes improved significantly regardless preoperative valgus deformity. Additional surgical time may be needed in order to obtain a good deformity correction in a valgus ankle. This short term analysis shows that LTTAR in a valgus ankle seems to be a safe option in experienced surgeons hands.

Severe Ankle Varus Malalignment Management with a Fix-Bearing Total Ankle Replacement Implant

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Despite Total ankle replacement (TAR) is currently considered a safe procedure and an optimal alternative to ankle fusion in end-stage ankle arthritis, still the precise indications and the limits of TAR are a highly controversial topic. Coronal malalignment correction with TAR is also a widely debated point. Purpose of this work was to confront two patient groups undergoing Total Ankle Replacement (a group of patients with a pre-operative ankle varus misalignment on coronal plane, versus a group of patients with neutral pre-operative ankle alignment) comparing clinical and radiographic results, complications and survival rate of the implant.Methods:171 patients, all affected by end-stage ankle arthritis and all treated with total ankle replacement with fix-bearing Trabecular Metal Total Ankle System (Zimmer-Biomet, Warsaw IN, USA), were divided in two groups. Group ‘A’ included 159 patients having a normal alignment or a slight valgus or valgus misalignment within 10°. Group ‘B’ included 12 patients with a pre- operative varus malalignment >10°. Each patient of the study was evaluated, clinically and radiologically, before and after surgery, and subsequently at 6 and 12 months follow-up, then once every year. Clinical evaluation comprised some score: visual analogue scale (VAS); American Foot and Ankle Society Score (AOFAS); and the Short Form (SF)-12 Quality of Life, in both of its ‘physical’ (PCS) and ‘mental’ (MCS) components. Radiological evaluated parameters were: tibio-talar surface angle (TTS), lateral distal tibial angle (LDTA-α), and anterior distal tibial angle (ADTA-β). Complications and implant survival rate were evaluated for both groups.Results:At a mean follow up of 2,75 years (range 2.09-5.66 years), improvement was found in all clinical and radiological evaluated parameters of two groups, without statistically significant differences between two groups at last follow-up. In group A most frequent reported complication was the presence of a fibular symptomatic hardware. Major complication were a deep arthroplasty infection and a 3 months post-operative ankle fracture-dislocation/periprostethic fracture. In group B there were 2 delayed wound healing, and one case of loosening of correction. No significant difference in complication and revision rate comparison between two groups was founded.Conclusion:Mid-term results reported in the present show that in patients with varus greater than 10 ° it is possible to obtain a post-operative alignment similar to pre-operative neutral ankles and that the complication rate is not greater. Despite this, is Authors opinion that major and complex misalignment should be approached by skilled surgeons, with an adequate learning curve experience, with a wide range of cases and in highly specialized centers.

Symmetry and reliability of the anterior distal tibial angle and plafond radius of curvature

Using the radiographs of uninjured extremities as a template for reduction of articular fractures may be beneficial. While there is a significant amount of radiographic data about the relationship of bony landmarks in the hip and knee, there is minimal data investigating the symmetry of lateral measurements in ankles side to side. The aim of this study was to determine if radiographic anatomic differences were evident when comparing bilateral lateral radiographs of uninjured patient ankles. A retrospective review of patients with bilateral lateral ankle radiographs for mid- or fore-foot related complaints was performed. Patient demographics and radiographic measurements relating to the anterior distal tibial angle (ADTA) and plafond radius of curvature (ROC) were collected. Paired student's t-test was used to determine similarities. 478 patient radiographs were evaluated and 215 met inclusion criteria. The average ADTA was 84.0° (76°-92°, σ=3.03°) and plafond ROC was 20.4mm (11.3-37.1mm, σ=4.01mm). There was no significant difference between left and right ankles in ADTA (p=0.08) and ROC (p=0.06). Females had a significantly smaller ROC and larger ADTA (p<0.001,p=0.03). Inter-observer and intra-observer reliability were excellent for the ADTA (>0.9) and good for the ROC (>0.75). This study demonstrates that the ADTA and plafond ROC measurements are reliable and symmetrical in patients. Furthermore, females are more like to have a flatter ADTA (closer to 90°) and a smaller ROC of their plafond. These findings confirm that the lateral radiograph of the uninjured ankle may be used as a template for reduction when treating articular injuries of the distal tibia.

