AOFAS Hindfoot Score Research Articles

Poor osteochondral repair by a biomimetic collagen scaffold: 1- to 3-year clinical and radiological follow-up.

Treatment of osteochondral injuries is challenging, and no gold standard has been established. Layered cell-free scaffolds are a new treatment option for these defects. The aim of this study was to evaluate the osteochondral repair in patients treated with the MaioRegen(®) scaffold, a cell-free biomimetic scaffold consisting of type I collagen and hydroxyapatite. Treatment using this scaffold has previously shown promising clinical results. Ten patients with osteochondral lesions in the knee (n=6) or in the talus (n=4) were enrolled. The patients underwent pre-operative MRI and CT scans and were assessed at 1- and 2.5-year timescales post-operatively. The cartilage and bone formations were evaluated semi-quantitatively using the MOCART score. Knee patients were clinically evaluated using KOOS, subjective IKDC and Tegner scores, whereas ankle patients were evaluated using AOFAS Hindfoot and Tegner scores. Two patients were re-operated and excluded from further follow-up due to treatment failure. None of the patients had complete regeneration of the subchondral bone evaluated using CT. At 2.5years, 6/8 patients had no or very limited (<10%) bone formation in the defects and 2/8 had 50-75% bone formation in the treated defect. MRI showed no improvement in the MOCART score at any time point. The IKDC score improved from 41.3 to 80.7, and the KOOS pain subscale improved from 63.8 to 90.8 at 2.5-year follow-up. No improvement was found with the remaining KOOS subscales, the Tegner or AOFAS Ankle-Hindfoot score. Treatment of osteochondral defects in the ankle and knee joint with a biomimetic scaffold resulted in incomplete cartilage repair and poor subchondral bone repair at 1- and 2.5-year follow-up. Clinical significant improvements were observed. These results raise serious concerns about the biological repair potential of the MaioRegen(®) scaffold, and we advise to use the MaioRegen(®) scaffold with caution. Prospective therapeutic study, Level IV.

Achilles Tendon Open Repair Augmented with Volar Turndown Tendon Flap and Deep Posterior Crural Fasciotomy

Objectives:The aim of the study was to investigate the outcomes after open repair of Achilles tendon rupture with augmented volar turndown gastrocnemius flap and deep posterior crural fasciotomy.Methods:Twenty-three (22male/1female) patients with acute Achilles tendon injury were operated. Open end to end repair and augmentation with a volar turndown gastrocnemius flap and fasciotomy of the deep posterior compartment was performed in each patient. Home physiotherapy program was instructed for each patient. Muscle strength, balance and jump performance were assessed.Results:All patients returned to their preinjury activity level and repairs healed without any major complication. One patient had serous drainage who did not require surgical intervention (4,3%). There was no significant difference between involved and uninvolved leg in terms of concentric and eccentric muscle strength (p=0.82 and p=0.53, respectively). In Y balance test, there was no significant difference between involved and uninvolved legs in anterior (p=0.06), posteromedial (p=0.97) and posterolateral (p=1.00). In addition, there were no significant differences between leg in vertical jump (p=0.16) and one leg hop (p=0.15) tests. AOFAS Hindfoot score was 98.6±2.3 (93-100).Conclusion:Open end to end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complication. Fasciotomy of the deep posterior compartment decreased the tension at the skin repair site while decompressing the supeficial compartment anteriorly. Additionally, the augmented bulky repair construct of the Achilles tendon cambered volarly through the deep posterior compartment and decreased irritation sense during and after tendon healing.

Clinical and MRI results after microfracture of osteochondral lesions of the talus

