Posttraumatic Ankle Osteoarthritis Research Articles

The effect of MSM in the treatment of ankle arthrosis: Is MSM as effective as methylprednisolone or hyaluronic acid?

Posttraumatic ankle osteoarthritis (PTAO) causes severe ankle and adjacent joint morbidity. We aimed to compare the treatment efficacy of previously tried and still applied intra-articular injections and oral methylsulfonylmethane (MSM) at functional and histopathological level in PTAO animal model. Thirty-two adult female Sprague-Dawley rats were divided into four groups (Group 1: Control, Group 2: 0.06 g/kg/day MSM, Group 3: 0.04 mg/µL methylprednisolone [MP], Group 4: 0.04 mg/µL hyaluronic acid [HA]). MSM was started orally between Day 0 to the end of 8 weeks. Intra-articular injections were applied to the right ankles of the subjects after surgery. All subjects were killed after radiological evaluation at the 8th week. Subsequently, functional (range of motion) and histopathological evaluation was performed. Radiological evaluation showed better results of the MP (p < 0.001) and MSM (p < 0.001) groups than the control group. Severity of osteoarthritis (OA) in the MP group was significantly less than in the HA group (p = 0.032). When the total Osteoarthritis Research Society International score was compared, the severity of OA was higher in the KS and HA groups than in the control group (p < 0.001). No significant statistical difference was found in the histopathological comparison of MSM and control group (p = 0.466). There was no difference between the groups in range of motion measurement according to the contralateral ankle joint. The radiological progression of OA was slowed in the MSM and MP groups, but significant histopathological worsening was found in the MP and HA applied groups. We suggest that the treatment methods used in daily practice need to be reviewed.

APPLICATION OF EXTERNAL TORQUE ENHANCES THE DETECTION OF SUBTLE SYNDESMOTIC ANKLE INSTABILITY IN A WEIGHTBEARING CT

One-fourth of all ankle trauma involve injury to the syndesmotic ankle complex, which may lead to syndesmotic instability and/or posttraumatic ankle osteoarthritis in the long term if left untreated. The diagnosis of these injuries still poses a deceitful challenge, as MRI scans lack physiologic weightbearing and plain weightbearing radiographs are subject to beam rotation and lack 3D information. Weightbearing cone-beam CT (WBCT) overcomes these challenges by imaging both ankles during bipedal stance, but ongoingdebate remains whether these should be taken under weightbearing conditions and/or during application of external rotation stress. The aim of this study is study therefore to compare both conditions in the assessment of syndesmotic ankle injuries using WBCT imaging combined with 3D measurement techniques.In this retrospective study, 21 patients with an acute ankle injury were analyzed using a WBCT. Patients with confirmed syndesmotic ligament injury on MRI were included, while fracture associated syndesmotic injuries were excluded. WBCT imaging was performed in weightbearing and combined weightbearing-external rotation. In the latter, the patient was asked to internally rotate the shin until pain (VAS&gt;8/10) or a maximal range of motion was encountered. 3D models were developed from the CT slices, whereafter. The following 3D measurements were calculated using a custom-made Matlab® script; Anterior tibiofibular distance (AFTD), Alpha angle, posterior Tibiofibular distance (PFTD) and Talar rotation (TR) in comparison to the contralateral non-injured ankle.The difference in neutral-stressed Alpha angle and AFTD were significant between patients with a syndesmotic ankle lesion and contralateral control (P=0.046 and P=0.039, respectively). There was no significant difference in neutral-stressed PFTD and TR angle.Combined weightbearing-external rotation during CT scanning revealed an increased AFTD in patients with syndesmotic ligament injuries. Based on this study, application of external rotation during WBCT scans could enhance the diagnostic accuracy of subtle syndesmotic instability.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

Injury severity at the time of sport-related ankle sprain is associated with symptoms and quality of life in young adults after 3–15 years

