Outcomes of Total Ankle Replacement with Preoperative Varus Deformity

Historically, coronal plane deformities of greater than 10° to 15° have been deemed contraindications for total ankle replacement (TAR). However, recent studies show satisfactory results in TAR with severe preoperative varus deformity. When correctly applying ancillary procedures, preoperative varus deformity can be structurally corrected, resulting in similar clinical scores to those obtained with "regular TAR." However, complications and revisions appear to increase with increasing deformity. Unfortunately, results of TAR in varus ankles consist of heterogeneous data (eg, with regards to prosthetic brands, bearing-types, duration of follow-up, and ancillary procedures) precluding strict conclusions. This could be solved by an international consensus group.

Osteotomy combined with lateral ligament reconstruction in treating osteochondral lesion in patients with talar injury and varus ankle

This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results.

Comparison of suture-button and screw fixation in the treatment of ankle syndesmotic injuries: Cohort study protocol

BACKGROUND

Syndesmotic injuries account for a significant number of ankle injuries. There is no consensus regarding the recommended method of treatment. The purpose of this study was to evaluate: METHODS:: This study was performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. The records of 200 patients with ankle fractures who had undergone surgical treatment in our clinics between January 2014 and January 2018 were retrospectively investigated. This retrospective cohort study was approved by the institutional review board in the 2nd Hospital of Jilin University. The primary outcome measure was the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and the Foot Function Index. Secondary outcome measures included visual analog scale score, complications, range of movement of ankle, reoperations, and radiologic outcomes. For statistical comparison of the clinical and radiologic findings between the 2 groups, we used SPSS, version 21.0 (SPSS, Chicago, IL), statistical software. P Values of < .05 were considered statistically significant.

CONCLUSION

The hypothesis was that the SB technique would achieve better functional outcomes as compared to the syndesmotic screw technique after surgery.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5793).

Quantitative assessments of static and dynamic balance performance in patients with chronic ankle instability

Patients with chronic ankle instability (CAI) have postural-control deficits during center-of-pressure excursions than do healthy individuals. While an external analysis of center-of-pressure excursions in CAI has been performed, a quantitative analysis of center-of-gravity movements, to detect the balance deficits associated with CAI, has yet to be performed. Therefore, the aim of the study is to quantify the balance deficits in patients with unilateral CAI.Forty-four patients with unilateral CAI (24 men; age, 31.7 ± 5.5 years) and 26 uninjured volunteers (12 men; age, 28.6 ± 5.9 years) underwent Neurocom Balance Manager assessments of dynamic and static balance responses in limits of stability, unilateral stance, and forward lunge tests.In the limits of stability test, there were no significant group differences in the forward direction; however, reaction times were longer in the CAI group than in the control group in the backward (P = .037, effect size [ES] = 0.49) and rightward directions (P = .032, ES  = 0.47). Furthermore, the CAI group showed more excursions in the rightward (P = .046, ES = 0.50) and leftward directions (P = .002, ES = 0.80), and less directional control in the leftward direction (P = .036, ES = 0.59). In the unilateral stance test, the center of gravity sway velocity was faster in the CAI group than in the control group, whether eyes were opened or closed (P < .05). There were no significant group differences in forward lunge-test outcomes.Patients with CAI have poor static and dynamic balance performance compared to that in healthy counterparts. Thus, balance retraining should be an essential component of rehabilitation programs for patients with CAI.

Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament

BACKGROUND

Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging.

OBJECTIVE

Our aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane.

METHODS

Magnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted.

RESULTS

By MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%.

CONCLUSIONS

PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.

Medial-sided Ankle Pain: Deltoid Ligament and Beyond

Abnormalities of the medial ligaments and posterior tibial tendon can occur because of acute injury or chronic instability or malalignment. Medial ankle injuries may occur because of pronation or supination-external rotation injuries. Deltoid ligament injuries have a significant impact on lateral ankle instability but can be overlooked in patients with lateral ligament injuries. Posterior tibial tendon dysfunction is usually associated with spring ligament or flexor retinaculum injury. Tarsal tunnel syndrome, accessory flexor muscles, and subtalar coalition should be considered as well as ligament and tendon tears in differential diagnosis of chronic medial ankle pain.

MRI of the tibioastragalus anticus of Gruber muscle: a rare accessory muscle and normal anatomical variant

We present the case of a 31-year-old man who sustained a hyperplantar flexion injury of his right ankle, and was evaluated using computed tomography and MRI to assess for osseous and ligamentous injury. The MRI and CT studies demonstrated a tibioastragalus anticus of Gruber (TAAG) muscle in the lower limb's anterior compartment. To our knowledge, the imaging of this muscle has not been previously described. The TAAG muscle arises from the lower third of the anterolateral tibia and the interosseous membrane. Its tendon passes laterally, deep to the tibialis anterior and extensor hallucis longus tendons, and inserts onto the anterior superolateral neck of the talus in a fan-like manner. Knowledge and recognition of this tendon are important for both diagnostic accuracy and surgical planning, and could potentially be used as a tendon transfer or graft in the appropriate clinical setting. The presence of this accessory muscle should not be confused with a pathological condition.

