Tibiotalar Angle Research Articles

Comparison of Intermediate to Long-Term Outcomes of Total Ankle Arthroplasty in Ankles with Preoperative Varus, Valgus, and Neutral Alignment

Preoperative ankle coronal malalignment has been considered as a risk factor for poor outcomes and failure after total ankle arthroplasty. The present study evaluated whether intermediate to long-term outcomes of total ankle arthroplasty in ankles with preoperative varus and valgus malalignment (5° to 20°) are comparable with those with neutral alignment (<5°). We enrolled 144 consecutive ankles that underwent primary total ankle arthroplasty (140 patients) using a mobile-bearing HINTEGRA prosthesis with a minimum follow-up of 4 years; the mean overall follow-up duration was 89 months (51 to 145 months). We divided all patients into 3 groups according to the preoperative coronal plane tibiotalar angle: the varus group (59 ankles, 5° to 20° of varus), the valgus group (34 ankles, 5° to 20° of valgus), and the neutral group (51 ankles, <5°). Patients in each group showed similar characteristics in mean age, sex, body mass index, and follow-up period. The mean Ankle Osteoarthritis Scale pain and disability score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, Short Form-36 Physical Component Summary score, visual analog scale pain score, and ankle range of motion did not differ meaningfully among the 3 groups at the final follow-up. The final tibiotalar angle showed that the degree of coronal alignment of the varus group was significantly less corrected compared with the neutral group (p = 0.010). The varus group had significantly more concomitant procedures (42 procedures [71.2%]) compared with the neutral group (p = 0.003). The prevalence of major complications did not differ among the 3 groups (p = 0.124). The overall probability of implant survivorship was 91.1% (97.7% in the varus group, 81.1% in the valgus group, and 90.9% in the neutral group) at a mean follow-up of 7.3 years. In the intermediate to long-term follow-up, mobile-bearing total ankle arthroplasty showed similarly good outcomes in patients with varus and valgus malalignment up to 20° compared with the neutral alignment group when neutrally aligned ankles were achieved postoperatively. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the results of the surgical treatment of chronic lateral ankle instability with knee flexor tendon autograft

Objective: To clinically and radiographically evaluate a group of patients undergoing lateral ankle ligament reconstruction surgery using knee flexor tendon autograft. Methods: The study included and prospectively evaluated 10 patients undergoing lateral ankle ligament reconstruction using knee flexor autograft. Clinical evaluation was performed using the American Orthopedic Foot and Ankle Score (AOFAS), preoperatively and after 1 year of follow-up. Radiographic evaluation included anteroposterior projections associated with ankle varus stress and profile projections of the ankle anterior drawer, also preoperatively and 1 year postoperatively. Results: A mean preoperative AOFAS of 69.3 (SD ± 11.49) was obtained. One year after surgery, there was an increase in the mean score of 98.2 (SD ± 3.01), showing a statistically significant improvement (p < 0.001). The anterior tibiotalar angle values improved markedly, with statistical significance. Although the anterior tibiotalar subluxation values also showed a marked improvement, it was not possible to calculate statistical significance; the group of 10 patients had to be divided into two, as six patients met the criteria when compared to the contralateral side (group 1) and four patients had an absolute value of anterior subluxation of more than 10 mm (group 2). Conclusion: After clinical and radiographic evaluation comparing preoperative and 1-year postoperative data, we conclude that in the analyzed group, the reconstruction technique used produced good or excellent results and should be considered for the treatment of chronic lateral ankle instability. Level of Evidence III; Retrospective Comparative Study.

Клинико-рентгенологические результаты многоуровневых оперативных вмешательств при подвывихе и вывихе бедра у детей с ДЦП

Introduction The purpose of this work was to study the results of orthopedic correction performed according to the principles of one-stage multilevel surgical intervention in cerebral palsy patients with hip dislocation. Material and methods We studied the results of operative orthopedic treatment in 50 children suffering from cerebral palsy (GMFCS levels IV and V, mean age 6.2 ± 1.4 years at the beginning of treatment) who underwent multilevel interventions with the purpose of hip joint reconstruction and correction of other orthopedic complications of cerebral palsy in the knee and foot. The parameters of the orthopedic status were studied as well as such radiographic data as the Reimers index, acetabular index, acetabular frontal depth index, projection neck-to-shaft angle, Wiberg index, tibiotalar angle, angle of the talocalcaneal divergence in the sagittal and frontal planes, coverage of the head of the talus with the navicular bone. The mean follow-up period was 2.8 ± 1.7 years. Results Patients underwent 91 reconstructive interventions during the study period involving 461 surgical elements (5.07 per operation on average). The goals of the pathology correction were achieved in all cases. In all patients, by the end of the first year after the operation, hip abduction was more than 30 degrees and flexion was more than 100 degrees. Comfortable sitting posture and correct passive symmetrical verticalization, pain relief in everyday life were reported in all cases. The shape and position of the foot made it possible to use comfortable regular footwear during verticalization, as well as during walking. By the end of the second follow-up year, a decrease in hip abduction to 20 ° was detected in only two patients. In two cases, a partial recurrence of foot valgus was observed which occurred by axial limb loading and required the use of an orthotic appliance. All radiological indicators examined after the treatment remained within the limits of normal values during the follow-up period. But there was a mild tendency to reduction of hypercorrection achieved which was within the normal boundaries. Conclusion Multilevel operations in children with severe types of cerebral palsy and hip dislocation as the leading pathology are aimed at achieving correction of all orthopedic problems in the lower limbs. The result of such interventions is not only normal anatomical parameters but also the creation of conditions for rehabilitation measures, especially postural management, which is extremely important for normal hip joint development and prevention of hip subluxation and dislocation recurrence in children.