Background Ankle sprains are the most common sports-related injuries. Individuals with time-loss ankle sprains often experience residual symptoms and chronic ankle instability years after injury. Up to 90% of post-traumatic ankle osteoarthritis cases are associated with severe ankle sprain. This study aimed to examine whether ankle injury severity sustained during youth sports participation is associated with ankle symptoms and function. Materials and Methods Cohort study included 50 young adults (mean age, 23 years) with a 3-to 15-year history of a youth-sport related ‘significant ankle sprain’ (SAS). The primary independent variable was injury severity, which was captured in the index SAS injury details through interviews. SAS was defined as ligament and other intra/extra-articular structure injuries that disrupted youth sport participation, at least 3 days of time loss, and required medical consultation. Severe SAS was defined as SAS involving >28 days of time loss, and non-severe SAS only involved ankle ligaments and/or with ≤28 days of time loss. The Foot and Ankle Outcome Score questionnaire was used to assess ankle symptoms and function. Descriptive statistics and multivariable linear regression models were used to examine the association between SAS severity and outcomes, with sex and time since injury as covariates. Results Compared to participants with non-severe SAS, participants with a history of severe SAS demonstrated significantly poorer outcomes in symptoms [-18.4 (99% CI: −32.2 to −4.6)], pain [-10.1 (99% CI: −19.2 to −1.1)] and QoL [-17.1 (99% CI: −33.1 to −1.1)] in multivariable linear regression models. Conclusions Severe ankle sprain with a loss of > 4 weeks from sports participation at the time of injury is independently associated with poorer ankle symptoms, pain, and ankle-related quality of life after 3–15 years. Secondary prevention measures are needed in individuals with a history of severe ankle sprains to mitigate the potential health consequences.

Continuous detrimental activity of intra-articular fibrous scar tissue in correlation with posttraumatic ankle osteoarthritis

Posttraumatic osteoarthritis is primarily characterized by articular cartilage destruction secondary to trauma or fracture events. Even while intra-articular scar tissue can be observed following ankle fractures, little is known about its nature and molecular events linking its biological activity and cartilage deterioration. Here, we investigated scar tissue's histological and molecular characteristics, and its relationship with localized articular cartilage alterations consistent with early osteoarthritic degeneration. Intra-articular scar tissues from sixty-two patients who underwent open reduction internal fixation for ankle fracture were obtained at hardware removal time (6–44 months after fracture). Histological analysis demonstrated that scar tissue has the nature of fibrosis with fibrous tissue hyperplasia, fibroblast proliferation, and chondrometaplasia. These fibrous scar tissues showed overexpressed pro-inflammatory cytokines and high mRNA expression levels of osteoarthritis-related markers (cytokines, chemokines, and enzymes) compared to the normal synovium. Furthermore, those transcriptional levels were significantly correlated with the grade of talar chondral degeneration. Our findings suggest that following an ankle fracture, the intra-articular fibrous scar tissue exhibits high catabolic and inflammatory activity, which has a long-lasting negative impact correlated to cartilage deterioration in the development of posttraumatic osteoarthritis.

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture–dislocations

PurposeAnkle fracture–dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations.MethodsA total of 67 patients with ankle fracture–dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, a 10-point visual analog scale (VAS) score (range 0–10), and complications before and after the definitive surgery were recorded.ResultsA significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036).ConclusionAnkle fracture–dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.

Functional and radiographic assessments of post-traumatic asymmetrical ankle osteoarthritis treatment using supramalleolar osteotomies

PurposeThis study's objective is to assess the effectiveness of supramalleolar osteotomies (SMOT) in the treatment of asymmetrical ankle osteoarthritis in terms of the improvement in alignment assessed radiographically and its impact on symptoms measured by the American Orthopedic Foot and Ankle Society ankle–hindfoot score (AOFAS ankle–hindfoot score).MethodsTwelve patients participated in this prospective observational case series study. Standing anteroposterior, true lateral, and mortise views radiographs were taken. For preoperative planning, the lateral distal tibial angle (LDTA), talar tilt (TT), talocrural angle (TCA), and anterior distal tibial angle (ADTA) were all measured. A medial opening wedge osteotomy mainly was used to treat the varus arthritis ankle. A further oblique fibular osteotomy is frequently necessary.ResultsThe male-to-female ratio was 3:1, and the mean age of the patients was 26.25 ± 13.032 years. There were highly statistically significant differences between pre-and post-operative AOFAS ankle–hindfoot score (p < 0.001). Statistically significant differences concerning ankle range of motion (p = 0.002, < 0.001) of dorsiflexion and planter flexion were detected. Comparison between pre-and post-operative patients' radiology characteristics shows statistically significant differences concerning TT (p = 0.016) and LDTA (p = 0.046).ConclusionSMOT is very effective in the treatment of post-traumatic ankle osteoarthritis and postpones ankle fusion or total ankle replacements. This surgery significantly improves functional and radiological outcomes as well as the range of motion in the ankle. Meticulous preoperative planning by radiological measurements of different angles around the ankle is considered the crucial factor in success of that operation.

