The Classic Three-Month Post-Operative Adaptation Phase in Foot and Ankle Surgery-An Expert Perspective

Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.

Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus

PURPOSE

The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates.

METHODS

Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5 mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy.

RESULTS

Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement.

CONCLUSION

The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Two-Staged Revision Total Ankle Arthroplasty Surgery with Primary Total Ankle Arthroplasty System: A Case Report

CASE

Case of a 2-staged revision surgical technique for the treatment of an aseptic total ankle arthroplasty (TAA) loosening: first surgery: removal of the loosened and painful TAA Scandinavian Total Ankle Replacement, with exclusion of infection, and reconstruction of the large bone defect (bone-defect downsizing surgery); proof of successful ankle bone reconstruction by CT-scan imaging; second surgery: implantation of a primary VANTAGE TAA (ankle reconstruction with new primary TAA).

CONCLUSION

The present case shows the management of a failed TAA with bone defect by performing a 2-step surgical approach: removal of loosened TAA with simultaneous bone stock restoration and then implantation of a new primary TAA. This concept is a possible alternative to a post-TAA ankle arthrodesis or to the use of a TAA revision system.

Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral defects in the talus? A systematic review and meta-analysis

BACKGROUND

The aim of this study is to systematically review the literature on clinical outcomes of patients who have undergone autologous matrix-induced chondrogenesis (AMIC) for treatment of osteochondral lesions of the talus (OCL) and compare the studies' outcomes.

METHODS

Pubmed and Embase were searched in January 2020 for articles concerning OCL surgery. Studies were included if they had a minimum 1-year follow-up and the primary measures were functional outcomes. The meta-analysis compared the Visual Analogic Score (VAS), the American Orthopedic Foot and Ankle Score (AOFAS), and the Foot Function Index (FFI) between baseline and follow-up of 1-2years, and 3-5years. A random effects model was used to evaluate outcome changes.

RESULTS

The search returned 15 studies, with a total of 492 patients. The VAS improved 4.45 and 4.6 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). AOFAS improved 31.59 and 32.47 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). The FFI showed a significant improvement of 30.93 points from baseline to year 3-5 (p<0.001). A total of 6 patients with revision surgeries have been reported within the follow up period. It was not possible to correlate clinical features like lesion size, surgical approach, and bone marrow stimulation technique to the reported outcome.

CONCLUSION

Surgical treatment of OCL via the AMIC procedure provided significant improvement in the functional outcome and pain scores when compared to the pre-operative values. Improvements were observed up to 5years post-operatively.

Neglected Iatrogenic Flexor Hallucis Longus Tendon Rupture After Haglund's Endoscopic Surgery: A Case Report

Rupture of the flexor hallucis longus (FHL) tendon is a rare condition that can occur with direct or indirect trauma; most of the injuries are complete ruptures resulting from laceration. Endoscopic calcaneoplasty is used for treatment of symptomatic Haglund's deformity, and complications of this procedure are rare. Iatrogenic FHL tendon rupture occurring after endoscopic calcaneoplasty has not been reported previously. This case report presents a rare complication after endoscopic calcaneoplasty and the proper method of treatment.

Medial Ankle Instability: The Deltoid Dilemma

Diagnosis and treatment of medial ankle instability (MAI) are still controversial and poorly discussed in literature. The purpose of this review is to highlight different clinical presentations of MAI and develop a guide for its management. The deltoid ligament complex is injured more commonly than expected, because deltoid ligament injuries may either be isolated or occur in combination with other lesions, such as lateral ankle ligament injury, posterior tibial tendon insufficiency, osteochondral lesion, and others. The presence of a pes planovalgus deformity in a patient without posterior tibial tendon insufficiency may indicate MAI.

