AOFAS Hindfoot Score Research Articles

Early to Mid-Term Follow-up of Total Ankle Arthroplasty in Patients <35 Years

Category: Ankle Arthritis; Ankle Introduction/Purpose: Younger age remains at the forefront of discussion when deciding between total ankle arthroplasty (TAA) and the ankle arthrodesis (AA) for treatment of end stage ankle arthritis. Unlike in the hip and knee, ankle arthritis is typically post-traumatic and presents at a much younger patient age. With the goal of preserving ankle motion, improving function and limiting adjacent joint degeneration, TAA has been shown to be safe and effective in patients < 55 years of age. However, it is not uncommon for debilitating ankle arthritis to occur in individuals within their fourth or even third decade of life resulting in significant patient comorbidity. The purpose of our study was to evaluate patient reported outcome measures and survivorship after primary TAA in patients < 35 years old. Methods: A retrospective chart review was conducted of patients < 35 years old who underwent primary TAA at a single institution from 2007-2020. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow up of 2 years. Patient reported outcome measures collected included VAS, SMFA dysfunction index, SF-36 and AOFAS hindfoot scores. Outcome measures were evaluated preoperative, 1 year postoperative, and at final follow up. Paired t-tests were performed to compare individual patients’ changes in PRO from preoperative to postoperative timepoints. Implant survivorship was evaluated as well as complications related to the index procedure. Implant survivorship based on need for complete revision of either the tibial or talar component Results: Twelve patients were included in the study. Average age at surgery was 28.5 years. Mean follow-up was 7.2 years. Mean VAS improved from 53.8 preoperatively to 14.7 (p= 0.152) at 1-year and 12.5 (p= 0.045) at final follow up, respectively. Mean SMFA improved from 40.0 preoperatively to 27.1 (p= 0.018) at 1-year and 24.0 (p= 0.006) at final follow up, respectively. SF-36 and AOFAS hindfoot scores also improved at 1 year and final follow-up compared to preoperative values [SF-36: 45.3 to 60.2 (p=0.06) and 67.0 (p=0.016); AOFAS: 40.6 to 70 (p= 0.08) and 68.9 (p=0.068)]. One patient required talar component revision due to aseptic loosening. One patient required subsequent removal of heterotopic bone due to impingement. No patients developed infection requiring surgical intervention. Conclusion: The onset of ankle arthritis typically occurs at a much younger age compared with that of the hip and knee and has a detrimental impact on patient quality of life. Despite a young age and increased activity demands, our results demonstrated that patients < 35 with end-stage ankle arthritis undergoing TAA demonstrated improved patient-reported outcomes greater than 2 years after surgery. Survivorship of TAA in our study was 91.7% at a mean follow-up of 7.2 years. We believe that TAA is a safe, effective and durable option for very young patients with high patient satisfaction at early to mid-term follow up.

Chronic Achilles Tendon Rupture Reconstruction with Semitendinous Autograft Tendon: A Case Series

Category: Sports; Ankle Introduction/Purpose: Chronic Achilles tendon ruptures is challenging because the tendon ends are usually retracted, and if the gap between the proximal and distal stumps are of more than 6 cms with the ankle in plantarflexion the currently literature shows that semitendinous tendon (ST) autograft reconstruction has satisfactory funcional outcome. The objetive of this study is evaluate the functional outcomes after Achilles tendon reconstruction with ST. Methods: Prospective case series, level IV of evidence, authorized by Ethics Committee of our institution, assessed the clinical outcome of patients submitted to achilles tendon reconstruction between march 2021 and june 2022. The patients were diagnosed by 2 orthopaedic foot and ankle surgeons board certificated and were subjected to the following inclusion criteria: age between 18-60 years, agreeing to participate, with chronic achilles tendon rupture (> 12 weeks) and gap between proximal and distal stump larger than 6cm confirmed by ultrasound with the ankle in plantarflexion position. Demographic data was obtained, including gender, BMI and height and the full ST length was measured intraoperatively. AOFAS Hindfoot Score and Achilles Tendon Total Rupture Score (ATRS) were evaluated pre and postoperatively (last evaluation). Results: 20 patients were included, with medium age of 45 years old (range 23 to 64 )and medium gap of 6,3 cm (range 6 to 6,6). (Table 1). The pre and postoperative AOFAS-hindfoot was 71 (range 48 to 83) and 89 (range 81 to 97), respectively, and the pre and posoperative ATRS was 33 (range 30 to 47) and 88 (range 86 to 92), respectively, both with statistic significance. The medium lenght of the ST from the posterior approach was 26.3 cm and the medium VAS for pain in the ST incision was 1. There were 2 cases of superficial infection treated with oral antibiotics for 7 days of full resolution and 1 case of superficial dehiscence treated with wound dressing. Conclusion: The surgical reconstruction of AT using ST harvested from posterior approach is a safe and reliable method for treatment of chronic AT ruptures with a gap larger than 6 cm, with a significant improvement in funcional scores and just 15% of minor complications.