The Use of Injection Methods for the Prevention and Treatment of Post-Traumatic Osteoarthritis of the Ankle Joint (Literature Review)

Summary. Treatment of post-traumatic osteoarthritis (OA) of the ankle joint remains an issue of modern orthopedics. Conservative therapy may lose its effect over time or cause considerable side effects. Intra-articular injections are successfully used in the treatment of ОA in other major joints, so it has been hypothesized that they also may be effective in patients with ankle OA.&#x0D; Objective: to analyze the literature devoted to injection methods of treatment of post-traumatic ankle OA.&#x0D; Material and Methods. The search for publications which evaluated the effectiveness of intra-articular therapy in reducing pain and improving function in the treatment of ankle OA was conducted on PubMed databases, from 2007 to 2022. Intra-articular therapy included corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cells (MSC), botulinum toxin A (BoNT-A), prolotherapy, and bone marrow aspirate.&#x0D; Results. 146 publications related to intra-articular therapy in the treatment of ankle OA were found. 40 publications were selected for analysis, of which there were 11 randomized controlled studies and 4 meta-analyses; other publications were of III and IV levels of evidence. The number of literature sources related to the effectiveness of intra-articular therapy was as follows: HA – 24, CS – 3, BoNT-A – 1, PRP – 5, MSc – 1, prolotherapy – 2, and bone marrow aspirate – 1.&#x0D; Conclusions. Intra-articular therapy may be effective in the treatment of post-traumatic OA of the ankle joint. However, modern literature data in this area are mostly of poor quality and consist of small sample studies. Since there are currently no studies comparing these techniques, it is difficult to determine whether one type of injection therapy should be preferred over another. This determines the need for further research, especially regarding the criteria for evaluating the effectiveness and long-term safety of these treatments.

Ankle joint contact force profiles differ between those with and without chronic ankle instability during walking

BackgroundIndividuals with chronic ankle instability (CAI) exhibit aberrant gait biomechanics relative to uninjured controls. Altered gait biomechanics likely contribute aberrant joint loading and subsequent early onset ankle joint degeneration. Joint (i.e. cartilage) loading cannot be directly measured without invasive procedures but can be estimated via joint contact forces (JCF) generated from musculoskeletal modeling. However, no investigation has quantified JCF in those with CAI during walking despite the link between ligamentous injury and ankle post-traumatic ankle osteoarthritis. Research questionDo patients with CAI exhibit altered ankle compressive and shear JCF profiles during the stance phase of walking compared to those without CAI? MethodsTen individuals with CAI and 10 individuals without a history of ankle sprain completed a gait assessment at their self-selected speed on an instrumented treadmill. Musculoskeletal modeling was applied to estimate ankle JCF variables within a generic model. Variables included the peak, impulse, and loading rates for compressive, anteroposterior shear, and mediolateral shear JCF. ResultsThose with CAI had significantly different JCF forces, relative to uninjured controls, in all directions. More specifically, lower compressive peak and impulse values were noted while higher anteroposterior shearing forces (1 st peak, impulse, loading late) were observed in those with CAI. Those with CAI also demonstrated higher mediolateral shearing forces (1 st peak and impulse). SignificanceOur finding suggests that those with CAI exhibit different ankle joint loading patterns than uninjured controls. Directionality of the identified differences depends on the axis of movement.

Supramalleolar osteotomy for the treatment of ankle osteoarthritis leads to favourable outcomes and low complication rates at mid-term follow-up: a systematic review.

The purpose of this systematic review was to evaluate both the clinical and radiographic outcomes following supramalleolar osteotomy (SMO) in patients with ankle osteoarthritis, and to analyse the level of evidence (LOE) and quality of evidence(QOE) of the included studies. A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following SMO for the treatment of ankle osteoarthritis were included and assessed. The level and quality of evidence of the included studies were also evaluated. Twenty-four studies with 1160 patients (1182 ankles) were included. Overall, 78.8% patients presented with post-traumatic ankle osteoarthritis. The weighted mean AOFAS score improved from 52.6 ± 9.7 (range 33.8-78.4) preoperatively to 78.1 ± 5.7 postoperatively at weighted mean follow-up of 50.4 ±18.6months (range 24.5-99.0). The most frequently utilised radiographic parameter was the tibial anterior surface angle, which improved from a preoperative weighted mean of 86.3° ± 5.6° (range 76.0°-102.0°) to a postoperative weighted mean of 89.9° ± 3.7° (range 84.9°-99.6°). The complication rate was 5.1% with non-union as the most commonly reported complication (1.6%). Secondary procedures were carried out in 28.2% of patients, the most common of which was implant and hardware removal (17.6%). The failure rate was 6.8%. Two studies were LOE II, 3 studies were LOE III, and 19 studies were LOE IV. The mean Modified Coleman Methodology Score was 59.3 ± 6.6 and the mean MINORS criteria score of all the included studies was 9.5 ± 3.7. This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. However, a moderate reoperation rate (28.2%) was reported. A low failure rate (6.8%) was reported, which must be interpreted in light of the shortcomings of the design of the included studies and a relatively short follow-up period. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data which underscores the need for further higher quality research to be conducted. Our review highlights that SMO may be an effective and safe procedure in the setting of early-to-intermediate-stage ankle osteoarthritis. IV.

