Weight-bearing X-rays Research Articles

Healthy 3D knee kinematics during gait: Differences between women and men, and correlation with x-ray alignment

BackgroundNormal 3D knee kinematics during gait is still not well understood, especially regarding differences between women and men.Research question: The objective of the present study was to characterize 3D knee kinematics during gait in healthy women and men with a validated tool. MethodsKnee kinematics was analysed with the KneeKG™ system in 90 healthy subjects (49 females and 41 males). 3D knee rotations were compared between women and men, and between right and left knees. Each subject underwent full-length weight-bearing x-rays. Correlations between abduction-adduction angles and lower-limb alignment measures on x-rays were assessed. ResultsIn the frontal plane, 2.0–5.0° more abduction occurred in women compared to men (0.000 ≤ p ≤ 0.015) throughout the entire gait cycle. In the transverse plane, 2.4–3.7° more external tibial rotation was seen in women than in men (0.002 ≤ p ≤ 0.041) during the initial and mid-swing phases. No difference was found between the right and left knees. Low correlations (−0.52 ≤ r≤−0.41, p < 0.001) were observed between radiographic hip-knee-ankle angle (HKA) and abduction-adduction angles throughout the stance phase. SignificanceKinematic differences between women and men in the frontal plane can be partly explained by their anatomical differences: women were less in varus than men (HKA of −0.8° vs. −2.6°, p < 0.001). Our study contributes to a better understanding of healthy 3D knee kinematics during gait and highlights the need for accounting of gender differences in future investigations. Better knowledge of natural knee kinematics will be helpful in assessing pathological gait patterns or determining the efficiency of conservative and surgical treatments to restore normal kinematics.

Periarticular bone predicts knee osteoarthritis progression: Data from the Osteoarthritis Initiative.

Osteoarthritis (OA) is a disease with a substantial public health burden. Quantitative assessments of periarticular bone may be a biomarker capable of monitoring early disease progression. The purpose of this study was to evaluate whether measures of periarticular bone associate with longitudinal structural progression. We conducted a 12-18 months longitudinal study using the Osteoarthritis Initiative (OAI). Participants received knee dual-energy x-ray absorptiometry (DXA), trabecular magnetic resonance (MR) imaging, and x-rays. Knee DXAs generated proximal tibial medial:lateral periarticular bone mineral density (paBMD) measures. Proximal tibial trabecular MR images were assessed for trabecular morphometry: apparent bone volume fraction (BVF), trabecular number, thickness, and spacing. Weight-bearing x-rays were assessed for medial tibiofemoral joint space narrowing (JSN). Chi-squared analyses assessed whether periarticular bone measures were predictive of worsening medial tibiofemoral JSN, adjusted for age, sex, and BMI. In all, 444 participants, mean age 64.2 ± 9.2 years, BMI 29.5 ± 4.6kg/m2, and 52% male at baseline. Medial JSN (radiographic progression) occurred in 40 participants (9%). Higher baseline medial:lateral paBMD, apparent BVF, trabecular number and thickness, and lower baseline and decreased trabecular spacing were all associated with more progression of JSN in the medial compartment. From lowest to highest baseline medial:lateral paBMD quartile groups, 2%, 5%, 11%, and 18% had medial JSN progression, respectively, between the 36- and 48-month visits, p-values = 0.001 and 0.002 unadjusted and adjusted. The rate of change in medial:lateral paBMD, apparent BVF, and spacing were associated with more medial JSN. For rate of medial:lateral paBMD change from lowest to highest quartile, the proportion of each group that experienced medial JSN progression were 5%, 5%, 11%, and 18%, with an unadjusted and adjusted p-value of 0.005. Baseline and most rates of periarticular bone change associate with knee OA structural progression, highlighting the close relationship between subchondral bone and JSN. Future studies should focus on developing these measures as predictive and pathophysiological biomarkers, and evaluating their deployment in clinical trials testing bone-targeted therapeutics.

Clinical and radiological outcomes of a cohort of 9 patients with anatomical fractures of the cuboid treated by locking plate fixation.