Mid Term Followup of Patient Reported Outcomes in Patients <50 years with a Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: End stage arthritis is a debilitating condition that significantly affects patients’ quality of life. Ankle arthritis differs from arthritis of the hip and knee in that ankle arthritis is often posttraumatic in nature and affects a younger patient population. Historically, younger age was a contraindication to total ankle arthroplasty (TAA) and ankle arthrodesis was the mainstay of treatment. Advances in TAA implant design and revision implants has expanded indications and increased usage of TAA. Despite this, many surgeons remain hesitant due to the lack of long term data on patient outcomes and survivorship in these patients. The purpose of our study was to evaluate patient reported outcome measures and survivorship after primary TAA in patients < 50 years of age at the time of surgery. Methods: A retrospective chart review was conducted of patients < 50 years of age who underwent primary TAA at a single institution from 2010-2020. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow up of 5 years. Patient reported outcome (PRO) measures collected included FADI, VAS, SMFA SF-36, AOFAS hindfoot scores, and FAOS scores. Outcome measures were evaluated preoperative, 1 year postoperative, and at final clinical follow up. Paired t-tests were performed to compare individual patients’ changes in PRO from preoperative to postoperative timepoints. Multiple comparisons correction was performed using the Bonferroni method. Implant survivorship was evaluated based on need for revision of either the tibial or talar component. Results: A total of 59 patients were included in the study. The average age at time of surgery was 43.2 years. All patients had a minimum follow up of 5 years with a mean follow up time of 8.8 years. Mean FADI improved from 53.3 (sd:14.1) preoperatively to 16.1 (sd:11.4) (p < 0.001) at 1-year postoperatively. Mean VAS and SMFA also improved from preoperative to 1-year postoperative timepoints [VAS: 68.2 (sd:27.0) to 10.3(sd:13.1) (p < 0.001); SMFA: 36.1 (sd:12.2) to 14.8 (sd:13.7) (p < 0.001)]. A total of 5 patients required revision of components during the follow up period. Three patients required complete revision of both tibial and talar components, 2 due to aseptic loosening and 1 due to deep infection requiring explant of components. Conclusion: Patients < 50 years undergoing TAA for end stage ankle arthritis have improved patients reported outcomes greater than 5 years after surgery. Despite the increased demands of the younger population, survivorship of total ankle implants in our study was 85% at a mean of 8.8 years postoperative. We believe that TAA is a safe and reliable option for young patients with high patient satisfaction at mid term follow up.

Revision Total Ankle Arthroplasty Outcomes in a Large Single-Center Series: Evaluation of Coronal Plane Deformity Correction and Patient Reported Measures

