Tibiotalar Angle Research Articles

Short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis

To investigate the short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis. The clinical and radiographic data of patients with moderate to severe varus-type ankle arthritis, who were admitted between May 2017 and November 2021 and treated with total ankle arthroplasty (TAA) using INBONE TM Ⅱ prosthesis, was retrospectively analyzed. A total of 58 patients (58 ankles) met the selection criteria and were included in the study. Among them, there were 24 males and 34 females, with an average age of 62.6 years (range, 41-85 years). According to the preoperative tibiotalar angle (TTA), the patients were divided into a moderate varus group (group A, TTA 5°-15°, n=34) and a severe varus group (group B, TTA>15°, n=24). There was no significant difference in gender, side, etiology, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, ankle dorsiflexion, plantarflexion, and total range of motion, and tibial lateral surface angle (TLS) between the two groups ( P>0.05). Yet the patients in group A were younger than group B, the degrees of oesteoarthritis (Takakura stage) and ankle pain [visual analogue scale (VAS) score] were milder, and the TTA, talar tilt angle (TT), hindfoot alignment angle (HAA) were smaller while the tibial articular surface angle (TAS) was larger, showing significant differences ( P<0.05). The pre- and post-operative VAS score, AOFAS score, the occurrence of early and late complications, the radiographic parameters of the ankle (TTA, TAS, TT, HAA, TLS), ankle dorsiflexion, plantarflexion, and total range of motion were recorded and compared. All patients were followed up 19-72 months, with an average of 38.9 months. Compared with the preoperative data, the VAS score of all patients significantly decreased ( P<0.05); the AOFAS score, ankle dorsiflexion range of motion, and total range of motion significantly increased ( P<0.05); and the TTA, TAS, TT, HAA, and TLS significantly improved at last follow-up ( P<0.05); but there was no significant difference in plantarflexion range of motion ( P>0.05). Early complications occurred in 13 patients, and only 1 patient underwent revision surgery due to a larger size of the talar component. At last follow-up, there was no significant difference in the difference of clinical parameters before and after operation between the two groups ( P>0.05); there was a significant difference in the difference of other radiographic parameters ( P<0.05) except TLS. No significant difference in the incidence of complications between the two groups was found ( P>0.05). TAA using the INBONE TM Ⅱtotal ankle prosthesis is an effective treatment for moderate or severe varus-type ankle arthritis, and good clinical and radiographic results can be obtained. Correcting bony deformities and balancing soft tissue are the keys to successful surgery.

Radiographic Measurements of the Foot and Ankle After Ankle Arthrodesis.

Ankle arthrodesis is an established treatment for ankle arthritis. For patients with ankle arthritis, the position of the talus during ankle arthrodesis may affect the radiographic parameters of the foot. The purpose of this study is to assess the radiographic relationship between talar alignment and the longitudinal arch of the foot before and after ankle arthrodesis. We retrospectively reviewed a single-surgeon series of 30 patients who had undergone ankle arthrodesis. Measured parameters included the lateral tibiotalar angle (LTTA), lateral talometatarsal angle (LTMA), lateral talocalcaneal angle (LTCA), cuneiform height (CH), and calcaneal pitch (CP). Additional data collected included demographics, fusion construct type, and visual analog scale (VAS) measurements. LTTA was increased from 68.2 ± 7.4 degrees preoperatively to 75.0 ± 6.4 degrees postoperatively (P = .001), LTMA increased from -2.0 ± 10.7 degrees to 4.0 ± 10.1 degrees (P < .001), CH increased from 20.1 ± 7.5 mm to 26.1 ± 8.4 mm (P < .001), LTCA and CP had no statistically significant change. VAS score decreased from 5.7 ± 2.7 to 1.3 ± 1.9 (P < .001). Correcting the talar alignment in the sagittal plane during ankle arthrodesis improved the radiographic parameters of the foot, contributing to restoration of the longitudinal arch. The clinical significance of these findings is that in patients undergoing ankle arthrodesis, the surgeon should be aware that the alignment of the foot will be altered at the time of ankle arthrodesis and should be considered in preoperative planning. Further research is needed to determine the effect of ankle arthrodesis in patients determined to have pes planus preoperatively. Level III, retrospective cohort study.

Patient-Reported Outcomes in Total Ankle Arthroplasty: Patient Specific Versus Standard Instrumentation.