Results of Ilizarov External Fixation in Rigid Equinus Deformity: An Experience of 30 Patients.

Equinus deformity is associated with congenital disorders, trauma, infections, burns and neuromuscular diseases. Tip-toe gait resulting from equinus deformity often makes ambulation difficult. Many modalities of treatment are available but most of them are challenging due to high risk of skin and soft tissue complications. The purpose of this study was to evaluate the results of Ilizarov external fixator with or without minimal soft tissue release in patients with rigid equinus deformity. 30 patients, with 21 (70%) males and 9 (30%) females, were included in this study. 17 (56.66%) patients had right foot, 10 (33.33%) had left foot and 3 (10%) had bilateral feet involvement. 17 (56.66%) had polio, 8 (26.66%) had cerebral palsy, 3 (10%) had posttraumatic and 2 (6.66%) had post-burn equinus deformities. Mean duration of equinus deformity was 5.1 years (range 1 to 11). The ankle range of mo-tion and radiographic lateral tibiotalar angle were assessed preoperatively and at last final follow-up. Kling et al. criteria were used to assess the morphological and functional outcome. The mean preoperative rigid equinus deformity was -32° (range -40 to -20). The mean duration of Ilizarov external fixation required to correct the equinus deformity was 3.6 months (range 2-5.5 months). The mean preoperative tibiotalar angle was 150.2° (range 113° to 169°), which reduced to a mean angle of 102.8° (range 87° to 117°) at final follow-up. Mean dorsiflexion and plantar flexion at final follow-up was 15° (range -5° to 10°) and 31° (15° to 40°), respectively. 4 (13.33%) patients had superficial pin tract infection which was treated by serial dressings and oral antibiotics. 2 (6.66%) patients had a recurrence of 10° of equinus deformity. Excellent to good results were seen in 93.33% of patients whereas 6.66% had poor results. Ilizarov external fixation being a minimal invasive procedure allows a greater degree of equinus deformity correction.

A study on effects of osseous configuration in relation to ankle joint instability-a radiographic study

The ankle joint is the second most important weight bearing region next to the knee joint. There is a natural tendency for forward dislocation of leg bones from the talus which is prevented mainly by two factors-bony and muscular. A total of 160 participants were part of the study after obtaining the written informed consent. 80 participants are having recurrent ankle sprain belong were considered as cases (group I). 80 participants who did not have ankle sprains, but visited the hospital for other complaints were considered as controls (group II). The radiographs of the lateral view of their ankle joint were taken. Significantly higher values of radius of the talus, height of the talus and the tibiotalar angle were reported in males when compared with females of group I (P<0.001). Significantly higher values of radius of the talus (P<0.001), height of the talus (P<0.001) and the tibiotalar angle (P<0.05) were reported in males when compared with females of group II. Comparison of radius and height of the talus, tibiotalar angle between the cases and controls (groups I and II). Radius of the talus was significantly higher in cases when compared to controls (P<0.001). Height of the talus was significantly higher in cases when compared to controls (P<0.05). Tibiotalar angle was significantly lower in cases when compared with controls (P<0.001). A larger radius, corresponding to a flatter talus, the more the height of the talus and a smaller tibiotalar sector, reflecting less angular coverage of the talus in the tibia, are significantly correlated with ankle instability leading to recurrent ankle sprain.

Effect of Preoperative Deformity on Arthroscopic and Open Ankle Fusion Outcomes.