Arthroscopic microfracture (AM) of osteochondral lesions of the talus is used to induce intrinsic refilling of the defect and reduce pain. The aim of this retrospective study was to investigate the clinical state after AM and the MRI outcome. A total of 22 patients [10 women, 12 men, 31years old (mean, 13-68 range)] treated for osteochondral lesions of the talus by AM were examined 2years (median) postoperatively and pre- and postoperative MRI results compared. Swelling/effusion, articular constriction, joint pain, and range of motion restriction were documented. Clinical state was evaluated using the AOFAS hindfoot score. MRI was used to assess the size of the defect, presence of bone marrow edema, cysts and effusion, thickness of repair tissue, and integrity of the cartilage. In all but six cases, the defect was located at the medial shoulder of the talus. The postoperative AOFAS score at follow-up was 87.5points (median 36-100points range). Seven patients were free of pain, 11 had "mild, occasional" pain, 1 "moderate daily", and 3 "severe, almost always present" pain (AOFAS). The defect volume was significantly reduced from 377mm(3) preoperatively (median, interquartile distance: 417mm(3)) to 249mm(3) postoperatively (median, IQD: 336mm(3), p=0.019, Wilcoxon). In 7 cases, the defect was completely filled, in 11 partially and in 4 only slightly. After AM of osteochondral lesions of the talus, 18 of 22 patients had no or mild, occasional pain at 2years follow-up. On MRI, the lesion volume had been reduced and filling with repair tissue was found.

Minimal-invasive Osteosynthese von Kalkaneusfrakturen

Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration. Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders typeII, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients. Impossible percutaneous reduction and fixation. Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously. Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day2, patients are mobilized with partial weight bearing for 6-8weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes. Between 1998 and 2008, 68patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37patients with intraarticular fractures (Sanders typesIIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2years postoperatively, the average was 5years postoperatively. Subjectively, 33 of 35patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64-100) at a mean of 5years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.

Changes in Pain, Function, and Gait Mechanics Two Years following Total Ankle Arthroplasty Performed with Two Modern Fixed-Bearing Prostheses

Total ankle replacement (TAR) continues to grow as an alternative to arthrodesis for patients who suffer from end-stage ankle arthritis. The purpose of this study was to examine changes in gait mechanics from before surgery to 1 and 2 years after surgery in patients who received a fixed-bearing TAR. Fifty-one patients with a primary fixed-bearing TAR and no complications requiring further surgery were identified from a database and enrolled in this non-randomized study. Subjects were examined preoperatively, and at 1 and 2 years postoperatively. Three-dimensional joint mechanics and ground reaction forces (GRF) were collected during level walking. The Four Square Step Test, Timed Up and Go (TUG), VAS, and the AOFAS-Hindfoot score were assessed for each subject at each time point. TUG, VAS and AOFAS-Hindfoot score along with all measured kinetic parameters demonstrated significant improvements across all of the time points (p < 0.05). Four Square Step Test time was significantly improved between the preoperative and 2-year postoperative time point (p < 0.05). Measured ankle dorsiflexion angles did not demonstrate significant change between any time points. All of the observed changes suggest improved or maintained functioning in patients who received a TAR with the greatest improvement occurring within the first year. Sagittal plane ankle range of motion and dorsiflexion angle at heel strike were unchanged across all of the time points. The results of this study indicate that patients with end-stage osteoarthritis demonstrate improvements in pain and gait up to 2 years following surgery while maintaining ankle range of motion.

Tibiotalocalcaneal Arthrodesis with lateral compression Plate

OBJECTIVE: The objective of this study was to evaluate the short-term clinical and radiographic results from a TTC fusion procedure using a lateral locking plate specifically designed for this purpose. METHODS: All the fourteen patients were evaluated using a variety of methods, including a visual analogue scale (VAS), the AOFAS hindfoot score and a subjective satisfaction scale. The average follow-up was 10 months. RESULTS: The average AOFAS score improved from 41 points preoperatively to 63 points postoperatively. The VAS pain score decreased from 7 to 3 points. Four patients reported excellent results, eight good, one fair and one poor. CONCLUSION: Our study provides support for using a specially designed plate for TTC fusion in hindfoot salvage surgery.