Correction of Recurrent Equinus Deformity in Surgically Treated Clubfeet by Anterior Distal Tibial Hemiepiphysiodesis.

Residual or recurrent equinus deformity is a common problem in surgically treated clubfeet. This deformity may occur due to soft tissue-related reasons or due to bony deformity. An increased anterior distal tibial angle (ADTA) was previously found in 48% of the operated clubfeet. This study aimed to determine the efficacy and safety of anterior distal tibial hemiepiphysiodesis (ADTE) in the treatment of recurrent equinus deformity in patients with an increased ADTA. Eighteen children (23 feet) treated by ADTE to correct recurrent equinus deformity in surgically treated clubfeet were included in this retrospective, single-center study. ADTE using 8 plates was performed in children with an increased ADTA (>82 degrees) and inability to dorsiflex the ankle (≤0 degree of dorsiflexion). The mean patient age was 11.3 years (range: 10.2 to 12.9 y). All patients had completed treatment with implant removal after an average of 20.3 months (range: 9 to 37 mo). The mean preoperative ankle dorsiflexion significantly improved from -3.3 degrees (range: -20 to -0 degrees) to 6.1 degrees (range: -15 to 10 degrees) at the time of 8-plate removal (correction rate: 9.4 degrees; P<0.0001). The ADTA was a mean of 87.5 degrees (range: 83 to 110 degrees) before surgery and significantly improved to 75.8 degrees (range: 63 to 106 degrees) at the time of implant removal (correction rate: 11.7 degrees; P<0.0001). Average follow-up was 43.9 months (range: 10 to 76 mo). Follow-up examinations were continued in 11 patients (13 feet) after implant removal. Changes of ankle dorsiflexion (mean: -2.5 degrees) and ADTA (mean: 3.6 degrees) occurred in this group. ADTE was safe and effective in the treatment of recurrent equinus deformity in surgically treated clubfeet with increased ADTA. Deterioration of ankle dorsiflexion and ADTA occurred after implant removal in some cases. The results of this study have to be analyzed with caution due to the limited number of included patients and its retrospective nature. Level IV-retrospective case series.

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PurposeSagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement. Patients and methodsA retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs. Results580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02). ConclusionsThe sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.

Reference values of the femur and tibia mechanical axes and angles in the sagittal plane, determined on the basis of three-dimensional modeling

Background: The reference values of the anatomical, mechanical lines and angles of the femur and tibia in the frontal plane have been sufficiently studied. At the same time, the data concerning the mechanical axis and angles in the sagittal plane are rather contradictory. Aims and objectives. The aim of this study was to determine the 3D reference values of the mechanical axes and angles of the femur and tibia in the sagittal plane. Materials and Methods: The study included data of 23 adult volunteers for whom computer tomography (CT) was done. The inclusion criteria were: absence of the deformity confirmed by long-leg films (using known reference lines and angles (RLA) assessment), absence of torsional deformity confirmed by CT and extended position of the limb. Results: It was found that the mechanical axis of the lower limb in the sagittal plane divides the distal joint line of the femur into two segments: anteriorly - 43.8+7.9%, posteriorly - 56.2+7.9%. The proximal joint line of the tibia, correspondingly, is divided into 23.3+8.8% anteriorly and 76.7+8.8% posteriorly. The found values of mechanical angles were the following: mechanical Posterior Proximal Femoral Angle (mPPFA) - 84.7 + 8.8 °, mechanical Posterior Distal Femoral Angle (mPDFA) - 81.1 + 3.95 °, mechanical Posterior Proximal Tibial Angle (mPPTA) - 81.6 + 2.8 °, mechanical Anterior Distal Tibial Angle (mADTA) - 79.9 + 2.98°. Conclusion: The obtained data on the mechanical axis of the lower limb for the sagittal plane can be used both for deformity assessing, planning and estimating the accuracy of deformity correction.

Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization for varus ankle osteoarthritis with excessive talar tilt angle

BackgroundAlthough supramalleolar osteotomy is the main joint-preserving method for the treatment of varus ankle osteoarthritis, it tends to be ineffective when ankle osteoarthritis presents in combination with an excessive talar tilt angle. The purpose of this study was to present a new surgical technique, supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization, for the treatment of varus ankle osteoarthritis with an excessive talus tilt angle and to evaluate the clinical and radiological results.MethodsFrom January 2013 to October 2016, a total of 17 patients with 17 cases of varus ankle arthritis with excessive talar tilt angles (larger than 7.3°) underwent surgical treatment using our new technique. The American Orthopaedic Foot and Ankle Society (AOFAS) clinical ankle-hindfoot scale and a visual analogue scale (VAS) were used to evaluate ankle function and pain before surgery and at the last follow-up. The medial distal tibial angle (MDTA), anterior distal tibial angle (ADTA), talar tilt angle (TTA), and hindfoot moment arm values (HMAVs) were evaluated on weight-bearing radiographs acquired preoperatively and at the last follow-up.ResultsThe AOFAS score improved significantly from 45.8 ± 2.1 before surgery to 84.8 ± 1.8 after surgery (p < 0.001), and the VAS score decreased from 4.9 ± 0.4 to 1.1 ± 0.2 (p < 0.001). The MDTA, TTA, and HMAV changed from 80.9° ± 0.4° to 90.1° ± 0.4°, 11.7° ± 0.6° to 1.4° ± 0.3°, and 12.6 mm ± 0.8 mm to 4.2 mm ± 0.6 mm, respectively (each p < 0.001). The ADTA showed no obvious change (p = 0.370). The staging of 11 cases (65%) improved. Intramuscular vein thrombosis of the lower limbs occurred in 1 patient 1 week after surgery, and superficial infection occurred in 1 patient.ConclusionsSupramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization can correct the load of the weight-bearing ankle and effectively improve the ankle function. As the talar tilt angle can be significantly improved after surgery, this technique can be used for the treatment of varus ankle osteoarthritis with an excessive TTA.

Radiological parameters determining outcome in pilon fractures treated by minimally invasive plate osteosynthesis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tibial pilon fractures are one of the challenging fractures to manage in the field of orthopaedics due to its complex fracture patterns as well as associated soft tissue injury. Minimally invasive plate osteosynthesis (MIPO) technique aims to reduce the surgical trauma to the surrounding soft tissues and hence maintain a more biologically favourable environment for fracture healing. The purpose of the study is to analyse the various factors especially radiological parameters determining functional outcome in pilon fractures treated by MIPO technique.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a prospective study conducted from June 2015 to May 2018. The study included 46 patients (33 males, 13 females) with pilon fractures treated by minimally invasive plate osteosynthesis. All patients were followed for average period of 2 years. Functional outcome was assessed using American Orthopedic Foot and Ankle Score (AOFAS).&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Among 46 patients, 21 patients (45.65%) had excellent, 16 patients (34.78%) had good and 6 patients (13.04%) had fair functional outcome. The quality of reduction was the most important parameter determining the functional outcome. We found that patients with higher lateral distal tibial angle (LDTA), anterior distal tibial angle (ADTA) and length of lateral malleolus (LLM) had better functional outcome than patients with lower values. The timing of surgery had no significant influence on the functional outcome of the patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; We like to conclude that apart from the quality of fracture reduction, radiological parameters like ADTA, LDTA, and LLM also play a crucial role in determining the functional outcome in pilon fractures.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Role of a tendon transfer as a dynamic checkrein reducing recurrence of equinus following distal tibial dorsiflexion osteotomy.

Tibial dorsiflexion osteotomy for recalcitrant equinus in clubfeet is reported to have a high recurrence rate with growth. We present the results of closing wedge tibial dorsiflexion osteotomy and tendon transfers in 15 feet and 11 patients. The mean age at presentation was 7 (range: 3.98-12.38) years. At a mean follow-up of 4.16 (range: 2.09-6.87) years, 11 of the 15 feet remained corrected. Mean correction of the dorsiflexion was 24.5° and mean correction of anterior distal tibial angle was 10.9° at final review. Muscle rebalancing appears to influence bone remodeling and reduce recurrence of equinus.

Ankle Salvage Following Nonunion of Distal Tibia Fractures.