Digit-Like Bony Anomaly of the Hindfoot: A Case Report

We report the case of an asymptomatic digit-like bony anomaly located on the plantar aspect of the calcaneus, which was incidentally found on radiographs of a 50-year-old male with a tibial shaft fracture. To the best of our knowledge, this is the first description of such an anomaly in the foot. The differential diagnosis includes accessory ossicles, polydactyly, heel spur, heterotopic ossification, osteochondroma, and pelvic digits.

Rehabilitation and Return to Sports: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement.

CONCLUSIONS

The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle.

Scaffold-Based Therapies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.

LEVEL OF EVIDENCE

Level V, expert opinion.

Realignment osteotomy in fibular malunion

Category:

Ankle Arthritis

Introduction/Purpose:

The incidence of fibula fractures continues to increase. The exact incidence of distal fibula malunions after fibular reconstructions is not known, but incidence up to 33% is described in the literature. The most frequent malunions of the fibula are shortening and malrotation, resulting in the widening of the ankle mortise and talar instability. It has been demonstrated that substantial fibular displacement may substantially increase the contact pressures in the ankle joint. Therefore distal fibular malunion is a risk factor for development of posttraumatic ankle osteoarthritis. The objectives of this study were to (1) describe our treatment algorithm and surgical technique in patients with posttraumatic fibula malunions; (2) determine intra- and postoperative complications rates, (3) to describe mid-term clinical and radiological outcomes and quality of life.

Methods:

21 consecutive patients (12 male, 9 female, mean age 42 years) with symptomatic fibular malunions were included into this prospective study. The initial injury was Weber B and C fracture in 7 and 14 ankles. The mean time between the injury and reconstructive surgery was 17.5 months. In all patients a z-shaped osteotomy of the fibula was performed to achieve the appropriate length/rotation of the fibula. Fixation was performed using a plate. If necessary, supramalleolar and inframalleolar deformities were corrected by supramalleolar tibial and calcaneal osteotomies, respectively. Prior to the osteotomies an anterior ankle arthroscopy was performed in all patients. All patients were evaluated pre- and postoperatively (mean follow-up 5.6 years). Radiological outcomes were assessed using standardized weight-bearing radiographs. Clinical outcomes were assessed using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, SF-36 questionnaire.

Results:

There were no intraoperative complications. In two patients early wound healing problems were observed, and resolved with i.v. antibiotics. Osseous healing was observed in all ankles within 10 weeks after surgery. The length and rotation of the fibula was improved in all patients, according to Weber criteria. All patients experienced significant pain relief (VAS: 6.5 ± 1.1 to 1.1 ± 0.9, P < 0.001) and functional improvement (AOFAS hindfoot scale: 47.1 ± 14.5 to 85.0 ± 7.5, P < 0.001; ROM:37° ± 6° to 45° ± 5°, P < 0.001). The SF-36 score also significantly increased in all 8 subgroups. In 11 patients hardware was removed due a discomfort after a mean of 11.7 months (range 7.2 – 22.8).

Conclusion:

A z-shaped osteotomy is an efficient and successful method to restore fibula length and rotation in patients with posttraumatic malunion. Our findings in this series of 19 ankles confirm that this realignment surgery results in significant pain relief and functional improvement.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

All-Arthroscopic Autologous Matrix-Induced Chondrogenesis-Aided Repair of a Patellar Cartilage Defect Using Dry Arthroscopy and a Retraction System

The technique of all-arthroscopic autologous matrix-induced chondrogenesis (AMIC)-aided repair of patellar cartilage lesions using a retraction system and dry arthroscopy has been recently described. We report the first clinical and radiological data at a short-term follow-up. Twelve patients underwent AMIC-aided cartilage repair for a patellar lesion. All steps of the procedure were performed arthroscopically, which include the use of an intra-articularly placed retraction plate for distraction of the patellofemoral joint and evacuation of saline solution for collagen matrix insertion and fixation. Clinical assessment performed before surgery and at a mean follow-up time of 38 months (range: 24-70) included the following scores: Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and visual analog scale (VAS). Magnetic resonance imaging was performed at the follow-up examination, including the magnetic resonance observation of cartilage repair tissue (MOCART) score. The mean KOOS and IKDC scores increased significantly (p < 0.01) from 50.3 and 37.4 points preoperatively to 90.1 and 79.4 postoperatively. The VAS score decreased from 7.8 to 2.3 points. Mean MOCART score at follow-up was 58.3 points. Cartilage repair of patellar lesions aided by a retraction system in a dry arthroscopy setup is a promising approach. Further studies are needed to evaluate this procedure and compare it to existing matrix implantation techniques. The level of evidence for the study is 4 (case series).