Total ankle arthroplasty (TAA) can now be performed using patient-specific instrumentation (PSI). Advantages include the ability to preoperatively plan and reduce the number of intraoperative surgical steps. The aim of this study was to compare PSI with standard instrumentation (SI) in a nonrandomized retrospective cohort study with respect to patient-reported outcome measures (PROMs). Secondary aims were to compare complications, reoperations, tourniquet time, fluoroscopy time, and postoperative alignment. In all, 159 patients (111 men, 48 women) undergoing a total of 168 Infinity TAA (Stryker, Memphis, TN) using PSI (Prophecy, Stryker, Memphis, TN) or SI between 2014 and 2021 were included with a minimum follow-up of 12 months. The PROMs were obtained preoperatively and at 1 year, and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and European Quality of Life 5 Dimension 3 Level (EQ-5D-3L). Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time, and intraoperative fluoroscopy times were obtained from the hospital records. There were 61 TAAs in the PSI group and 107 TAAs in the SI group. There was no significant difference in total MOXFQ, AOS, or EQ-5D. There was a significantly reduced tourniquet time (PSI mean: 95.39 minutes, SI mean: 116.87 minutes, P < .001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, P < .001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, P = .005). This study supports the use of PSI to decrease operative time, reduce intraoperative fluoroscopy, improve accuracy of implantation, and improve postoperative alignment in TAA. There was a significant difference (P = .032) in favor of PSI in the walking/standing domain of the MOXFQ at 12 months but no significant difference in overall PROMs. Level III, Retrospective.

Results of treatment of congenital vertical talus by the Dobbs method

Congenital vertical talus is a rare foot deformity. The hindfoot is valgus and equinus, the midfoot is dorsiflexed and forefoot is abducted due to a fixed dorsal dislocation of the navicular on the head of the talus and the cuboid on the anterior part of the calcaneus. The epidemiology and etiology of vertical talus is unknown. Dobbs et al. (J Bone Joint Surg Am 88(6):1192–200, 2006) described a minimally invasive alternative which allowed to avoid the need for extensive soft tissue release procedures in treatment of congenital vertical talus. Eleven congenital vertical talus feet (group 5 according to Hamanishi) in eight children (four boys and four girls) constituted the study material. Upon the diagnosis, the patients’ age ranged from 5 to 26 months old (the mean – 14.6). The treatment involved serial manipulation and casting according to the reverse Ponseti method (from 4 to 7 casts) followed by a minimally invasive approach consisting in temporary stabilization of the talonavicular joint with the use of K-wire and Achilles tenotomy according to the Dobbs technique. Then patients continued the shoe and bar program for 2 years. The X-ray measurements on lateral radiographic included the talocalcaneal angle, tibiotalar angle and talar axis—first metatarsal base angle whereas AP radiographic images—the talocalcaneal angle and talar axis—first metatarsal angle. The Wilcoxon test was used to compare dependent variables. The final clinical assessment made during the last follow-up (the mean: 35.8 months, the range: 25–52) revealed that neutral position of the foot and normal range of motion were observed in ten cases and recurrence of foot deformity in one case. The last X-ray examination showed normalization all of radiological parameters, except for one case, and examined parameters were statistically significant. The minimally invasive technique described by Dobbs should be the first option in treatment of congenital vertical talus. It allows to reduce the talonavicular joint, brings good results and preserves foot mobility. The attention should be put on early diagnosis.

Tibiotalar and Tibiotalocalcaneal Arthrodesis with Paragon28 SilverbackTM Plating System in Patients with Severe Ankle and Hindfoot Deformity

The treatment of end-stage ankle osteoarthritis (OA) and associated hindfoot deformities remains a major challenge for orthopedic surgeons. Numerous techniques and surgical approaches have been proposed for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis, from arthroscopic to open, as well as numerous devices proposed for internal fixation (retrograde intramedullary nails, cannulated screws, and plating systems). The aim of this study was to retrospectively analyze the results, with at least 18 months of follow-up, with SilverbackTM TT/TTC Plating System Paragon28 in a group of 20 patients with severe OA and hindfoot deformities (mainly secondary post-traumatic OA). The demographic characteristics and past medical history of the patients were collected and analyzed to identify the cause of the pathology. The degree of OA and deformity were quantified based on foot and ankle weight-bearing radiography and CT examination. Pre- and post-operative clinical and functional scores (ROM, VAS, AOFAS, FFI, and SF-36) and radiographic parameters (anterior distal tibial angle, tibiotalar angle, coronal tibiotalar angle, and hindfoot alignment angle) were evaluated. All of the patients showed clinical and radiographic fusion at an average of 14 weeks (range 12-48), with improvement in pain and functional scores, without major surgical complications and/or infections. Despite the limitations of our study, the results with this new plating system showed good results in terms of bone consolidation, post-operative complications, and improvement of pain and quality of life in patients with severe OA and deformities of the ankle and hindfoot.