Coronal deformity is considered a relative contraindication for arthroscopic ankle fusion. This study assessed whether preoperative coronal ankle joint deformity influenced the outcome of arthroscopic ankle fusion. Ninety-seven patients had 62 arthroscopic and 35 open ankle fusions between 2005 and 2012. Clinical outcomes were prospectively recorded with use of the Ankle Osteoarthritis Scale (AOS) and Ankle Arthritis Scale (AAS) preoperatively and at 6, 12, and 24 months and final follow-up. Radiological alignment was measured using the tibiotalar angle, the tibial plafond angle, the lateral talar station, and the lateral tibiotalar angle. Both groups had the same demographics. Preoperative deformity was the same regarding sagittal alignment and overall coronal alignment, but the arthroscopic group had less tibial deformity (tibial plafond angle range 0-19 degrees vs 0-43 degrees). At final follow-up, the mean AOS was 34.2 for arthroscopic (95% confidence interval [CI], 23.3-45.2) vs 33.9 for open (95% CI, 17.8-49.9). The AAS at final follow-up was 26.0 for arthroscopic (95% CI, 21.0-31.0) vs 27.5 for open (95% CI, 19.7-35.2). Both groups had the same tibiotalar angle, lateral talar station, and lateral tibiotalar angle at follow-up. Regression analyses revealed no influence of type of surgery, preoperative deformity, postoperative radiological alignment, age, sex, body mass index, smoking status, etiology of the arthritis, and need for bone grafting on outcome scores (all P > .05). Arthroscopic and open ankle fusion yielded equivalent results for both patient-reported outcome measure and radiographic alignment in patients with coronal and sagittal joint deformity. Patients with higher tibial plafond angles more often underwent open fusion. III, comparative series.

Pes Planus and Distal FIbular Stress Fractures

Category: Ankle, Hindfoot Introduction/Purpose: Fibular stress fractures accounts for 4.6% to 21% of all stress fractures. There have been isolated reports of distal third fibular stress fractures within 4-7 cm of the tip of the lateral malleolus in young and athletic patients related to overuse injuries. We examine a case series of middle aged female patients with planovalgus foot deformities and associated hindfoot valgus who presented with distal third fibular stress fractures. We propose that this type of distal fibular stress fracture is a result of increased stress loading of the distal fibula at the superior margin of tibio-fibular interosseous ligaments. Methods: From October 2015 through September 2016, we evaluated six patients (six cases) who presented to Baylor College of Medicine foot and ankle specialty clinic. These patients were found to have distal fibular stress fractures. Detailed initial history was documented. The diagnosis of distal fibular stress fracture was confirmed with both clinical examination and radiographic evidence among all patients. Additionally, all patients were found to have planovalgus deformity with associated hindfoot valgus. Radiographic measurements were taken in all patients, including lateral talo-calcaneal angle, Meary’s angle, calcaneal inclination angle, and AP tibio-talar angle. Distance of distal fibular stress fracture location to tip of lateral malleolus, as well as the distance between medial cuneiform and 5th metatarsal were measured. Single independent observer performed all measurements. Results: Among the six patients in the study, all were female, with average age of 58 years (45-64). Four patients carried the diagnosis of osteopenia and/or osteoporosis from DEXA scan. There is no evidence of association with tobacco use or alcohol use. The mean radiographic distance between location of stress fracture to tip of lateral malleolus is 5.8 cm (4.2cm-7 cm). There was evidence of pes planus from Meary’s angle, which averaged 6.7° (3°-11°) convex downward, and measurement of calcaneal inclination angle averaged 19° (13°-30°). Furthermore, measurement of tibio-talar angle averaged 1.7° valgus alignment consistent with chronic hindfoot valgus deformity. While all patients were treated successfully with immobilization, one patient underwent medial calcaneal osteotomy to correct the hindfoot valgus after recurrent fracture. Conclusion: It is hypothesized that increased stress loading of the fibula due to lateralization of the load axis contributes to this condition. The apex of this stress culminates in the lateral aspect of the fibula above the distal tibio-fibular ligament complex and results in a characteristic valgus fracture of the fibula. The increased stress from deformity results in the fracture rather than increased load from exercise or other repetitive stress. The significance of this proposition is that recognition of this type of fracture should lead the clinician to address the underlying planovalgus deformity in the treatment of this fracture type.

Novel Double Osteotomy Technique of Distal Tibia for Correction of Asymmetric Varus Osteoarthritic Ankle

Category: Ankle, Ankle Arthritis Introduction/Purpose: A most challenging condition for balancing a varus arthritic ankle is the presence of a defect in the medial tibial plafond. After our initial results with a medial tibial plafond plasty did not fulfill our expectations of success, we hypothesized that adding a correcting supramalleolar osteotomy of the distal tibia would move the loading force to the tibiotalar joint more medially and thus act as an evertor force to the talus. In this study we asked (1) what surgical technique was used in detail; (2) what complications were observed; (3) what is the postoperative pain relief; (4) what is the patients’ mid-term functional outcome including range of motion; (5) what is the patients’ mid-term radiographic outcome including hindfoot alignment and progression of ankle osteoarthritis? Methods: Twenty consecutive patients were included into this study, no patients were lost for follow-up with a 4-year minimum required by the study. The mean age of the patients was 44 ± 12 years (range, 17-60 years). Followup averaged 5.9 ± 2.1 years (range, 4-11.2 years). All intraoperative and postoperative complications were recorded. The postoperative pain relief was assessed using a visual analog scale (VAS). Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and by measuring the ankle’s range of motion. Weight-bearing radiographs were used to assess osteotomy union and hindfoot alignment. Hindfoot alignment was assessed by measurement of the tibial ankle surface (TAS) angle, the tibiotalar (TT) angle, tibial lateral surface (TLS) angle, the tibiotalar tilt, and the moment arm of the calcaneus. Osteoarthritis grading was performed preoperative and postoperatively according to Takakura et al. Results: There were no intraoperative or perioperative complications. All patients had osseous fusion within 6 postoperative months. The average VAS pain score decreased significantly from 7.9 ± 1.3 (range, 6-10) to 1.3 ± 1.6 (range, 0-7). The average AOFAS hindfoot score increased significantly from 49 ± 15 points (range, 36-68) preoperatively to 86 ± 12 points (range, 66-96) postoperatively. The mean preoperative and postoperative ankle range of motion were comparable with 39° ± 11° (range, 25°- 46°) and 38° ± 9° (range, 28°-46°). The varus tilt improved significantly from 19.4° ± 8.2° (range, 6°-32°) to 6.9° ± 3.9° (range, 1°- 12°). According to Takakura’s classification, three ankles deteriorated by one stage, 11 ankles improved by one stage, and six ankles showed no changes. Conclusion: The novel double osteotomy was found to be an efficient and successful method to restore tibiotalar joint congruency and to normalize hindfoot alignment. The key of success of medial tibial plafond plasty may be the move of the joint load medially by the additional supramalleolar correcting osteotomy, thus creating an eversion force to the talus. Further in vitro studies are needed to evaluate these hypotheses.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