Cuboid fractures are very rare. Hence, their treatment has not been standardized. Advances in imaging techniques, particularly three-dimensional computed tomography (3D CT), and the introduction of cuboid-specific plates has improved the care of these injuries. The aim of this study was to determine the radiological and clinical outcomes of anatomical reconstruction of comminuted cuboid fractures with a locking plate. Fixation of comminuted cuboid fractures with a cuboid-specific locking plate leads to stable anatomical reduction and good functional outcomes. This was a retrospective study of 9 consecutive cases of comminuted cuboid fracture treated at a single hospital between January 2009 and December 2015. A 3D CT scan was performed preoperatively with subtraction of the posterior tarsal bone to allow the articular facets to be viewed and analyzed. Fracture fixation was done with a Locking Cuboid Plate (DePuy Synthes™). Associated lesions in the foot were treated during the same procedure. The patients were reviewed by an independent observer who performed a clinical examination, and determined the AOFAS and Maryland Foot Score. The success of the reconstruction was determined by comparing the parameters on weight-bearing X-rays views between the fixed and non-operated cuboid. The mean follow-up was 4.1 years (range 1-6). The Maryland Foot Score was 93.1 [86-100] and the AOFAS was 91.9 [82-100]. The reconstruction was anatomical and long lasting in all 9 cases. There was no foot misalignment in the frontal plane, based on the radiographs (hindfoot axis 5.5° [0-9]). The mean Djian-Annonier angle was 123.9° [108-130]. Cuboid fractures can be treated effectively through appropriate imaging and with a cuboid-specific locking plate as evidenced by very good midterm clinical and radiological outcomes in this study. IV Retrospective study.

Twelve-Year Follow-Up of Navigated Computer-Assisted Versus Conventional Total Knee Arthroplasty: A Prospective Randomized Comparative Trial

BackgroundNavigated computer-assisted total knee arthroplasty (TKA) was introduced to expedite long-term survival based on improved postoperative implantation accuracy. However, long-term outcome data after 10 years or more are rare, even available meta-analyses show controversial study results. MethodsIn a prospective randomized trial, 100 conventional TKAs (group CONV) were compared with 100 computer-assisted TKAs (group NAV) after a mean follow-up of 12 years postoperatively. A long-leg weight-bearing X-ray was performed for measuring mechanical axis of the limb, lateral distal femoral angle, and medial proximal tibial angle. Tibial slope, patella alpha angle, and radiolucent lines were also observed. Clinical investigation included evaluation of 4 different scores: Insall Knee Score, Western Ontario and MacMaster University Index score, Hospital for Special Surgery Knee Score, and visual analog scale. ResultsBased on a follow-up rate of at least 75%, no difference in TKA survival was found 12 years postoperatively: 91.5% in group CONV vs 98.2% in group NAV (P = .181). Since 5-year follow-up, no additional TKA revision had been performed in both groups. Group CONV showed a nonsignificant higher inaccuracy of neutral lower limb axis (1.8° ± 1.4°) compared to group NAV (1.6° ± 1.7°, P = .700). All X-ray assessments were not significant different within both study groups (P ≥ .068). Clinical examination showed no differences in evaluations (P ≥ .204). All collected outcome score results were similar (P ≥ .222). ConclusionTwelve years postoperatively, no differences were found in terms of long-term survival, implantation accuracy, clinical outcome or score results.

Wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture

Objective To evaluate the clinical results of wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture. Methods From February 2014 to February 2015, 9 cases of rockbottom malunion after calcaneal fracture were treated with wedged osteotomy and subtalar arthrodesis. They were 8 men and one woman, aged from 31 to 49 years (average, 40.5 years). Weight-bearing X-rays were taken before surgery and at final follow-ups. Talar declination, lateral talocalcaneal angle, lateral talo-first metatarsal angle and Bohler’s angle were used to evaluate correction of the malunion. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and visual analogue scale (VAS) for pain were used to assess functional recovery. Results Eight of them were fully followed up for an average time of 30.6 months (from 27 to 38 months). All the osteotomy sites and subtalar joints obtained bony union after an average of 17.1 weeks (from 12 to 22 weeks). The talar declination was improved from 2.5° (from-6° to 13°) preoperatively to 13.2° (from 5° to 19°) postoperatively, the lateral talocalcaneal angle from-0.2° (from-15° to 10°) preoperatively to 20.2° (from 7° to 25°) postoperatively, the talo-first metatarsal angle from 21.1° (from 10° to 30°) preoperatively to 9.9° (from 5° to 14°) postoperatively, and the calcaneal Bohler’s angle from-25.6° (from-39° to-10°) preoperatively to 22.4°(from 10° to 35°) postoperatively. The AOFAS score averaged 26.6° (from 12 to 53) preoperatively and 79.7 (from 72 to 89) at the final follow-up; the VAS score averaged 7.5 (from 6 to 9) preoperatively and 2.6 (from 2 to 3) at the final follow- up. Both scores demonstrated improvements after operation. Conclusions Since the pathoanatomy of rockbottom malunion after calcaneal fracture consist in severe loss of calcaneal height, resulting in horizon-talization of the talus and anterior ankle impingement, wedge osteotomy and sutalar arthrodesis can effectively correct the malunion, restore the loss of calcaneal height and hindfoot malalignment, and relieve the symptoms. Key words: Calcaneus; Fractures, bone; Arthrodesis; Malunion; Osteotomy