TIBIOCALCANEAL ARTHRODESIS: A COMPARISON OF ANTERIOR APPROACH AND TRANSFIBULAR APPROACH.

The aim of this study was to evaluate the clinical and radiologic results and complications of patients who underwent ankle arthrodesis performed by the transfibular approach and anterior approach in end-stage ankle osteoarthritis. Between 2016 and 2022, 41 patients who satisfied the inclusion criteria for this retrospective comparative analysis were included. Of them, 19 patients are included in the anterior approach group and 22 patients are included in the transfibular approach group. The mean age of the participants is 58.9 years. Collected data included the BMI, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale, visual analogue scale (VAS) score, diabetes, smoking, time to fusion, nonunion, union rate, preoperative and postoperative coronal tibiotalar angle and complications. The mean time to bone union was 14.3 weeks (range 11-17 weeks) in the anterior approach group, and 11.3 weeks in the transfibular approach group. Statistically significant difference was found between the two groups. Nonunion occurred in one case in the transfibular approach group and three cases in the anterior approach group. There was no significant difference in the nonunion rate between the both groups (p = 0.321). VAS score, and AOFAS score of the two groups were similar and no significant differences were found (p = 0.491, p = 0.448, p = 0.146, p = 0.073, p = 0.173, p = 0.506, respectively). A stable and firm ankle arthrodesis and plantigrade foot can be achieved with both transfibular approach and anterior approach technique. Level of Evidence III, Retrospective Comparative Study.

The Gradual Correction of Adult Severe Rigid Equinus Deformity Using Minimal Invasive U-Osteotomy With Taylor Spatial Frame.

U-osteotomy with Taylor Spatial Frame correction is a rarely reported treatment method particularly well-suited for severe rigid equinus deformity in adults. The purpose of this study was to evaluate the effectiveness and efficacy of deformity correction and clinical outcome using this technique. We present a retrospective review of 30 feet in 26 patients who received U-osteotomy with Taylor Spatial Frame. Radiologic outcomes were measured using the anterior tibiotalar angle (TTA) with conventional weightbearing radiographs. Functional assessments included American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores and patient satisfaction using Likert scale. The etiology included trauma (9), neglected or relapsed clubfoot (6), spina bifida (5), poliomyelitis (4), Charcot-Marie-Tooth disease (4), and iatrogenic (2). All patients had equinus deformity with TTA more than 140 degrees (median 157.5, 141-177). There were varus deformity in 19 feet, limb length discrepancy in 6 legs, and genu procurvatum deformity in 2 legs. The duration of gradual correction was 53.6±13.5 days (33-73 days), and the external fixation time was 147.8±25.2 days (98-203 days). At last follow-up, TTA in all patients improved significantly (P < .001) to 113.5 degrees (111.8-116.0). All patients had plantigrade feet, except for 2 cases of residual mild equinovarus deformity, 2 cases of residual mild hindfoot varus deformity, 1 case of moderate hindfoot varus recurrence. The AOFAS scores significantly improved (P < .001) from 51.0 points (29.0-66.0) to 76.0 points (69.5-88.0). Eighteen patients were very satisfied, 6 patients were somewhat satisfied, and 2 patients were somewhat dissatisfied. Using minimally invasive U-osteotomy with Taylor Spatial Frame to gradually correct the adult severe rigid equinus deformity proved to be an effective and relatively safe method associated with high patient satisfaction rates. Level IV, case series.

Can immediate postoperative radiographs predict outcomes in pediatric clubfoot?