Combined Medial and Lateral Anatomic Ligament Reconstruction for Chronic Rotational Instability of the Ankle

This study aimed to extend knowledge on the arthroscopic evaluation of the unstable ankle joint and the outcome of ligament reconstruction on rotational instability. In contrast to previous studies, we investigated the combined repair of lateral and medial ligaments. Ninety-six patients underwent medial and lateral ligament reconstruction between 2006 and 2008, 81 of whom, with a mean age of 31.9 (range, 14 to 44) years, completed the 12-month followup and were therefore included in this study (Table 1). Clinical, radiographic, and concomitant arthroscopic examination was performed prior to the ligament stabilization. Postoperative followup included clinical and radiographic evaluation after 3, 6, and 12 months. Arthroscopy showed a lesion of the anterior fibulotalar ligament (AFTL), calcaneofibular ligament (CFL), and tibiocalcanear ligament (TCL) (Deep part of deltoid ligament complex) in 67 patients. An avulsion of the proximal insertion point of the ATTL was additionally found in 14 cases. Clinical results 3 months after surgery showed a significant increase in the AOFAS-Hindfoot Score as well as a significant decrease of the Visual Analogue-Scale for pain (VAS) (p < 0.0001). This outcome persisted at the 12-month examination. Rotational instability of the ankle joint in most cases has an injury of the lateral ligaments and a component of the deltoid, the TCL, but rarely with a combined lesion of the TCL and the anterior tibiotalar ligament (ATTL) (Superficial part of deltoid ligament complex). The combined lateral and medial ligament reconstruction with an anchor technique had a good clinical outcome with high patient satisfaction with few complications.

Long-Term Clinical Outcomes Following the Central Incision Technique for Insertional Achilles Tendinopathy

The central incision technique, more than any other exposure, allows for optimal access to the diseased Achilles tendon as well as the Haglund's prominence and the retro calcaneal bursa. We hypothesized that the central incision technique would be an effective, well-tolerated surgical incision for the surgical treatment of insertional Achilles tendinopathy with minimal to no loss of plantarflexion strength. Retrospective review of a single surgeon's experience with 27 patients, 29 surgical procedures utilizing this central approach. Isokinetic testing of plantarflexion strength, AOFAS Foot and Ankle Survey and AOFAS hindfoot score were administered to 22 patients at a mean followup time of 4 years. An additional telephone assessment was performed at a mean followup time of 7 years. Average recovery time was 5.7 (range, 2 to 16) months. There was no significant difference in plantarflexion strength between the operative and nonoperative sides. At the early (4-year) assessment, 15 patients had an AOFAS hindfoot score of 100; the average AOFAS hindfoot score was 96. The long-term assessment at a mean of 7 years; 22 patients (including the two bilateral cases) reported pain scores of 0 and they had no strength deficits. Overall, there was a 96% (22 of 23) satisfaction rate. Surgical debridement and resection for insertional Achilles tendinopathy using the central incision technique appears to be a technically optimal procedure affording 96% pain-free patients out 7 years with minimal to no loss of strength.

Treatment of peroneal tendon dislocation and coexisting medial and lateral ligamentous laxity in the ankle joint

Acute dislocation of the peroneal tendon is caused by massive combined flexion-torsion trauma supported by preexisting ligamentous laxity of the ankle joint. This study aimed to investigate the clinical outcome of combined treatment of peroneal tendon dislocation and lateral and medial ligamentous laxity. Between 2005 and 2007, forty-two patients with peroneal tendon dislocation and coexisting ligamentous laxity were treated. The superior extensor retinaculum was reconstructed using anchor technique and periosteal flap repair, whereas the preexisting ligamentous laxity with regard to the extensor inferior retinaculum was addressed using anchor reconstruction. All patients underwent arthroscopy prior to surgery. Thirty-eight of a total of 42 patients (aged 17-31) completed the 24-month follow-up. Clinical and arthroscopic examination was accomplished consistently by always the same two surgeons. Postoperative follow-up comprised clinical evaluation after 3, 6, 12 and 24 months. Clinical results showed a significant (P<0.0001) increase in the AOFAS-Hindfoot Score as an often used but not validated outcome measure, as well as a significant decrease in the Visual Analogue Scale and in the internal and external rotation, after 3 months. The clinical outcome was confirmed at the 6-, 12- and 24-months measuring points. No dislocation of the peroneal tendon recurred within the 24-month follow-up. Subjective patient satisfaction was stated as high. Combined treatment of peroneal tendon dislocation and coexisting lateral and medial ligamentous laxity in the ankle joint following arthroscopy results in good clinical outcome and high patient satisfaction. Case series, Level IV.