Effectiveness of talonavicular arthrodesis for Müller-Weiss disease

To evaluate the short-term effectiveness of talonavicular arthrodesis for Müller-Weiss disease. Between May 2013 and February 2015, 13 patients with Müller-Weiss disease were treated with talonavicular arthrodesis. There were 11 females and 2 males with an average age of 59 years (range, 42-67 years). The disease duration was 8-20 years (mean, 13 years). According to Maceira stage, there were 7 cases of stage Ⅲ, 6 cases of stage Ⅳ. The foot longitudinal arch height measured on weight-bearing X-ray films was (43.1±1.8) mm; the Meary angle and talocalcaneal angle measured on lateral X-ray films were (-2.8±2.3)° and (5.8±2.4)°, respectively; the calcaneal valgus angle measured on Saltzman position X-ray films was (-2.0±0.7)°. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 43.5±12.4, and visual analogue scale (VAS) score was 7.3±1.5. All the patients were followed up 14-39 months (mean, 20 months). The symptoms of foot pain and intermittent claudication disappeared in all patients. All cases achieved bony union, the fusion time was 12-16 weeks (mean, 13 weeks). There was no complications such as wound infection, skin necrosis, or internal fixator broken. At last follow-up, the foot longitudinal arch height, Meary angle, talocalcaneal angle, and calcaneal valgus angle were (52.5±2.2) mm, (1.3±2.2)°, (16.5±3.7)°, and (0.4±0.7)°, respectively; the AOFAS score and VAS score were 83.8±9.1 and 1.0±0.4, respectively; all were significantly improved when compared with preoperative ones ( P<0.05). If the subtalar and calcaneocuboid joints are relatively healthy, talonavicular arthrodesis may be a reliable and effective surgical option for Müller-Weiss disease that is resistant to conservative treatment.

Femoral supracondylar osteotomy for the treatment of valgus knee osteoarthritis in young and middle-aged patients

To evaluate the clinical efficacy of open supracondylar osteotomy of the femoral condyle for the treatment of valgus knee osteoarthritis. From April 2008 to June 2015, 21 patients with valgus knee osteoarthritis underwent an open wedge femoral supracondylar osteotomy using the distal femur dissection plates combined with autologous iliac bone graft for the bone defect. There were 8 males (8 knees) and 13 females (15 knees), ranging in age from 30 to 54 years old, with a mean age of 41.2 years old. All the patients had valgus deformity and knee joint pain in the lateral compartment. The average tibiofemoral angle was (162.0±2.6)° which was measured on the image of preoperative lower extremity weight-bearing X-ray. Clinical outcomes were comprehensively assessed according to the bone healing time, postoperative complications, progress of knee osteoarthritis after operation, the Hospital for Special Surgery rating system (HSS), and tibiofemoral angle before and after operation. All 21 patients were followed up, the valgus deformity of knee joint was corrected in all patients after operation. No obvious delayed union or nonunion were found, and no serious complications were found. The HSS knee score was improved from the preoperative 57.3±3.1 to the final follow-up time 88.6±2.7. Tibiofemoral angle was improved to the postoperative(176.0±1.4)°. Open wedge femoral supracondylar osteotomy has a clear surgical approach, and it is easy to control the bone mass of osteotomy and can effectively correct the valgus deformity and improve the function of knee joint using this method. It is an effective method for the treatment of valgus knee osteoarthritis in young and middle-aged patients.

