AOFAS Ankle-hindfoot Score Research Articles

Is arthroscopic surgery as successful as open approach in the treatment of lateral ankle instability?

To evaluate the clinical results of arthroscopic repair and open Ahlgren-Larsson method in patients with chronic lateral ankle instability. We retrospectively evaluated 60 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS, and VAS scores. Sixty patients with chronic lateral ankle instability were evaluated. 28 patients were treated with Ahlgren-Larsson method, and 32 patients were treated with arthroscopic repair. Follow-up duration was 35 ± 12months for the open surgery group and 19 ± 2months for the arthroscopic surgery group. The mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, BMI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in VAS in terms of pain and patient satisfaction in favor of arthroscopy group. Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid. II.

SMOT with Medial Distraction Arthroplasty for Ankle Arthritis with Increased Talar Tilt: A Comparative Study

Category:Ankle ArthritisIntroduction/Purpose:An increased preoperative talar tilt (TT) angle was reported to be positively correlated with treatment failure after supramalleolar osteotomy (SMOT) for varus ankle osteoarthritis. Distraction arthroplasty was reported to have the ability to correct increased TT angles. The purpose of the current study was to compare the outcomes between SMOT with and without medial distraction arthroplasty (MDA) in the treatment of varus ankle osteoarthritis with increased TT angles.Methods:We retrospectively reviewed the functional outcomes and radiological findings of 56 patients who underwent SMOT with or without MDA for varus ankle osteoarthritis with increased TT angles. The AOFAS ankle-hindfoot score and AOS scores were used for functional evaluation. The tibial anterior surface (TAS) angle, talar tilt (TT) angle, tibial medial malleolar (TMM) angle, talocrural (TC) angle, tibial lateral surface (TLS) angle, and hindfoot alignment (HFA) angle were evaluated preoperatively and at the time of the last follow-up.Results:In the SMOT group, the AOFAS score and AOS pain and function scores were significantly improved (P <0.01 for each) at a mean follow-up of 67.5 months. The TAS, TT, TC, TLS, and HFA angles were all significantly improved (P <0.01 for each).Similarly, in the SMOT with MDA group, the AOFAS score, AOS pain and function scores, and the TAS, TT, TC, TLS, and HFA angles were all significantly improved postoperatively (P <0.01 for each) at a mean follow-up of 37.8 months. When comparing the two groups, the postoperative TT angle was significantly smaller in the SMOT with MDA group (P = 0.03) than in the SMOT group. In addition, the failure rate of TT angle correction was significantly higher in the SMOT group (P = 0.02) than in the SMOT with MDA group.Conclusion:SMOT is a promising procedure for functional improvement and malalignment correction for varus ankle osteoarthritis, even in patients with increased talar tilt. SMOT with MDA is a effective method to correct the varus ankle OA with increased talar tilt.

Management of early ankle osteoarthritis through anterior joint-preserving surgery: a retrospective evaluation at mid- to long-term follow-up.

Chronic anterior ankle pain is a recognized and straightforward characteristic of anterior impingement syndrome. This retrospective study aims to evaluate outcomes, clinical and radiological results in patients affected by anterior ankle impingement, in a context of early osteoarthritis, and treated with mini-open anterior ankle arthrolysis, in the perspective to delay or avoid other demolitive surgical options, such as total ankle replacement and joint fusion. In total, 49 patients (50 feet, mean age 45years) undergone mini-open anterior ankle arthrolysis for anterior impingement, fulfilled inclusion criteria and gave their consent and have been enlisted in the study. Patients were retrospectively reviewed with AOFAS ankle-hindfoot score and SF-36 score at a minimum follow-up of 36months. Statistical analysis was performed. A marked improvement was noticed in terms of preoperative clinical score (mean AOFAS score 47.32 ± 17.89) compared to follow-up clinical score (mean AOFAS score 70.66 ± 16.62; p < 0.005), and all of 8 SF-36 domains showed statistically improved (p < 0.05) from preoperative to follow-up. Statistical significance has been shown. It is possible to consider the mini-open anterior arthrolysis, thanks to the reduction of the painful symptomatology, a valid tool for procrastinating more invasive interventions such as arthrodesis or prosthetic replacement in patients with grade 1 or 2 of ankle osteoarthritis.