Endoscopic treatment of posterior ankle pain

The aim of this study is to describe the indications for two-portal hindfoot endoscopy in the treatment of posterior ankle compartment pathologies and to express the effectiveness of this technique by short- to mid-term outcomes on 59 consecutive patients. In our institute, between 2003 and 2009, patients operated by single surgeon with hindfoot endoscopy were enrolled. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and Maryland foot scores (MFS) were obtained preoperatively and postoperatively. In the final follow-up, besides the scores, patients were asked whether they were satisfied and whether they would elect this treatment again. The indications for 59 patients were posterior ankle impingement syndrome (14), osteochondral lesion of talus (13), isolated flexor hallucis longus (FHL) tenosynovitis (11), synovial osteochondromatosis (2), pigmented villonodular synovitis (2), peroneal tenosynovitis (4), subtalar joint arthrosis (4), tibiotalar arthrosis (4), intraosseous talus cyst (4; 1 bilateral), and talus fracture (1). FHL tendon was affected in all cases, and tenolysis was performed for each patient. The mean preoperative AOFAS-hindfoot scores increased from 56.7 ± 14.5 to 85.9 ± 12.5 (P < 0.0001), and the mean preoperative MFS increased from 54.8 ± 17.5 to 84.9 ± 15.9 (P < 0.0001), postoperatively. Four patients with posttraumatic arthritis were dissatisfied. Two sural nerve-related complications were identified. Hindfoot endoscopy was demonstrated to be a safe and effective procedure for the treatment of various hindfoot pathologies in this cohort, excluding patients with posttraumatic arthritis. Our results show that the prevalence of FHL tenosynovitis may be higher than previously reported and should always be considered in differential diagnosis of posteromedial ankle pain. Case series with no comparison group, Level IV.

Posttraumatic arthrodesis of the subtalar joint – outcome in workers compensation and rates of non-union

Regardless of the simple surgical technique, the success of the subtalar arthrodesis is limited by the rate of non-unions of the arthrodesis. The functional outcome of workers compensation is known to be poorer compared to patients without pending litigation. The aim of this study was to quantify the rate of non-unions and to determine risk factors leading to failure of the osseous consolidation after arthrodesis of the subtalar joint. The outcome assessed is a general health assessment with the SF-36 questionnaire and more illness specific with the AOFAS hindfoot score. Secondly, the influence of the health insurance status of the patients with or without worker's compensation on the outcome was tested. The inclusive criterion was an arthrodesis of the subtalar joint with and without autologous cancellous bone grafting and screw osteosynthesis. This cohort study included the clinical course of 115 patients with posttraumatic osteoarthritis from 2000 to 2006. The average age of the patients (n=115) was 47±11.0 years, 83% of the treated patients were men. 68% of the patients suffered of secondary osteoarthritis after calcaneal fracture. The time interval from trauma to presenting at the physician due to therapy resistant pain was in the average 5.5±9.9 years. After primary arthrodesis (n=101) of the subtalar joint osseous consolidation was proved in 55% cases, consolidation was questionable in 21% and the rate of no consolidation with revision was remarkable high with 24%. The duration of osseous consolidation was proved by plain projection radiography or computer tomography and clinical reduction of pain. For primary arthrodesis osseous consolidation was reached after 6.4±6.3 month, after secondary arthrodesis osseous consolidation was reached after 9.4±13.1 month. After revision surgery 57% of the arthrodesis healed, 12% the osseous consolidation was questionable, and the failure rate was still 12%. The outcome measures of the patients with SF-36 and the more functional related AOFAS hindfoot score showed poor outcome rates after subtalar fusion in posttraumatic osteoarthritis. The AOFAS hindfoot score was 47±24 points after primary arthrodesis and 46±17 points after secondary arthrodesis of the subtalar joint. The patients regained their former ability to work only in 30% after fusion of the subtalar joint. If revision surgery was necessary 8% of the patients got back to their work prior to the injury.