Conservative “functional” management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.

Tratamiento quirúrgico de las dismetrías y deformidades angulares de miembros inferiores mediante epifisiodesis con tornillos transfisarios (técnica de Metaizeau)

We evaluated children with lower limb length discrepancy and angular deformity operated by the Metaizeau technique in the 2010-2014 period through a retrospective study of 11 patients analyzed in 2 groups. Group 1 (Lower limb length discrepancy), consisted of 5 patients, among whom 3 were operated only by Metaizeau technique, whereas the other 2 additionally required procedures for femoral elongation. We evaluated initial discrepancy, predicted discrepancy for ultimate control and at maturity, and final discrepancy. Group 2 (Angular deformity), consisted of 6 patients, among whom 1 had genu varum, 4 genu valgum and, 1 ankle valgus. We evaluated anatomic femorotibial angle, anatomic lateral distal femoral angle, medial proximal tibial angle, and tibio talar angle. In both groups the complications were assessed. The average follow-up was 2 years and 5 months. In Group 1 we obtained the following values: average initial discrepancy, 7.64 cm; average discrepancy predicted for ultimate control, 8.54 cm; average final discrepancy, 7.62 cm and average correction achieved, 0.91 cm. In Group 2 the values were: average correction anatomic femorotibial angle, 16.85˚; average correction anatomic lateral distal femoral angle, 16.85˚ and average correction medial proximal tibial angle, 7.62˚. We found no complications in any patient. In 8 patients (72.72%) the technique was effective, while in 3 (27.27%) the results were poor due to technical errors or prediction errors . Metaizeau Technique, respecting the surgical details and making an accurate prediction is an effective, simple and uncomplicated procedure.

Is the use of headless compression screws appropriate in arthroscopic ankle arthrodesis?

This study aims to evaluate whether the use of headless compression screws is appropriate in arthroscopic ankle arthrodesis. Twenty-two feet of 22 patients (12 males, 10 females; mean age 43.7 years; range 21 to 63 years) in whom we applied arthroscopic ankle arthrodesis were examined retrospectively. Mean follow-up duration was 59.3 months (range 36 to 92 months). Coronal and sagittal plane alignment and concomitant pathologies were evaluated on patients' radiographs. Assessments related to pain and functionality were performed by the American Orthopaedic Foot and Ankle Society (AOFAS) scoring. Radiographic union was achieved in 21 of the total 22 ankles (95.4%). Mean time to union was 10.3±3.5 weeks (range 6.6 to 13.8 weeks). Mean AOFAS pain score increased from 8.1±10.2 to 35.0±6.3 and functional score increased from 21.3±5.5 to 43.4±3.8 (p<0.001). On coronal plane, preoperative tibiotalar angle of 6.6±5.5° decreased to 2.3±2.1° postoperatively. On sagittal plane, while preoperative tibiotalar angle was 17±4.9°, it was 17±4.5° postoperatively. One patient had subtalar pain and one patient had nonunion postoperatively. The use of headless compression screws is an appropriate choice in the ankle area owing to their advantages of providing successful fixation whilst not causing screw head irritation or pain.