Nonunions of the distal tibia in close proximity to the ankle joint can be a challenge to treat. The purpose of this study was to evaluate radiographic and clinical outcomes of patients who underwent ankle-sparing bone transport for periarticular distal tibial nonunions. Twenty-one patients underwent ankle-sparing bone transport between January 2006 and July 2016. The mean age of the patients was 48.6 years, and 71% (15/21) were male. Patients were followed for an average of 14.6 months (range, 10.6-17.7 months), with an average of 8.6 months in-frame. Thirteen of 21 patients had infected nonunions. Primary endpoints included time to union and American Orthopaedic Foot & Ankle Society (AOFAS) score. All fractures achieved union. Mean time to union was 37.4 weeks. Mean AOFAS score was 86.3 points (range, 37-100). A score of 37 was observed in 1 patient with preexisting Charcot foot. Radiographic evaluation at 6 months revealed a mean lateral distal tibial angle of 89.2 degrees and a mean anterior distal tibial angle of 76 degrees. Leg length discrepancy was less than 1.2 cm in all patients. Superficial pin infection was observed in 7 patients, and operative wound infection at the level of bone resection was observed in 3 patients. The ankle-sparing bone transport technique was an effective alternative to bone graft and arthrodesis for the treatment of periarticular nonunions of the distal tibia and was safe for use in patients with infected nonunions in close proximity to the ankle joint. Level IV, case series.

Treatment of pediatric patients with lower leg deformities associated with physeal arrest: analysis of 28 cases

Aim. To retrospectively analyze the results of two treatment methods for lower leg deformities associated with partial growth arrest.&#x0D; Materials and methods. Group I comprised 15 children who underwent osteotomy, acute overcorrection, and external fixation by Ilizarov with subsequent lengthening of the segment. Group II comprised 13 patients who underwent epiphysiodesis of the healthy part of the growth plate by drilling, osteotomy with external fixation by use of an Ortho-SUV Frame, and subsequent gradual deformity correction and lengthening.&#x0D; Results. In group I, overcorrection of varus deformities by mechanical axis deviation (MAD) was 18.28 ± 5.25 mm, overcorrection by mechanical medial proximal tibial angle (mMPTA) was 14.86 ± 4.45°, and overcorrection by mechanical lateral distal tibial angle (mLDTA) was 12.85 ± 3.02°. Overcorrection of valgus deformities according to MAD was 15.12 ± 8.28 mm, overcorrection by mMPTA was 10.38 ± 2.77°, and overcorrection by mLDTA was 7.5 ± 3.9°. Recurrence of the deformity was observed in 11 (73%) cases (range, 5–16 months).&#x0D; In group II, the accuracy of correction (AC) in varus deformities for MAD was 98% and 94% for mMPTA and mLDTA. For valgus deformities, AC for MAD was 90% and 96% for mMPTA and mLDTA. The AC for anatomical proximal posterior tibial angle and anatomical anterior distal tibial angle was 96% for procurvation deformities and that for recurvation deformities was 92%. Deformity recurrence was observed in only one case within 6 months after frame removal. In 2 cases, repeat limb length discrepancy correction surgeries were performed.&#x0D; Conclusion. Use of epiphysiodesis of the healthy portion of the growth plate in combination with osteotomy, computer-assisted external fixation with subsequent gradual deformity correction, and lengthening in patients with deformities associated with partial physeal arrest significantly decreased the number of deformity recurrences.

Trabecular Metal Total Ankle Using Transfibular Approach

Category: Ankle Arthritis Introduction/Purpose: The Trabecular Metal total ankle, introduced in 2012, is the most recent design of a lateral approach, total ankle replacement. The objectives of this study were to (1) determine postoperative radiographic outcomes including hindfoot alignment, alignment of prosthesis components, and periprosthetic radiolucencies, and (2) determine the failure rate of prosthesis components in the short-term. Methods: Fifty-six consecutive primary total ankle replacements were performed between October 2012 and November 2014 using a Trabecular Metal prosthesis (Zimmer Biomet, Warsaw, IN, USA) through transfibular approach. There were 30 male and 26 female patients with a mean age of 66.7 ± 9.2 years (46.7–84.9). Radiographic assessment was performed using preoperative and postoperative weight-bearing radiographs (Figure 1). Periprosthetic radiolucency was assessed by two independent observers, according to each of the 6 zones around the tibial and talar components. Hindfoot alignment was analyzed by medial distal tibial angle, tibio-talar tilt, calcaneal moment arm, and anterior distal tibial angle. Degenerative changes in the tibiotalar and adjacent joints were assessed according to the Kellgren-Lawrence scale. Prosthesis alignment was measured by α, β, and γ angles. The mean time to final follow-up was 19.5 ± 5.2 months (12.0-32.8). All patients were available for a minimum of one year of follow-up. Results: At the latest follow-up, radiolucencies were observed in tibial zones 1 through 6 in 33.9%, 26.8%, 7.1%, 5.4%, 10.7%, and 21.4%, respectively. Radiolucencies were seen in talar zones 1 through 6 in 12.5%, 3.6%, 0.0%, 0.0%, 5.4%, and 0.0%, respectively. The prosthesis alignment α, β, and γ angles were 87.0° ± 3.1° (80°–95°), 87.1° ± 5.3° (75°–100°), and 5.2° ± 6.1° (-7°–20°). In all patients, osseous union of the fibular osteotomy was observed within 4 months postoperatively. In two patients, a painful loosening of the tibial component was observed, resulting in revision of tibial component at 17.6 and 24.6 months after the index procedure. Conclusion: The short-term results of a lateral approach, Trabecular Metal implant are encouraging and comparable with those of other third-generation ankle implants. All osteotomies healed in appropriate alignment.