How To Diagnose and Treat Infection in Total Ankle Arthroplasty

Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.

Contrast-enhanced CT imaging as a non-destructive tool for ex vivo examination of the biochemical content and structure of the human meniscus

The biochemical and histopathological techniques used to investigate meniscal content and structure are destructive and time-consuming. Therefore, this study evaluated whether contrast-enhanced computed tomography (CECT) attenuation and contrast agent flux using the iodinated contrast agents CA4+ and ioxaglate correlate with the glycosaminoglycan (GAG) content/distribution and water content in human menisci. The optimal ioxaglate and CA4+ contrast agent concentrations for mapping meniscal GAG distribution were qualitatively determined by comparison of CECT color maps with Safranin-O stained histological sections. The associations between CECT attenuation and GAG content, CECT attenuation and water content, and flux and water content at various time points were determined using both contrast agents. Depth-wise analyses were also performed through each of the native surfaces to examine differences in contrast agent diffusion kinetics and equilibrium partitioning. The optimal concentrations for GAG depiction for ioxaglate and CA4+ were ≥80 and 12 mgI/ml, respectively. Using these concentrations, weak to moderate associations were found between ioxaglate attenuation and GAG content at all diffusion time points (1-48 h), while strong and significant associations were observed between CA4+ attenuation and GAG content as early as 7 h (R²  ≥ 0.67), being strongest at the equilibrium time point (48 h, R²  = 0.81). CECT attenuation for both agents did not significantly correlate with water content, but CA4+ flux correlated with water content (R²  = 0.56-0.64). CECT is a promising, non-destructive imaging technique for ex vivo assessment of meniscal GAG concentration and water content compared to traditional biochemical and histopathological methods. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1018-1028, 2017.

Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity

Management of diabetic Charcot midfoot deformity is one of the most demanding aspects of foot and ankle surgery. Its treatment should aim at reducing the rate of complications, including foot and ankle amputations or limb loss. Attempting reconstruction at Eichenholtz stages I and II carries the risk of infection and loss of fixation. It is advisable to limit surgical reconstruction to Eichenholtz stage III in the absence of any evidence of infection or vascular insufficiency. Achilles lengthening or gastrocnemius-soleus release is an essential initial step in surgery. Addressing the medial foot column first is a key to a successful reconstruction.

Sports Activity After Reconstruction of Osteochondral Lesions of the Talus With Autologous Spongiosa Grafts and Autologous Matrix-Induced Chondrogenesis

BACKGROUND

For the treatment of osteochondral lesions of the talus (OCLTs), autologous matrix-induced chondrogenesis (AMIC) is a safe 1-step procedure with good clinical and radiological results. However, data regarding postoperative sports activity after AMIC are limited.

PURPOSE

To identify significant factors influencing the rate of postoperative sports and recreational activities.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The sports and recreational activities of 60 patients (mean age, 34.9 ± 11.5 years) undergoing the AMIC procedure were retrospectively analyzed at a mean of 46.9 ± 17.8 months (range, 24.5-87.0 months) postoperatively. The visual analog scale (VAS) for pain score, Tegner activity scale score, activity rating scale (ARS) score, and satisfaction with surgery outcomes were assessed.