Total ankle arthroplasty with severe preoperative varus deformity

Advancements in total ankle arthroplasty (TAA) over the past several decades have led to improved patient outcomes and implant survivorship. Despite these innovations, many implant manufacturers still consider a preoperative coronal plane deformity greater than 10° a relative contraindication to TAA. Without proper intraoperative alignment, these implants may experience abnormal wear and hardware failure. Correcting these deformities, often through the use of soft tissue procedures and/or osteotomies, not only increases the difficulty of a case, but also the intraoperative time and radiation exposure. The authors report a case in which a 54-year-old man with a severe right ankle varus deformity of 29° underwent successful TAA using the INBONE II Prophecy total ankle system (Wright Medical Technology, Inc, Memphis, Tennessee) and additional soft tissue reconstruction. Intraoperatively, the patient's coronal deformity was corrected to 1.8°. At 8 months postoperatively, the patient ambulated without restriction and had substantial improvement in validated patient outcome scores, specifically the Academy of Orthopaedic Surgeons Foot and Ankle Module and the Short Form Health Survey-12 This unique report documents the first time that this particular implant, with an exclusive preoperative computed tomography-derived patient-specific guide, has been used effectively for a severe preoperative varus deformity greater than 20° without the need for an osteotomy. Future studies should be directed toward the prospective evaluation of different total ankle implant systems and their outcomes with severe coronal plane deformity, specifically computed tomography-derived patient-specific guided implants.

Medial malleolar screw hemiepiphysiodesis for ankle valgus in children with spina bifida

Medial malleolar screw hemiepiphysiodesis has been shown to be an effective procedure for the treatment of ankle valgus in children with spina bifida. The purpose of this study was to highlight the guided growth technique and discuss its efficacy. We retrospectively reviewed 10 spina bifida patients with 18 ankle valgus deformities treated with medial malleolar screw hemiepiphysiodesis. Medical reports were obtained to document age at surgery, gender, concurrent operative procedures and postoperative early and late complications. Anteroposterior and lateral weight bearing radiographs of both ankles were evaluated using the tibiotalar angle, pre and postoperatively. The average age at operation was 10.05 years. Average follow up was 15.33 months (11-21 months). During follow-up, the average preoperative distal tibiotalar angle of 16.27 degrees improved to an average of 2.88 degrees with statistical significance (p < 0.05). No major complications were detected. In conclusion, hemiepiphysiodesis is a safe and sufficient method to correct ankle valgus deformity in children with spina bifida, with a low incidence.

Children ankle valgus deformity treatment using a transphyseal medial malleolar screw

INTRODUCTION

Ankle valgus deformity is rare in children. It generally leads to difficulties wearing shoes, walking instability and mechanical pain. No medical treatment is effective and the only option is surgical correction of the deformity. Two main options are available: supramalleolar osteotomy and medial malleolar epiphysiodesis. We report our experience with epiphysiodesis using a transphyseal medial malleolar screw.

PATIENTS AND METHODS

This is a retrospective study of all children followed for ankle valgus and treated by transphyseal medial malleolar screw epiphysiodesis in our department. The study included 10 cases of ankle valgus deformity in seven children (four with multiple extostoses, two type 1 neurofibromatosis, one Larsen's syndrome) who completed skeletal maturity. At surgery, median bone age was 12 years (10 to 13 years and 6 months) and the median tibiotalar angle was 17.5° (10° to 30°).

RESULTS

At skeletal maturity, preoperative valgus was corrected in six patients (9/10 ankles). The median tibiotalar angle was 5° (0° to 25°). Valgus was not corrected in one patient (30° to 25°). No postoperative complications occurred.

DISCUSSION

Epiphysiodesis by transphyseal medial malleolar screw is a simple, efficient and safe procedure to correct a significant or symptomatic ankle valgus deformity in children before skeletal maturity.

LEVEL OF EVIDENCE

Level IV, retrospective study.

[Osteotomies in varus malalignment of the ankle]

OBJECTIVE

Joint-preserving osteotomies in patients with symptomatic varus malalignment of the ankle. Osseous procedures together with soft-tissue rebalancing are performed at the level of the distal tibia/fibula or calcaneus. Realignment of the joint line will subsequently reduce intraarticular forces at the ankle and thereby slow down the degenerative process.

INDICATIONS

Varus malalignment of the ankle with remaining cartilage in the tibiotalar joint.

CONTRAINDICATIONS

Severe neurovascular deficiencies. Severe instability of the hindfoot. Severe cartilage lesions of the entire ankle (grade 3-4 according to Outerbridge).

