Median AOFAS Score Research Articles

Results of Surgical Treatment of Ankle and Posterior Malleolus Fractures Using Different Surgical Techniques

Background. Almost half of the patients with ankle fractures have fracture of the posterior malleolus. Conclusions of the existing studies are contradictory and do not provide a decisive answer to the question of the need for fixation of the posterior tibial fragment.
 Aim of the study — to compare the radiologic and functional outcomes of osteosynthesis of the posterior tibial fragment in unstable ankle fractures using closed reduction and minimally invasive technique and direct open reduction using posterolateral and posteromedial surgical approaches.
 Methods. Prospective multicenter study enrolled 132 patients with complex ankle and posterior malleolus fractures. They were divided into three groups depending on the technique of fixation of posterior tibia. Functional and radiologic results of treatment were assessed at 12, 24, and 48 weeks after osteosynthesis. The AOFAS and Neer scales were used.
 Results. Bone union occurred in all patients at an average of 8.3±0.8 weeks after surgery. Analysis of postoperative CT scans showed that the use of posterior approaches provided statistically significantly more precise reduction of the fragments of posterior tibia. Functional results of patients of the second (posterolateral approach) and third (posteromedial approach) groups at 24 and 48 weeks of follow-up were statistically significantly superior to those of the first group. The median AOFAS score at 48 weeks of follow-up was 86 for group 2 patients and 90 — for group 3. The median scores on the Neer scale were 88 and 94 points respectively.
 Conclusion. Posterior approaches in the surgical treatment of patients with complex ankle and posterior malleolus fractures allow for more precise fragment open reduction compared to closed one. These patients also show better mid-term functional outcomes.

Short- and long-term results for severe hallux valgus correction using a first metatarsal distal osteotomy

PurposeThe purpose of this study is to analyze the short- and long-term results of severe hallux valgus (HV) treated with a L-Reverse osteotomy. MethodsPatients treated with L-Reverse osteotomy for severe HV between the years 2006–2015 were included. Patients were evaluated preoperatively, at 3 months and 4 or more years postoperatively. Changes in the HV angle (HVA) and intermetatarsal angle (IMA) were measured. Clinical outcomes were assessed using the AOFAS score. Results28 patients were included. Pre-operative IMA changed from 18.1° (18–18.9°) to 7° (6.3–8.5°), and HVA from 38.5° (34.5–41.3°) to 10.0° (8.4–11.8°) at 3 month follow up (p < 0.005). Long term follow up was of 5.6 (4.9–6.4) years. IMA value was 7.5° (6.1°−8.1°) and HVA was 10.1° (6.7°−16.3°), with no statistical difference with initial correction (p = 0.14). Median AOFAS score was 92.7 (89–4–96.1). ConclusionL-Reverse osteotomy can achieve correction of HV severe deformities with good outcomes in long term follow up. Level of evidenceIII

Ultrasound-guided hyaluronic acid injection for the treatment of insertional Achilles tendinopathy: A prospective case series

BackgroundHeel pain is a common condition and often involves the Achilles tendon and is classified as insertional or non-insertional. Several operative and non-operative treatments have been described, but there is no consensus on the most effective therapy. The aim of this study is to evaluate a case series of patients with insertional Achilles tendinopathy refractory to conservative treatment submitted to a single-dose ultrasound-guided injection of hyaluronic acid (40 mg/2.0 mL). MethodsWe prospectively included 25 patients (29 feet) who underwent a single ultrasound-guided injection of hyaluronic acid after conservative treatment failure. Clinical outcomes such as pain (using the Visual Analog Scale – VAS), function (using the American Orthopedic Foot & Ankle Society – AOFAS score), personal satisfaction, and complications were evaluated. Statistical analysis was performed using the R software. ResultsMost patients were female (80%) and there was a right-side predominance (55%). The median VAS was 8 points [range 4–10] at baseline, decreasing to 3 points [range 0–8] at the six-month follow-up, with statistical significance (p < .001). The median AOFAS score was 71 points [range 38–87] at baseline, increasing to 90 points [range 48–100] at the six-month follow-up (p < .001). The personal satisfaction level was 69%, and 48% of patients considered the result excellent. There were no Achilles tendon ruptures, infections, or allergic reactions post injection. ConclusionSingle-dose injection of hyaluronic acid is a safe treatment option, improving function and reducing pain for six months in patients with insertional Achilles tendinopathy after conservative treatment failure. Level of evidenceIV, case series.