RESULTS

Corrective calcaneal osteotomy was performed in 38 of 60 (63.3%) patients. Ligament repair was performed in 41 of 60 (68.3%) patients. The mean VAS score improved significantly from 6.9 ± 1.6 points (range, 5-10 points) preoperatively to 2.3 ± 1.9 points (range, 0-6 points) at latest follow-up (P < .001). No significant change in the mean Tegner activity scale score (3.3 ± 2.0 preoperatively to 3.4 ± 2.2 postoperatively; P = .526) and the mean ARS score (2.6 ± 4.3 preoperatively to 2.3 ± 3.4 postoperatively; P = .874) was noted. The percentage of patients involved in sports activity before the onset of symptoms became significantly lower at the time of surgery (from 95.0% to 53.3%; P < .001); no significant difference was noted postoperatively (from 53.3% to 58.3%; P = .663). No significant difference of the weekly sports frequency and the duration of sports activity was found postoperatively.

CONCLUSION

Patients undergoing AMIC repair of an OCLT participate at a similar low postoperative sports and recreational activity level compared with the preoperative level.

[Bizarre parosteal osteochondromatous proliferation of the metatarsal bone]

A bizarre parosteal osteochondromatous proliferation (BPOP), also known as a Nora lesion, is a rare benign bone formation. It emanates mainly from the intact cortex of the metaphysis of short tubular bones (hands or feet). Conventional radiographs should be complemented using cross-sectional imaging modalities (CT/MRI). In the absence of symptoms a non-operative regime with radiological and clinical controls is possible. If symptomatic, excision biopsy is the treatment of choice, though a high recurrence rate has been reported. Histopathological examination confirms the diagnosis and typically shows an endochondral ossification zone and an unusually mineralized cartilaginous matrix referred to as "blue bone".

Computed Tomographic Evaluation of Joint Geometry in Patients With End-Stage Ankle Osteoarthritis

BACKGROUND

Deformation of the talus and the distal tibia can be frequently observed during ankle joint osteoarthritis (OA). The aim of this study was to objectify these morphologic changes. We hypothesized that a flattening of the talus and a broadening of the distal tibia surface occurs in end-stage OA of the ankle joint.

METHODS

Twenty-seven computed tomography (CT) ankle joint examinations of unilateral ankle OA were matched by sex and age with 27 CT examinations of healthy ankle joints. Three-dimensional reformatting and measurements were performed with geometry analysis software. The following parameters were assessed: sagittal radius of the talus, talus height, and mediolateral and anteroposterior width of the distal tibial joint surface.

RESULTS

Medial, midsagittal, and lateral sagittal arc radii of osteoarthritic tali were significantly larger compared to tali of controls. There was a statistically significant difference in the height of the osteoarthritic talar dome in the medial and in the lateral frontal segment and in the medial central segment compared to tali of controls. The anteroposterior width and the sagittal curvature of the distal tibia was significantly larger in OA ankles than in the control group. The mediolateral measurements were comparable across both groups.

CONCLUSION

Flattening of the talus appears to be more pronounced in the frontal aspect of the talus. The distal tibia broadens anteroposteriorly. These findings may contribute to better understanding of ankle OA development.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

A cationic gadolinium contrast agent for magnetic resonance imaging of cartilage

A new cationic gadolinium contrast agent is reported for delayed gadolinium enhanced magnetic resonance imaging of cartilage (dGEMRIC). The agent partitions into the glycosaminoglycan rich matrix of articular cartilage, based on Donnan equilibrium theory, and its use enables imaging of the human cadaveric metacarpal phalangeal joint.

Total ankle replacement

BACKGROUND

About 1% of adults suffer from painful osteoarthritis of the ankle. The current literature contains no information on the percentage of such patients who derive long-term relief of symptoms from conservative treatment. Advanced ankle osteoarthritis can be treated with non-joint-preserving measures, such as total ankle replacement and ankle fusion.

METHODS

This review is based on selected relevant publications, guidelines from Germany and abroad, and the authors' personal experience.