Mid-Term Outcomes of Bone Marrow Stimulation for Primary Osteochondral Lesions of the Talus: A Systematic Review

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Arthroscopic bone marrow stimulation (BMS) is the most common reparative surgical intervention in the treatment of small osteochondral lesions of the talus (OLT). BMS has shown favorable short term clinical outcomes but several recent studies have shown less satisfactory results in the mid- to long-term due to fibrocartilagenous repair tissue deterioration over time following BMS. However, conflicting results with good mid- to long-term outcomes following BMS have been reported. There is still a lack of evidence on the success rates of BMS at mid-term and longer-term follow-up. The purpose of this systematic review was to evaluate the clinical evidence of mid- to long-term outcomes following BMS for the treatment of OLT.Methods:A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Methodological quality of evidence was decifered using the Modified Coleman methodology score (MCMS). Studies reporting outcomes of BMS for primary ostechndral lesions at a minimum 4-year follow-up were included. Clinical outcomes, radiological outcomes, and reported data were evaluated.Results:Fifteen studies containing 853 patients (858 ankles) were included at a weighted-mean follow-up time of 71.9 (48-141) months. The mean age was 35.3 (24.7-41.9) and the mean lesion size was 110.5mm2 (87-140). Nine studies (60%) used the AOFAS ankle hindfoot score with a weighted-mean postoperative score of 89.9 (78.4-91.8). Six studies showed both pre and post-operative AOFAS scores and showed a weighted-mean improvement of 24.5 (16-38.5). Four studies utilised the VAS score. The weighted-mean postoperative VAS scores were 2.4 (1.8-2.6). Three studies (20%) measured post-opeartive MRI at mid-term using the MOCART score and showed 48% complete filling, 74% complete integration, 76% surface damage, and 78% inhomogeneous repair tissue. Complication rate was 3.2% and reoperation rate was 6% following BMS at mid-term.Conclusion:This systematic review found good clinical outcomes following BMS for primary OLT at mid-term follow-up based on the AOFAS score. The complication rates were relatively low and the data showed a reoperation rate of 6% at mid-term.However, the radiological and MRI outcomes did not show similarly positive results, which may lead to recurrence and reoperation at long-term. Data were variable and numerous aspects largely under-reported in the literature relevant to the systematic review. Further high quality studies, a validated outcome scoring system and further MRI reports are required to accurately assess the success of BMS at mid-term.

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BackgroundThe main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.MethodsFrom January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.Results27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49–119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7–7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0–11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9–10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).ConclusionsDespite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument

BackgroundThe aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors.Materials and methods118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined.ResultsHannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations.ConclusionsPercutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome.

Prospective Randomized Trial Comparing Mobile-bearing and Fixed-bearing Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: Outcomes of total ankle replacement for the treatment of end-stage ankle arthritis continue to improve. Debate continues whether a mobile-bearing total ankle replacement (MB-TAR) or a fixed-bearing total ankle replacement (FB-TAR) is superior, with successful outcomes reported longterm for MB-TAR and at intermediate-to-longterm follow-up for newer generation FB-TAR. Although comparisons between the two total ankle designs have been reported, to our knowledge, no investigation has compared the two designs with a high level of evidence. This prospective, randomized controlled trial conducted at a single institution compares patient satisfaction, functional outcomes and radiographic results of the mobile-bearing STAR and the fixed-bearing Salto-Talaris in the treatment of end-stage ankle arthritis. Methods: This investigation was approved by our institution’s IRB committee. Between November 2011 and November 2014, adult patients with end-stage ankle osteoarthritis failing nonoperative treatment were introduced to the study. With informed consent, 100 patients (31 male and 69 female, average age 65, range 35 to 85) were enrolled; demographic comparison between the two cohorts was similar. Exclusion criteria included inflammatory arthropathy, neuropathy, weight exceeding 250 pounds, radiographic coronal plane deformity greater than 15 degrees or extensive talar dome wear pattern (“flat top talus”). Prospective patient-reported outcomes, physical exam and standardized weightbearing ankle radiographs were obtained preoperatively, at 6 and 12 months postoperatively, and then at yearly intervals. Data collection included visual analog pain score (VAS), short form 36 (SF-36), foot and ankle disability index (FADI), short musculoskeletal functional assessment (SMFA) and AOFAS ankle-hindfoot score. Surgeries were performed by non-design team orthopaedic foot and ankle specialists with total ankle replacement expertise. Statistically analysis was performed by a qualified statistician. Results: At average follow-up of 4.5 years (range 2-6 years) complete clinical data and radiographs were available for 84 patients; 7 had incomplete data, one had died, 4 were withdrawn after enrolling but prior to surgery and 4 were lost to follow-up. In all outcome measures, the entire cohort demonstrated statistically significant improvements from preoperative evaluation to most recent follow-up. There was no statistically significant difference in improvement in clinical outcomes between the two groups. Radiographically, tibial lucency/cyst formation was 26.8% and 20.9% for MB-TAR and FB-TAR, respectively. Tibial settling/subsidence occurred in 7.3% of MB-TAR. Talar lucency/cyst formation occurred in 24.3% and 2.0% of MB-TAR and FB-TAR, respectively. Talar subsidence was observed in 21.9% and 2.0% of MB-TAR and FB-TAR, respectively. Re-operations were performed in 8 MB-TAR and 3 FB-TAR, with the majority of procedures being to relieve impingement or treat cysts and not to revise or remove metal implants. Conclusion: For the first time, with a high level of evidence, our study confirms that patient reported and clinical outcomes are favorable for both designs and that there is no significant difference in clinical improvement between the two implants. The incidence of lucency/cyst formation was similar for MB-TAR and FB-TAR for the tibial component, but the MB-TAR had greater talar lucency/cyst formation and tibial and talar subsidence. As has been suggested in previous studies, clinical outcomes do not correlate with radiographic findings. Re-operations were more common for MB-TAR and in the majority of cases were to relieve impingement or treat cysts rather than revise or remove metal implants.