Complex approach to the conservative treatment of hallux rigidus

Introduction. Hallux rigidus (HR) is a common source of forefoot pain, which leads to progressive loss of range of motion in the first metatarsophalangeal (MTP1) joint and pathologically affects biomechanics of the whole lower limb. HR is characterized by degeneration of the articular surfaces of MTP1 joint with the formation of bone growths, cysts and erosions, osteochondral defects and loose bodies. The frequency of occurrence of HR is 1 in 40 adults older than 50 years, and this localization of osteoarthritis is the most common among all joints of the foot. The aim of this article is to improve the results of conservative treatment of HR through the use of physical rehabilitation methods, such as manual therapy, therapeutic exercises and foot orthotics.Materials and methods. This study included retrospective cases of 24 patients (28 feet), who underwent a single course of conservative treatment of HR at the European Clinic for Sports Traumatology and Orthopedics (ECSTO) of the European Medical Center (EMC) since January 2014 to December 2018. The patients’ mean age was 51 years (range, 41 to 69 years). Median time between the beginning of treatment and final examination was 26 months (interquartile range from 17 to 36 months). Patient satisfaction, VAS pain scale, AOFAS and FAAM questionnaires and MTP1 dorsiflexion were evaluated in this study.Results. According to AOFAS scale, we obtained 18% (5/28) of excellent, 78% (22/28) of good, 4% (1/28) of fair and no poor results. Median AOFAS score significantly increased from 58.5 points before treatment to 87.0 points on the final examination (p&lt;0.05). Median FAAM daily activity subscale showed 98% of functional outcome with median subjective score of 95%, median FAAM sports score was 97% and median subjective sports score rate was 90%. Patient’s satisfaction at the final examination was “excellent” in 57% (16/28), “good” in 39% (11/28), “fair” in 4% (1/28) of cases and no poor results were obtained. Median VAS pain scale decreased from 5 points before treatment to 1 point at the final examination (p&lt;0.05). Median angle of the MTP1 dorsiflexion significantly increased from 23° before treatment to 30° on the final examination (p&lt;0.05).Conclusion. Described approach of the conservative treatment of HR is an effective method of treatment of early stages of the disease with high patient satisfaction rate and functional outcome.

Clinical and radiological mid- to long-term results after direct fixation of posterior malleolar fractures through a posterolateral approach.

Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach. Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m2 at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors. After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected. Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term. Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

BackgroundTraditionally, size of the posterior fragment is considered the most important indicator for fixation in trimalleolar fractures. It remains unclear which factors contribute to worse functional and radiological outcome. This study was designed to determine predictors for the development of posttraumatic osteoarthritis and worse functional outcome in trimalleolar fractures.MethodsThis retrospective cohort study evaluated outcomes of 169 patients with a trimalleolar fracture treated between 1996 and 2013 in a level-1 trauma hospital in the Netherlands after a mean follow-up of 6.3 (range 2.4 to 15.9) years. The average fragment size was 17%. Twenty patients had a posterior fragment smaller than 5% of the intra-articular surface, 119 patients a fragment of 5–25% and 30 patients a posterior fragment larger than 25%. In total, 39 patients (23%) underwent fixation of the posterior fragment.ResultsClinical union was achieved in all 169 patients. The median AOFAS score after follow-up was 93 (interquartile range 76–100) and the median AAOS score was 92 (interquartile range 81–98). A persistent postoperative step-off larger than 1 mm was found in 65 patients (39%) and osteoarthritis was present in 49 patients (30%). Higher age and postoperative step-off > 1 mm were independent, significant risk factors for the development of osteoarthritis. Osteoarthritis and BMI were independent, significant risk factors for worse functional outcome.ConclusionIt is advisable to correct intra-articular step-off of intraarticular posterior malleolar fragments to reduce the risk of developing osteoarthritis and, consequently, the risk of worse functional outcome after long-term follow-up.Level of evidenceLevel IIB.

Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis' injuries in Weber B and C type fractures

BackgroundThis study compared clinical and radiographic results of patients who underwent stabilization of syndesmosis with one tricortical syndesmotic screw divided into three different groups: Group A without preoperative fractured ankle computed tomography (CT) scan, Group B with preoperative fractured CT scan, and Group C with preoperative bilateral ankle CT analysis. MethodsBetween June 2016 and May 2017, fifty-one patients with fracture type AO/OTA 44 B and C were analyzed. Of those, 14 (27.45%) were assigned to Group A, 19 (37.25%) to Group B, and 18 (35.30%) to Group C. Clinical outcomes with AOFAS score at 3, 6 and 12 months were recorded. Seven measurements on axial CT scan images were confronted between the injured and uninjured ankle to check the accuracy of reduction. ResultsAt three months of follow up the median AOFAS score was 70.86 ± 2.98 with no significative difference between groups (p = 0.105). At 12 months of follow up the median AOFAS score was higher in group C (93.44 ± 3.01) compared to Group B and Group C. The seven variables measured at the CT scan after syndesmotic reduction were statistically different between groups. We found a better restoration of the tibiofibular distances and the correct ankle anatomy in Group C respect to Group A and Group B. ConclusionsUse of the pre-operative CT scan of the injured and uninjured ankle give to the surgeons the more and accurate information for the reduction and help him intraoperative in the correct maneuvers. The accuracy of the syndesmosis reduction determines better clinical outcomes.

Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study

BackgroundThe transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented. Methods21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs. ResultsThe median maximal concentric strength was equal,1300 vs 1336W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219J vs. 2398J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes. ConclusionsPatients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.

The Syndesmotic Insufficiency in Mobile Bearing TAR – A Challenging and Underestimated Problem

Category: Ankle Arthritis Introduction/Purpose: The consequence of a missed syndesmotic insufficiency during mobile bearing total ankle replacement (TAR) surgery is subsequent valgus deformity leading to dissociation of the distal tibiofibular joint and failure of the TAR. The purpose of this study was to retrospectively review the patients who developed a syndesmotic insufficiency, which lead to a revision surgery, after primary TAR in our centre. The primary goal was to identify red-flags for possible syndesmotic insufficiency in preoperative planning of TAR, in order to reduce this type of complication. Methods: We identified twenty patients (12 females and 8 males) with a missed instability of the distal tibio-fibular joint appearing 3.5 years (range 0.8-9.5 years) after primary TAR. Patient’s records, preoperative and postoperative radiographs and intraoperative fluoroscope images were reviewed especially with regard to previous ankle or lower leg fractures. Functional outcome was assessed with the use of the American Orthopaedic Foot&amp;Ankle (AOFAS) hindfoot score. Results: The mean follow-up after last revision surgery was 3.5 years. The median AOFAS Score at last follow-up was 72.5. We could identify 3 risk factors for possible failure: (a) The nature of trauma: Weber-C-Type fractures or Maisonneuve-Type fractures were found in 13 of 20 cases. (b) A defect in the lateral tibial plafond after for example, a pilon fracture or arising due to cyst formation, was found in 3 cases. Here we concluded that the defect lead to a subsequent valgus tilt of the tibial component, acting as a stress riser in the distal tibio-fibular joint. (c) The remaining 4 cases showed a high tibial resection probably leading to an iatrogenic lesion of the anterior and posterior distal tibio-fibular ligaments. Conclusion: Knowing the etiology of posttraumatic osteoarthritis of the ankle joint is mandatory to identify a syndesmotic insufficiency in the preoperative work-up for mobile bearing three-component TAR. Due to these findings, our surgical protocol for TAR was adapted accordingly. If one or more of the risk factors are present during surgery we suggest performing distal tibio- fibular fusion.