RESULTS

Before surgery is considered, conservative measures such as physiotherapy and orthopedic aids should be used to the fullest possible extent. No randomized trials have yet been published comparing total ankle replacement with ankle fusion. Total ankle replacement with newer types of prosthesis yields good to very good intermediate-term and long-term results, with mean success rates of up to 90% at 10 years (range, 68-100%). Independent risk factors for the failure of ankle replacement are age over 70 years (odds ratio [OR] 3.84), primary osteoarthritis (OR 7.19), post-traumatic osteoarthritis (OR 6.2), and type of prosthesis (e.g., single hydroxyapatite coating: OR 15.04). The average range of motion of the replaced ankle joint is 25° to 30°, with values as high as 60°.

CONCLUSION

Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. It can restore joint function and make the patient mobile with little or no pain. There are, however, many contraindications to be taken into account. There is a need for further studies of the biomechanics of arthritic and replaced ankle joints and for long-term follow-up studies of total ankle replacement.

Ankle Joint Fusion With an Anatomically Preshaped Anterior Locking Plate

We present a novel fixation plate for primary ankle joint fusion. A single anatomically preshaped angular stable plate was used with an anterior approach. An excellent result with good bone consolidation was present at the 1-year follow-up examination.

Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery

BACKGROUND

The aim of this study was to quantify the incidence of postoperative wound complications in elective foot and ankle surgery as well as the risk factors for postoperative wound complications.

METHODS

Two hundred ninety-five elective orthopaedic foot and ankle operative procedures were performed in 290 patients between January 2006 and June 2010. A logistic multiple regression model was used to identify independent risk factors for postoperative wound healing complications/infection.

RESULTS

The overall prevalence of postoperative wound complications within our cohort was 16.9%. In 4 patients (1.4%) deep infection was diagnosed requiring operative irrigation and debridement. Using a logistic multiple regression model we identified the following statistically independent risk factors: age ≥ 60 years (OR = 8.98, 95% CI = 3.55 to 25.02), tobacco use (OR = 48.77, 95% CI = 15.55 to 139.71), and tourniquet time ≥ 90 minutes (OR = 7.02, 95% CI = 2.77 to 19.32).

CONCLUSION

Patients at risk for postoperative wound healing complications following elective orthopaedic foot and ankle surgery include those with higher age, tobacco use, and prolonged use of tourniquet.

LEVEL OF EVIDENCE

Prognostic Level III, comparative study.

Transcutaneous pleural biopsy with a retrograde forceps: a novel approach

PURPOSE

Pleural biopsies are commonly performed to investigate the cause of exudative pleural effusion. Biopsy needles (e.g. Abrams needle, Cope needle) are traditionally used to perform the biopsy. However, certain complications such as pneumothorax and haemothorax have been described. We present a technique utilizing a novel retrograde forceps, which could improve the simplicity and lower the complication rate of performing closed pleural biopsies.

DESCRIPTION

A retrograde forceps (Retroforceps, Karl Storz, Tuttlingen, Germany) was used to perform 20 transcutaneous pleural biopsies in a cadaver thorax under thoracoscopical control. Video documentation of the procedure from outside and inside the thorax was performed. The surgeon performing the biopsy was blinded to the thoracoscopical view. After the removal of the forceps, it was checked whether biopsy material was retrieved. The video material was retrospectively used to confirm whether the biopsy was taken from the pleura parietalis.

EVALUATION

Biopsy material was retrieved in 19 out of 20 biopsy attempts. Video material confirmed that the biopsy was taken from the pleura parietalis in all cases.

CONCLUSIONS

Using a retrograde biopsy forceps is a simple and practicable procedure suitable for clinical application. This technique could potentially reduce the incidence of pneumothorax.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD.

Comparison of cannulated screws versus compression staples for subtalar arthrodesis fixation

BACKGROUND

Different fixation techniques have been described in the literature for isolated subtalar arthrodesis (ISA). The purpose of this study was to compare the fusion rate and clinical outcome of ISA using cannulated compression screws or compression staples.