Tibiotalocalcaneal Arthrodesis With a Curved, Interlocking, Intramedullary Nail

Tibiotalocalcaneal fusion with a straight rod has a risk of damaging the lateral plantar neurovascular structures and may interfere with maintaining normal heel valgus position.We report the results of a prospective study of tibiotalocalcaneal (TTC) arthrodesis with a short, anatomically curved interlocking, intramedullary nail. Forty-five arthrodesis in 42 patients, performed between Jan 2003 and Oct 2008, were prospectively followed. The mean followup was 48 (range, 10 to 74) months. The main indications for the procedure were failed ankle arthrodesis with progressive subtalar arthritis, failed ankle arthroplasty and complex hindfoot deformity. The outcome was measured by a combination of pre and postoperative clinical examination, AOFAS hindfoot scores, SF-12 scores and radiological assessment. Union rate was 89% (40/45). Eighty-two percent (37/45) reported improvement in pain and 73% (33/45) had improved foot function. Satisfactory hindfoot alignment was achieved in 84% (38/45). Postoperatively there was a mean improvement in the AOFAS score of 37. Complications included a below knee amputation for persistent deep infection, five nonunions, and three delayed unions. Four nails, six proximal and six distal locking screws were removed for various causes. Other complications included two perioperative fractures, four superficial wound infections and one case of lateral plantar nerve irritation. With a short, anatomically curved intramedullary nail, we had a high rate of tibiotalocalcaneal fusion with minimal plantar neurovascular complications. We believe a short, curved intramedullary nail, with its more lateral entry point, helped maintain hindfoot alignment.

Surgical treatment of flatfoot resulting from calcaneal fractures malunion

To explore the operative approach and efficacy of flatfoot after calcaneal fractures malunion. A total of 116 flatfoot patients after old calcaneal fractures were treated from January 1998 to January 2008. There were 94 males and 22 females with an average age of 33.5 years old (range: 16 - 46). They included unilateral flatfoot after old calcaneal fractures (n = 110) and bilateral flatfoot after old calcaneal fractures (n = 6). The surgical treatments included open reduction, calcaneal osteotomy without subtalar fusion or a reconstruction of calcaneal thalamus and subtalar arthrodesis. A total of 101 patients were followed up for an average of 14 months (range: 12 - 24). No wound healing problem or infection was observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 12 weeks (range: 10 - 14). The mean time of complete weight loading was 13 weeks (range: 11 - 15 weeks). The height of foot arch increased from 4.2 mm ± 1.7 mm to 14.1 mm ± 4.1 mm (P < 0.05). Calcaneal inclination angle increased from 11.2° ± 2.5° to 19.1° ± 4.4° (P < 0.05). Bohler angle increased from 5.4° ± 3.5° to 25.8° ± 5.2° (P < 0.05). Meary angle recovered from 22.2° ± 4.4° to 5.1° ± 3.2° (P < 0.05). The mean AOFAS Ankle and Hindfoot score increased from 33.4 (range: 27 - 43) to 85.8 (range: 78 - 98). As to flatfoot after old calcaneal fractures, surgical treatment has a favorable efficacy. A customized operative approach may achieve a satisfactory outcome.

Surgical treatment of malunited or nonunited talus fractures

To explore the operative methods of malunited or nonunited talus fractures. Twenty-two patients of malunions or nonunions after displaced talar fractures were treated from January 2000 to January 2008. There were 17 males and 5 females with an average age of 34 years (ranged from 15 to 52 years). According to classification of posttraumatic talar deformities (Zwipp 2003), there were 10 cases of type I (malunion and/or joint displacement), 8 cases of type II (nonunion with joint displacement), 4 cases of type III (type I/II with partial AVN). The surgical treatments included open reduction, osteotomy, correction and internal fixation with plate, screw or K-wire, or the ankle, subtalar arthrodesis. Seventeen patients were followed up for 14 months in average (ranged from 12 to 24 months). No wound healing problems or infections were observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 14 weeks (ranged from 12 to 18 weeks). The mean time of completely weight loading was 14 weeks (ranged from 12 to 18 weeks). The mean AOFAS ankle and hindfoot score increased from 35.4 (ranged from 28.0 to 41.0) to 86.6 (ranged from 78.0 to 98.0). As to posttraumatic talar deformities, surgical treatment can lead to a favorable outcome. According to concrete status of malunions or nonunions after displaced talar fractures, suitable surgical treatment should be applied to obtain satisfactory outcome.