SURGICAL TECHNIQUE

Varus deformities of the distal tibia: medial opening-wedge osteotomy or lateral closing-wedge osteotomy. The lateral closing procedure requires an osteotomy of the fibula. Varus deformity of the hindfoot: valgization by lateral closing- wedge osteotomy of the calcaneus and lateral shift of the calcaneal tuberosity, i.e., Z-shaped osteotomy. Additional procedures at the first metatarsal and softtissue procedures must be considered in all these patients.

POSTOPERATIVE MANAGEMENT

Immobilization in a non-weight-bearing cast for 6-8 weeks. Thereafter, increase in weight bearing as tolerated. Physiotherapy for muscular strengthening and restoration of gait pattern.

RESULTS

Twelve patients with an osteotomy of the distal tibia presented with a significant reduction of pain on a visual analog scale (p = 0.0001) and an increased range of motion of 33 degrees (5-55 degrees ) preoperatively compared to 39 degrees (25-50 degrees ) postoperatively. Radiologic assessment also revealed an improvement of preexisting arthritic signs. All 18 patients treated with a Z-shaped calcaneal osteotomy reported pain relief with osseous consolidation after 6 months.

Coexistence of anomalous m. peroneus tertius and longitudinal tear in the m. peroneus brevis tendon

The longitudinal tear in the m. peroneus brevis tendon is frequently observed as a less common cause of chronic ankle pain and disability. In this case the rare association of a longitudinal tear in the m. peroneus brevis tendon and an anomalous m. peroneus tertius origin of muscle bulk and insertion were detected during a routine dissection of the lower left extremity. The m. peroneus tertius was originating separately from the fibula rather than as a slip from extensor digitorum longus. The muscle bulk was also bulkier than normal. The fanned-out m. peroneus tertius tendon adhered almost on the entire dorsal surface of the fifth metatarsal bone. According to our case report one of the possible causes of the longitudinal tear in the m. peroneus brevis tendon can be an anomalous m. peroneus tertius with its different origin and insertion points and muscle bulk, via changing the ankle motion mechanism. This anomaly should be considered in the patients presenting with ankle pain in the clinic.

Development of genu varum in achondroplasia: relation to fibular overgrowth

Genu varum in the achondroplastic patient has a complex and multifactorial aetiology. There is little mention in the literature of the role of fibular overgrowth. Using the ratio of fibular to tibial length as a measurement of possible fibular overgrowth, we have related it to the development of genu varum. Full-length standing anteroposterior radiographs of 53 patients with achondroplasia were analysed. There were 30 skeletally-immature and 23 skeletally-mature patients. Regression analysis was performed in order to determine if there was a causal relationship between fibular overgrowth and the various indices of alignment of the lower limb. Analysis showed that the fibular to tibial length ratio had a significant correlation with the medial proximal tibial angle and the mechanical axial deviation in the skeletally-immature group. We conclude that there is a significant relationship between fibular overgrowth and the development of genu varum in the skeletally-immature achondroplastic patient.

Congenital diastasis of the inferior tibiofibular joint with clubfoot and imperforate anus

Congenital diastasis of the inferior tibiofibular joint is a rare condition of unknown etiology, first described in 1972. Although its clinical presentation at birth is a talipes equinovarus deformity of the foot, it may be associated with limb length discrepancy and other skeletal and visceral abnormalities. We present one such case of congenital inferior tibiofibular diastasis of Onimus type A variety (vertical diastasis) with talipes equinovarus, high imperforate anus, short first ray of the foot, intact superior tibiofibular joint, and no limb length discrepancy. Closed manipulation and casting had been unsuccessful, and at this time, the patient had not pursued any treatment during the past one year. A colostomy for the imperforate anus had been performed 36 hours after his birth and was planned for subsequent posterior sagittal anorectalplasty to reestablish continuity. His ankle joint was reconstructed along with soft tissue release for talipes equinovarus. Two years after surgery, he has a plantigrade stable foot with no limb length discrepancy. We propose that if the reconstructed joint is carried out in early childhood, it will provide better reciprocal joint surfaces with less chances of degenerative arthritis in later life. However, leg length inequality and recurrence of the deformities are not uncommon, necessitating further surgical interventions.

Tarsal tunnel syndrome in athletes

BACKGROUND

The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition.

HYPOTHESIS

Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months.

RESULTS

Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment.

CONCLUSION

Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.

[Interposition arthrodesis of the ankle]

OBJECTIVE

Bony fusion of the ankle in a functionally favorable position for restitution of a painless weight bearing while avoiding a leg length discrepancy.

INDICATIONS

Disabling, painful osteoarthritis of the ankle with extensive bone defect secondary to trauma, infection, or serious deformities such as congenital malformations or diabetic osteoarthropathies.

CONTRAINDICATIONS

Acute joint infection. Severe arterial occlusive disease of the involved limb.