Complications and functional outcome after fixation of distal tibia fractures with locking plate – A multicentre study

IntroductionThe aim of this study was to evaluate the proportion of complications and the functional outcome following ORIF with low-profile locking plates in patients with distal tibia fractures. MethodRetrospective data was retrieved using county databases, operation books, health record and X-ray images for 6 hospitals (1 level 1, 5 level 2) in the Region of Southern Denmark. Between January 2007 and April 2011 70 consecutive patients with 71 distal tibia fractures were treated with low-profile locking plate were included. The proportion of post-operative complications, classified as minor and major complications, was retrieved from electronic health records and patient interviews. Long-term functional outcome assessed by EuroQol EQ-5D-5L questionnaire, AOFAS Ankle-Hindfoot scale, and return to pre-injury job function through patient interview and examination. ResultsThere were 32 43A, 5 43B and 34 43C-fractures, 12 open and 10 high-energy fractures. Forty-nine cases (69%) experienced complications during the follow-up time, of which 34 were minor complications and 15 were major complications. Median EQ-5D-5L index value was 0.76, median EQ VAS-score was 80, and median AOFAS score was 73. Thirty-three percent of working patients had not returned to work as a result of the fracture. ConclusionsOur study suggest that treatment of distal tibia fractures with low-profile locking plates might have a higher proportion of complications and worse functional outcome than previously reported. Level of evidenceTherapeutic level IV Case Serie.

Central Calcaneal Osteotomy for Correction of Flexible Pes Planovalgus Deformity

Lateral column lengthening procedures have been extensively reported either as primary procedures or adjuncts to combined soft tissue procedures and osteotomies for the correction of the pes planovalgus deformity. There is also considerable debate as to the ideal procedure that is not followed by recurrence and obviates the need for revision surgeries and minimizes complications. We describe a technique and present the clinical results of lateral column lengthening that provides a powerful correction to restore normal foot alignment. We retrospectively reviewed 26 feet in 21 patients with a mean age of 35.4 years (range, 12-75) over an average follow-up period of 71 months (range, 12-147) who underwent reconstructive surgery for flexible pes planovalgus foot. The reconstructive procedures included a central calcaneal osteotomy in all patients, a medial column stabilization procedure, flexor digitorium transfer (FDL), and a gastrocnemius or Achilles tendon lengthening. Clinical evaluation was carried out with the AOFAS ankle-hindfoot scores. Standard weight-bearing anterior posterior (AP) and lateral radiographs before surgery and at follow-up were analyzed for radiographic parameters of correction. The median AOFAS score increased from 50 to 90. Two patients reported dissatisfaction with the result. There were no nonunions nor complications related to hardware. Radiographic improvement of the talonavicular coverage angle was a 74% change from baseline value. All radiographic parameters improved (P < .001) except the lateral talocalcaneal angle (P = .48). No secondary subsidence of the arch was observed within the follow-up time. Correction of flexible pes planovalgus deformity with a central calcaneal osteotomy was an effective, reproducible method to restore normal foot alignment and good function. Level IV, retrospective case series.

The Role of Weil and Triple Weil Osteotomies in the Treatment of Propulsive Metatarsalgia

The Weil and triple Weil osteotomy are widely used to treat third rocker metatarsalgia. The aim of this study was to analyze the results and complications of Weil and triple Weil osteotomy used for the treatment of third rocker metatarsalgia. This is a report of 82 patients who were operated due to third rocker metatarsalgia from March 2004 to May 2007. A total of 76 completed the study, 68 women and eight men, with a total of 93 operated feet, 52 right and 41 left ( 17 bilateral). The clinical results were evaluated using the AOFAS score for the assessment of lesser metatarsals and interphalangeal joints, and weightbearing lateral and AP foot X-ray for radiological evaluation. The median AOFAS score was 90 (range, 34 to 100). We had good results in 80% and unsatisfactory in 20%. Prior to surgery 75 feet were index minus, but after all 81 feet were plus-minus. With regard to complications, we had serious recurrence of metatarsalgia in 4.3%, moderate stiffness in 60.2% (severe in one case), floating toes in 4.3% and delays in bone healing in 7.5%. We believe that Weil and triple Weil osteotomies are effective procedures in the treatment of third rocker metatarsalgia. We feel preoperative planning with tracing on the weightbearing AP radiographs is an essential step.