Conversion of Ankle Fusions to Ankle Replacements

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis remains a prominent treatment choice for ankle arthritis in a majority of patients. Long term studies have shown a compensatory development of ipsilateral adjacent joint arthritis after ankle arthrodesis, and some patients who receive an ankle arthrodesis develop pain in surrounding joints, or even at the fusion site. As total ankle arthroplasty (TAA) design, instrumentation, and techniques have improved, the use of total ankle arthroplasty has become more widespread. Very few studies have been published on conversion of ankle arthrodesis to ankle arthroplasty, but they have shown improved function and patient-related outcome scores. The purpose of this study was to assess the radiographic, clinical, and patient-reported outcomes of patients undergoing ankle arthroplasty after conversion from a CT-confirmed ankle arthrodesis. Methods: This was a retrospective cohort study of patients with previous CT-confirmed ankle arthrodesis who underwent conversion to total ankle arthroplasty. Minimum follow up was 1 year. Nonunions of ankle arthrodesis were excluded. AOFAS ankle-hindfoot score, foot function index (FFI), pain, revision surgeries, complications, and patient demographics were assessed. Radiographs prior to TAA, and at latest follow-up were also reviewed. Results: 10 patients were included in the study with an average age of 54.5 years. No implants had to be revised. 1/10 (10%) patients had to undergo secondary surgery for heterotopic ossification removal. The same patient had to undergo another subsequent surgery for posterior ankle decompression. 2/10 (20%) patients had a mild talar subsidence of the TAA at latest follow-up, with no patients having tibial subsidence. Talar osteolysis was noticed in 2 patients (20%) at latest follow-up, with no patients having tibial osteolysis. Only one patient (10%) was noted to have a mild valgus alignment of TAA with no varus malalignments. All radiographic changes noted were clinically asymptomatic. The average AOFAS total score was 58 (range 23,89). The mean FFI total score was 41.9 (range 0,90). Conclusion: Conversion of ankle fusion to TAA is a challenging operation but can be a viable option for patients with ongoing pain after an ankle arthrodesis. We noted low revision rates and few complications at 1 year.

Primary Arthrodesis Compared with Open Reduction and Internal Fixation for Lisfranc Injuries with the First Tarsometatarsal Joint Dislocation

Category: Trauma Introduction/Purpose: The first tarsometatarsal (TMT) joint is very crucial for midfoot stability. To address its importance, retrospective analyses of treatment for the first TMT joint dislocation with Lisfranc injury was performed in a multi-center manner. Comparison of open reduction internal fixation (ORIF) and primary arthrodesis was conducted for the injury. Methods: This multi-center study was involved ten clinical institutions in different area of China. .From January 2003 to June 2015, 126 Lisfranc injuries with first TMT joint dislocation underwent surgical intervention. Of this group, forty one (32.5%) feet were first TMT joint dislocation only. Eighty five feet were first TMT joint dislocation and fractures. They were 76 males (60.3%) and 50 females (39.7%) with a mean age of 45.5 (range, 20-87) years. The duration from injury to surgery is 11.7 (range, 4-26) days. Two groups were divided by surgery methods as open reduction internal fixation (ORIF) group and primary arthrodesis group. Ninety two patients were performed by ORIF, while primary arthrodesis group including 34 cases. Outcome measures included clinical examination, radiographs, AOFAS ankle-hindfoot scores, visual analogue scale (VAS) and SF-36 scores. Complications and revision rate were analyzed as well. Results: 126 patients were followed up for 29.5 months. At 1.5 years postoperatively, the AOFAS score was 79 and 85 in ORIF group and arthrodesis group.The VAS score was 3.1 separately in two groups.The mean Physical Functioning sores of SF-36 was 80.3 points and 83.5• points. The Bodily Pain score of SF-36 was 76.1 points and 84.6• points.Redislocation of first tarsometarsal joint were observed in 16 cases among ORIF group.36 patients in ORIF group had pain in midfoot, eight of them had persistent pain with the development of deformity or osteoarthrosis.No redislocation and no hardware failure was identified in arthrodesis group Conclusion: Primary stable arthrodesis of the first ray gives a better short and medium term outcome than open reduction and internal fixation for Lisfranc injury with the first ray dislocation. Possible complication and revision could be avoided by primary arthrodesis for dislocated first ray injuries.