Sagittal Plane Corrections around the Knee.

AbstractStability of the knee joint depends on soft tissues integrity and bony balance in the frontal and sagittal planes during gait. Although frontal plane imbalance is a well-known knee pathology, commonly treated by high tibial osteotomy, sagittal plane imbalance is less common, with fewer and more challenging surgical treatment options. The purpose of this review is to describe the biomechanical effects of sagittal knee imbalances and to outline the indications, techniques, and outcomes of sagittal knee osteotomies. The article details the reference axes and methods to measure posterior tibial slope (PTS), the principal indicator of sagittal imbalance, and its influence on anteroposterior tibial translations and rotational stability of the joint. The authors also outline the roles of the anterior and posterior cruciate ligaments in maintaining sagittal balance, with focus on the associations between PTS and ligament deficiencies, as well as posterolateral corner injuries. Different techniques and indications of tibial osteotomy in the sagittal plane, both above and below the anterior tibial tubercle, are compared in terms of technical difficulty, clinical benefits, and complication rates. The authors conclude on the importance of understanding sagittal knee imbalance, particularly in cases of ligament deficiencies, where the deformity can be the primary cause for lesions. Surgeons must identify the underlying deformities associated with sagittal imbalance, which can be recognized on weight-bearing X-rays and magnetic resonance imaging scans. Different techniques of sagittal osteotomies offer effective treatments for certain indications and should be considered in selected cases for unstable knees with ligament lesions.

Scarf osteotomy without internal fixation for correction of hallux valgus: A clinical and radiographic review of 148 cases

BackgroundHallux valgus is a common condition with in excess of 120 procedures described in the literature for its correction. Traditionally, distal metatarsal osteotomies have been employed in the treatment of mild deformities, with proximal osteotomies being reserved for more severe presentations. The Scarf osteotomy without internal fixation allows large translations which can successfully correct severe hallux valgus deformities, without limitations related to screw placement. MethodsThis is a retrospective single surgeon case series performed over a three year period. One hundred and forty-eight cases were identified, with an average follow up time of 16.5 months. Visual analogue scales were used to obtain preoperative and postoperative pain and cosmetic scores, with the Foot and Ankle Disability Index (FADI) index used to assess functional status. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were assessed on preoperative and postoperative AP weight-bearing foot X-rays. ResultsThe mean pain score improved from 7.04/10 preoperatively to 0.29/10 postoperatively. The mean cosmetic score improved from 2.1/10 to 9.1/10 postoperatively. The mean preoperative HVA and IMA were 35.04° and 15.04°, respectively. The mean postoperative HVA and IMA were 11.54° and 4.83°, respectively. The mean postoperative FADI score was 103.4/104. We report a loss of correction in two cases. One revision surgery was performed. ConclusionsWe report a large series of cases of the modified Scarf osteotomy as described by Maestro—a versatile, cost-effective, safe and reliable technique with the potential for three dimensional correction. Whilst this is a technically demanding procedure, we recommend the use of the modified Scarf osteotomy in the treatment of a wide range of hallux valgus deformities.

Is it possible to use stress radiographs as a tool to diagnose medial meniscus posterior root tears?