Profile and Frequency of One Hundred Ankle Osteoarthritis Cases in an Indonesian Tertiary Hospital

Osteoarthritis is one of the most common cases in orthopedics and traumatology clinic. Ankle osteoarthritis is less common than osteoarthritis of hip and knee. Limited data and literature resulted in suboptimal treatment strategy. The purpose of this study was to describe the profile and frequency of ankle osteoarthritis at Dr. Hasan Sadikin General Hospital Bandung, a tertiary referral hospital in Indonesia. A cross-sectional descriptive observational study was conducted on all patients diagnosed with ankle osteoarthritis enrolled in the medical record database at Dr. Hasan Sadikin General Hospital Bandung, Indonesia in November 2020–November 2021. Results showed that the majority of the patients were female (52%), aged ≥60 years old (44%), graduated from senior high school education (56%), and housewives (30%). The 100 patients were proportionally distributed with most of them were categorized as suffering from secondary osteoarthritis with post-trauma predominance. From the perspective of body mass index, 85% patients were classified as above normal. As many as 76% of patients presented to the hospital in an advanced stage. With the high rate of posttraumatic ankle osteoarthritis, concerns should be given more to the ankle trauma management, as well as to the population with high body mass index. Increased health promotion for general population and health care providers is also needed to reduce the tendency of late presentation at the health care facility.

Comparisons between ankle distraction arthroplasty and supramalleolar osteotomy for treatment of post-traumatic varus ankle osteoarthritis

BackgroundAnkle distraction arthroplasty and supramalleolar osteotomy were both options for post-traumatic varus ankle arthritis (VAA), but their comparative effectiveness was scarcely reported. This study aimed to compare the outcomes of two operative methods for treatment of Takakura-Tanaka stage 3 post-traumatic VAA.MethodsThis was a retrospective study, comprising 73 consecutive patients who presented with Takakura-Tanaka stage 3 post-traumatic VAA treated by either ankle distraction arthroplasty (n = 32) or supramalleolar osteotomy (n = 41) from January 2016 to December 2019. All patients had a minimum 24-month follow-up assessments. The outcome measures were visual analog scale (VAS), the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, complications, patient-rated overall satisfaction and ankle function.ResultsAt an average of 32 months (range, 24–52 months) follow-up, significant improvement was observed for VAS, AOFAS, range of motion (ROM) and most radiographic parameters (except for TAS and TLS for ankle distraction arthroplasty group) compared to preoperative baselines (p < 0.05) for both groups. However, both groups did not differ significantly in terms of VAS or AOFAS, excellent and good rate (78.1% versus 85.4%, p = 0.422), overall rate of postoperative complications (28.1% vs. 17.1%, p = 0.257), or various radiographic parameters (e.g. tibial anterior surface angle, talar tilt angle and tibial lateral surface angle) (all p > 0.05). The ankle distraction arthroplasty group had a better postoperative ankle motion than did the supramalleolar osteotomy group, in terms of plantarflexion (37.8 ± 4.2 vs. 30.4 ± 3.6, p = 0.006), dorsiflexion (36.5 ± 6.4 vs. 28.3 ± 5.5, p = 0.004), varus (32.1 ± 4.5 vs. 27.1 ± 3.1, p = 0.017) and valgus (28.4 ± 3.7 vs. 25.2 ± 2.8, p = 0.046).ConclusionsBoth operative treatments are effective for Takakura-Tanaka stage 3 post-traumatic VAA. In practice, individualized treatment option tailored to the ankle condition and patients’ specific need should be considered.Level of evidence: III, retrospective comparative series.