Comparison of the period of return to practice in All-Inside Arthroscopic and Open Techniques for the Modified Broström Procedure for Ankle Instability

Category: Arthroscopy Introduction/Purpose: Lateral ankle instability (LAI) is common injury in general population and open modified Broström operation (OMBO) is standard treatment of lateral ankle instability. Recently arthroscopic modified Broström operation (AMBO) is performed and many studies show that there are no difference in clinical &amp; radiologic outcomes between open and arthroscopic operation. But not previously reported, comparison between OMBO and AMBO with the period of return to practice. The purpose of this study is to evaluate the time of return to practice in patients with clinical functional outcomes. Methods: From January 2012. to July 2014. 60 patients were included. They were divided into 2 groups: AMBO (30 patients) and OMBO (30 patients.). All patients followed a standardized treatment and rehabilitation program. We measured the period of return to practice by 7 Questions asked in each groups to compare period of return to practice. Survey is consisted of about time of walking, running, jumping, squatting, climbing stairs, rising up heels and toes without pain. And we also compared the time from the symptom of instability onset to date of operation. And for clinical outcome, evaluations were performed preoperatively, postoperatively, and 6months postoperatively using the AOFAS ankle-hindfoot score, pain VAS score and subjective satisfaction for rehabilitation, activity level of patients. Results: For comparison of the dates of operation, the average period of AMBO was faster (6.37±3.378 weeks) than OMBO (14.47±5.794 weeks). And for return to practice, AMBO showed faster return to practice (7.07±2.96 weeks) in walking without pain than OMBO (11.03±8.58 weeks). And other survey showed no difference in period of return to practice between OMBO and AMBO. There were no difference in postoperatively 6 month AOFAS and VAS score, but postoperatively VAS score showed significantly lower in AMBO than OMBO. AMBO was found to be faster return to practice in 2 out of 7 questions in high physical activity group, and also subjective satisfaction rate for rehabilitation of AMBO was higher than OMBO. Conclusion: For general population, except walking, there was no difference in the period of return to practice and clinical outcomes between the AMBO and OMBO for the treatment of lateral ankle instability. However, this study showed that AMBO was able to receive the surgery more quickly than OMBO. and AMBO can be a treatment option and should be considered carefully in atheletes who have lateral ankle instability that AMBO showed good results in higher activity level group for period of return to practice, subjective satisfaction, lower postoperatively pain.

Early Functional, Radiological Outcomes and Satisfaction Rates of Total Ankle Arthroplasty in an Asian Population.

Few studies have outlined the outcomes and complications in Asians undergoing total ankle arthroplasty. This study reports the functional, radiological outcomes and satisfaction rates in our Asian population. Patients who underwent primary total ankle arthroplasty from 2007 to 2013 were recruited. Outcomes evaluated were the AOFAS Ankle-Hindfoot Score (AHS), Visual Analogue Scale (VAS), and the Short Form 36 (SF-36)questionnaire. Outcome scores were collected prospectively up to 2 years. Patient satisfaction was evaluated on a 6-point scale based on North American Spine Society Low Back Pain Instrument and classified as satisfied or unsatisfied. Forty-one patients underwent primary total ankle arthroplasty. All patients experienced improvements in AHS, VAS, and Mental Component Summary score of the SF-36 at both 6-month and 2-year postoperative interval. The mean AHS score improved from 35 ± 19 points preoperatively to 64 ± 24 at 6 months (P<.001) and 72 ± 26 at 24 months (P <.001). VAS scores improved from 7 ± 2 preoperatively to 3 ± 3 (P < .001) at 6 and 24 months. The Physical Component Summary (PCS) of the SF-36 has an established minimum clinically important difference (MCID) of 5. The mean improvement in PCS in our cohort met this MCID for the PCS; 63% and 71% of patients were satisfied with the procedure at 6 months and 2 years postoperatively, respectively. Revision rate in this series was 9.7%. Total ankle arthroplasty has good patient satisfaction rates, with favorable early clinical outcome in Asian patients. Therapeutic, Level II.