Demographics and Functional Outcome of Toe Fractures

Toe fractures are common; however, there are few data on demographics and functional outcome. We studied outcomes in 339 consecutive patients with toe fractures treated between January 2006 and September 2008. Two hundred and sixty-four patients, aged 16 to 75, were mailed an outcome questionnaire, and overall subjective satisfaction with the outcome of treatment was measured using a visual analog scale (VAS). Most frequently affected were the first (38%) and fifth (30%) toes, and most (75.6%) of the fractures were caused by stubbing or crush injury. More than 95% of the fractures were displaced less than 2 mm, and all of the fractures were treated conservatively. The questionnaire was returned by 141 (53%) patients with a median follow-up of 27 months. Respondents were female in 57.4% of cases and had a median age of 45 years. The median AOFAS score was 100 (P 25, P 75 = 93,100) points; the median VAS was 10 (P 25, P 75 = 8, 10) points. Univariate regression analysis revealed no statistically significant associations between outcome and the particular toe or phalanx involved, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and the presence of diabetes mellitus. Satisfaction VAS was dependent on age ( P = .047) and gender ( P = .049) in the multivariate analysis. The AOFAS midfoot score was not influenced by any of the covariates. This is the first epidemiological investigation using 2 outcome-scoring systems to determine function and satisfaction following treatment of toe fractures.

Demographics and outcome of metatarsal fractures

Although metatarsal fractures are amongst the most common injuries of the foot, this is the first study on outcome after metatarsal fractures. All consecutive patients with metatarsal fractures treated between January 2006 and September 2008 were re-evaluated. Patients aged 16 to 75 were sent a questionnaire consisting of the American Orthopaedic Foot Ankle Society midfoot score and a Visual Analogue Scale (VAS) for patient satisfaction. Four-hundred metatarsal fractures were identified in 322 patients. The fifth metatarsal was involved in more than 50% of patients. Most fractures were caused by an inversion injury or fall from height (75%). Out of 247 patients between 16 and 75 years, a total of 166 patients (67.2%) returned the questionnaire with a median follow-up of 33 months. All patients were treated conservatively. The median AOFAS score was 100 points (P(25)-P(75), 87-100), the median VAS was 9 points (P(25)-P(75), 8-10). The AOFAS and VAS scores correlated negatively with the body mass index (BMI) (R (s) = -0.409 and -0.305; p < 0.001). Patients with diabetes reported lower VAS (p = 0.010) and AOFAS scores (p = 0.020). Females reported a lower AOFAS score (p = 0.034). An increase in dislocation (>2 mm) resulted in a decrease in VAS score (p = 0.017). Multivariable analysis indicated that the VAS score was significantly affected by BMI and dislocation >2 mm (p = 0.013). The AOFAS score was affected by BMI (p = 0.011). This is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months. Outcome is dependent on BMI, diabetes, gender, and dislocation at the fracture site.

Die operative Therapie der degenerativen Tibialis-anterior-Sehnenruptur

A degenerative tear of the anterior tibial tendon is a rare event compared to other tendons. The purpose of this study was to evaluate the functional results after surgical refixation. In a retrospective study, we report the functional outcome of five consecutive operatively treated patients suffering from a tear close to the insertion site of the anterior tibial tendon. All patients were assessed postoperatively, the AOFAS and Richter scores were obtained and the range of motion in the ankle joint was evaluated. Preoperatively all patients presented with a significant walking impairment due to a reduced active dorsiflexion, so the decision for surgical refixation was made. In all cases an MRI scan was performed preoperatively. Postoperative immobilisation without weight-bearing was done for six weeks. All patients returned to their former activity level, were satisfied with the postoperative result and had a normal gait in the follow-up examination. The range of motion was equal on both sides, the median AOFAS score was 86 and the median Richter score was 90 out of 100. There were no postoperative complications. Untreated tears of the anterior tibial tendon lead to significant impairment of the ankle joint and deformities of the foot. There is no consensus about the treatment with recommendations for operative and non-operative treatment. Various surgical procedures have been described. The surgical reconstruction of the tendon leads to a restored function of the ankle joint and allows a normal gait and is therefore desirable. Due to the loss of function and the good results after surgical treatment in our study, the non-operative treatment is not advisable. Surgical repair of degenerative tears of the anterior tibial tendon leads to very good functional results and high patient satisfaction.