Category: Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide, the incidence of major complications and need for revision TAA will continue to increase. A better understanding of the ability to durably correct deformity and improve patient reported outcomes (PROs) in the TAA revision setting is paramount for surgeons facing the impending wave of failed TAA. Thus, the purpose of this study was to present the largest single-center case series of revision TAA to date and to evaluate improvement in PROs and maintenance of correction of coronal plane deformity in patients undergoing this procedure. Methods: This was a single-center, retrospective review of 87 revision TAAs performed between 2007 and 2022. Reoperations for cyst formations only or without metallic component exchange were excluded. The two most common implants used for revision TAA were Inbone II (n=65) and Inbone I (n=14). Mean follow-up was 2.8 ± 2.9 years. Data on patient preoperative characteristics, concurrent procedures, and postoperative complications were collected. The primary outcome measures were time to major complication, reoperation, and infection. Secondary outcomes included PROs and correction of coronal plane deformity measured from both the tibial plafond and talar articulating surface from pre- to post-operatively. Cox regression analyses were performed to compute survivorship. Results: The most common concurrent procedures performed concomitantly with revision TAA were gastrocnemius recession (n=31, 35.6%), subtalar arthrodesis (n=18, 20.7%), and talonavicular arthrodesis (n=5, 5.7%). Mean preoperative coronal plane deformity measured off both the tibial plafond and talar articular surface improved after revision TAA. 1- and 5-year survivorship from major complication, reoperation, and infection is shown in Table 2. Fourteen patients underwent subsequent revision, including TAA (n= 6, 6.9%), arthrodesis (n= 4, 4.6%), below-the-knee amputation (n= 2, 2.3%), or implantation of an antibiotic spacer (n= 2, 2.3%). At one-year postoperatively, mean VAS pain score, SF36, and AOFAS Hindfoot score was 18.2 ± 16.0, 73.0 ± 13.3, and 68.8 ±:9.3, respectively, representing an improvement in PROs after revision TAA. Conclusion: In the largest single-center series of patients undergoing single or double component exchange revision TAA, we demonstrate durable improvements in coronal plane deformity measured off both the tibial plafond and talar articular surface. We also noted 63.0% survivorship with regards to reoperation and improvements in average PROs across the cohort. Overall, revision TAA is a successful procedure, but is associated with higher failure rates at 5 years than primary TAA.

Extruded talus injuries are associated with significant complications: A double center series with minimum 1-year follow up

BackgroundExtruded talus (ET) injuries are rare, but high-energy open pantalar dislocations. Literature on these injuries is sparse and optimal treatment protocols are ill defined. The current study documents the clinical and radiological outcomes in cases seen at 2 centers, in an attempt to determine whether surgeons should choose primary reimplantation or primary talectomy and fusion for these injuries. MethodsPatients with ET injuries were identified from the database of two hospitals. Baseline demographics and treatment details were evaluated, and patients were called for follow-up. Radiological evaluation was conducted, and function was evaluated by the AOFAS hindfoot score. Outcomes and complications were compared between patients who had undergone primary talectomy versus primary reimplantation. Predictors of poor functional outcomes were determined. ResultsOf 23 patients seen by us, 15 were available for follow-up at 45.7 ± 22.2 months. Of these 19 had undergone reimplantation and 4 had talectomy with tibio-calcaneal arthrodesis. The mean percentage AOFAS score was 66.2 ± 14.6 at follow up. AVN was noted in 5, ankle arthrosis in 10, subtalar arthrosis in 4 and infection in 4 cases; no patient needed salvage arthrodesis during this time. There was no difference in baseline demographics, range of motion, AOFAS scores or complication rates between patients undergoing primary reimplantation versus primary talectomy. The number of complications per patient showed a negative, moderate correlation with the AOFAS score (Pearson’s correlation coefficient 0.6, P value = 0.02). ConclusionDespite best treatment, ET injuries result in significant impairment of functional outcomes and complications. Within the numbers available, no difference in outcomes or complication rates was noted between primary reimplantation or talectomy. However, we recommend reimplantation as the treatment of first choice as this offers the chance to salvage the ankle joint and preserves bone stock for future fusion or arthroplasty.

Comparative Study between Arthroereisis and Corrective Osteotomies for the Management of Symptomatic Flexible Pes Planovalgus in Adolescents