Primary Arthrodesis Compared with Open Reduction and Internal Fixation for Lisfranc Injuries with the First Tarsometatarsal Joint Dislocation

Category: Midfoot/Forefoot Introduction/Purpose: Retrospective analyses of treatment for the first tarsometatarsal joint dislocation with Lisfranc injury. Comparison of open reduction internal fixation (ORIF) and primary arthrodesis was conducted for the injury. Methods: This was a multi-center study, involving nine clinical institutions in different area of China. .From January 2003 to June 2015, 126 Lisfranc injuries with first tarsometatarsal joint dislocation underwent surgical intervention. Of this group, 41 (32.5%) feet were first tarsometarsal joint dislocation only. 85 feet were first tarsometarsal joint dislocation and fractures. They were 76 males (60.3%) and 50 females (39.7%) with a mean age of 45.5 (range, 20-87) years. The duration from injury to surgery is 11.7 (range, 4-26) days. Two groups were divided by surgery methods as open reduction internal fixation (ORIF) group and primary arthrodesis group. Ninety two patients were performed by ORIF, while primary arthrodesis group including 34 cases. Outcome measures included clinical examination, radiographs, AOFAS ankle-hindfoot scores, visual analogue scale (VAS) and SF-36 scores. Complications and revision rate were analyzed as well. Results: 126 patients were followed up for average of 29.5 months．At 1.5 years, the mean AOFAS Midfoot score at latest follow-up was 79 points and 85 points separately in ORIF and arthrodesis group（P&lt;0.05）. The VAS score was 3.1and 2.2 separately（P&lt;0.05）.The BP score of SF-36 was 76.1 points and 84.6 points（P&lt;0.05). Five patients in the open-reduction group had loosen or broken hardware. Redislocation of first tarsometarsal joint were observed in 16 cases among ORIF group. 36patients in ORIF group had pain in midfoot, eight of them had persistent pain, and they were eventually revised with arthrodesis. Two patients had painful hardware and the symptom disappeared after removal of the hardware. No redislocation and no hardware failure was identified in arthrodesis group. Conclusion: Primary stable arthrodesis of the first ray gives a better short and medium term outcome than open reduction and internal fixation for Lisfranc injury with the first ray dislocation. Possible complication and revision could be avoided by primary arthrodesis for dislocated first ray injuries.

Prospective, Double Blind Randomized Controlled Trial on the Use of Immediate Post-Operative Electrical Muscle Stimulation to Preserve Muscle Function and Volume Following Achilles Tendon Surgery

Category: Ankle Introduction/Purpose: Post-surgical muscle atrophy is common after Achilles tendon repair and immobilization. Muscle atrophy takes significant rehabilitation effort and time to recover, sometimes never returning to pre-operative level. Neuromuscular stimulation has been shown to improve pain and accelerate recovery following orthopedic surgery. The mechanism of this effect has not yet been elucidated. We theorized that muscle atrophy was a critical link to positive patient outcomes and that NMES could be achieving its effect by a muscle volume preserving mechanism. It was theorized that electrical muscle stimulation used immediately after surgery and through the course of immobilization could mitigate calf muscle atrophy, improve post-operative patient reported scores, and perhaps speed functional recovery of Achilles tendon repairs. Methods: This was an IRB approved prospective, double blind randomized controlled trial with 40 patients. Pre-operative and post-operative measurements of calf circumference, Focus on Therapeutic Outcomes (FOTO) Score, and AOFAS ankle-hindfoot score were measured. All subjects had MRI scans pre-operative and at post-operative weeks 2 and 6 to measure cross sectional muscle volumes. A four lead NMES device was applied in a standardized fashion at time of surgery with both patient and surgeon blinded to activity of the device (20 active, 20 ‘sham’). All patients followed a standardized post-operative protocol. Chi-square test was used for categorical variables and two-sample t-tests for continuous variables. Linear mixed models were used to compare changes in muscle cross sectional area and clinical outcomes of interest over time between the groups. Statistical significance was set at p&lt;0.05 for all tests. The study was powered at 80%. Results: There were 40 subjects with a mean age and BMI of 48.9 years and 32.2, respectively. There were no differences in demographic characteristics or pre-operative scores between groups. The active treatment group trended toward higher FOTO and AOFAS scores at post-operative weeks 2 and 6, though not statistically significant, and both groups were similar at 12 weeks. Volumetric MRI measurements trended toward less muscle loss in the active treatment group at 6 weeks post-operative, but failed to reach statistical significance. Calf circumference measurements were not different between groups at any post-operative interval. Both groups used the devices similarly, but there was a 6.4% incidence of stimulator use on an incorrect setting (8% in active, 5% in sham), which was statistically significant (p&lt;0.001). Conclusion: This prospective RCT was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy. No statistically significant difference was found between active NMES and sham treated patients. There was a trend showing some maintenance of calf volume per MRI. It is possible the reported beneficial effect of NMES is due to an induced cortical plasticity that would be manifest later in the rehabilitation cycle and is not due to a size preserving effect alone. Neuromuscular stimulation does not improve muscle volume or patient reported functional outcomes when used for 6 weeks following Achilles tendon surgery.