Radiographic Assessment of Lower Limb Lengthening in Achondroplastic Patients, Using the Ilizarov Frame: A 5-19 Year Follow up Study

Background: The effectiveness of the Ilizarov ring fixator in correcting achondroplasia’s lower limb deformities is known. However, whether the long term postoperative result is comparable to normal population standards, has not been analyzed. Materials and Methods: Nineteen (19) achondroplastic patients, 12 males and 7 females, aged 19-38 years, who at the age of 9-19 years, had undergone both tibia and femur lengthening, using the Ilizarov method, were included in the study. Patients were evaluated 5-19 years after their last surgery, using standardized long lower limb anteroposterior and lateral standing radiographs. Tibial and femoral lengthening gain was measured. A comparison between the achondroplastic patients at follow up and comparative radiographic parameters of the normal population was made, concerning– at the frontal plane- LPFA (lateral proximal femoral angle), LDFA (lateral distal femoral angle), MPTA (medial proximal tibial angle), LDTA (lateral distal tibial angle) and MAD (mechanical axis deviation) and – at the sagittal plane- PDFA (posterior distal femoral angle), PPTA (posterior proximal tibial angle) and ADTA (anterior distal tibial angle). Results: Mean angle values at follow up were: LPFA 118, LDFA 95.5, MPTA 87.8, LDTA 93, PDFA 85.1, PPTA 84, ADTA 88.3 while MAD mean value was 28. LPFA, LDFA, LDTA, PPTA, ADTA and MAD values were statistically significantly different (p<0.001) between achondroplastic patients and normal population. Conclusions: The use of the Ilizarov method for lower limb deformity correction, in achondroplastic patients, provides a functional length gain. It substantially corrects the three-dimensional deformities of the disease but, it does not restore the radiological image within normal standards. Level of Evidence Level II, Retrospective Prognostic study.

Bone transport of the tibia with a motorized intramedullary lengthening nail — a case report