SURGICAL TECHNIQUE

Lateral approach to the distal fibula. Fibular osteotomy 7 cm proximal to the tip of the lateral malleolus and posterior flipping of the distal fibula. Exposure of the ankle. Removal of all articular cartilage and debridement of the bone defect. Determination of the size of the defect and harvesting of a corresponding tricortical bone graft from the iliac crest. Also harvesting of autogenous cancellous bone either from the iliac crest or from the lateral part of the proximal tibia. Insertion of the tricortical bone graft and filling of the remaining defect with cancellous bone. Fixation with three 6.5-mm titanium lag screws. Depending on the extent of the defect additional stabilization of the bone graft with a titanium plate. Fixation of the lateral fibula on talus and tibia with two 3.5-mm titanium screws for additional support. Wound closure in layers. Split below-knee cast with the ankle in neutral position.

RESULTS

Between January 2002 and January 2004 this technique was used in five patients with extensive bone defects (four women, one man, average age 57 years [42-77 years]). No intra- or early postoperative complications. The AOFAS (American Orthopedic Foot and Ankle Society) Score was improved from 23 points preoperatively to 76 points postoperatively (average follow-up time of 25 months). Two patients developed a nonunion and underwent a revision with an ankle arthrodesis nail. A valgus malposition after arthrodesis in one patient was corrected with a supramalleolar osteotomy.

Outcome after foot and ankle deformity correction using circular external fixation

BACKGROUND

External fixation is the method of choice for correction of chronic severe foot and ankle deformities. We report our experience and outcomes of circular external fixation.

METHODS

Fifty-five patients (60 feet) were treated with circular external fixation. The mean age at surgery was 36 (range 16 to 65) years. The mean followup was 4.4 (range 1 to 10) years. The mean time spent in external fixation was 2.1 (range 1 to 12) months.

RESULTS

There were six excellent, 35 good, eight fair, and six poor results, five of which had below knee amputations. All the patients who had an amputation were treated for infected nonunion of the ankle.

CONCLUSION

Circular external fixation was found to be an effective method for treating a variety of complex foot and ankle problems. The complications were more common in patients with infected nonunions.

Percutaneous supramalleolar osteotomy for distal tibial (near articular) ankle deformities

Supramalleolar osteotomies are performed to realign the distal tibia and to improve foot and ankle function. This procedure requires a thorough preoperative and intraoperative understanding of limb-deformity parameters and of the center of rotation of angulation method of surgical planning. Radiographic, gait, and clinical analyses along with intraoperative fluoroscopic images are paramount to deformity correction. This article describes the radiographic and clinical analyses and technical considerations in performing a focal dome supramalleolar osteotomy.

Split lesions of the peroneus brevis tendon in the Japanese population: an anatomic and histologic study of 112 cadaveric ankles

Split lesions of the peroneus brevis tendon are believed to be rare and have received little attention in populations of Asian countries. The purpose of this study was to investigate the incidence of split lesions in the Japanese population. The peroneus tendons of 112 ankles from 30 male and 26 female adult human embalmed cadavers with an average age of 76.9 years (range, 55-93) were dissected. The presence of split lesions, determined by either thinning or longitudinal splitting of the peroneus brevis tendon, was examined. Forty-two ankles (37.5%) had split lesions, of which 21 (50%) showed a thinning appearance without splitting, and 12 (28.6%) had well-defined, full-thickness longitudinal tears. The incidence of split lesions of the peroneus brevis tendon in the Japanese population was similar to that in studies of the U.S. population, but the condition of the lesions was less severe. Although the clinical presence is expected to be extremely rare, we must consider a neglected split lesion of the peroneus brevis tendon when residual pain is observed in the retrofibular location.

Ankle arthroplasty with preoperative coronal plane deformity: short-term results

The treatment of coronal plane deformity during total ankle arthroplasty is understood poorly. This study tests the hypotheses that preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement, and that factors can be identified that place ankles at risk of having progressive edge-loading develop. Of 86 consecutive patients who had total ankle replacement, 35 had preoperative coronal plane alignment > or =10 degrees. Lateral ligament reconstruction was done in seven patients and superficial deltoid release was done in four patients at the time of ankle replacement. Ankles with talar and tibial deformities improved talar and tibial alignment toward a neutral weightbearing axis postoperatively. Ankles with only a talar deformity improved the talar alignment toward a neutral weightbearing axis postoperatively. No changes in alignment were shown during the subsequent 2 years. Postoperative ankle articulations were congruent. Patients with preoperative incongruent joints are 10 times more likely to have progressive edge-loading develop than patients with congruent joints. Surgeons must be attentive to coronal plane alignment during and after ankle replacement. Longer followup is needed to assess the longevity of the correction and the impact of minor malalignment on implant wear.

Findings of fibular hemimelia syndrome with radiographically normal fibulae

We have noted a number of patients with features of fibular hemimelia with radiographically normal fibulae. This study was undertaken to further define this group. A review of hospital records and radiographs over a 72-year period identified 149 limbs in 123 patients with features of fibular hemimelia syndrome. Sixteen limbs in fourteen patients had findings of fibular hemimelia with radiographically normal fibulae. Thirteen of 16 had absent lateral rays with either ball and socket ankle joint, tarsal coalition or both. Six of the 13 had limb shortening. Three limbs in three patients did not have absent lateral rays, but had at least two other features of fibular hemimelia syndrome. All of these three limbs had ball and socket ankles and tarsal coalitions and two had shortening. These patients represent a mild subset of fibular hemimelia syndrome and we propose that they be classified as type 0 fibular hemimelia.