Aim:Medial meniscus posterior root tear (MMPRT) causes meniscal extrusion, loss of meniscus function, arthritic changes. Clinical history, physical examination and magnetic resonance imaging (MRI) findings are useful for the diagnosis of MMPRT. The aim of this study is to evaluate the utility of stress X-rays in the diagnosis of MMPRT.Methods:Twenty patients who had undergone high tibial osteotomy between March 2015 and May 2016 and whose preoperative bilateral varus and valgus stress x-rays (Telos device) along with weight bearing x-rays were available were included. These patients were grouped into two according to integrity of posterior roots of their medial menisci; there were ten patients both in the study and control groups. Lateral joint space width (LJW) on varus stress x-rays, medial joint space width (MJW) on valgus stress x-rays as well as LJW and MJW on weight bearing x-rays were measured bilaterally. Intragroup comparisons of joint space widths between index and opposite knees were performed. Differences of MJW and LJW between index and opposite knees were calculated. Differences of joint space widths between stress x-rays and weight bearing x-rays were also calculated. The changes in joint space widths between the two groups were compared. Statistical analyses were performed utilizing SPSS 18.0. Significance level was set at 0.05.Results:In MMPRT group, opening of LJ space of index knees under varus stress was greater than that of opposite knees (Index: (mean±SD) 10,27±1,17 mm, opposite: 8,61±1,37 mm; p<0,0001). In the control group the difference was not significant (Index: 9,29±2,55 mm, opposite: 9,68±1,44 mm; p=0,566). The difference in the opening of LJW (under varus stress) between index and opposite knees was significantly greater in the study group (p=0,013). The difference between LJW under weight-bearing and varus stress conditions was significantly greater in the study group. (Study: 3,64±0.217 mm, control:2,28±0,182 mm, p=0.018).Conclusions:The findings of this study showed that in patients who had MMPRTs, an increased opening in the LJW was observed under varus stress conditions. This may be relevant with the fact that when varus stress is applied, meniscal extrusion is increased in case of a MMPRT. Stress x-rays could be a useful tool in the diagnosis of MMPRTs. Further studies are needed to determine the sensitivity and specificity of this diagnostic tool.

Osteochondral autograft transplantation with biplanar distal tibial osteotomy for patients with concomitant large osteochondral lesion of the talus and varus ankle malalignment

BackgroundOsteochondral lesions of the talus (OLTs) are amongst the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (>10 mm), Osteochondral autograft transplantation is usually recommended. This article highlights biplanar distal tibial osteotomy as an approach and management for patients with concomitant large OLTs and varus ankle malalignment.MethodsFrom January 2012 to July 2014, 13 patients (6 male and 7 female) underwent surgery in our faculty and their average age was 55.4 (ranging from 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, followed by an osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight-bearing X-rays were conducted and used for the measurement of radiographic parameters such as the tibial articular surface (TAS) and tibial lateral surface (TLS) angles. Ankle function of the subjects was evaluated according to the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot score (AOFAS-AH) questionnaires and Visual Analog Scale (VAS).Results11 patients completed the follow-up over a mean period of 21.2 months. The average area of talar lesion was 135.9 mm2 while the average depth was 11.4 mm. The mean time for osseous union was 8.5 weeks. Donor site morbidity was not recorded in any of the cases. The mean AOFAS-AH and VAS improved from 53 to 90 points (p < 0.05) and 6.7 to 1.9 points (p < 0.05) respectively. The mean TAS angle improved from 83.1 to 90.3° (p < 0.05).ConclusionsBiplanar distal tibial osteotomy with the combination of osteochondral autograft transplantation could be used to address patients with concomitant large OLTs and varus ankle malalignment as this technique provides excellent visualization of the talar defect, favorable biomechanical environment for the ankle joint with high rate of good and excellent results.

Association of Abnormal Metatarsal Parabola With Second Metatarsophalangeal Joint Plantar Plate Pathology.

Plantar plate pathology is common, yet it is unclear whether, and to what extent, the length of the second metatarsal contributes to this problem. We conducted a retrospective case-control (1:2) study to examine radiographic risk factors for plantar plate tears. One hundred patients (age 55.7 ± 12.3 years) with plantar plate injuries and 200 healthy controls (age 56.3 ± 11.3 years) were included. Cases were defined as patients with nonacute, isolated, plantar plate pathology of the second metatarsophalangeal joint confirmed by intraoperative inspection at a single foot and ankle specialty practice from June 1, 2007, to January 31, 2014. Patients presenting for pain outside of the forefoot served as the control group. Controls were matched on age (±2 years), gender, and year of presentation. Weight-bearing foot x-rays were assessed for several predetermined angular relationships by a single rater. Conditional logistic regression was used to identify risk factors for plantar plate injury. A long second metatarsal, defined as a metatarsal protrusion index less than -4 mm, was the only significant risk factor for plantar plate pathology in both the univariate and multivariable analyses (multivariate odds ratio 2.5 [95% confidence interval 1.8 to 3.3], P = .002). We found that a long second metatarsal was a risk factor for developing second metatarsophalangeal joint plantar plate tears. This knowledge may aid foot and ankle surgeons when contemplating the need for second metatarsal shortening osteotomies (eg, Weil osteotomy) during plantar plate surgery and when deciding on the amount of shortening for second metatarsal osteotomies. Level III, retrospective comparative study.