Computer-Assisted TKR Vs Conventional TKR: Post-Operative Ankle Radiographic Finding and Ankle Clinical Assessment

Background: Few previous studies showed that the conventional total knee replacement (TKR) has affection to the same side of talar tilt (TT). We expected to prevent this problem by the computer-assisted (CAS) TKR. Objective: The purpose of this study was to compare between pre and post-operative talar tilt and ankle clinical assessment on the CAS TKR and the Conventional TKR in 28 patients (56 knees) whom underwent bilateral TKR. Material and Method: 28 patients, 56 knees, whom underwent both CAS total knee replacement (TKR) and conventional total knee replacement (TKR), in both knees, with the combination of Gap Balance and Measurement Resection techniques performed by one surgeon (P. Sriphirom) at Rajavithi Hospital, Bangkok. The post-operative has a 12 months follow-up for ankle radiographic finding by tibiotalar angle (TTA), tibial articular surface angle (TAS), and talar tilt (TT) = (TAS-TTA) and for ankle clinical assessment by foot functional index (FFI) from pre-operation and post-operation from both groups. The study also compares the CAS TKR with the Conventional TKR for pre-operation and post-operation. Results: 56 knees, 28 patients, mean age = 67.79 years whom underwent bilateral TKR by the Conventional group and the CAS group had pre-operative TT (TT = TAS - TTA). The Conventional group = 1.5 (-5, 8), the CAS group = .5 (-5, 8), P value = .65. On post-operative TT the Conventional group = .0 (-5, 3), the CAS group = 1.0 (-3, 8), the P value = .4. The comparison of pre-operative TT and post-operative TT in the Conventional group, the P value = .01. On pre-operative TT and post-operative TT in the CAS group, the P value = .65. TT was significantly different in the Conventional group but was not significantly different in the CAS group. The ankle clinical assessment by foot functional index (FFI), which is (1) Pain, (2) Difficulty living, and (3) Daily life activity limitation. The pre-operative FFI in the Conventional group = 1.85 (.81, 6.88) and pre-operative FFI in the CAS group = 1.91 (.24, 66.5), the P value = .57. The post-operative FFI in the Conventional group = 1.68 (0.24, 7.0) and post-operative FFI in the CAS group = 1.65 (.24, 6.76), the P value = .04, which showed a significantly different between the post-operative FFI from both groups. In the Conventional group the post-operative FFI was not significantly different from pre-operative FFI, the P value = .2 but for the CAS group the post-operative FFI was not significantly different from pre-operative FFI, the P value = .04. Conclusion: This study has shown that the conventional TKR effected to post-operative talar tilt but the CAS TKR has less effect and was not significantly different to ankle joint. Finally, the study needs to be conducted on more patients and to be observed on a longer term follow-up.

Correlation Between the Talar Tilt Angle and Hindfoot Varus in Medial Ankle OA

Category: Ankle Arthritis Introduction/Purpose: Radiographically medial ankle osteoarthritis shows different features according to talar tilt which is known to an important determining factor in low tibial osteotomy surgery. However, little is known about the reason of this presentation. We hypothesized that the talar tilt angle and degree of hind foot varus might be correlated. Methods: We reviewed radiographs of 184 patients diagnosed with medial ankle osteoarthritis between May 2006 and February 2015. A total of 126 ankles in 97 patients diagnosed as Takakura stage 1–3b medial ankle osteoarthritis, were reviewed. We measured tibio-talar angle, talar tilt angle, tibial-anterior surface angle, and hindfoot alignment angle We divided the ankles into 4 groups according to tibio-talar angle by 10 degrees, and each group was further divided into 2 subgroups based on median talar tilt angle. We analyzed the correlation between talar tilt and hindfoot alignment angle in each group. We analyzed the differences in the hind foot alignment between the subgroups. Ankle radiographs of selected patients were measured by two observers to determine the interobserver reliability. One of the observers evaluated all radiographs twice to determine the intraobserver reliability. Results: The tibiotalar angle was strongly correlated with the talar tilt angle (r=−0.845), while there was no correlation between tibio-talar angle and hindfoot alignment angle(r=-0.595). Among the groups, tibio-talar angle of 70-80 showed a significantly different hindfoot alignment between the 2 subgroups (p=0.0187). In the rest groups, there was no significant difference between tibio-talar and hindfoot alignment angle. The interobserver and intraobserver reliability for all radiographic measurements was good to excellent Conclusion: We could find out a definite correlation between talar tilt and hindfoot alignment angle in certain degree of varus ankle OA, and no correlation between tibio-talar angle and hindfoot alignment, which might have a clincal relevance in determining the method of osteotomy surgery.