Distal tibial transphyseal osteotomy for ankle varus deformity in an operated case of clubfoot

Ankle varus deformity arises due to a number of congenital and acquired causes leading to significant functional debility in the patients, especially children. We report a less commonly used technique, the transphyseal osteotomy of distal tibia, for the correction of varus deformity of the ankle joint in a thirteen-year-old boy. Full correction of the deformity could be achieved using this technique. The patient is fully functional with normal gait. No recurrence was detected at follow-up visit 26 months later.

Three-dimensional starch model for simulation of corrective osteotomy for a complex bone deformity: a case report

The complex valgus deformity of the right ankle of a 24-year-old Maffucci syndrome man was corrected by three-dimensional osteotomy followed by limb lengthening. Before surgical correction of the deformity, we used computed tomography data to make a life-size three-dimensional plastic model of the deformed ankle for an accurate understanding of the anatomical deformity. We then used this model to perform a simulated osteotomy. The real osteotomy was performed immediately afterwards and valgus and recurvatum deformities were corrected accurately. We recommend simulated surgery using a three-dimensional plastic model which will improve the pre-operative planning technique and the accuracy of the end results.

Nail patella syndrome: a review of the phenotype aided by developmental biology

Nail patella syndrome (NPS) is an autosomal dominant condition affecting the nails, skeletal system, kidneys, and eyes. Skeletal features include absent or hypoplastic patellae, patella dislocations, elbow abnormalities, talipes, and iliac horns on x ray. Kidney involvement may lead to renal failure and there is also a risk of glaucoma. There is marked inter- and intrafamilial variability. The results of a British study involving 123 NPS patients are compared with previously published studies and it is suggested that neurological and vasomotor symptoms are also part of the NPS phenotype. In addition, the first data on the incidence of glaucoma and gastrointestinal (GI) symptoms in NPS are presented. NPS is caused by loss of function mutations in the transcription factor LMX1B at 9q34. The expansion of the clinical phenotype is supported by the role of LMX1B during development.

[A case of ball-and-socket deformity of the ankle joint]

Ball-and-socket deformity of the ankle joint is a rare entity that is usually associated with inequality of leg length, fibular hypoplasia, coalition of the tarsal bones, and ray deficiency. This deformity was encountered in a nine-year-old girl with a short right limb, cavovarus foot, partial fusion of the 4th and 5th metatarsals, and talocalcaneonavicular coalition. No surgical intervention was necessary; the patient was recommended to wear a high-heeled shoe of 2.5 cm thickness to compensate for the difference in the leg length.

Ball-and-socket ankle joint with hypoplastic sustentaculum tali

A case of unilateral ball-and-socket ankle joint associated with short limb and hypoplastic sustentaculum tali is reported. We think that hypoplastic sustentaculum tali was the cardinal feature in the anatomical and kinematic alterations of the foot in this patient. We review the embryonic development of hindfoot to ascertain the possible origin of this unusual finding.

Valgus deformity of the ankle following harvesting of a vascularized fibular graft in children

Progressive valgus ankle deformity is a problematic postoperative donor-site morbidity of a vascularized fibular graft in children. To prevent this complication, tibiofibular metaphyseal synostosis (the Langenskiöld procedure) has been recommended. The authors objectively evaluated the preventive and therapeutic effects of this procedure on five children who had received free vascularized fibular grafts. Their average age at the time of operation was 3 years (range: 1 to 9 years). The Langenskiöld procedure was performed primarily in four patients, and not in one patient. The anteroposterior (A-P) mortise angle and the empirical axis of the donor-site ankle were measured radiographically. With regard to the A-P mortise angle, four of five patients showed valgus with a mild lateral wedging of the distal tibial epiphysis. The patient who did not receive the operation showed the largest A-P mortise angle and mild osteoarthritic changes. The empirical axis exceeded normal range in all of the five patients. These observations indicated that valgus deformity of the ankle in children after harvesting a vascularized fibular graft is inevitable, even if the Langenskiöld procedure is performed. The procedure can delay the ankle valgus. The authors recommend close follow-up of the children who receive the Langenskiöld procedure after harvesting a vascularized fibular graft.

Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial release

Clubfoot is a bony deformity characterized by inversion, adduction, and equinus that often require surgical intervention. This study assessed the gait kinetics and kinematics of children with unilateral and those with bilateral clubfoot, comparing them with age-and gender-matched normal (control) children. Patient satisfaction also was examined using a questionnaire, and muscle strength was evaluated at the ankle and knee. In evaluating the kinematics, it was important to note that deviations occurred at the ankle of children with clubfoot. Differences in kinematics and kinetics at the hip and knee between normal children and those with clubfoot resulted from lack of motion at the ankle. Furthermore, the strength of ankle plantarflexors was weak, which reduced plantarflexion during push-off. This restricted motion may have been caused by residual bony deformities and muscle tightness resulting from the original condition that contributed to muscle stiffness during gait.

Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw

Valgus deformity of the ankle in children is associated with a wide variety of clinical conditions. A retrospective review was performed of 17 children (29 involved extremities) with ankle valgus deformity who had been managed by use of a percutaneously placed, transphyseal medial malleolar screw. Median age at the time of surgery was 11 years, 2 months. Median postoperative follow-up was 2 years, 2 months. Tibiotalar axis and ankle mechanical axis were the best radiographic indicators of ankle valgus deformity. Fibular station and epiphyseal wedging were poor predictors of ankle alignment. Significant improvement in the tibiotalar axis (median, 12 degrees) was noted at follow-up, and the median rate of correction was 0.59 degree/month. Resumption of physeal growth and recurrence of deformity (rate of 0.60 degree/month) was seen when the screws were removed before skeletal maturity. The transphyseal medial malleolar screw is a minimally invasive, minimally morbid, technically simple method of reversible partial epiphysiodesis at the ankle and is an effective technique for the correction of ankle valgus deformity associated with a wide variety of clinical conditions in children.

Pure dislocation of the ankle: three case reports and literature review

Ankle dislocation without fracture is an extremely rare injury. The results of treatment are reported for three patients who had a posteromedial open dislocation, a lateral open dislocation, and a posterior closed dislocation of the ankle. Management consisted of immediate reduction, debridement and capsular suture in the open dislocations, and immobilization with a short leg cast in all patients. At followup no patient had tibiotalar joint instability; a 10 degrees to 15 degrees loss in the range of dorsiflexion was observed in two patients. One patient reported paresthesia in the area of the superficial peroneal nerve. The three patients achieved good long-term functional and radiographic results. Predisposing factors that contribute to the pathogenesis of this lesion are internal malleolus hypoplasia, ligamentous laxity, weakness of the peroneal muscles, and previous ankle sprains. Among the three patients, medial malleolus hypoplasia was present in one patient and previous sprains were seen in the clinical history of another patient.

Transphyseal osteotomy of the distal tibia for correction of valgus/varus deformities of the ankle

This study is a retrospective review of the results of consecutive cases of a transphyseal osteotomy of the distal tibia. Indications for the procedure are significant valgus or varus deformities of the ankle needing acute correction because of problems with the skin and brace fit as well as progressive deformity. Twenty-one patients with a variety of underlying diagnoses, five with bilateral deformities, underwent this procedure. The technique involved making either a medially based closing or opening wedge with the distal limb of the osteotomy through the physis or the physeal scar so that it was very close to the ankle joint. A fibular osteotomy was not necessary except in three ankles. All osteotomies healed. All patients were able to ambulate and use their braces as soon as their osteotomies healed, and none had any further pressure sores or brace-related problems, although some had mild residual valgus or varus deformities. There were no significant leg-length discrepancy problems as a result of the surgery. This osteotomy is a treatment alternative for significant angular deformities of the ankle that require acute correction.

Evidence for digenic inheritance in some cases of Antley-Bixler syndrome?

The Antley-Bixler syndrome has been thought to be caused by an autosomal recessive gene. However, patients with this phenotype have been reported with a new dominant mutation at the FGFR2 locus as well as in the offspring of mothers taking the antifungal agent fluconazole during early pregnancy. In addition to the craniosynostosis and joint ankylosis which are the clinical hallmarks of the condition, many patients, especially females, have genital abnormalities. We now report abnormalities of steroid biogenesis in seven of 16 patients with an Antley-Bixler phenotype. Additionally, we identify FGFR2 mutations in seven of these 16 patients, including one patient with abnormal steroidogenesis. These findings, suggesting that some cases of Antley-Bixler syndrome are the outcome of two distinct genetic events, allow a hypothesis to be formulated under which we may explain all the differing and seemingly contradictory circumstances in which the Antley-Bixler phenotype has been recognised.

Clinical outcome after primary triple arthrodesis

BACKGROUND

To analyze the effects of multiple preoperative, intraoperative, and postoperative factors on the intermediate results of triple arthrodesis, we focused on preoperative deformity, preoperative diagnosis, degree of clinical and radiographic correction, and arthritis of the ankle.

METHODS

Between 1987 and 1995, 160 patients were managed with a total of 183 triple arthrodeses. Patients who had an infection or neuroarthropathy or who were managed with a revision arthrodesis were excluded from our study. Of the 160 patients, 111 (132 feet) who had been followed for a minimum of two years formed our study group. Each patient had an arthrodesis with rigid screw fixation and realignment of the joint surfaces without resection of wedges. The average duration of follow-up was 5.7 years (range, 2.0 to 10.8 years).