Second-Look Arthroscopic Evaluation and Clinical Outcome after the Supramalleolar Osteotomy for the Medial Compartment Ankle Osteoarthritis

Category: Ankle, Ankle Arthritis, Arthroscopy, Hindfoot Introduction/Purpose: This study aimed to evaluate the clinical and radiological outcomes of asymmetric ankle osteoarthritis after supramalleolar osteotomy (SMO) without BMSP(bone marrow stimulation procedure) and confirm cartilage recovery by second look arthroscopy. The hypothesis was that SMO without BMSP for medial compartment ankle osteoarthritis would show tibio-talar articular cartilage regeneration in the medial compartment, as well as satisfactory clinical and radiological outcomes. Methods: We retrospectively reviewed 20 ankles of 18 consecutive patients who were followed up for over 1 year after SMO from August 2007 to February 2013. Visual analog scale (VAS) pain scores and the AOFAS ankle-hindfoot scores were used for the functional evaluations. The tibial anterior surface angles and the tibial lateral surface angles were measured on radiographs, and the ankle osteoarthritis was classified by the Takakura stage. Among the 20cases, 19 caseshad ankle arthroscopy performedprior to SMO, and second-look ankle arthroscopywas performed in 14 cases at postoperative 1 year. Tibio-talarcartilage regeneration was evaluatedaccording to the modified Outerbridge classification for the 12 cases that had undergone SMO without a bone marrow–stimulating procedure (BMSP). Results: The mean VAS and AOFAS scores significantly improved from 6.7 preoperatively to 1.2 postoperatively and from 60.9 preoperatively to 87.9 postoperatively, respectively (P&lt;0.05). The mean TAS and TLS angles significantly improved from 83.5? and 76.5preoperatively to 94.4? and 80.3? postoperatively respectively (P&lt;0.05). All preoperative TakakurastageIIIa cases and 1 case of preoperative stage IIIb improved to postoperative stage II. At 2nd look arthroscopy, articular cartilage regeneration of the medial compartment of the tibio-talar joint was observed in 10 of 12 cases (83%), whereas cartilage deterioration was not observed in any case.Cartilage grading, however, did not show correlations with clinical outcomes. Conclusion: SMO without BMSP for medial compartment ankle osteoarthritis demonstrated marked tibio-talar articular cartilage regeneration in the medial compartment (83%) by second look arthroscopy, as well as satisfactory clinical and radiological outcomes.

Mid-term (5-10 year) Results of the Salto Talaris Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: The Salto Talaris total ankle replacement is a modern fixed-bearing implant used to treat symptomatic ankle arthritis with the goals of providing pain relief, restoring mechanical alignment, and allowing motion of the ankle joint. This prosthesis has been used in the United States increasingly over the last 10 years, primarily for older patients with end-stage ankle arthritis but indications are expanding to younger and more active patients. The goal of this study is to report the midterm clinical results of one of the largest cohort of patients in the United States who underwent ankle replacement with this prosthesis. Methods: This is a review of patients with a minimum of 5-year up to 10-year follow-up who were prospectively registered within our institutional database prior to proceeding with total ankle arthroplasty using the Salto Talaris prosthesis. Follow-up examinations were scheduled annually after the one-year postoperative mark to evaluate patients both clinically and radiographically. At each annual assessment, patients rated their current level of pain using the visual analog score (VAS) and reported their functional level using the American Orthopaedic Foot and Ankle (AOFAS) ankle-hindfoot scores, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health survey. These scores were analyzed to assess differences between their levels preoperatively, one year postoperatively and at their most recent follow-up. Preoperative and postoperative radiographs were reviewed for component loosening. Criteria for failure was defined as undergoing revision requiring exchange or removal of the metallic components for any reason. Results: We identified 106 patients who had a Salto Talaris total ankle replacement between March 2007 and February 2012. Of these, 72 patients (mean age, 61.9 years) met the requirement for a minimum follow-up of 5 years (range 60 to 115 months, mean 81.1 months). Average outcome in the VAS was 7.1 at one year post-op and 11.7 at last follow-up (preop: 70.0). Significant improvements were seen in the SMFA, AOFAS ankle-hindfoot score, and the SF-36 from preoperatively to their final follow-up. Survivorship was 97.2% with two patients undergoing revision arthroplasty for aseptic loosening and a third patient scheduled for revision for a chronic wound infection. 14 patients (19%) with midterm follow-up required a total of 17 additional surgical procedures on the ipsilateral ankle or hindfoot. Conclusion: Patients who underwent total ankle arthroplasty with the Salto Talaris prosthesis have continued to show significant improvements in pain and functional outcomes at mid-term follow-up. This has shown to be an effective treatment option with durable results for patients with end-stage ankle arthritis.

Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up.

Although platelet-rich plasma (PRP) injection has shown controversial results for the treatment of Achilles tendinopathy, it remains the most used biological treatment. Recent findings seem to demonstrate that the stromal vascular fraction (SVF) within adipose tissue may counteract the impaired tendon homeostasis. The aim of this study was to prospectively compare the efficacy of PRP and SVF injection for the treatment of non-insertional Achilles tendinopathy. Fourty-four patients were recruited in the study; 23 of them were assigned to the PRP group whereas 21 to the SVF group, treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18-55years) were clinically assessed pre-operatively and at 15, 30, 60, 120 and 180days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after 4 (US only) and 6months. Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A scored significantly better at 15 and 30days in the SVF in comparison to PRP group (p < 0.05). At the following time points the scores were not significantly different between the two groups. No correlation has been found between clinical and radiological findings. Both PRP and SVF were safe, effective treatments for recalcitrant Achilles tendinopathy. The patients treated with SVF obtained faster results, thus suggesting that such a treatment should be taken into consideration for those patients who require an earlier return to daily activities or sport. Randomized Controlled Clinical Trial, Level 1.

Subtalar arthroscopy and fluoroscopy in percutaneous fixation of intra-articular calcaneal fractures.

Percutaneous fixation of intra-articular calcaneal fractures is traditionally assisted only by intraoperative fluoroscopy. Previous studies have demonstrated that the additional use of subtalar arthroscopy in anatomical reduction of the posterior calcaneal facet of the subtalar joint for less complex calcaneal fractures yielded positive results up to 2-year follow-up. This study aims to investigate long-term outcomes of these patients using similar evaluation parameters. We hypothesized that this novel technique with dual-imaging can provide sustainable, long-term benefits with good functional outcomes and significant restoration of the Bohler's angle. We performed a retrospective study of 15 Sanders II, AO-OTA 83-C2 intra-articular calcaneal fractures in 14 patients who underwent subtalar arthroscopy and fluoroscopy guided percutaneous fracture fixation with a minimum follow-up of 5 years. Outcome measures were assessed using the ankle and hindfoot NPRS, AOFAS ankle-hindfoot score, and SF-36 Physical Function subscale preoperatively and at 3 months, 6 months, 1 year, 2 years and 5-8 years postoperatively. The Bohler's angle was measured preoperatively, immediately postoperatively and at 5-8 years postoperatively. We report excellent functional outcomes in all scores as well as continued improvements in the majority of patients across all time points with minimal subsidence of the corrected Bohler's angle over our study time frame. Subtalar arthroscopy with intraoperative fluoroscopy in anatomical reduction of the posterior calcaneal facet of the subtalar joint is most useful in Sanders type II, AO-OTA 83-C2 fractures with excellent functional outcomes and good preservation of the corrected Bohler's angle on long-term follow-up.

Three dimensional morphological evaluation of calcaneal fracture malunionand its clinical relevance

Objective To analyze 3D morphological evaluation of calcaneal fracture malunion based on CT post-processing techniques. Methods Eighteen patients with 19 calcaneal fracture malunion treated in our hospital from May 2010 to June 2015 were analyzed. The average age was 43.3 years (range, 23 to 62 years). There were 12 males (13 feet) and 6 females(6 feet). According to Stephens-Sanders classification, 3 feet were of type Ⅰ, 7 feet type Ⅱ and 9 feet type Ⅲ. Depending on the type of malunion and the preoperative evaluation of 3D morphology, the operation for the calcaneal fracture malunion was performed. The 3D structure of the calcaneus after shaded surface display reconstruction was extracted by interactive and automatic segmentation. The morphological measurements were achieved by means of a 3D measurement method. The data were analyzed using SPSS 18.0 software. The quantitative data were compared by paired t test. Results Making the telephone appointment for outpatient follow-up, all patients were followed up with an average time of 19.1 months. The mean AOFAS ankle-hindfoot score increased from (31.4 ± 6.1) point operatively to (77.4 ± 7.6) at final follow-up. The length of the calcaneal axis, the height of the posterior facet and the length of the posterior facet at final follow-up were significantly restored than those before operation (P<0.001). The mean Bohler′s angle and the mean Gissane′s angle were improved from (17.5° ± 5.6°) and (96.6° ± 9.9°) before operation to (34.2° ± 3.2°) and (124.1° ± 8.9°) at final follow-up respectively (P<0.001). Conclusion Three dimensional morphological evaluation of calcaneus was useful to access the postoperative outcome for calcaneal fracture malunion. The current data will be helpfulfor the reduction of calcaneal malunion. Key words: Calcaneus; Fracture, malunited; Image processing, computer-assisted; Imaging, three-dimensional

Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail with a valgus curve

Objective To investigate the clinical effects of tibiotalocalcaneal arthrodesis (TTCA) using a retrograde intramedullary nail with a valgus curve. Methods At our department, 22 patients underwent TTCA using a retrograde intramedullary nail with a valgus curve from June 2009 to January 2014 and were available for complete follow-up. They were 12 men and 10 women, aged from 46 to 79 years (average, 62.2 years). There were 3 cases of primary ankle osteoarthritis, 9 ones of traumatic arthritis, one of ankle arthritis secondary to severe talar avascular necrosis, 3 ones of progressive subtalar arthritis following failed ankle replacement, 5 ones of progressive subtalar arthritis following failed ankle arthrodesis, and one of arthritis secondary to equinovarus. The outcome measurements included the American Foot and Ankle Society (AOFAS) ankle-hindfoot scale, EQ-5DTM functional score, radiologic assessment and clinical examination. Results The mean follow-up was 21.3 months (range, from 14 to 38 months). A plantigrade foot and bony union were achieved in all the patients after a mean time of 3.9 months (range, from 2.4 to 6.2 months). Postoperative radiologic results showed a good hindfoot alignment in all the patients. Superficial infection oc-curred in one patient and loosening of the distal screw in another who asked for removal. The mean postop-erative EQ-5DTM functional score and AOFAS ankle-hindfoot score were 69.3 (range, from 20 to 90) and 69.9 (range, from 45 to 85), respectively. Conclusion TTCA using a retrograde curved intramedullary nail may lead to solid fusion and good hindfoot alignment. Key words: Foot deformities; Arthrodesis; Bone nail; Arthritis

Is Syndesmotic Screw Removal Needed Before Weight-Bearing Ambulation?

Category: Trauma Introduction/Purpose: In syndesmosis injury, numerous clinical and biomechanical investigations showed some concensus as follows; 1)There are no difference in stainless steel versus titanium screws. 2)A 4.5-mm screw apparently provides greater resistance to shear stress than a 3.5-mm screw. 3)The level of placement probably does not affect outcome. 4)Three-cortical versus four-cortical screw placement does not affect biomechanical stability. But, whether the syndesmosis screw should be removed prior to weight-bearing or not is still debated. The aim of this study is to compare the functional outcome between screw removal and retain group, and between diastasis and no diastasis group. Methods: One hundred twelve patients had undertaken open reduction and internal fixation due to syndesmosis injury, who divided into 4 groups; (A) syndesmotic screw removal before weight-bearing (postoperative 3 months, n=56) and (B) retained group (n=56), (C) recurrence of diastasis (n=16) and (D) no diastasis (n=40) after screw removal. Radiological diastasis, VAS, AOFAS ankle-hindfoot score, SF-12, complications (screw loosening and breakage) were evaluated between groups. Results: AOFAS ankle-hindfoot score shows 75.10±10.40 in group A, 77.07±10.60 in group B, and SF12 shows 45.78±5.68 in group A, 47.33±5.83 in group B, there is no significant difference between group A and B in AOFAS ankle-hindfoot score and SF- 12 (p=0.487, p=0.319). Radiological diastasis significantly develops (p=0.025) in group A (16/56) compare to B (2/56), but screw loosening or breakage significantly develops (p=0.001) in group B (8/56) compare to group A (0/56). AOFAS ankle-hindfoot score shows 70.33±6.22 in group C, 76.50±10.26 in group D, and SF12 shows 49.85±3.83 in group C, 47.40±8.01 in group D, there is no significant difference between group C and D in AOFAS ankle-hindfoot score and SF-12 (p=0.808, p=0.065). There is no significant difference between group C and D B in VAS, AOFAS ankle-hindfoot score and SF-12. Conclusion: Diastasis recurrence is significantly higher in removal group. But, screw retain group shows higher breakage, loosening rate than removal group. Clinical outcome such as VAS, AOFAS ankle-hindfoot score and SF-12 is no significant different in two groups.Also, if diastasis recurred, it did not affect clinical outcome. Therefore, we couldn’t conclude that syndesmotic screw removal is needed before weight-bearing (postoperaive 3 months).