Abstract pes planovalgus is a common foot deformity observed in adolescents which is characterized by a loss of the medial longitudinal arch and malalignment of the foot; hindfoot valgus and forefoot abduction which could progress with time causing pain that occur secondary to pressure medially over the prominent talar head. The treatment of this deformity should be directed to correct the foot malalignment, secure the stability of the foot during stance and correct the abnormal gait. The aim of the treatment is to obtain a foot with normal alignment which exhibits no pain and preventing the degenerative changes that may take place in the future. Surgical options should be offered to patients when conservative treatment failed. Numerous surgical procedures were described in pesplanovalgus correction that varies from bony osteotomies, subtalar extra-articular arthroeresis, intraarticular arthrodesis and triple arthrodesis accompanied with soft tissue procedures as indicated. When these are compared, all techniques have advantages and disadvantages. This study was conducted to evaluate the short term outcome of two methods of correction of pesplanovalgus; the extra-articular subtalar arthroereisis using subtalar sinus tarsi implant and bony corrective osteotomies in correction of flexible PPV in adolescents. Soft tissue procedures added to the operation if indicated mainly (gastroconemius recession and accessory navicular excision) Our study included 40 feet (25 patients) with pesplanovalgus. The patients divided into two groups 20 feet each. Group A underwent arthroereisis and group B underwent corrective osteotomies. The inclusion criteria were; Idiopathic flexible flatfoot deformity, symptomatic patients only and age between 10-14 years old. While the exclusion criteria were rigid flatfoot, flatfoot in adults (above 14 yrs old), severe talonavicular uncoverage angle (>40), neurogenic cases (cerebral palsy patient), patients with generalized ligamentous laxity. The outcome was assessed clinically by patient satisfaction, heel valgus angle, AOFAS hindfoot score and FAAM score. Radiologically the outcome was assessed by comparing the preoperative and postoperative measures of the lateral TCA, the AP and lateral talo-1st MTS angles, talonavicular coverage angle and the calcaneal pitch angle. Clinically the patient satisfaction was comparable in each of Group A were 17 patients (85.0%) were Satisfied; and 3 patients (15.0%) were unsatisfied compared to Group B were 18 patients (90.0%) were Satisfied and 2 patients (10.0%) were unsatisfied. Additionally, the two groups were comparable in heel valgus angle with the mean±SD in each of group A and group B was 2.75±2.62 compared to 2.05±2.01 respectively. Furthermore, the two groups were comparable in AOFAS score with the mean±SD in each of group A and group B was 89.25±8.34 compared to 91.25±8.97 respectively. As well as, the two groups were comparable in FAAM score with the mean & ±SD in each of group A and group B was 91.08±6.51, compared to 95.75±7.23 respectively. Radiologically; The two groups were comparable in lateral talus 1st met angle with the mean±SD in each of group A and group B was 3.45±3.06 compared to 2.02±2.08 respectively. Additionally, the two groups were comparable in lateral talocalc angle with the mean±SD in each of group A and group B was 32.65±5.05 compared to 30.50±5.62 respectively. Furthermore, the two groups were comparable in calc pitch angle with the mean±SD in each of group A and group B was 15.75±4.64 compared to 15.70±3.77 respectively. As well as, the two groups were comparable in AP talus 1st met angle with the mean±SD in each of group A and group B was 6.72±5.17 compared to 4.55±4.18 respectively. Also, the two groups were comparable in AP talonavicular coverage with the mean±SD in each of Group A and Group B was 6.95±4.77 compared to 4.10±3.30 respectively. There is no statistically significant difference between the group A and group B in all clinical and radiological measures. The extra-articular subtalar arthroereisis and bony corrective osteotomies in our study had been proved to be effective procedure for correction of flexible PPV feet in adolescents with comparable results.

Comparison of clinical and radiological outcomes between extended lateral and sinus tarsi approach in the surgical treatment of displaced intraarticular calcaneal fractures surgery

Purpose: The aim of this stud was to compare the clinical and radiological results between Sinus-tarsi (ST) and Extended-Lateral (EL) approaches in open reduction internal fixation of intra-articular calcaneal fractures.
 Materials and Methods: 51 calcaneal fractures of 48 patients surgically treated between 2012 and 2017 were retrospectively analyzed. The patients were divided into two groups. Preoperative CT, early postoperative and postoperative 1st-year radiographs, and The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score scores were evaluated.
 Results: According to the Sanders classification, nine patients in the EL group were type 2(36%), 16 patients type 3 (64%), 8 patients in ST group type 234.8%), 13 patients (56.5%) type 3, 2 patients (8.7%) type 4. The mean AOFAS-Hindfoot score was 85(63-100) in the ST group and 83(52-93) in the LE group at one year. Mean preoperative waiting time was shorter, with an average of 2(1-4) days in ST and 6(3-12) days in LE. 
 Conclusion: ST approach shortens the preoperative waiting time in intra-articular calcaneal fracture surgery, provides a sufficient vision for anatomical restoration, and effectively avoids complications.