The goal of treatment for pediatric idiopathic clubfoot is to enable the patient to comfortably walk on his or her soles without pain. However, currently accepted treatment protocols are not always successful. Based on the abnormal bone alignment reported in this disease, some studies have noted a correlation between radiographic characteristics and outcome, but this correlation remains debated. To assess the correlation between immediately postoperative radiographic parameters and functional outcomes and to identify which best predicts functional outcome. To predict the outcome and prevent early failure of the Ponseti's method, we used a simple radiographic method to predict outcome. Our study included newborns with idiopathic clubfoot treated with Ponseti's protocol from November 2018 to August 2022. After Achilles tenotomy and a long leg cast were applied, the surgeon obtained a single lateral radiograph. Radiographic parameters included the tibiocalcaneal angle (TiCal), talocalcaneal angle (TaCal), talofirst metatarsal angle (Ta1st) and tibiotalar angle (TiTa). During the follow-up period, the Dimeglio score and functional score were examined 1 year after surgery. Additionally, recurring events were reported. The correlation between functional score and radiographic characteristics was analyzed using sample and multiple logistic regression, and the optimal predictor was also identified. In total, 54 feet received approximately 8 manipulations of casting and Achilles tenotomy at a mean age of 149 days. The average TiCal, TaCal, Ta1st, and TiTa angles were 75.24, 28.96, 7.61, and 107.31 degrees, respectively. After 12 mo of follow up, we found 66% excellent-to-good and 33.3% fair-to-poor functional outcomes. The Dimeglio score significantly worsened in the poor outcome group (P value < 0.001). Tical and TaCal showed significant differences between each functional outcome (P value < 0.05), and the TiCal strongly correlated with outcome, with a smaller angle indicating a better outcome, each 1 degree decrease improved the functional outcome by 10 percent. The diagnostic test revealed that a TiCal angle of 70 degrees predicts an inferior functional outcome. The TiCal, derived from lateral radiographs immediately after Achilles tenotomy, can predict functional outcome at 1 year postoperatively, justifying its use for screening patients who need very close follow-up.

Decision-making factors and their thresholds for total knee arthroplasty in lateral tibiofemoral osteoarthritis patients: a retrospective cohort study

BackgroundThere has been no study examining lateral tibiofemoral (TF) osteoarthritis (OA) and objective decision-making factors affecting when patients decide to have total knee arthroplasty (TKA). The purpose of this study was to assess which factors and their thresholds cause patients with lateral TF OA to decide on TKA.MethodsWe conducted a retrospective cohort study and identified patients who had initially been diagnosed with isolated lateral TF OA from October 2004 to February 2021. We finally included 56 patients; patients who had chosen conservative treatment followed by in-depth interviews for the deliberation stage (n = 32), and the other patients who decided to undergo TKA for the decision-making stage (n = 24). Demographic, clinical, and radiographic characteristics were considered candidate predictive factors. Radiographic variables included the Ahlbäck grade, hip–knee–ankle (HKA) angle, joint line convergence angle (JLCA), and TF subluxation. Univariate and multivariate logistic regression analyses were performed.ResultsClinically, the pain visual analog scale (VAS) score was significantly higher and the knee flexion angle was lower at the decision-making stage. Radiographic measurements showed that the Ahlbäck grade, HKA angle, JLCA, and TF subluxation measured at the center, in addition to the tibiotalar angle, differed statistically between the two stages. According to univariate analyses, two clinical characteristics and six radiographic variables on the ipsilateral side of the leg, and one radiographic variable on the contralateral side of the leg were included as factors influencing the patients’ decision to undergo TKA. After making adjustments based on multivariate analysis, the ipsilateral knee pain VAS (OR = 1.61; 95% CI = 1.14–2.28, p = 0.007) and medial TF subluxation measured at the center (OR = 1.14, 95% CI = 1.01–1.32, p = 0.072) were found to be significant factors for choosing TKA. The area under the curve (AUC) for pain VAS was 0.757 and the cutoff value was 4.5. The AUC for TF subluxation measured at the center was 0.697 and the cutoff value was −4.10% of medial TF subluxation.ConclusionHigher ipsilateral knee pain VAS and more severe medial TF subluxation measured at the center were independent factors affecting patient decisions to undergo TKA with lateral TF OA. Understanding the determining factors that may affect patient decision-making when considering TKA may be an essential aspect of evaluating the prognosis of patients with lateral TF OA.Level of evidenceIII.