METHODS

Thirty-three patients (33 feet) underwent ISA using screw (17 feet) or staples (16 feet) fixation. Patients were followed for 42.7 ± 16.4 months (range, 24.5-84.3 months). The subtalar fusion was assessed radiographically and clinically. Clinical outcome measures included the visual analog scale (VAS) for pain and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score.

RESULTS

The average pain score decreased significantly from 6.4 ± 1.1 (range, 5-9) to 0.8 ± 1.3 (range, 0-4) (P < .001). In the screws group, the average AOFAS hindfoot score increased significantly from 54.6 ± 8.8 (range, 37-67) preoperatively to 86.1 ± 7.1 (range, 71-91) postoperatively (P < .001). In the staples group, the average AOFAS hindfoot score increased significantly from 53.4 ± 11.1 (range, 33-69) preoperatively to 83.4 ± 6.9 (range, 71-91) postoperatively (P < .001). The AOFAS hindfoot score was comparable in both groups (P = .149). Only the AOFAS hindfoot score function subgroup in the screw fixation was significantly higher than in the staples fixation group (P = .005). There were 4 cases of nonunion at the site of subtalar arthrodesis (2 from screws group, 2 from staples group). The complication rate was comparable in both groups.

CONCLUSION

The fusion rate was comparable in both groups, while the postoperative functional outcome was significantly better in the screw fixation group.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

Ankle fusion with a trabecular metal spacer and an anterior fusion plate

We present a novel operative technique for ankle joint fusion in a case of severe talar bone loss. Fusion was achieved with a trabecular metal spacer combined with a single anterior, anatomically preshaped, angular, stable plate. Excellent postoperative results with good bone consolidation and preservation of lower leg length were present shown at 1 year of follow-up.

Osteochondral lesions of the ankle joint in professional soccer players: treatment with autologous matrix-induced chondrogenesis

Acute and recurrent ankle sprains and other trauma to the ankle joint are common injuries in soccer and can be accompanied by or result in osteochondral lesions of the ankle joint, majorly of the talus. Conservative treatment frequently fails. Several operative treatment techniques exist; however, the choice of the right procedure is difficult due to lack of literature with a high level of evidence. We present our treatment method for acute and chronic ankle osteochondral lesions with cystic formation approached by a new surgical technique combining bone plasty and a collagen matrix (autologous matrix-induced chondrogenesis).

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Development of a New Device for Synovial Biopsies

Background. Synovial biopsy is a reliable procedure that permits the identification of specific pathologies. Currently available needles for blind synovial biopsy usually consist of 2 components. We designed a novel 1-piece device for blind and minimal invasive synovial biopsy of the knee joint. Methods. A convex-shaped trocar with internal sharp plunger at the distal end and a fluid channel was engineered. Synovial biopsy of the suprapatellar recessus of the knee was performed in 8 different cadavers. The intra-articular position of the tip was confirmed by aspiration of prior injected saline fluid. The trocar was levered upward with the open notch of the device facing the anterior wall of the recessus. Then, the punch mechanism was closed and the device removed. Routine histology of the obtained tissue was performed. After the intervention, the joints were prepared for macroscopic inspection of the synovial tissue, including penetration and biopsy sites. Results. Fifteen interventions were performed. In all cases, sufficient synovial tissue was obtained. Mean length of the biopsies was 2.4 mm (range 2.0-4.3 mm) and width was 2.0 mm (range 1.4-2.6 mm). Inside the suprapatellar recessus, the mean distance from the entry site of the device to the biopsy site was 3.8 cm (range 1.1-3.4 cm). Histological analysis confirmed synovial and capsule tissue in all cases. Conclusion. This new device is a potentially useful tool for quick synovial biopsy of the knee in the clinical setting.