Normal knee gait kinematics: Describing a normal cohort and illustrating differences between genders

Introduction Gait analysis has been extensively studied by many different disciplines using various methods. Despite numerous attempts to understand the “normal” gait cycle, our current body of knowledge is insufficient to allow us to model normal locomotion in a clinically relevant manner. The primary objective of our study was to characterize normal knee3D kinematics during treadmill gait using the KneeKG™ apparatus. Materials and methods Ninety-five patients, 52 females and 43 males, were recruited to participate in our study. Each patient completed the KOOS and SF-12 questionnaires, underwent a KneeKG™ examination, and had full-length weightbearing (FLWB) x-rays. We analyzed the results of the questionnaires, generated gait cycle 3D kinematics (sagittal, transverse, and frontal plane), and measured clinically relevant angles on the FLWB x-rays. Furthermore, we compared knee kinematics between men and women and between the right and left knees of the same patient. We also attempted to find a correlation, using Pearson correlation statistics, between the hip-knee-ankle angle (HKA) and the frontal plane kinematic. Results Average age of our cohort was 36.1 years (SD: 13.3). Our cohort had scores superior to 98 in all five subsections of the KOOS questionnaire. Knee gait cycle kinematics in all planes was similar to what has been reported in the literature. When comparing men and women, significant differences were found in the sagittal motion and transverse rotation planes and in the entirety of the gait cycle in the frontal plane. When comparing the right and left knees, significant differences were only found in the frontal plane. No meaningful correlations could be made between the HKA angle and abduction. Discussion – conclusion As three-dimensional analysis of human gait progressively becomes a clinically useful tool in musculoskeletal diseases, an understanding of normal gait as well as a creation of a normal gait data bank is essential. We believe the results of our study contribute to understanding the kinematics of the gait cycle and foster the notion that cohorts should be divided for gender to account for gait differences in the frontal plane.

Clinical effectiveness in severe knee osteoarthritis after intra-articular platelet-rich plasma in association with hyaluronic acid injection: three case reports

Osteoarthritis (OA) is a degenerative disorder resulting from loss of joint cartilage and underlying bone and causes pain and loss of function. The treatment of knee OA is still a challenge because of the poor self-regeneration capacity of cartilage. The nonsurgical interventions include control of the aggravating factor (such as weight control and the use of walking aids), symptomatic treatment (such as acetaminophen or nonsteroidal anti-inflammatory drugs), prolotherapy, and viscosupplementation. However, the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) has not been widely used because of lack of clinical evidence and several limitations in patients with severe knee OA. Three patients who suffered from knee pain and poor walking endurance were diagnosed with advanced knee OA. They underwent PRP treatment in association with intra-articular HA injection and showed pain relief and functional improvement. The follow-up standard weight-bearing X-ray images of knees also confirmed the improvement and indicated the possibility of regeneration of the articular cartilage. These cases provide clinical and radiographic evidence for a new therapy for advanced knee OA. This treatment strategy of PRP in association with HA injection can offer a chance to treat severe knee OA, rather than immediate surgery, or a chance for those who cannot undergo surgery. It can also postpone the need of arthroplasty and can significantly improve the daily activity function.

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.

Angular Correction with Chevron-Akin Double Osteotomy in Mild, Moderate, and Severe Hallux Valgus