Patient Specific Instrumentation and Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total Ankle Arthroplasty (TAA) can now be performed using Patient Specific Instrumentation (PSI). Advantages include the ability to pre-operatively plan bone resections and implant position and reduce the number of intra- operative surgical steps. The aim of this study was to compare PSI with Standard Instrumentation (SI) in a non-randomised retrospective cohort study with respect to patient reported outcomes, tourniquet time, fluoroscopy time and post-operative alignment. Methods: 159 patients (111 male, 48 female) undergoing a total of 168 INFINITY TAA using PSI (Prophecy, Wright Medical Technology) or SI between 2014 and 2020 were included with a minimum follow up of 12 months. Patient reported outcome measures (PROMS) were obtained pre-operatively and at one year and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS) and EQ-5D Index. Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time and intra-operative fluoroscopy times were obtained from the hospital records. Results: There were 106 TAA in the SI group and 62 TAA in the PSI group. The was no significant difference in total MOXFQ, AOS or EQ5D. There was however a significant difference (p=.032) in favour of PSI in the walking/standing domain of the MOXFQ at 12 months. There was a significantly reduced tourniquet time (PSI mean: 95.39 mins, SI mean: 116.87 mins, p&lt;.001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, p&lt;.001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, p=.005). Conclusion: This study supports the use of patient specific instrumentation to decrease operative time, reduce intraoperative fluoroscopy and improve accuracy of implantation in TAA. The walking/standing domain of the MOXFQ has been shown to be the most sensitive to change and in this study demonstrated a further potential benefit.

Evaluation of the relationship between hallux valgus and foot measurements in radiographic images of adult female.

In the present study, we aimed to determine the relationship of HV angle with angles and measurements obtained from lateral and anteroposterior (AP) radiological images of the foot in individuals with HV. The present study had a retrospective design, and the participants consisted of 66 female patients between the ages of 19 and 64 who applied to Orthopedics and Traumatology and were diagnosed with Hallux valgus. Metatarsus adductus angle, metatarsus primus adductus angle, hallux valgus angle, hallux interphalangeal angle, metatarsal break angle, first metatarsal protrusion distance, metatarsal width, talocalcaneal angle, AP Meary's angle were measured on AP view and calcaneal inclination angle, talar declination angle, lateral talocalcaneal angle, first metatarsal declination angle, fifth metatarsal declination angle, navicular height, lateral Meary's angle, tibiotalar angle were measured on a lateral radiograph. The IBM SPSS 21.0. program was used for statistical analysis, and the level of significance was taken as p < 0.05. There were statistically significant differences between the right and left feet in MPA and AMA measurements. The results showed that HV angle (HVA) had a weak relationship with MAA and MW, as well as a moderately positive relationship with MPA. However, it had a moderately negative relationship with AMA and a weak negative relationship with HIPA. We believe that in addition to the HVA angle, MPA and AMA angles should be considered in the diagnosis of HV, especially as the HVA angle is moderately positively correlated with the MPA angle and moderately negatively correlated with the AMA angle.

Management of Elderly Traumatic Ankle Arthritis with Ilizarov External Fixation

ObjectiveTo evaluate the clinical curative effect of Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.MethodsFrom June 2013 to August 2019, 72 patients with elderly traumatic ankle arthritis were treated with arthrodesis through Ilizarov external fixation technique in our institution. Conventional double‐feet standing X‐ray films were taken before and after operation. The tibiotalar angle on X‐ray image was measured to evaluate the degree of talipes varus and valgus. The Foot and Ankle pain score of American Orthopaedics Foot and Ankle Society (AOFAS) and Visual Analog Scale (VAS) were compared by using paired t‐test to evaluate the functional recovery.ResultsAll of the patients acquired effective postoperative 18–49 months follow‐up, with an average of 31.5 months. All patients were included in the analysis, among which 38 cases were males and 34 cases were females, with an average of 65.4 years (ranging from 60 to 74). All ankles achieved bony fusion; the clinical healing time was 12.7 weeks on average (11–18 weeks). The AOFAS score was 45.36 ± 6.43 preoperatively and 80.25 ± 9.16 at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The VAS score was 8.56 ± 1.85 on average preoperatively and 2.72 ± 0.83 at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The tibiotalar angle was 101.93° ± 4.12° preoperatively and 94.45° ± 2.37° at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The results of the functional evaluation indicated that 44 patients (61.1%) had excellent results, 18 (25%) had good results, and 10 (13.9%) had fair results.ConclusionOur study demonstrated that it is possible to obtain satisfactory outcome with Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.