What are the Injures that Lead to Post-Traumatic Ankle Osteoarthritis? A Long-Term Retrospective Analysis of 533 Patients

Category:Ankle Arthritis; Ankle; TraumaIntroduction/Purpose:Ankle osteoarthritis (AO) is an incapacitating condition for patients and a substantial burden for medical assistance. It is well known that the vast majority of AO occurs as a sequela of previous trauma. However, it is currently unknown what types of injuries of the foot and ankle most commonly lead to end-stage arthritis. Therefore, the purpose of this study was to investigate the etiology of end-stage ankle osteoarthritis in all patients who underwent ankle fusion or replacement at a tertiary care center over 20 years. We hypothesized that the most common injury patterns would correspond to low-energy lesions.Methods:The electronic medical record was queried using current procedural terminology (CPT) codes for ankle fusion or ankle replacement to identify all patients who underwent either of these procedures at a single tertiary academic center over 20 years. Etiologies were broadly grouped as Pilon/Plafond fracture, ankle fracture, talus fracture, tibia fracture, single or recurrent sprains, infection/septic joint, systemic disorder (Charcot arthropathy, rheumatoid arthritis, hemophilic arthropathy), and idiopathic/primary osteoarthritis. Each fracture pattern was then subclassified using commonly accepted classification systems by two independent observers in addition to the grade of arthritis at the time of fusion or replacement. Reliability among readers was assessed by Kleiss kappa. Normative data were analyzed by ANOVA and comparison among groups and methods by Student's T- test.Results:A total of 533 patients were included in this study. The initial injury patterns were broadly classified as pilon/plafond (65), ankle (173), sprains (110), talus (17), tibia (22), tibiotalar dislocation without fracture (1). Other identified etiologies included rheumatoid arthritis (18), Charcot arthropathy (11), progressive collapsing foot deformity (21), septic arthritis (5), and cavovarus (6). The average time interval between the initial injury and definitive treatment for end-stage arthritis was 558 days. Ankle fractures classified as 44C1 (14,1%), 44B3 (10.6%), 44B2 (9.3%) followed by pilon 43C3 (6.5%) and 43C1 (4.1%) were the most prevalent subclassification found in the fractures group.Conclusion:The primary etiology for AO is secondary due to trauma. A history of ankle sprains and instability was found in 20.6%. Fractures corresponded to 54,6% of our cohort, ankle fractures producing most of these lesions. When considering the subtype of injury, ankle fractures with a 44C1 and a 44B3 classification were the more frequent presentation. These findings could support the argument that complex low-energy rotational traumas do not carry a benign course. Comprehension of the AO etiology scenario may guide prevention policies and specific primary treatment guidelines to diminish disease impact on the population and health care system.

Comparison of Midterm Outcomes Between the Intramedullary Fibular Nail and the Locking Plate for the Treatment of Unstable Ankle Fractures in Active Young Patients

Category:Trauma; AnkleIntroduction/Purpose:We aimed to compare the midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using plates for the treatment of unstable ankle fractures in active young patients.Methods:In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and the three-dimensional (3D) reconstruction model using the CT scan images as well as the development of posttraumatic ankle osteoarthritis (PTOA) assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud and Molander score (OMAS), the Foot and Ankle Outcome Score (FAOS) and visual analog scale (VAS) pain score as well as complications.Results:In an assessment by both plain radiography and the 3D reconstruction model, the fair or poor reduction was more observed in the IMN group than in the ORIF group at final follow-up (P <.001). Poor reduction in the IMN group was significantly related to Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures (P <.001). PTOA was observed in 21.3% in the IMN group compared to 9.1% in the ORIF group (P =.024). There were no significant differences in clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P <.001).Conclusion:Surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures.

Toward Preventing Arthritis: A Comparison of Synovial RNA in Osteoarthritic Ankles and Knees