Arthroscopic Ankle Fusion

Category: Ankle Arthritis Introduction/Purpose: Arthroscopic ankle arthrodesis (AAA) has been shown to result in reduced postoperative stay and better short-term outcome than open ankle arthrodesis. Coronal ankle joint deformity often is considered a contraindication for AAA. The aim of this study was to examine whether a preoperative coronal deformity influenced the midterm outcome after AAA for end-stage ankle arthritis. Methods: The Canadian Orthopaedic Foot and Ankle Society (COFAS) database prospectively collects data about the outcome of patients after surgical treatment of end-stage ankle arthritis. The database yielded 98 patients who had isolated ankle arthrodesis at the University of British Columbia between 2005 and 2013. The cohort consisted of 66 men and 32 women who had 62 arthroscopic and 38 open arthrodesis. The preoperative coronal deformity was measured using the tibiotalar angle (between a line perpendicular to the anatomical axis of the tibia and the proximal talar surface) and the tibial plafond angle (between a line perpendicular to the tibial axis and the distal tibial surface) on weight-bearing x-rays. Primary outcome measure was the COFAS Ankle Arthritis Scale (COFAS-AAS) at final follow-up. Secondary outcome measures were the reduction of the COFAS-AAS (ΔCOFAS-AAS) and the medial tibiotalar surface angle (between the anatomical axis and the proximal talar surface) at final follow-up. Results: The tibiotalar angle was lower in the arthroscopic than in the open group (8.2°±7.0 vs. 12.3°±8.2, p=.014) with similar range in both groups (0-25° vs. 0-27°). However, the tibial plafond angle (3.6°±11.4 vs. 11.4°±12.3, p&lt; .005) and its range (0-19° vs. 0-43°) were markedly different. (Figure) The arthroscopic group scored slightly better regarding COFAS-AAS (26.0±19.8 vs. 28.8±23.6, p=.529) and ΔCOFAS-AAS (- 28.1±19.6 vs. -25.9±20.8, p= .603). Concerning patients with tibial plafond angles ≤19°, again the arthroscopic group had slightly better COFAS-AAS (26.0±19.8 vs. 28.9±12.4, p=.588) and ΔCOFAS-AAS (-28.1°±19.6 vs. -26.0°±18.5, p=.627). Regression analyses revealed no effect of tibiotalar or tibial plafond angle onto COFAS-AAS (p=.267 and p= .965) and ΔCOFAS- AAS (p=.741 and p=.392). Radiographic outcome was similar in both groups (medial tibiotalar angle 89.3°±2.2 vs. 88.1°±4.4, p=.135). Conclusion: Both, arthroscopic and open arthrodesis were associated with significant improvements in the COFAS-AAS and acceptable radiographic alignment. Former studies used the tibiotalar angle to describe preoperative coronal ankle joint deformity. In the presented study the range of the preoperative tibiotalar angle was similar in both groups, whereas all patients with tibial plafond angles ≥20° had an open arthrodesis. Therefore, the tibial plafond angle seems to better assist when deciding between arthroscopic or open arthrodesis in patients with a coronal ankle joint deformity. Within these limits preoperative coronal deformity had no influence on the outcome of arthroscopic ankle arthrodesis.

Diagnosis of Deltoid Ligament Contracture in Varus Ankle Osteoarthritis

Category: Ankle Arthritis Introduction/Purpose: In total ankle replacement arthroplasty, ligament balancing is important to obtain a stable ankle joint and to prevent edge loading which would lead to asymmetric accelerated polyethylene wear and component loosening. Deltoid ligament release is recognized as an essential step in surgical technique for correcting varus instability. However, necessity of deltoid ligament release in every ankles with varus deformity is suspected recently because varus deformity could be corrected without deltoid ligament release in several ankles. The aims of this study were to assess the prevalence of deltoid ligament contracture and to identify the radiographic parameters that could predict the deltoid ligament contracture in ankle osteoarthritis which needs total ankle arthroplasty. Deltoid ligament contracture was determined when valgus stress radiograph showed talar tilt ≥ 0.5° and medial clear space ≤ 4 mm in this study. Methods: The plain weight-bearing radiograph and the valgus stress radiograph of 118 ankles (103 patients) with osteoarthritis were retrospectively evaluated. The 118 ankles were comprised 68 ankles of asymmetric varus-osteoarthritis(OA) group which showed medial joint space obliteration and tibiotalar angle ≥ 10°, 37 ankles of end-stage neutral-OA group which showed overall superior joint space obliteration and tibiotalar angle ≤ 10° and 13 ankles with end-stage varus-OA group which showed overall superior joint space obliteration and tibiotalar angle ≥ 10°. Various radiographic parameters of plain weight-bearing anteroposterior radiograph – talar tilt, distance from medial malleolus to talar dome (MM-T distance), talus center migration – were investigated. The individual associations between the deltoid ligament contracture and these radiographic parameters and the most important radiographic parameter were determined using logistic regression analysis. The optimal threshold of the most important radiographic parameters for predicting deltoid ligament contracture was determined with use of receiver operating characteristic curve analysis. Results: Thirty-seven ankles in the asymmetric varus-OA group (54%) had deltoid ligament contracture, while one ankle of the end-stage neutral-OA group (2.7%) and one ankle of the end-stage varus-OA group (7.7%) had deltoid ligament contracture. Among the 118 ankles, the talar tilt (Exp(B): 1.239, P=0.000) and the MM-T distance (Exp(B): 1.141, P=0.016) were significantly associated with the deltoid ligament contracture in the univariate logistic regression analysis. And only the talar tilt (Exp(B): 1.251, P=0.000) was significantly associated with the deltoid ligament contracture between the two significant radiographic parameters in the multivariate logistic regression analysis. The optimal threshold for predicting deltoid ligament contracture was 8.9° of the talar tilt, with a sensitivity of 76.9% and a specificity of 77.2%. Conclusion: This study showed that half of varus ankle osteoarthritis and most of end-stage ankle osteoarthritis did not have deltoid ligament contracture and the talar tilt could predict the deltoid ligament contracture. During total ankle arthroplasty, clinicians should determine deltoid ligament contracture before deltoid ligament release by using the talar tilt, because there may be a risk of valgus instability when deltoid ligament was released in ankles without deltoid ligament contracture.