Joint Preservation Surgery for Correction of Flexible Pes Cavovarus in Adults

Cavovarus foot deformity often results from muscular imbalance. If deformities are still flexible, surgical correction can be aimed primarily at improving muscular balance. We retrospectively assessed the outcome of 19 procedures (in 15 patients) to evaluate patient satisfaction. All patients had a flexible deformity. The surgical procedures that were used included soft-tissue releases, tendon transfers and lengthenings, and osteotomies of either the first metatarsal or the calcaneus. The surgical results in terms of pain, function and alignment of the foot were evaluated by means of standardized questionnaire (AOFAS foot score and the Dutch version of the Foot Function Index), patient interview, physical examination and X-ray. The changes in calcaneal pitch and talus-metatarsal I angle were calculated. Overall patient satisfaction was good. The results were very satisfactory in five procedures, satisfactory in ten, moderately satisfactory in two, unsatisfactory in one, and very unsatisfactory in one procedure. The AOFAS hindfoot score was on average 82.5 +/- 16. The talus-metatarsal I angle significantly decreased from 22.5 to 17 degrees (p = 0.002). The anatomical corrections of the foot did not show association with the patients' clinical characteristics. Our results show that in joint preserving flexible pes cavovarus correction patient satisfaction is generally good. Radiographic alignment of the foot was not significantly associated with patient-based outcome in this small series of patients.

Lambrinudi Arthrodesis with Posterior Tibialis Transfer in Adult Drop-Foot

The adult drop-foot is one of the most disabling disorders that affects gait and quality of life. Despite orthoses and orthopaedic shoes, the disability often progresses. We have used the Lambrinudi arthrodesis to correct the bony component of drop-foot in association with a posterior tibial tendon transfer to provide lateral ankle stability and active dorsiflexion. This study presents results obtained in a consecutive series of 19 patients. Nineteen patients (mean age, 54.7 years) were treated for drop-foot with an osseous dorsiflexing procedure according to Lambrinudi's original technique and a posterior tibial tendon transfer to the lateral cuneiforme bone. Outcome measurements included extended radiographic and clinical investigations, including the AOFAS Hindfoot Score, SF-36, ROM and VAS. The mean followup time was 39 (range, 24 to 62) months. The AOFAS Hindfoot Score improved from 38.9 preoperatively to 73.2 (p < 0.001) at last followup, and the SF-36 scores improved from 38.3 to 70.5 (p < 0.001). All patients were able to wear normal shoes at final followup. In this study of 19 patients, Lambrinudi arthrodesis combined with posterior tibial transfer proved to be a reliable and reproducible treatment for semi-rigid and rigid adult drop-foot caused by several aetiologies. It provided a stable correction of the adult drop-foot and high patient satisfaction in the mid- to long-term. In particular, it enabled the patient to wear normal shoes.

Treatment of acute Achilles tendon ruptures with Achillon device: Clinical outcomes and kinetic gait analysis

We reviewed the outcomes of the Achillon minimally invasive suture system and an early semi-functional rehabilitation program for the treatment of acute Achilles tendon ruptures. From December 2006 to April 2008, 18 consecutive patients with acute Achilles tendon ruptures were retrospectively reviewed with an average follow-up of 22 months. Clinical data were assessed with the patient satisfaction and the AOFAS hindfoot score. Biomechanical gait parameters were obtained using the NedAMH/IBV dynamometric platform. At last follow-up the AOFAS score was 98 (range, 89-100) and correlated well with kinetic gait analysis. All patients regained normal range of motion and were able to resume their previous activities after six months, with a high rate of satisfaction. Three patients had scar adhesions. There were no cases of recurrent rupture or nerve injury. The Achillon device allows semi-functional rehabilitation and provides satisfactory results with a low rate of complication.