Category:Ankle; Ankle Arthritis; Basic Sciences/Biologics; TraumaIntroduction/Purpose:Osteoarthritis (OA) of the lower limb is a debilitating, incurable, expensive and prevalent condition in people over 45. Although ankle posttraumatic OA (PTOA) has the highest incidence, primary OA is increasingly recognized. The difference in OA incidence between lower limb joints is partly driven by differences in cartilage architecture and chondrocyte function at each site, with ankle chondrocytes showing reduced responsiveness to inflammatory mediators and more metabolic activity than those in the knee. Synovium also contributes to the pathogenesis of OA, however its potentially differential role in knee versus ankle OA remains an unanswered question. We aim to understand the molecular contribution of synovial dysregulation in the progression of ankle and knee OA to uncover candidate pathways for the development of targeted therapeutic paradigms.Methods:After obtaining informed consent from patients undergoing total knee or ankle replacement, basic surgical, past medical history, and imaging data was collected. Synovium samples were harvested during surgery and processed for RNA. Bulk 150 bp, paired-end RNA seq was conducted using standard protocols using the Illumina NovaSeq6000 platform. After quality control trimming, reads were aligned to human reference genome (GRCh38) using STAR (v 2.5) using the Maximum Mappable Prefix method and HTSeq (V0.6.1) was used to index mappable reads per gene. Counts were corrected for gene length using the FPKM method. Differential expression was determined using the edgeR (v 3.16.5) package for R, after adjustment using a scaling normalization factor and P-values were corrected using the Benjamini and Hochberg method. Similarities between samples were determined using Spearman Correlation and degree of similarity was visualized considering the first three Principal Components (PC).Results:RNA was obtained from 6 end-stage ankle OA, 1 end-stage knee OA patients. Of the ankle samples, two were PTOA and the remaining four were primary OA. The PTOA and the primary OA samples showed high sample correlation regardless of class (correlation coefficients ranged from 0.844 to 0.941). In contrast, the total knee sample was less correlated with the ankle samples (correlation coefficients ranged from 0.719 to 0.878). By using the first three PC, we observed that there was no obvious differentiation among the ankle OA samples, but there was clear separation between ankle and total knee samples. We observed an enrichment of genes annotated to the Gene Ontology clusters 'Extracellular Structure Organization' and 'Inflammatory Response' when comparing the two types of OA.Conclusion:These initial pilot results of an ongoing study support our hypothesis that synovial transcriptome differs between the knee and ankle in end-stage osteoarthritis and that anatomic site is a larger driver of synovial expression differences than OA type. This is supported by previous differences reported between ankle and knee chondrocytes in end-stage OA. These findings emphasize the importance of investigating synovial tissue to better understand the microenvironment of the ankle joint and pathogenesis of all etiologies of OA. The ultimate goal is the development of clinical tests and therapeutics aimed at slowing or discontinuing the degenerative process in ankle arthritis.

Reliability of Manually Segmenting T1ρ Magnetic Resonance Sequences of Talar Articular Cartilage.

Quantifying early posttraumatic ankle osteoarthritis pathogenesis using compositional magnetic resonance (MR) imaging sequences is becoming more common. These MR sequences are often manually segmented to isolate the cartilage of interest before cartilage compositional values (eg,T1ρ or T2) are quantified. However, limited information is available regarding the reliability and reproducibility of manual segmentation for the entire talar dome. The purpose of this study was to determine the intraobserver and interobserver reliability of manually segmenting T1ρ MR sequences of the entire talar dome and 4 subregions of interest. Descriptive observational study. Laboratory. Ten uninjured healthy individuals (4M and 6F: 21.40 [3.03]y, 170.00 [7.93]cm, 71.03 [14.97]kg) participated. None. Two investigators manually segmented 10 T1ρ ankle MR sequences using ITK-SNAP software to calculate T1ρ mean relaxation times and cartilage volumes. Each observer repeated the segmentation twice, with segmentations separated by 1 month. Intraobserver and interobserver reliability was determined using intraclass correlation coefficients (ICCs) with 95% confidence intervals and root mean square coefficient of variations (RMSCVs). For T1ρ relaxation time, intraobserver (ICC = .994-.997, RMSCV = 1.31%-1.51%) and interobserver reliability (ICC = .990, RMSCV = 2.36%) was excellent for the overall talar dome. Excellent intraobserver (ICC = .975-.980, RMSCV = 3.88%-4.59%) and excellent interobserver reliability (ICC = .970, RMSCV = 5.13%) was noted for overall talar cartilage volume. The results demonstrate that manual segmentation of the entire talar dome from a T1ρ MR is reliable and repeatable.