Reliability of the Radiographic Sagittal and Frontal Tibiotalar Alignment after Ankle Arthrodesis.

BackgroundAccurate measurement of the tibiotalar alignment is important in radiographic outcome assessment of ankle arthrodesis (AA). In studies, various radiological methods have been used to measure the tibiotalar alignment leading to facultative misinterpretation of results. However, to our knowledge, no previous study has investigated the reliability of tibiotalar alignment measurement in AA. We aimed to investigate the reliability of four different methods of measurement of the frontal and sagittal tibiotalar alignment after AA, and to further clarify the most reliable method for determining the longitudinal axis of the tibia.MethodsThirty-eight weight bearing anterior to posterior and lateral ankle radiographs of thirty-seven patients who had undergone AA with a two screw fixation technique were selected. Three observers measured the frontal tibiotalar angle (FTTA) and the sagittal tibiotalar angle (STTA) using four different methods. The methods differed by the definition of the longitudinal tibial axis. Method A was defined by a line drawn along the lateral tibial border in anterior to posterior radiographs and along the posterior tibial border in lateral radiographs. Method B was defined by a line connecting two points in the middle of the proximal and the distal tibial shaft. Method C was drawn „freestyle”along the longitudinal axis of the tibia, and method D was defined by a line connecting the center of the tibial articular surface and a point in the middle of the proximal tibial shaft. Intra- and interobserver correlation coefficients (ICC) and repeated measurement ANOVA were calculated to assess measurement reliability and accuracy.ResultsAll four methods showed excellent inter- and intraobserver reliability for the FTTA and the STTA. When the longitudinal tibial axis is defined by connecting two points in the middle of the proximal and the distal tibial shaft, the highest interobserver reliability for the FTTA (ICC: 0.980; CI 95%: 0.966–0.989) and for the STTA (ICC: 0.997; CI 95%: 0.996–0.999) is provided. Intergroup analysis for FTTA measurements revealed a statistically significant difference between the method in which the lateral border of the tibia was used to determine the longitudinal axis of the tibia, and the other methods in which the longitudinal axis was defined by bisecting the tibia.ConclusionsWhen the longitudinal axis of the tibia is defined by connecting two points in the middle of the proximal and the distal tibial shaft for measuring the FTTA and STTA, the most favorable interobserver reliability is provided. Therefore, this method can be recommended for evaluating the frontal and the sagittal alignment on anterior to posterior and lateral radiographs after ankle arthrodesis.

A Comparison of Knee and Ankle Coronal Plane Alignment According to Quadriceps Exercise Method in Early Phase of Total Knee Arthroplasty: Lower Extremity Isometric Co-Contraction and Quadriceps Isolated Isometric Contraction

Background: Total knee arthroplasty (TKA) recovers the alignment of the knee joint, but fails to automatically restore the alignment and function of the hip and ankle joints. It may affect the alignment and stability of the knee joint, therefore therapeutic intervention in hip and ankle joint is necessary for the rehabilitation process after TKA. Objects: The aim of this study was to comparison of the effects of the two exercise methods on the coronal plane alignment after TKA. This study conducted an experiment by dividing subjects into a lower extremity isometric co-contraction group (LEIC) and a quadriceps isolated isometric contraction (QIIC) group. Methods: A total of 37 subjects were randomly assigned to the LEIC (=19) or the QIIC (=18). Exercise was applied to five times per week for three weeks, starting on the eighth day after surgery. Range of motion exercises were performed as a common intervention and then each group performed quadriceps isometric contraction exercises with 10 sets of 5 repetitions. Radiological imaging was performed prior to surgery, one month and six months after surgery. In addition, the hip-knee-ankle angle (HKA) and tibiotalar angle (TTA) were measured. Results: The HKA was close to neutral in the LEIC rather than the QIIC (p.05). According to the comparison of the TTA before surgery, the LEIC showed significant changes in the varus direction (p.05). Conclusion: The LEIC method triggered changes in the TTA and brought the HKA close to the neutral. Thus, LEIC is more effective than QIIC in creating stability in the coronal plane alignment of the knee and ankle joints after TKA.