Impact of preoperative varus on ankle replacement survival

IntroductionThe severity of a foot or ankle deformity is a major prognostic factor for the success of ankle replacement. Varus deformity is at once the most arthrogenic and the most frequent. HypothesisThe severity of preoperative varus is a negative factor for ankle replacement survival. Material and methodA retrospective study compared results in a continuous series of 57 Salto-Talaris® ankle replacements according to preoperative varus: 31 moderate (5–15̊) and 26 severe (> 15̊). Radiological and clinical assessment at a minimum 1 year focused on complications, revision and implant exchange and on AOFAS score, range of motion and tibiotalar angle at last follow-up. ResultsAt a mean 2.4 years’ follow-up, implant survival in the moderate and severe varus groups was respectively 83% and 92%. Postoperative AOFA score and range of motion improved significantly in both groups, without significant difference. Analysis of cumulative survival showed no significant intergroup difference. DiscussionSeverity of preoperative varus did not impact implant survival. Only postoperative alignment and stability emerged as survival factors. These results were related to the quality of associated procedures aiming to reduce deformity and to achieve ligament balance. Level of evidenceIV, retrospective comparative study.

Early Radiographic and Clinical Outcomes of a Novel, Fixed-Bearing Fourth-Generation Total Ankle Replacement System.

The Cadence Total Ankle System is a 2-component, fixed-bearing fourth-generation total ankle arthroplasty (TAA) system that was introduced for clinical use in 2016. The purpose of this study was to report non-inventor, non-industry funded survivorship, radiographic and clinical outcomes, and early complications following use of this implant at a minimum of 2 years. This single-center retrospective study included patients who underwent TAA by 2 surgeons with this novel fixed-bearing system between January 2017 and September 2018. Forty-eight patients were evaluated at an average of 33.6 months. Radiographic outcomes included preoperative and postoperative tibiotalar angle on anteroposterior radiographs of the ankle, sagittal tibial angle (STA) on lateral radiographs of the ankle, and periprosthetic lucency formation and location. Revision and reoperation data were collected, and patient-reported outcomes were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Subgroup analysis assessed associations between preoperative deformity, postoperative implant alignment, PROMIS scores, and periprosthetic lucency formation. Survivorship of implant was 93.7%, with 3 revisions, 1 due to infection and 2 due to loosening of the implant (1 tibial and 1 talar component). Three patients had reoperations (6.3%): 2 for superficial infection and 1 for gutter debridement due to medial gutter impingement. Fifteen patients (35.8%) developed periprosthetic lucencies, all on the tibial side. PROMIS scores improved after surgery in all domains except Depression. Patients with significant postoperative periprosthetic lucency had worse postoperative PROMIS Physical function scores than patients without lucency (P < .05). This study demonstrated excellent minimum 2-year clinical and radiographic outcomes and low revision and reoperation rates of this new fourth-generation TAA system. Future studies with longer follow-up, especially on patients with periprosthetic lucency, are necessary to investigate the long-term complications and understand the long-term functional and radiographic outcomes of this implant.

Design of a New “U”‐shaped Staple and Its Clinical Application in Postoperative Ankle Valgus of Congenital Pseudarthrosis of the Tibia in Children