What are the Injures that Lead to Post-Traumatic Ankle Osteoarthritis? A Long-Term Retrospective Analysis of 533 Patients

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Ankle osteoarthritis (AO) is an incapacitating condition for patients and an important burden for medical assistance. It is well known that the vast majority of AO occurs as a sequela of previous trauma, however, it is currently unknown what types of injuries of the foot and ankle most commonly lead end-stage arthritis. The purpose of this study was to investigate the etiology of end-stage ankle osteoarthritis in all patients who underwent ankle fusion or replacement at a tertiary care center over a 20-year period. Our hypothesis was that the most common injury patterns would correspond to low-energy lesions.Methods:The electronic medical record was queried using current procedural terminology (CPT) codes for ankle fusion or ankle replacement to identify all patients who underwent either of these procedures at a single tertiary academic center over a 20-year period. Etiologies were broadly grouped as Pilon/Plafond fracture, ankle fracture, talus fracture, tibia fracture, single or recurrent sprains, infection/septic joint, systemic disorder (Charcot arthropathy, rheumatoid arthritis, hemophilic arthropathy) and idiopathic/primary osteoarthritis. Each fracture pattern was then subclassified using commonly accepted classification systems by two independent observers in addition to the grade of arthritis at time of fusion or replacement. Reliability among readers was assessed by Kleiss kappa. Normative data were analyzed by ANOVA and comparison among groups and methods by Student's T- test.Results:A total of 533 patients were included in this study. The initial injury patterns were broadly classified as: pilon/plafond (65), ankle (173), sprains (110), talus (17), tibia (22), tibio-talar dislocation without fracture (1). Other identified etiologies included rheumatoid arthritis (18), charcot arthropathy (11), progressive collapsing foot deformity (21), septic arthritis (5), and cavovarus (6). The average time interval between the initial injury and definitive treatment for end-stage arthritis was 558 days. Ankle fractures classified as 44C1 (14,1%), 44B3 (10.6%), 44B2 (9.3%) followed by pilon 43C3 (6.5%) and 43C1 (4.1%) were the most prevalent subclassification found in the fractures group.Conclusion:The main etiology for AO is secondary, due to trauma. History of ankle sprains and instability was found in 20.6%. Fractures corresponded to 54,6% of our cohort, ankle fractures producing most of these lesions. When considering the subtype of injury, ankle fractures with a 44C1 and a 44B3 classification were the more frequent presentation. These findings could support the argument that complex low-energy rotational traumas do not carry a benign course. Comprehension of the AO etiology scenario may guide prevention policies and specific primary treatment guidelines with the objective of diminishing disease impact on population and health care system.

Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis.

Posttraumatic osteoarthritis of the ankle and hindfoot is a common and frequently debilitating disorder. 70% to 90% of ankle osteoarthritis is related to prior trauma that encompasses a spectrum of disorders including fractures and ligamentous injuries that either disrupt the articular surface or result in instability of the joint. In addition to clinical evaluation, imaging plays a substantial role in the treatment planning of posttraumatic ankle and hindfoot osteoarthritis. Imaging evaluation must be tailored to specific clinical scenarios and includes weight bearing radiography that utilizes standard and specialty views, computed tomography which can be performed with a standard or a weight bearing technique, magnetic resonance imaging, and ultrasound evaluation. This review article aims to familiarize the reader with treatment rationale, to provide a brief review of surgical techniques and to illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis, such as joint-preserving procedures, ankle fusion, subtalar fusion, tibiotalarcalcaneal fusion and ankle arthroplasty. Preoperative findings will be discussed along with the expected postoperative appearance of various procedures in order to improve detection of their complications on imaging and to provide optimal patient care.

Posttraumatic Osteoarthritis. Effective Combination of Non-steroidal Anti-inflammatory Drugs and SYSADOA