Bone resection and subsequent bone transport and bone lengthening is a well-established treatment for a tibial non-union with shortening (Rozbruch et al. 2008). To our knowledge, this is the first description in the literature of bone transport and subsequent bone lengthening of the tibia only by use of a motorized intramedullary nail. A 53-year-old male twisted his leg while downhill skiing and sustained an OTA classification 43-A2.3 (4) closed fracture of the distal tibia and fibula (Marsh et al. 2007). Both fractures were treated with open reduction and locking plates in January 2009. A non-union developed with loosening of the osteosynthesis, and 7 months after the initial operation the patient was reoperated with bone allograft and exchange of the plates and screws. The non-union did not heal. The patient was referred to our institution 20 months after the first reoperation. At this time, the tibial plate was loose, with broken screws (Figure 1). The tibia had a varus deformity of 16 degrees and was 2.2 cm shortened (Figure 1). The non-union site was tested clinically and found to be loose. Figure 1. Frontal plane varus deformity without sagittal plane deformity of the tibia, with leg-length discrepancy of 2.2 cm in patient with tibial non-union. We operated the patient 24 months after the first reoperation. After removal of all previously inserted implants and screws, except a distal AP screw, the non-union site was found at surgery to be atrophic. The non-union site (3.1 cm bone segment) was resected to vital bone. The fibula was osteotomized at the level of the tibial resection. A proximal percutaneous tibial osteotomy was performed 9 cm from the knee joint line. A custom-made motorized tibial lengthening nail (Fitbone TSA (Tibial Segment Actuator) was inserted. The nail had a length of 35 cm and was capable of 4 cm of bone transport initially and 2 cm of bone lengthening subsequently. The nail had 8 degrees of anterior bending, starting 40 mm from the proximal tip of the nail. The nail was locked with 2 proximal and 2 distal locking screws to the tibia. In addition, a screw was inserted into a sliding hole in the middle part of the tibia, allowing bone transport of the middle tibial segment (Figure 2). A tibio-fibular screw was inserted distally to protect the distal tibio-fibular joint. Acute shortening of the bone defect was not performed. A radiograph taken immediately after surgery showed that 3.1 cm of bone had been resected. Bone transport was initiated 10 days postoperatively at a rate of 1 mm daily (Figure 3). There were no clinical signs of infection and the white blood cell and C-reactive protein levels were normal before surgery. However, biopsies of the resected bone were cultured and showed growth of coagulase-negative staphylococci, which were sensitive to dicloxacillin. Dicloxacillin was therefore administered orally for 3 months. Figure 2. Immediately postoperatively, showing tibial bone gap after bone resection. The bone transport and lengthening nail is inserted in the tibia after proximal tibial osteotomy and distal fibula osteotomy. Figure 3. A. 1 month after surgery. 4 weeks postoperatively, 3.3 mg of recombinant BMP-7 (eptotermin alfa, Osigraft; Stryker) was administered percutaneously to the docking site. A loose proximal locking screw was exchanged at the same surgery and intraoperative fluoroscopy showed that the fibula osteotomy was still loose, allowing lengthening of the fibula. Partial weight bearing was allowed from 2 months postoperatively when the proximal tibia had been lengthened 5 cm (3 cm of bone transport plus 2 cm of leg lengthening). The docking site was united 5 months postoperatively, and full weight bearing was allowed at this time. Healing time for the regenerate was 45 days/cm of bone lengthening. The distal tibio-fibular screw bothered the patient and was removed at 6 months postoperatively. The nail was removed 15 months postoperatively. At the latest follow-up, 18 months after nail insertion and 3 months after nail removal, the patient had no pain or restrictions in daily activities. Motion of the knee and the ankle on the operated side was equal to that on the healthy side. Motion of the knee was from full extension to 140 degrees of flexion and motion of the ankle was from 15 degrees of dorsal flexion to 30 degrees of plantar flexion. An AP radiograph showed no mechanical axis deviation in the operated leg compared to the healthy leg. There was equal leg length. There was a 3-degree varus deformity in the frontal plane. There was no deformity in the sagittal plane on the lateral radiograph. The posterior proximal tibial angle (PPTA) and the anterior distal tibial angle (ADTA) equalled the preoperative values of 78 degrees (PPTA) and 83 degrees (ADTA). There have not been any clinical signs of infection.

Bone transport of the tibia with a motorized intramedullary lengthening nail — a case report