Arthroscopic release to treat subtalar stiffness after calcaneal fracture

To report the results of arthroscopic release to treat subtalar stiffness after calcaneal fractures. From September 2004 to December 2006, 10 cases of subtalar stiffness were treated. There were 8 male and 2 female cases, with an average age of 36 years old (ranging from 18 to 48). All, but 2 cases, had single subtalar involvement. The routine triple portals (lateral, anterolateral, posterolateral portals) were applied with the patient placed in the lateral decubitus position. The anterior capsule, lateral gap, calcaneofibular ligament, posterior capsule together with the posteromedial corner of the subtalar joint were released step by step under arthroscopic control. Finally, manual release was performed. All cases were followed-up for 12 to 36 months (mean, 24.5 months). According to the AOFAS hindfoot activity rating scale, 10 cases were rated as Grade III, 2 as Grade II before the surgery. Nine cases were improved to Grade I, 3 to Grade II at the last follow-up after the surgery. AOFAS hindfoot scores were significantly improved from 71.4 before the surgery to 90.6 at the last follow-up (P < 0.01). All cases returned to the previous work at an average of 1.8 months (range, 1 to 3 months) after the surgery. Arthroscopic release to treat subtalar stiffness after calcaneal fracture has such advantages as minimally-invasiveness, simplicity and effectiveness.

Primary Isolated Subtalar Arthrodesis: Outcome after 2 to 5 Years Followup

Favorable to excellent clinical results have been reported for isolated subtalar joint arthrodesis. Pedobarography after subtalar bone-block distraction arthrodesis have demonstrated a more laterally shifted gait line. However pedobarographic measurements after primary in-situ isolated subtalar arthrodesis have not been reported. This is the first study considering this. Physical examination, AOFAS Hindfoot score, full weightbearing anterior/posterior and lateral radiographs were assessed in 15 feet. Peak pressures, ground reaction force and force distribution at foot-flat and push-off were measured. Average AOFAS-Score significantly improved. Subjective satisfaction was high. Non-union was found in 1 foot (7%), screws were removed in 4 of the 15 feet (27%). One new asymptomatic arthritic talonavicular joint was found. The pressure and force distributions under the operated and contralateral foot showed a different pattern compared to a normal foot. Ground reaction force under both the operated and contralateral feet were lower than a normal foot. This study found good clinical, subjective and radiographic results matching that of the reported literature. However, pedobarographic assessment suggests that great functional differences still remain when compared to a normal foot. Subtalar arthrodesis may induce an abnormal gait pattern by preventing compensation of axial rotation of the tibia. This is also reflected in the unaffected side, which may indicate an effort in the general locomotor control to keep a symmetrical gait pattern. This finally alters the pressure and force distribution under both feet. Nevertheless, subtalar arthrodesis is considered a valuable treatment for various isolated subtalar disorders.

Combined Ipsilateral Fractures of Talus and Calcaneus

The purpose of this study was to evaluate the frequency of combined ipsilateral talar and calcaneal fractures, the fracture pattern in combination and the clinical outcome of the combined operative treatment. Out of 950 patients with calcaneal fractures and 190 patients with talar fractures treated operatively between 1984 and 2003, 11 patients (1% of calcaneal and 6% of talar fractures) were identified with combined ipsilateral talar and calcaneal fractures. Closed reduction and external fixation was performed in one patient with a crush foot injury, and ORIF in all other patients and fractures. All patients underwent clinical and radiological evaluation after a minimum followup period of one year using the AOFAS-Hindfoot Score. Seven patients had central talar body and 4 patients talar neck fractures. Nine calcaneal fractures were extraarticular sustentaculum, as well as processus anterior fractures, and two were intraarticular fractures. Average followup was 6 (range, 1 to 12.5; median, 4.5) years. There were no perioperative complications related to ORIF. AOFAS-Hindfoot-Score averaged 78.6 (range, 50 to 100). The followup x-rays showed post-traumatic arthritis in the ankle joint in 3 patients and in the subtalar joint in five. AVN with peudarthorsis was present in one patient with an intraarticular calcaneal fracture. Patients with intraarticular calcaneal fractures presented with the worst functional results (AOFAS-Score, 50 and 64), none of these patients required a secondary ankle or subtalar fusion. All other patients had good and excellent functional outcome. Combined ipsilateral talar and calcaneal fractures are rare injuries. Extraarticular calcaneal fractures are more common in this injury pattern, while there was no preference for either talar neck or talar body fractures. Operative treatment with anatomic open reduction and internal fixation may result in favorable clinical outcome. Combined surgical approaches to the hindfoot did not result in increased morbidity.