Category: Bunion Introduction/Purpose: Hallux valgus affects a substantial number of patients requiring foot and ankle orthopaedic surgery. Chevron osteotomy is commonly used in mild hallux valgus for angular correction, and the chevron-Akin double osteotomy is a more powerful tool, with presumed usefulness in moderate and severe deformity. The objective of this study was to use radiographic analysis to determine the average and maximum corrections achievable with the chevron-Akin double osteotomy. Methods: This retrospective study included a total of 30 patients and a total of 33 feet. Pre- and postoperative hallux valgus angles (HVA) and intermetatarsal angles (IMA) were evaluated using standard weight-bearing AP plain x-rays and the differences pre- to post- were calculated. Patients were grouped based on the severity of preoperative hallux valgus into mild, moderate, and severe pathology. The pre- to post- changes of HVA and IMA, and the postoperative values of each angle, were compared between severity groups by using ANOVA, and means and standard deviation were reported at each level of severity. The rate of correction to normal was noted in each severity group. The study was approved by our institutional review board. Results: Of the 33 feet, 3 were categorized as mild, 19 as moderate, and 11 as severe. In the mild group, average improvement was 13 in HVA and 6 in IMA; maximum correction achieved was 14 in HVA and 9 in IMA; and 3 of 3 (100%) were corrected to the normal range. In the moderate group, average improvement was 16.5 in HVA and 5.2 in IMA; maximum correction achieved was 29 in HVA and 9 in IMA; and 18 of 19 (95%) were corrected to the normal range. In the severe group, average improvement was 28.5 in HVA and 8.8 in IMA; maximum correction achieved was 43 in HVA and 20 in IMA; and 9 of 11 (82%) were corrected to the normal range. Conclusion: This study demonstrates that the combined chevron-Akin double osteotomy is capable of both small and large degrees of angular correction in hallux valgus. It shows that the use of the chevron-Akin double osteotomy can be expanded to cases of moderate to severe angular deformity.

Gravity Reduction View

Category: Trauma Introduction/Purpose: The determination of stability and ultimate need for operative stabilization of Weber B fibula fractures largely depends on the presence of a competent deltoid ligament. While various radiographic parameters and the application of manual or gravity stress have been proposed to elucidate instability, the prognostic capability of these modalities remains unclear. Given that a recent study found no difference between operative and nonoperative treatment for stress-positive Weber B ankle fractures, the value of stress views is questionable; what may be ultimately more important is the determination of anatomic positioning of the mortise. We propose a novel view, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise. We also propose a treatment algorithm based on the use of the GRV. Methods: To obtain the GRV, the patient is positioned in lateral decubitus with the injured fibula directed upward and elevated with a leg holder. The x-ray cassette is placed posterior to the heel, with the beam angled at 15˚ of internal rotation to obtain a mortise view. Our treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view. If the MCS on GRV remains wide or decreases, surgery is recommended as the GRV confirms a non- anatomic mortise. If the MCS remains within normal limits on the static and GRV views, a trial of nonoperative treatment with immobilization and repeat radiographs in 1-2 weeks is undertaken. If the MCS is normal on repeat weightbearing x-rays, the patient is treated conservatively; if increased, surgery is recommended. To further assess mortise stability, the MCS is compared to the superior clear space (SCS). Results: 23 patients with Weber B distal fibula fractures were managed according to this treatment algorithm. The mean age was 49.1 years old (range: 18-74). Of these patients, 15 underwent operative treatment and 10 patients were initially treated nonoperatively, although 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, all patients had a final MCS that was less than the SCS (final mean MCS for patients treated operatively or nonoperatively 2.85 mm vs. mean SCS of 3.34), indicating effectiveness of the treatment algorithm. Conclusion: The Gravity Reduction View is a novel radiographic view in which deltoid competency, reducibility and initial anatomic positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the reduction view (GRV). We have developed a treatment algorithm based on the GRV and have found it to be predictive of mortise alignment and useful in guiding treatment.

Radiographical definition of the proximal tibiofibular joint – A cross-sectional study of 2984 knees and literature review