Osteoarthritis (OA) is the most frequent joint desease and is the leading cause of the functional loss and disability among older patients. The heterogeneity of OA determines the absence of a 100% effective therapeutic strategy for all patients. In addition, this heterogeneity may be the main reason for the failure of clinical trials of therapeutic agents designed to restore cartilage. The SYSADOA group of drugs, in particular – glucasamine and chondroitin, is among the most studied compounds, have a good safety profile and showed proven efficacy in the early stages of osteoarthritis. The use of these drugs in combination with non-steroidal anti-inflammatory drugs (NSAIDs) is widespread in the world and is included in the recommendations of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis – ESCEO. The objective: to assess the clinical efficacy and safety of the combination of diclofenac potassium 50 mg, chondroitini sulfatis 400 mg and glucosamini sulfatis 500 mg; chondroitini sulfatis 400 mg and glucosamini sulfatis 500 mg in treatment of patients with knee and ankle post-traumatic osteoarthritis in the early stages (I–II according to Kelgren and Lawrence). Materials and methods. The study was designed as a randomized comparative prospective placebo-controlled in parallel groups. The level of evidence for this study is II-B. Patients of the main group N1 underwent surgical treatment for joint trauma and had a radiographically and clinically confirmed diagnosis: post-traumatic osteoarthritis stage I-II (according to Kelgren and Lawrence) of the ankle (N1.1=15) and knee (N1.2=15) joints. Time from injury and surgery was 14.3±2.3 months. Patients from main group received combination of diclofenac potassium, chondroitini sulfatis and glucosamini sulfatis for 10 days at the begining of the treatment course, and followed with combination of chondroitin and glucosamin for 3 months further. The comparison group included similar patients in terms of the number, gender, age and the nature of OA (N2.1=15; N2.2=15), these patients were prescribed diclofenac potassium 50 mg 2 times a day (for the first 10 days of treatment), and further followed with placebo (for the next 3 months). All enrolled patients also were prescribed basic non-pharmacological treatment, which included body weight control, physical therapy, mechanotherapy, exercises, together with orthopedic devices to unload and stabilize the affected joint. The results of treatment were assessed clinically at 3 months and 6 months after the start of treatment using VAS, functional state of the ankle (according to AOFAS) and knee (according to Lysholm scale); on each visit information about adverse reactions was collected. Results. After 3 months, the intensity of pain according to VAS in the N1.1 group was 24.8±2.1 points, and in the N2.1 group 29.2±3.2 (p&lt;0.05). After 6 months, the VAS results were accordingly 15.1±3.4 vs 26.7±0.9 (p&lt;0.01). The functional capacity of the ankle joint, evaluated by AOFAS, after 3 months in N1.1 group achieved 81.7±4.3 and 68.4±5.6 points in N2.1 group (p&lt;0.01). At 6 months, the AOFAS score was 93.9±3.8 vs 79.4±4.1 (p&lt;0.05). After 3 months VAS score in patients with early stages of knee OA (group N1.2 and N2.2) was 21.2±1.9 vs 28.3±3.1 mm (p&lt;0.05); after 6 months – 14.7±1.4 vs 23.9±2.8 mm (p&lt;0.01). The level of functional activity after 3 months of treatment according to the Lysholm scale achieved 86.8±2.9 points versus 68.4±5.6 points (p&lt;0.05) and after 6 months - continued to grow and got to 97.4±1.2 vs 86.2±2.9 points (p&lt;0.01). There were no statistical differences in number and intensity of the adverse events in the studied groups (p&gt;0.5). Conclusions. In the early stages of post-traumatic osteoarthritis of the knee and ankle joints (I–II according to Kelgren and Lawrence), a 3-month course of treatment with combination of NSAID and SYSADOA (diclofenac with chondroitin and glucosamin), followed by further treatment with SYSADOA (chondroitin and glucosamine) demonstrated superior efficacy compared to the placebo/standard treatment with the same level of safety.

Epidemiological study of post-traumatic ankle osteoarthritis after ankle sprain in 195,393 individuals over middle age using the National Health Insurance Database: A retrospective design

ObjectivesThis study aimed to determine the risk of ankle OA onset after an incidence of sprain, relative to the risk of onset in healthy population, and to investigate the effect of gender, age, BMI, and exercise on the development of ankle OA after sprain. DesignRetrospective cohort study. MethodsUsing a sample cohort dataset from 2002 to 2013 provided by the Korean National Health Insurance Sharing Service, we calculated the mean survival time and cumulative incidence rate in sprained and healthy populations using Kaplan-Meier analysis. A Cox proportional hazards model was used to analyze the adjusted hazard ratio (HR) of sprain for the development of OA with 95% confidence intervals (CIs). Adjusted HRs of gender, age, BMI, and exercise (yes/no) were analyzed in the sprained group. ResultsAmong the selected population of 195,393 individuals, 40,876 (20.9%) were diagnosed with an ankle sprain, and 1543 (3.85%) of those individuals developed ankle OA. Of the 154,517 healthy individuals (79.1%), 4062 (2.66%) cases had progressed to OA. The sprained group had 46% (HR, 1.46; 95% CI, 1.38–1.55) greater rate of progression to ankle OA than did healthy individuals. In the sprain group, individuals who were female, obese, and overweight had 40% (HR, 1.40; 95% CI, 1.26–1.55), 43% (HR, 1.43; 95% CI, 1.12–1.82), and 22% (HR, 1.22; 95% CI, 1.10–1.35) higher incidence to develop ankle OA, respectively, compared to those who were male, underweight and normal. ConclusionsThis study found that ankle sprain was a significant risk factor for a diagnosis of early OA. Female gender and high BMI increased the incidence of ankle OA after sprain.