The influence of knee malalignment on the ankle alignment in varus and valgus gonarthrosis based on radiographic measurement

PurposeThe lower limb misalignment as calculated by radiography has an evident effect on the development and progression of knee osteoarthritis (OA). However, whether the knee malalignment has an influence on ankle alignment is unknown. The purpose of this study was to discuss the correlation between knee and ankle alignment in varus and valgus gonarthrosis. MethodsThis is a retrospective study of 149 patients with symptomatic varus and valgus knee OA who intend to take total knee arthroplasty (TKA) between January and October 2013. A protocol for the measurement of knee-ankle alignment and angles on full-length standing anteroposterior radiographs of the lower extremity was outlined in detail with step-by-step instructions. Two observers measured the angles chosen. The Pearson’s correlation tests were used for the statistical analysis. ResultsPearson’s correlation test results for unilateral varus or valgus gonarthrosis showed that the varus or valgus deformity of the knee can influence the tilt angle and tibiotalar angle of the ankle in operative side signficantly(p<0.05), and the tilt angle of the ankle can also be affected in nonoperative side (p<0.05). Moreover, the tilt angle of the bilateral ankle can be simultaneously affected in bilateral varus gonarthrosis (p<0.05). ConclusionThese findings suggest that the varus and valgus deformity of the knee can induce the tilt of the ankle and influence the ankle alignment, which may further accelerate the degeneration of the ankle. Moreover, the knee alignment in the nonoperative side can also result in the change of ankle alignment at the same time.

Rate of Correction and Recurrence of Ankle Valgus in Children Using a Transphyseal Medial Malleolar Screw.

Transphyseal medial malleolar screw (TMMS) hemiepiphysiodesis is an effective treatment for ankle valgus in children. There is limited evidence on the effect of age and diagnosis on the rate of correction as well as the deformity recurrence after screw removal. The purpose of this study was to determine (1) the rate of correction of ankle valgus after hemiepiphysiodesis using a TMMS, (2) the effects of clinical diagnosis and age at surgery on the rate of correction, and (3) the rate of valgus recurrence after TMMS removal. In this retrospective study we included 16 male and 21 female patients (63 ankles) with an average age at surgery of 11.0 years (range, 5.4 to 14.8 y) who underwent TMMS hemiepiphysiodesis for the treatment of ankle valgus. There was a mean radiographic follow-up of 1.6 years (range, 0.4 to 4.9 y) before screw removal. For subjects who received screw removal (43 ankles), the average time from insertion to removal of the screw was 1.4 years (range, 0.4 to 5.2 y). Valgus deformity was assessed on anteroposterior ankle radiographs by measurement of tibiotalar angle. Linear mixed effects models were used to determine rates of correction and valgus recurrence. The average rate of correction in tibiotalar angle was 0.37±0.04 degrees per month (P<0.001). Clinical diagnosis and age at surgery significantly affected the amount of postoperative correction in tibiotalar angle (P<0.05). Eighteen of 22 ankles (81.8%) demonstrated recurrence of ankle valgus after screw removal. The average recurrence rate in patients who underwent screw removal was 0.28±0.08 degrees per month (22 ankles, P=0.002). This study supports the effectiveness of the TMMS hemiepiphysiodesis for treating pediatric ankle valgus, but the effects of additional skeletal growth should be considered as the ankle may rebound into valgus after correction and screw removal. The results from this study can help with surgical planning to predict the amount of correction that may be achieved depending on underlying diagnosis and age at surgery. Level IV-retrospective study.

Hind- and Midfoot Motion After Ankle Arthrodesis

After ankle arthrodesis (AA), compensatory increased range of motion in adjacent joints might lead to increased osteoarthritis. Evaluation of patient-reported outcomes after AA with validated questionnaires is rare. Likewise, reliable radiographic analysis of the position of the AA, expected to influence the range of motion of the hind- and midfoot, is lacking. Therefore, the current study was performed. Seventeen patients with unilateral AA were included. Sagittal hind- and midfoot range of motion was measured radiographically. The position of the AA in the sagittal and coronal planes and osteoarthritis of adjacent joints were also evaluated radiographically. Measurements were compared to the contralateral side. Patient-reported outcomes via validated questionnaires were compared to a control group (n = 18). Average follow-up was 3.5 years. Mean combined hind- and midfoot sagittal range of motion after AA equaled that of the contralateral side (20.8 vs. 21.0 degrees; P = .93). The tibiotalar angle after AA equaled that of the contralateral side (107 vs. 107 degrees; P = .86). The talus was translated posteriorly after AA (T-T ratio 0.45 vs. 0.34; P < .001). Low intraclass correlation coefficients (ICC) precluded reliable evaluation of the coronal position of the hindfoot (ICC, 0.07 and -0.34) and osteoarthritis in adjacent joints (ICC range, 0-0.54). SF-36 physical health scores after AA are lower as compared with those of controls (50 vs. 56; P = .01). Scores on the Foot and Ankle Outcome Score and Ankle Osteoarthritis Scale were also significantly lower. Patient satisfaction with AA was high (average visual analog scale score, 83). No increased sagittal range of motion in the hind- and midfoot after AA was found at 3.5 years of follow-up as compared with the contralateral side. Tibiotalar angles were equal. The talus was translated posteriorly. The hindfoot alignment view was not suitable to analyze the position of the hindfoot. Low ICC of the Kellgren and Lawrence scale precluded evaluation of osteoarthritis of adjacent joints. Patients scored lower than controls on self-reported outcome questionnaires but were satisfied with the result of AA.