Revision Subtalar Joint Fusion With a Porous Metal Spacer and an Intramedullary Nail: A Case Report

Nonunion of hindfoot arthrodesis can be difficult to successfully treat and will often require bone graft techniques. Large amounts of autogenous bone graft can be difficult to procure and will be associated with donor site morbidity. The use of porous metal implants has been shown to satisfactorily bridge segmental bone defects and to work in conjunction with allogeneic bone graft material, without the risks associated with autogenous bone graft donor site morbidity. The purpose of the present report is to describe the use of a perforated, porous metal implant combined with an intramedullary nail for revision surgery of failed subtalar joint fusion in an adult female patient.

Commercially available trabecular metal ankle interpositional spacer for tibiotalocalcaneal arthrodesis secondary to severe bone loss of the ankle

Retrograde tibiotalocalcaneal nailing arthrodesis has proved to be a viable salvage procedure; however, extended bone loss around the ankle has been associated with high rates of nonunion and considerable shortening of the hindfoot. We present the surgical technique and the first 2 cases in which a trabecular metal™ interpositional spacer, specifically designed for tibiotalocalcaneal nailing arthrodesis, was used. The spacer can be implanted using either an anterior or a lateral approach. An integrated hole in the spacer allows a retrograde nail to be inserted, which provides excellent primary stability of the construct. Trabecular metal™ is a well-established and well-described material used to supplement deficient bone stock in surgery of the spine, hip, and knee. It has shown excellent incorporation and reduces the need for auto- and allografts. The trabecular metal™ interpositional ankle spacer is the first trabecular metal spacer designed specifically for ankle surgery. Its shape and variable size will make it a valuable tool for reconstructing bone loss in tibiotalocalcaneal nailing arthrodesis.

Dry arthroscopy with a retraction system for matrix-aided cartilage repair of patellar lesions

Several commercially available cartilage repair techniques use a natural or synthetic matrix to aid cartilage regeneration (e.g., autologous matrix-induced chondrogenesis or matrix-induced cartilage implantation). However, the use of matrix-aided techniques during conventional knee joint arthroscopy under continuous irrigation is challenging. Insertion and fixation of the matrix can be complicated by the presence of fluid and the confined patellofemoral joint space with limited access to the lesion. To overcome these issues, we developed a novel arthroscopic approach for matrix-aided cartilage repair of patellar lesions. This technical note describes the use of dry arthroscopy assisted by a minimally invasive retraction system. An autologous matrix-induced chondrogenesis procedure is used to illustrate this novel approach.

Ankle osteoarthritis: etiology, diagnostics, and classification

Osteoarthritis (OA) is defined as the syndrome of joint pain and dysfunction caused by substantial joint degeneration. In general, OA is the most common joint disease and is one of the most frequent and symptomatic health problems for middle-aged and older people: OA disables more than 10% of people who are older than 60 years. This article reviews the etiology of ankle OA, and describes the onset and development of posttraumatic ankle OA, the most common form of OA in the tibiotalar joint. Various methods of clinical and radiographic assessment are described in detail.

Delayed gadolinium-enhanced MRI of cartilage of the ankle joint: results after autologous matrix-induced chondrogenesis (AMIC)-aided reconstruction of osteochondral lesions of the talus

AIM

To assess cartilage quality using delayed gadolinium-enhanced magnetic resonance imaging after repair of osteochondral lesions of the talus using autologous matrix-induced chondrogenesis (AMIC).

MATERIALS AND METHODS

A three-dimensional (3D) spoiled gradient-echo (SGE) sequence at 3 T was used to obtain quantitative T1 relaxation times before and after Gd-DTPA2 (Magnevist, 0.2 mM/kg bod weight) administration to assess 23 cases of AMIC-aided repair of osteochondral lesions of the talus. Delta relaxation rates (ΔR1) for reference cartilage (RC) and repair tissue (RT), and the relative delta relaxation rate (rΔR1) were calculated. The morphological appearance of the cartilage RT was graded on sagittal dual-echo steady-state (DESS) views according to the "magnetic resonance observation of cartilage repair tissue" (MOCART) protocol. The study was approved by the institutional review board and written consent from each patient was obtained.