Bone resection and subsequent bone transport and bone lengthening is a well-established treatment for a tibial non-union with shortening (Rozbruch et al. 2008). To our knowledge, this is the first description in the literature of bone transport and subsequent bone lengthening of the tibia only by use of a motorized intramedullary nail. A 53-year-old male twisted his leg while downhill skiing and sustained an OTA classification 43-A2.3 (4) closed fracture of the distal tibia and fibula (Marsh et al. 2007). Both fractures were treated with open reduction and locking plates in January 2009. A non-union developed with loosening of the osteosynthesis, and 7 months after the initial operation the patient was reoperated with bone allograft and exchange of the plates and screws. The non-union did not heal. The patient was referred to our institution 20 months after the first reoperation. At this time, the tibial plate was loose, with broken screws (Figure 1). The tibia had a varus deformity of 16 degrees and was 2.2 cm shortened (Figure 1). The non-union site was tested clinically and found to be loose. Figure 1. Frontal plane varus deformity without sagittal plane deformity of the tibia, with leg-length discrepancy of 2.2 cm in patient with tibial non-union. We operated the patient 24 months after the first reoperation. After removal of all previously inserted implants and screws, except a distal AP screw, the non-union site was found at surgery to be atrophic. The non-union site (3.1 cm bone segment) was resected to vital bone. The fibula was osteotomized at the level of the tibial resection. A proximal percutaneous tibial osteotomy was performed 9 cm from the knee joint line. A custom-made motorized tibial lengthening nail (Fitbone TSA (Tibial Segment Actuator) was inserted. The nail had a length of 35 cm and was capable of 4 cm of bone transport initially and 2 cm of bone lengthening subsequently. The nail had 8 degrees of anterior bending, starting 40 mm from the proximal tip of the nail. The nail was locked with 2 proximal and 2 distal locking screws to the tibia. In addition, a screw was inserted into a sliding hole in the middle part of the tibia, allowing bone transport of the middle tibial segment (Figure 2). A tibio-fibular screw was inserted distally to protect the distal tibio-fibular joint. Acute shortening of the bone defect was not performed. A radiograph taken immediately after surgery showed that 3.1 cm of bone had been resected. Bone transport was initiated 10 days postoperatively at a rate of 1 mm daily (Figure 3). There were no clinical signs of infection and the white blood cell and C-reactive protein levels were normal before surgery. However, biopsies of the resected bone were cultured and showed growth of coagulase-negative staphylococci, which were sensitive to dicloxacillin. Dicloxacillin was therefore administered orally for 3 months. Figure 2. Immediately postoperatively, showing tibial bone gap after bone resection. The bone transport and lengthening nail is inserted in the tibia after proximal tibial osteotomy and distal fibula osteotomy. Figure 3. A. 1 month after surgery. 4 weeks postoperatively, 3.3 mg of recombinant BMP-7 (eptotermin alfa, Osigraft; Stryker) was administered percutaneously to the docking site. A loose proximal locking screw was exchanged at the same surgery and intraoperative fluoroscopy showed that the fibula osteotomy was still loose, allowing lengthening of the fibula. Partial weight bearing was allowed from 2 months postoperatively when the proximal tibia had been lengthened 5 cm (3 cm of bone transport plus 2 cm of leg lengthening). The docking site was united 5 months postoperatively, and full weight bearing was allowed at this time. Healing time for the regenerate was 45 days/cm of bone lengthening. The distal tibio-fibular screw bothered the patient and was removed at 6 months postoperatively. The nail was removed 15 months postoperatively. At the latest follow-up, 18 months after nail insertion and 3 months after nail removal, the patient had no pain or restrictions in daily activities. Motion of the knee and the ankle on the operated side was equal to that on the healthy side. Motion of the knee was from full extension to 140 degrees of flexion and motion of the ankle was from 15 degrees of dorsal flexion to 30 degrees of plantar flexion. An AP radiograph showed no mechanical axis deviation in the operated leg compared to the healthy leg. There was equal leg length. There was a 3-degree varus deformity in the frontal plane. There was no deformity in the sagittal plane on the lateral radiograph. The posterior proximal tibial angle (PPTA) and the anterior distal tibial angle (ADTA) equalled the preoperative values of 78 degrees (PPTA) and 83 degrees (ADTA). There have not been any clinical signs of infection.

Distal tibial hypertrophic nonunion with deformity: treatment by fixator-assisted acute deformity correction and LCP fixation

Distal tibial hypertrophic nonunion with angular deformity has been successfully treated by circular external fixator. The inconvenience of the bulky external fixator and frequent pin tract infection would not be accepted in certain cases. This study included thirteen patients (mean age 39 years) with angular deformity of the distal dia-/metaphyseal tibial shaft. Five patients were originally treated by interlocking nail, three were treated by plate and screws fixation, four treated conservatively and one had deformity secondary to fracture of a lengthening regenerate. All patients were treated by osteotomy and acute correction of the deformity using temporary unilateral fixator and internal fixation by a locking compression plate (LCP). The external fixator was removed at the end of surgery. The results were evaluated both clinically and radiologically. All osteotomies healed within 3 (2–4) months. All patients were able to work within an average of 2.3 months. The function of the upper ankle joint was unrestricted in twelve cases, and in 1 case there was a mild functional deficit. The mean follow-up was 60 months (24–120). The frontal plane alignment parameters (the mechanical axis deviation, the lateral distal tibial angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior proximal tibial angle and the anterior distal tibial angle) were within normal values postoperatively. No cases of deep infection or failure of fixation were encountered. Acute correction of distal tibial shaft hypertrophic nonunion with deformity and LCP fixation is a reliable option in well-selected cases.