Posterior malleolus fractures and their role in prognosis of malleolar fractures

Introduction: The treatment of ankle fractures with involvement of the posterior tibial margin remains a subject of debate. We have evaluated the clinical, radiological, and functional outcome of such fractures in 25 patients, all of which were managed surgically over an average follow- up period of 6 months. The treatment options available for malleolar fractures, to attain a proper anatomical alignment and stability of ankle joint, can lead to rewarding outcome for the patient.Materials and Methods: 25 patients with posterior malleolus fractures were managed surgically between June 2019 to November2021 were included in this series. The mean age, gender ratio, mode of trauma, fracture union time, and complications were noted. The AOFAS Hindfoot scores were used for assessing the Ankle function.Results: Of the 25 patients in the study, 21 were males and 4 were females. The mean age was 38.12 years. The mean fracture union (radiological) time was 14.04 weeks (range: 10–18 weeks). However Ankle function was excellent in 17 cases (68%) on the AOFAS hindfoot score with a average AOFAS score of 94.8. Also platting gives a better result than using cannulated cancellous screws. Better syndesmotic stability is observed after surgically treating posterior malleolus fractures.Conclusion: Fixation of the posterior malleolus to reduce persistent fragment displacement, regardless of size, as well as to restore syndesmotic stability, may lead to improved outcomes. We conclude that posterior malleolar fractures encountered in clinical practice need thorough assessment and meticulous surgical intervention. We achieved stable fixation and performed early mobilization of the ankle joint, which limits the complications of mainly ankle stiffness and have achieved excellent clinical and functional outcomes of surgically fixing the posterior malleolus fractures.

Peroneus Longus Tendon Autograft: A Promising Graft for ACL Reconstruction

Background: With the increasing use of hamstring tendon as an autograft in anterior cruciate ligament (ACL) reconstruction, some shortcomings have been found on the donor site. Therefore, an alternative autograft option with adequate strength and less donor site morbidity will be very valuable. Peroneus longus tendon has been found to be a promising option. Indication: Primary ACL reconstruction. Technique Description: Peroneus longus tendon graft is harvested with a longitudinal skin incision at 2 to 3 cm (2 finger-breadths) above and 1 cm (1 finger-breadth) behind the lateral malleolus, followed by superficial fascia incision in line with skin incision. The peroneus longus and peroneus brevis tendons were then identified. The tendon division location was marked at 2 to 3 cm above the level of the lateral malleolus. After that, an end-to-side suture was performed between the distal part of the peroneus longus tendon and peroneus brevis tendon. The peroneus longus tendon was stripped proximally with a tendon stripper to at least 5 cm from the fibular head to prevent peroneal nerve injury. Graft preparation was performed with a standard procedure to obtain the suitable graft size. In routine arthroscopic ACL reconstruction, peroneus longus tendon graft fixation can be performed with a cortical suspension device, bioabsorbable screws, or a combined technique. Results: Recent studies showed that peroneus longus autograft had a comparable outcome with hamstring tendon autograft in primary ACL reconstruction at a 1-year follow-up. The use of peroneus longus tendon autograft resulted in larger graft diameter and less thigh hypotrophy. The mean (±SD) for the AOFAS-Hindfoot Score in the peroneus longus group was 97.3 ± 4.2, while the mean FADI score was 98 ± 3.4, both of which were considered excellent results. Discussion/Conclusion: The use of peroneus longus autograft in primary ACL reconstruction is a safe procedure with an excellent outcome. Peroneus longus tendon autograft can be recommended as an alternative graft in single-bundle ACL reconstruction. Further study of the functional outcome and knee stability evaluation is recommended.

Double hindfoot arthrodesis using a single-incision medial approach in the correction of adult-acquired flatfoot deformity: a case series.

Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach. A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed. All radiographic parameters evaluated showed a significant improvement (p < .05), except the calcaneal pitch. Pain decreased by 5.1 points (p < .001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics. Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases.