RESULTS

As seen radiographically, arthritis of the ankle was significantly more severe postoperatively than preoperatively (p<0.01), although patient satisfaction was not associated with the presence of arthritis. On a scale (not a visual analog) of 0 (not satisfied) to 10 (completely satisfied), overall satisfaction averaged 8.3 points (range, 0 to 10 points). The postoperative modified ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society averaged 60.7 points (range, 0 to 94 points). There was a significant association (p = 0.001) between satisfaction of the patient and postoperative alignment. Ten patients had a total of eleven complications: four superficial wound problems, three nonunions, one case of superficial peroneal neuritis, one case of Charcot-like neuroarthropathy of the foot (in a patient in whom diabetes developed during the follow-up period), one rupture of the Achilles tendon, and one case of peroneal tenosynovitis. Of the 111 patients, 101 (91 percent) stated that they would have the procedure again under similar circumstances, and this response was independent of the preoperative diagnostic or deformity group.

CONCLUSIONS

Triple arthrodesis for the treatment of various deformities and etiologies is effective in relieving pain and improving functional deficits. Although a high prevalence of subsequent arthritis of the ankle was noted clinically and radiographically, we could detect no association between satisfaction of the patient and arthritis.

[Principles of deformity correction around the knee]

Lower limb frontal and sagittal plane alignment and joint orientation have significant consequences for function and wear on the hip, knee and ankle. There is a normal range for the orientation of these joints relative to the mechanical and anatomic axis of the femur and/or tibia. We can use the normal joint orientation to accurately plan realignment of a deformed femur or tibia. In the frontal plane we use both anatomic and mechanical axis lines for planning. In the sagittal plane, the mechanical axis has less relevance and, therefore, only the anatomic axis is used for planning.

Development of the ball-and-socket ankle as assessed by radiography and arthrography. A long-term follow-up report

We studied the development of ball-and-socket deformity of the ankle by arthrography and radiography in 14 ankles of ten patients with congenital longitudinal deficiency of the fibula accompanied by various anomalies. The mean follow-up was for 18 years 10 months. In three ankles in infants less than one year old the lateral and medial sides of the ankle were already slightly round. In another seven ankles the ball-and-socket appearance developed before the age of five years. This was thought to be due to osseous coalition which limits eversion and inversion. In another four ankles in children who were over the age of one year at the initial examination, the deformity was demonstrated by arthrography and radiography at their first examination. Ball-and-socket deformity accompanied by tarsal coalition is an acquired deformity secondary to limitation of movement of the subtalar and midtarsal joints. It has completely developed by about five years of age.

Ankle valgus and clubfeet

Congenital equinovarus is a complex deformity that involves the ankle as well as the foot. Although equinus is the obvious and presenting ankle deformity that is typically addressed with serial manipulation, casts, and surgery, ankle valgus is a more insidious and often overlooked problem that evolves with growth. With a high prevalence (67% in this series), it may, in some cases, ameliorate the effects of residual hindfoot varus. More commonly, it may result in prominence of the medial malleolus, lateral shift of the ground reactive forces, compression of the lateral portion of the distal tibial epiphysis, fibular impingement, and excessive shoe wear. If mistaken for hindfoot valgus ("overcorrected clubfoot"), inappropriate hindfoot surgery may result. Although one may temporize with orthoses, definitive treatment options include medial malleolar epiphysiodesis or, in mature patients, supramalleolar osteotomy. We recommend a weight-bearing anteroposterior radiograph of the ankles in any patient presenting with valgus and suspected of having overcorrected congenital equinovarus, particularly if surgical intervention is being contemplated. If valgus deformity is noted in the ankle, hindfoot surgery may be contraindicated.

[The childhood ankle joint. Deformities, abnormalities and clinical variations]

The ankle joint unites high functionality with high load on a small surface. Congenital as well as acquired variations lead to a derangement of the complex concerted action of tendons, ligaments and joints. This causes dysfunction and the development of typical deformities. It is necessary to discriminate physiological variants, congenital, posttraumatic and tumoral variations for the differential diagnosis. In most instances this is only possible with the aid of radiological clarification. Congenital malformations in the region of the upper and lower ankle joint are generally rare. One disease is club foot, with malposition and deformity in the upper and lower ankle joint. Extreme malposition can also be found in talus verticalis and congenital hypoplasias and aplasias of fibula and tibia. A rather frequently found disease, which first occurs in the adolescence, is osteochondrosis dissecans.

Newly described form of X-linked arthrogryposis maps to the long arm of the human X chromosome

Arthrogryposis is a heterogeneous birth defect characterized by limitation of movement at multiple joints. One in 3,000 infants is born with arthrogryposis, and at least a third of these cases have a genetic cause. Four distinct types of X-linked arthrogryposis have been reported, and a severe lethal form recently was mapped to Xpll.3-qll.2. We now report an extended family affected with a novel variant of X-linked arthrogryposis that involves only the lower limbs. Linkage analysis with polymorphic DNA markers maps the disease locus in this unique family to the long arm of the human X chromosome between DXS1220 and DXS1205 in Xq23-27.