ObjectiveThere has been a lack of suitable epiphysis blocking materials due to the characteristics of less tissue coverage and narrow epiphysis in children's distal tibial medial malleolus. Therefore, this study is to investigate the clinical efficacy and safety of a new “U”‐shaped staple in the treatment of postoperative ankle valgus of congenital pseudarthrosis of the tibia (CPT).MethodAccording to the inclusion and exclusion criteria, 33 patients with postoperative ankle valgus of CPT were treated with new “U”‐shaped staples from May 2013 to September 2019. The deformity of ankle valgus was gradually corrected by implanting a new “U”‐shaped staple on the medial side of the distal tibia. Clinical indexes such as the operation time, intraoperative bleeding and hospital stay were observed. Tibiotalar angle was selected as the evaluation index of ankle valgus. American Orthopedic Foot & Ankle Society (AOFAS) scale was used for clinical evaluation of ankle function. The tibiotalar angle, deformity correction rate and complications were evaluated by preoperative, postoperative and last follow‐up imaging data. Student's t‐test was used for statistical analysis.ResultsThirty‐three patients, including 12 males and 21 females were included. All the patients were followed up for at least 14 months, with an average of 35 months. The average operation time was 23 (15–40) min, the average amount of intraoperative bleeding was 7.5 (4–10) mL, and the average hospital stay was 4.2 (3–6) days. The intraoperative tibiotalar angles of all patients were 74.2° ± 4.6°, the tibiotalar angle were 86.8° ± 4.9° when internal fixation was removed, and the tibiotalar angles at the last follow‐up were 84.3° ± 5.9°. The average orthopedic rate was 0.68° per month. No patients suffered from serious complications such as screw prolapse, osteomyelitis, wound infection, etc. Postoperative wound pain complications occurred in two patients, which were relieved after conservative treatment. The AOFAS score improved from 46.2 ± 9.4 before the operation to 74.6 ± 5.7 at the last follow‐up (P < 0.01). The ankle movement was good without joint stiffness. There was no epiphyseal plate injury after the removal of internal fixation.ConclusionThe new “U”‐shaped staple is characterized by simple implantation, low notch, lower risk of fixation failure and close fitting with cortical bone. It is a safe and effective internal fixation system for the treatment of ankle valgus in children.

Calcaneal positioning in equinus immobilization of the ankle joint: A comparison of common orthoses used in the treatment of acute Achilles tendon ruptures

Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture as they can be used to position the foot in equinus and protect the torn tendon from strain in the healing phase. The aim of the study was to test four different orthoses ability to position the foot in equinus. The study was performed as a cross-sectional study. 15 healthy study participants underwent radiographic examination with 11 true lateral radiographs of the right ankle and foot, one with the ankle joint in neutral position; one of a circular equinus cast (CEC); three of an adjustable equinus boot (AEB) with the foot in 30°, 15°, and 0° of plantar flexion, respectively; three of a fixed angle orthosis with 1, 2, and 3 wedges with a plateau (WWP); and three of a fixed angle orthosis with 1, 2, and 3 wedges without plateau (WWOP). The primary outcome was the Achilles Relief Distance (ARD). Secondary outcomes were the tibiocalcaneal angle (TCA), the tibiotalar angle (TTA), and the tibio- 1st metatarsal angle (1MTP). All measurements were performed by a radiologist. The mean (SD) ARD was 11 mm (7) in CEC, 23 mm (6) with 3 WWP, 11 mm (5) with 3 WWOP, and 15 mm (5) using AEB in 30° of plantarflexion. The mean (SD) TCA was 86° (7,8) in CEC, 76° (7,3) with 3 WWP, 90° (6,9) with 3 WWOP, and 84° (6,6) using the AEB in 30° of plantarflexion. CEC, AEB, and WWOP showed statistically significantly larger plantarflexion than WWP. CEC, AEB and WWOP produced significantly greater plantarflexion compared to WWP.

A Long-Term Study of Alignment Correction Following Proximal Femoral Varus Osteotomy and Pemberton Osteotomy in Children With Legg-Calvé-Perthes Disease and Developmental Dysplasia of the Hip.

Proximal femoral varus osteotomy (PFVO) is a common procedure performed in children with developmental dysplasia of the hip (DDH) and Legg–Calvé–Perthes disease (LCPD). However, the long-term effect on angular deformities of the knees and ankles following PFVO remains controversial. This study investigated the relationship between PFVO and alignment changes in the knee and ankle after the procedure. Twenty-five patients undergoing PFVO procedure with a minimum 4-year evaluation period were enrolled in the study, including 14 unilateral LCPD and 11 unilateral DDH. The standing scanogram examinations were collected before the operation, immediately following surgery, after a 1-year follow-up, after a 3-year follow-up, and at the final visit to the clinic. The radiographic parameters included leg length, femoral neck-shaft angle (FNSA), femorotibial angle (FTA), mechanical axis deviation (MAD), tibiotalar angle (TTA), and mechanical lateral distal femoral angle (mLDFA). At the final examination, FNSA demonstrated insignificant change between the operative and non-operative limbs in the DDH group. Compared with the postoperative result, FNSA significantly improved in the LCPD group (p = 0.039). Both groups did not develop statistical significance in TTA, mLDFA, MAD, and leg length discrepancy after more than a 5-year follow-up. From a biomechanical perspective that the foot passes more medial to the knee under the center of leg mass, varus knee was prone to develop. In order to correct the mechanical axis, the knee reverted to a valgus position gradually. Our study indicates that patients with LCPD or DDH receiving PFVO and Pemberton osteotomy narrow the gap of angular growth in knees and ankles between the operative and non-operative limbs after a long-term follow-up.