Evaluation of a Modified Spoon-Shaped Medial Incision in the Surgical Repair of a Chronic Achilles Tendon Rupture

This study aims to investigate the clinical significance of preventing incision skin necrosis and the improved function offered in patients with a chronic Achilles tendon rupture treated surgically with a modified spoon-shaped medial incision. From January 2013 to January 2017, 50 patients (N = 50) who were admitted to our department with a clinically and radiologically confirmed chronic Achilles tendon rupture met inclusion criteria and were divided retrospectively into two groups. In group A (n = 26), a modified spoon-shaped medial incision in the surgical repair of Achilles tendon rupture was performed. In group B (n = 24), a traditional posterior medial incision was used. All skin healing was observed. Functional evaluation was performed using American Orthopedic Ankle & Foot Society scale(AOFAS) hindfoot score and Achilles tendon total rupture score(ATRS). Return-to-work time and major complications were also measured. The patients were followed for 12 to 48 months. All incisions exhibited primary healing in group A, while four incisions healed delay for skin necrosis which includes superficial, deeper necrosis, and skin defection caused by the necrosis in group B. Both groups had similar results regarding return-to-work time. There were no infections in either group. There was no rerupture of the Achilles tendon in either group. Patients in group A had better AOFAS hindfoot score (p = .020) and ATRS (p = .010), and the difference was significant (p ≤ .05).Using the modified spoon-shaped medial incision in the surgical repair of a chronic Achilles tendon rupture seems to be a safe and effective method that may reduce risk of incision skin necrosis and offers better function in patients with a chronic Achilles tendon rupture.

Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center

BackgroundThe aim of this retrospective monocentric study was to investigate the outcomes of surgically treated intra-articular calcaneus fractures in a maximum care trauma center.MethodsOne hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between 2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries.ResultsMean follow-up was 91 months (range 12–183). The overall complication rate was 29% (37/129 ft). Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion (18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%) after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70). The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores (p < 0.01).ConclusionsOur data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary subtalar fusion with caution due to the high revision rate. Smoking status should always be considered.Level of evidence: Level III, retrospective cohort study.

Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis.

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control andclinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD:±11.3) versus 71.7 (SD:±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.

Comparison of midterm results of Platelet Rich Plasma (PRP) versus Steroid for plantar fasciitis: A randomized control trial of 118 patients

BackgroundPlantar fasciitis, which is a common cause of heel pain, often results in significant morbidity. In cases who are not responsive to initial conservative treatment, invasive procedures, often in the form of local infiltration of steroid are required. These procedures are associated with significant complications. Local Platelet Rich Plasma (PRP) infiltration is an emerging addition to these treatments. However, whether it is more effective in reducing pain and improving function than other treatments (such as steroid injections or whole blood) remains controversial. MethodsSkeletally mature patients with plantar fasciitis who had failed conservative therapy were randomized using envelope method into 2 groups: PRP and Steroid group. The participants were assessed for pain using Visual Analog Scale on the day of presentation, and then after therapy at 2 weeks, 4 weeks, 3 months, and 6 months. They were additionally assessed on final follow-up using AOFAS hind-foot Score. Results118 patients were randomized into 2 groups: 58 patients to the PRP group and 60 to the Steroid group. PRP was associated with greater improvement in VAS score and resulted in superior AOFAS score at 6 months as compared to steroid injection. The authors did not find any local or systemic complications in any of the groups. The result and difference were more pronounced as the time from injection increased and maximal benefit was observed at 6 months follow-up. None of the patients needed a repeat injection at 6 months. ConclusionOur study expands on the previous studies to provide a better evidence for superiority of PRP over local injection of steroid in plantar fasciitis, and the authors conclude that PRP provides better pain relief and function as compared to steroid injection. Level of evidenceLevel 1 Prospective Randomized Control Trial (RCT);

Combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in a 58-year-old female: a case report

BackgroundCombined anterior and posterior ankle impingement has seldom been reported. Cedell fracture, fracture of posteromedial tubercle of talus, is an uncommon and easily missed injury which may elicit posteromedial ankle impingement. The injury mechanisms and management strategies of these two lesions have been reported individually. But the concurrent lesion of both of them has not been reported.Case presentationWe reported a 58-year-old female with combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in whom open osteophytes debridement, fracture internal fixation and posterior talotibial ligament reconstruction were performed. The AOFAS hindfoot score was 90 at 1 year follow-up. To our knowledge, this was the first reported case with anterior, posterior and posteromedial impingement which was treated operatively with an excellent short-term outcome.ConclusionsTo fully recognize this occult lesion and avoid missing is imperative for reducing the morbidities. We suggest CT and MRI as excellent imaging modalities that can help the timely diagnosis and appropriate treatment for this combined impingement with circumferential lesions.