The pediatric foot and ankle

MR imaging can be extremely helpful in evaluating congenital and acquired deformities of the foot and ankle. Knowledge of the normal developmental anatomy of the foot and ankle is important to accurately identify abnormalities versus normal variants. The foot and ankle may be abnormal because of trauma, infection, tumor, or systemic disease. MR imaging can help in the differential diagnosis of abnormalities as well as in treatment planning and follow-up.

"Os post peronei" and the posterolateral nutcracker impingement syndrome

Impingement syndromes have been described in relation to accessory or anomalous bony additions to the foot skeleton. We describe a hitherto undescribed accessory bone in the hindfoot causing posterolateral impingement in a 28-year-old woman.

The camptodactyly-arthropathy-coxa vara-pericarditis syndrome: clinical features and genetic mapping to human chromosome 1

OBJECTIVE

To delineate the clinical features in patients with the autosomal recessive camptodactyly-arthropathy-coxa vara-pericarditis syndrome (CACP) and to determine the location of the involved gene.

METHODS

Eight affected individuals (ages 2-15 years) with CACP from 4 consanguineous kindreds were clinically evaluated. Four patients are newly described and 4 have been reported previously. Findings were compared with those in 21 other previously reported cases. DNA obtained from the 8 affected patients and their available siblings and parents was used in a genome-wide search for linkage.

RESULTS

Congenital camptodactyly and childhood-onset noninflammatory arthropathy were present in all affected patients. Seven patients developed bilateral coxa vara deformity, and 1 developed coxa magna with cystic erosions. Two of the patients also had symptoms or signs of pericarditis. A genome-wide search for linkage identified homozygosity for a series of genetic markers on human chromosome 1q in all affected patients. The marker D1S191 yielded a maximum logarithm of the odds ratio (LOD score) of 3.3 at theta = 0. The CACP gene lies within a 1.9-cM candidate interval defined by the markers D1S2107 and D1S222.

CONCLUSION

The principal features of the CACP syndrome are congenital or early-onset camptodactyly and childhood-onset noninflammatory arthropathy. Coxa vara deformity or other dysplasia associated with progressive hip disease may develop over time. Clinical pericarditis may also occur. A locus responsible for causing CACP syndrome is assigned to a 1.9-cM interval on human chromosome 1q25-31 by homozygosity mapping. This now facilitates the identification of the responsible gene and permits testing for locus homogeneity in other CACP kindreds.

Does walking speed influence the time pattern of muscle activation in normal children?

Dynamic electromyography (EMG) of the extrinsic muscles of the ankle is used more and more frequently to assist in the planning of tendon transfers in children with equinovarus deformities. Since these children walk at low speeds (1 to 4km/h), and since walking speed modifies the EMG-time pattern, the clinical investigator must be able to differentiate EMG modifications due to pathology versus those due to slow walking speed. The aim of this work was to study the effect of walking speed on the EMG-time pattern of the extrinsic ankle muscles in healthy children between 4 and 11 years of age. This pattern was found to change significantly with speed of progression but is independent of growth over this age range. A nomograph of EMG timing, taking into account walking speed, is proposed for clinical gait analysis.

Valgus ankle secondary to acquired fibular pseudoarthrosis in children. Long-term results of the Langenskiöld operation

Nine cases of acquired absence of the fibular shaft were studied to determine the growth contribution of the distal fibula; in 6 cases the absence was caused by osteomyelitis and in 3 cases by trauma. The average valgus and external rotational deformities were 15.2 degrees and 10 degrees, respectively. In 3 of 7 cases surgically treated with Langenskiöld operation or supramalleolar corrective osteotomy, the valgus deformity recurred during the postoperative growth period. The speculated causes of gradual valgus deformity are the loss of physiologic thrust from the proximal to distal fibula, the tethering effect of contracted soft tissue on distal fibula and early physeal closure of the lateral part of the distal tibia due to continuous, uneven axial overloading. The Langenskiöld operation was found effective for the stability of ankle joint in the initial period, but could not prevent the postoperative revascularization of the ankle. However, it is strongly recommended that any types of prophylactic surgery should be carried out before the development of an epiphyseal deformity of distal tibia, and to prevent secondary osteoarthritis of the ankle joint.

Screw epiphysiodesis for ankle valgus

Progressive ankle valgus is an insidious deformity that may develop during childhood due to a variety of etiologies including neuromuscular disease, skeletal dysplasia, chromosomal anomalies, and clubfoot. This may be concomitant with, or mistaken for, hindfoot valgus. The surgical options for treatment include supramalleolar osteotomy or hemiepiphysiodesis of the medial distal tibial physis. We report the rationale and technique of retarding medial malleolar growth by means of inserting a single 4.5-mm vertical screw. In a population of 31 children (50 feet), we have observed satisfactory improvement of ankle valgus with low morbidity and without permanent physeal closure. This represents a safe, predictable, and effective solution for children who present with progressive and symptomatic ankle valgus.