Efficacy Comparison of 3 Kinds of Distal Tibial Hemiepiphyseal Implants in the Treatment of Postoperative Ankle Valgus of Congenital Pseudarthrosis of the Tibia.

Congenital pseudarthrosis of the tibia (CPT) is a complex and serious disease in orthopaedics which often requires multiple operations for treatment. Postoperative ankle valgus deformity is easily seen after the operation of CPT. The aim of this study is to retrospectively evaluate the effectiveness of three different implants for treating postoperative ankle valgus after CPT. A total of 41 patients with postoperative ankle valgus after CPT from December 2010 to July 2019 were selected. Of these 41 patients, 23 patients were treated with "U"-shaped staple, 10 patients were treated with hollow screw and 8 patients were treated with cortical bone screw. The evaluation index was tibiotalar angle. The general data, preoperative, postoperative, and final follow-up imaging data were recorded, and the deformity correction rate and complications were compared. All the patients were performed with postoperative follow-up visit for at least 12 months (31 mo on average). In the "U"-shaped staple group, the preoperative tibiotalar angle was 74.8±4.8 degrees, the tibiotalar angle was 85.8±4.5 degrees when the internal fixation was removed; in the hollow screw group, the average preoperative tibiotalar angle was 72.2±6.1 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed; in the cortical bone screw group, the average preoperative tibiotalar angle was 75.1±4.2 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed. The correction rate of the "U"-shaped staple group was 0.71 degrees/month, with that of in the hollow screw group and cortical bone screw group being 0.64 degrees/month and 0.61 degrees/month, respectively. There was no significant difference in the correction rate between the 3 groups. One case of internal fixation complication was reported in the hollow screw group; 2 cases of missing correction effect were reported, 1 in cortical bone screw group and 1 in hollow screw group; and 2 cases showing symptom of wound pain were reported in the "U"-shaped staple group. Ankle valgus is a common postoperative complication of congenital tibial pseudarthrosis. Temporary hemiepiphysiodesis with "U"-shaped staple or screws is an effective treatment for postoperative ankle valgus deformity of CPT in children. Level IV-retrospective study.

Ankle Mortise Instability in Multiple Hereditary Exostoses

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Accuracy of CT-Derived Patient-Specific Instrumentation for Total Ankle Arthroplasty: The Impact of the Severity of Preoperative Varus Ankle Deformity.

Significant preoperative varus tibiotalar deformity was once believed to be a contraindication for total ankle arthroplasty (TAA). Our primary goal was to evaluate the influence of increasing preoperative varus tibiotalar deformity on the accuracy of final implant positioning using computed tomography (CT)-derived patient-specific guides for TAA. Thirty-two patients with varus ankle arthritis underwent TAA using CT-derived patient-specific guides. Patients were subcategorized into varying degrees of deformity based on preoperative tibiotalar angles (0°-5° neutral, 6°-10° mild, 11°-15° moderate, and >15° severe). Postoperative weightbearing radiographs were used to measure coronal plane alignment of the tibial implant relative to the target axis determined by the preoperative CT template. Average follow-up at the time of data collection was 36.8 months. Average preoperative varus deformity was 6.06° (range: 0.66°-16.3°). Postoperatively, 96.9% (30/31) of patients demonstrated neutral implant alignment. Average postoperative tibial implant deviation was 1.54° (range: 0.17°-5.7°). Average coronal deviation relative to the target axis was 1.61° for the neutral group, 1.78° for the mild group, 0.94° for the moderate group, and 1.41° for the severe group (P = .256). Preoperative plans predicted 100% of tibial and talar implant sizes correctly within 1 size of actual implant size. Conclusion. Our study supports the claim that neutral postoperative TAA alignment can be obtained using CT-derived patient-specific instrumentation (PSI). Furthermore, final implant alignment accuracy with PSI does not appear to be impacted by worsening preoperative varus deformity. All but one patient (96.9%) achieved neutral postoperative alignment relative to the predicted target axis. Level IV, Clinical Case Series.