BackgroundProximal tibiofibular joint (PTFJ) injuries are not uncommon but relatively understudied. This study evaluates the effectiveness of 2 radiographic methods in assessing the integrity of the PTFJ. Study designThis is a cross-sectional study of 2984 consecutive patients with knee X-rays done in a single institution over a 4-month period. A total of 5968 knee X-rays were assessed using 2 methods–[1] The direction in which the fibula points to in relation to the lateral femoral epicondyle on anteroposterior view and Blumensaat line on lateral view. [2] The degree of tibiofibular overlap as percentage of widest portion of the fibula head. Sensitivity and specificity of these methods in diagnosing a disrupted PTFJ are calculated. Variables including quality of X-rays, weight-bearing status of AP views and degree of knee flexion on lateral views are also recorded. Univariate analysis was carried out to investigate the association between variables using chi-square test for nominal data and student t-test for continuous data. ResultsThe fibular points towards the lateral femoral epicondyle on AP view in 94.4% of the patients and points towards the posterior half of the Blumensaat line on lateral view in 98.1% of the patients. Using this method, weight-bearing X-rays are significantly associated with the direction the fibula is pointing (p<0.01) on the AP view and the degree of knee flexion is associated with the direction the fibula is pointing (p<0.01) on the lateral view.The AP tibiofibular overlap ranges from >0% to <75% in 94.1% of the patients and the lateral tibiofibular overlap ranges from >0% to <75% in 84.5% of the patients.This method is associated with whether true orthogonal X-rays of the knees are taken (p=0.048). ConclusionThe direction in which the fibula is pointing and the percentage of tibiofibular overlap are highly specific radiographic methods useful in defining the PTFJ. The first method requires a weight-bearing view on AP assessment and >20 degrees of flexion on lateral assessment. True orthogonal AP and lateral views are required for the second method to be used.

Establishing a Customized Guide Plate for Osteotomy in Total Knee Arthroplasty Using Lower-extremity X-ray and Knee Computed Tomography Images.

Background:The conventional method cannot guarantee the precise osteotomies required for a perfect realignment and a better prognosis after total knee arthroplasty (TKA). This study investigated a customized guide plate for osteotomy placement in TKAs with the aid of the statistical shape model technique using weight-bearing lower-extremity X-rays and computed tomography (CT) images of the knee.Methods:From October 2014 to June 2015, 42 patients who underwent a TKA in Guizhou Provincial People's Hospital were divided into a guide plate group (GPG, 21 cases) and a traditional surgery group (TSG, 21 cases) using a random number table method. In the GPG group, a guide plate was designed and printed using preoperative three-dimensional measurements to plan and digitally simulate the operation. TSG cases were treated with the conventional method. Outcomes were obtained from the postoperative image examination and short-term follow-up.Results:Operative time was 49.0 ± 10.5 min for GPG, and 62.0 ± 9.7 min in TSG. The coronal femoral angle, coronal tibial angle, posterior tibial slope, and the angle between the posterior condylar osteotomy surface and the surgical transepicondylar axis were 89.2 ± 1.7°, 89.0 ± 1.1°, 6.6 ± 1.4°, and 0.9 ± 0.3° in GPG, and 86.7 ± 2.9°, 87.6 ± 2.1°, 8.9 ± 2.8°, and 1.7 ± 0.8° in TSG, respectively. The Hospital for Special Surgery scores 3 months after surgery were 83.7 ± 18.4 in GPG and 71.5 ± 15.2 in TSG. Statistically significant differences were found between GPG and TSG in all measurements.Conclusions:A customized guide plate to create an accurate osteotomy in TKAs may be created using lower-extremity X-ray and knee CT images. This allows for shorter operative times and better postoperative alignment than the traditional surgery. Application of the digital guide plate may also result in better short-term outcomes.

Application of weight bearing biplanar stereoradiography in assessment of lower limb deformity

Background: The purpose of this study was to investigate the agreement between the three-dimensional (3D) weight-bearing radiological measurements of leg deformities in the presence of leg rotation and knee flexion in a biplanar stereoradiography system (EOS imaging) and measurements of computed tomography (CT) scans. Methods: Upright biplanar X-rays of six Sawbones; with deformity were registered in no flexion/rotation angle, in 10° and 20° of axial rotation, and 10° and 20° of knee flexion. A CT scan of each bone was registered in supine position, and the 3D reconstruction of each bone was generated. Two-dimensional (2D) lengths and deformity angles were measured on the plain X-rays by two independent observers. Two independent observers generated the 3D reconstructions of the biplanar X-rays and the leg deformity parameters were measured in 3D using custom-developed software. 2D and 3D measurements were compared to CT measurements performed by two observers and repeated three times. The intraclass correlation and limit of agreement between the three measurement techniques were evaluated using Bland-Altman plots. Results: The intraclass correlations were good to excellent for the three imaging modalities (intraclass correlation coefficients = 0.71-0.95). Frontal deformity angles and lengths were significantly different in the 2D X-rays and CT (P 0.05). Conclusions: The 3D measurements of the weight-bearing biplanar X-rays were comparable to 3D CT in assessment of the lower limb deformity.