Full thickness open tear of the tendoachilles - Functional outcomes following a stable, single stage repair

ObjectiveOpen injuries of the Tendoachilles present a challenge to the treating surgeon. Although, common in our setting, there is a paucity of literature regarding management of the same. The purpose of this retrospective study was to analyse the functional outcomes following debridement and primary repair of open tears of the Tendoachilles. Materials and methodsPatients with open tears of the tendoachilles, between January 2012 to January 2017. After obtaining demographic data, including mechanism of injury, all patients were managed by adequate debridement and primary repair, by Pennington’s modification of Kessler’s technique in a single sitting, paratenon closed circumferentially, plantaris reinforcement used when end to end repair couldn’t be achieved. Below knee cast for 2 months. Weight bearing started at three months. Statistical analysis using paired t-test for calf circumference, ankle range of motion comparing with uninjured limb. Functional outcome assessment by AOFAS hindfoot score and Achilles tendon rupture score. Results23 male patients, mean age 35, were analysed. Field injury was the most common mechanism, with slip in Indian lavatory pans accounting for four patients. Average time to surgery from injury was 22 hours. Plantaris reinforcement in one case. No case of wound dehiscence, scar adherence, tendon rerupture or infection. One patient had serous discharge at three weeks which settled with oral antibiotics. 21 patients performed single heel raise. There was no significant difference in calf circumference and ankle range of motion compared to uninjured limb. Mean AOFAS score was 92, mean Achilles tendon rupture score 77. ConclusionThough open injuries of the tendoachilles is fraught with complications, early debridement, adequate repair of the tendon edges with circumferential closure of the paratenon, yields adequate functional outcomes with minimal complications.

“Double-bundle” tibialis anterior tendon transfer for prevention of pes equinus after Chopart amputation

Objective: Assess patient performance and quality of the stump after amputation at the Chopart (midtarsal) joint, with double-bundle transfer of the tibialis anterior muscle tendon to the talar neck. Methods: This study evaluated the medical records of 5 patients who underwent Chopart amputation with double-bundle transfer of the tibialis anterior tendon to the talar neck, assessing pre and postoperative performance and gait. Results: The patients were operated on between January 2008 and December 2018, and the data obtained from the survey allow us to conclude that, after the proposed procedure, all patients reported an improvement in walking, besides noting a significant reduction in the degree of stump equinus. Conclusion: The surgical technique described in this article produced a significant improvement in patient performance as assessed by the AOFAS hindfoot score, and prevented the formation of ulcers in the anterior region of the stump. Level of Evidence IV; Therapeutic Study; Case Series.

Achilles tendon reconstruction combining a modified Dresden technique and endoscopic flexor hallucis longus transfer

Objective: The purpose of this paper is to describe a minimally invasive chronic Achilles tendon rupture reconstruction combining a modified Dresden technique and endoscopic flexor hallucis longus (FHL) tendon transfer. Methods: Our prospectively collected database was queried for patients presenting with chronic Achilles tendon rupture. Patients were included if they presented any of the following criteria: more than 65 years of age, history of previous DVT, active smoking habit and Diabetes. Pre and post-operative SF-36 and AOFAS hindfoot scores, complications, and patient satisfaction grades were recorded. Results: Eight patients met the inclusion criteria; the median age was 49 years old (range 22 - 67 years). Two complications were registered (sural neuritis and minor wound dehiscence). Mean AOFAS score increased from 48 (range 40 - 63) to 91,6 (range 85 - 95). Regarding SF-36 score, the SFF-36 improved from 51,6 to 79,3 points and the SFM-36 enhance from 25 to 61,5 points. All patients evaluated their satisfaction regarding the performed procedure as satisfactory. Conclusion: Chronic Achilles tendon rupture reconstruction combining a modified Dresden technique and endoscopic FHL transfer is an attractive option in high-risk patients, with favorable results at the short-term follow-up. Level of Evidence IV; Therapeutic Study; Case Series.

Évaluation à moyen terme de l’arthrorise subtalaire pour la correction des pieds plats souples chez l’enfant

BackgroundThe role of subtalar arthroereisis (STA) for treating flexible flatfoot (FFF) in children is controversial. We hypothesized that (1) STA provided significant radiographic correction of low longitudinal arch and forefoot abduction in paediatric FFF and that (2) mid-term clinical outcomes were satisfactory and comparable to a normal population. MethodsA retrospective comparative study was performed of paediatric patients with symptomatic FFF who underwent STA between 2012 and 2015. Multiple measurements on preoperative and latest follow-up radiographs were recorded by two observers and compared to assess for correction of the FFF. Intra- and inter-observer reliability was also assessed. Ankle and hindfoot range of motion (ROM), AOFAS hindfoot score and VAS-FA score were compared with controls without foot symptoms or deformity. From 70 consecutive feet, 62 (31 patients) treated at 10.5 years of age were identified and compared to 48 controls (24 patients). Mean follow-up was 62 months. ResultsIntra- and inter-observer reliability was excellent for all angles (range, 0.81–0.97). Radiographic measurements demonstrated significant improvement after surgery (p<0.001) but significance was not reached in talonavicular coverage angle (p=0.49) and calcaneo-fifth metatarsal angle (p=0.53) on dorsoplantar view. At latest follow-up, patients had less hindfoot inversion than controls (15.1° vs. 19.3°, p=0.03), lower AOFAS scores (94.1 vs. 99.6 points, p=0.01), due to pain (p=0.01) and alignment (p=0.006) subscores. Using the VAS-FA score, patients were found to demonstrate higher pain at rest (p range, 0.02–0.03) and during activity (p=0.009), and felt limited when standing on one leg (p range, 0.01–0.03) and running (p=0.04). No loss of correction was found after removal of the implant. ConclusionThis study showed that STA corrected the low longitudinal arch in symptomatic paediatric FFF, but did not correct forefoot abduction in relation to the hindfoot. Mid-term assessment revealed STA provided satisfactory ankle and hindfoot ROM, pain and function levels, but limitations are witnessed compared to unaffected individuals. This aspect should be considered when counselling patients and their parents or caregivers to allow for realistic expectations. Level of evidenceIII, retrospective comparative study.

Midterm assessment of subtalar arthroereisis for correction of flexible flatfeet in children

BackgroundThe role of subtalar arthroereisis (STA) for treating flexible flatfoot (FFF) in children is controversial. We hypothesized that (1) STA provided significant radiographic correction of low longitudinal arch and forefoot abduction in paediatric FFF and that (2) mid-term clinical outcomes were satisfactory and comparable to a normal population. MethodsA retrospective comparative study was performed of paediatric patients with symptomatic FFF who underwent STA between 2012 and 2015. Multiple measurements on preoperative and latest follow-up radiographs were recorded by two observers and compared to assess for correction of the FFF. Intra- and inter-observer reliability was also assessed. Ankle and hindfoot range of motion (ROM), AOFAS hindfoot score and VAS-FA score were compared with controls without foot symptoms or deformity. From 70 consecutive feet, 62 (31 patients) treated at 10.5 years of age were identified and compared to 48 controls (24 patients). Mean follow-up was 62 months. ResultsIntra- and inter-observer reliability was excellent for all angles (range, 0.81–0.97). Radiographic measurements demonstrated significant improvement after surgery (p<0.001) but significance was not reached in talonavicular coverage angle (p=0.49) and calcaneo-fifth metatarsal angle (p=0.53) on dorsoplantar view. At latest follow-up, patients had less hindfoot inversion than controls (15.1̊ vs. 19.3̊, p=0.03), lower AOFAS scores (94.1 vs. 99.6 points, p=0.01), due to pain (p=0.01) and alignment (p=0.006) subscores. Using the VAS-FA score, patients were found to demonstrate higher pain at rest (prange, 0.02–0.03) and during activity (p=0.009), and felt limited when standing on one leg (p range, 0.01–0.03) and running (p=0.04). No loss of correction was found after removal of the implant. ConclusionThis study showed that STA corrected the low longitudinal arch in symptomatic paediatric FFF, but did not correct forefoot abduction in relation to the hindfoot. Mid-term assessment revealed STA provided satisfactory ankle and hindfoot ROM, pain and function levels, but limitations are witnessed compared to unaffected individuals. This aspect should be considered when counselling patients and their parents or caregivers to allow for realistic expectations. Level of EvidenceIII, retrospective comparative study.