RESULTS

The AMIC cases had a mean T1 relaxation time of 1.194 s (SD 0.207 s) in RC and 1.470 s (SD 0.384 s) in RT before contrast medium administration. The contrast-enhanced T1 relaxation time decreased to 0.480 s (SD 0.114 s) in RC and 0.411 s (SD 0.096 s) in RT. There was a significant difference (p > 0.05) between the ΔR1 in RC (1.372 × 10(-3)/s, range 0.526-3.201 × 10(-3)/s, SD 0.666 × 10(-3)/s) and RT (1.856 × 10(-3)/s, range 0.93-3.336 × 10(-3)/s, SD 0.609 × 10(-3)/s). The mean rΔR1 was 1.49, SD 0.45). The mean MOCART score at follow-up was 62.6 points (range 30-95, SD 15.3).

CONCLUSION

The results of the present study suggest that repair cartilage resulting from AMIC-aided repair of osteochondral lesions of the talus has a significantly lower glycosaminoglycan (GAG) content than normal hyaline cartilage, but can be regarded as having hyaline-like properties.

Autologous matrix-induced chondrogenesis in osteochondral lesions of the talus

Recurrent ankle sprains and other trauma as well as ankle malalignment can lead to chronic osteochondral lesions of the talus. Conservative treatment frequently fails. Several operative treatment techniques exist; however, the choice of the right procedure is difficult. This article presents a new surgical technique suitable for treatment osteochondral lesions that combines bone plasty and a collagen matrix.

Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis

BACKGROUND

Osteochondral lesions (OCLs) of the talus are a common entity in sports orthopaedics. There are several operative techniques with a good outcome on follow-up examinations. However, limitations such as sacrificing healthy cartilage (osteochondral autograft transfer system [OATS], mosaicplasty), multiple-stage operative procedures (matrix-induced autologous chondrocyte transplantation [MACI], autologous chondrocyte implantation [ACI]), high costs (ACI, allograft), and limited availability (allograft) do remain and reflect potential drawbacks of the currently used techniques.

PURPOSE

To describe a novel operative technique for the treatment of OCLs of the talus in the form of an economically efficient, 1-step procedure combining OCL debridement, spongiosaplasty, and sealing of the OCL area with a collagen matrix.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-six patients underwent surgery receiving a modified autologous matrix-induced chondrogenesis (AMIC)-aided repair of OCLs of the talus consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold. Ligament repair was performed in 17 of 26 cases. A corrective calcaneal osteotomy was performed in 16 of 26 cases. Clinical and radiological assessment was performed before and a minimum of 24 months after surgery (mean, 31 months; range, 24-54 months). Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. Radiological imaging included single-photon emission computed tomography-computed tomography (SPECT-CT) and magnetic resonance imaging (MRI). The magnetic resonance observation of cartilage repair tissue (MOCART) score was applied, and sport activity was documented.

RESULTS

The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17-79 points) to 89 points (range, 61-100 points) postoperatively (P < .01). The preoperative pain score averaged 5 (range, 2-8), improving to an average of 1.6 (range, 0-7) postoperatively (P < .01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 62 points (range, 20-95 points). Complete filling of the defect at the level of the surrounding cartilage was found in 35%, and complete filling with a hypertrophic cartilage layer was found in 50% of the patients. Normal signal intensity of the repair tissue compared with the adjacent native cartilage was seen in 15%, with nearly normal activity in 69%. Nineteen patients (73%) participated in sports before the onset of symptoms compared with 3 (12%) at the time of surgery. The number increased to 16 patients (62%) at postoperative follow-up.

CONCLUSION

The modified AMIC procedure is safe for the treatment of OCLs in the ankle with overall good clinical and MRI results.

Solid bolt fixation of the medial column in Charcot midfoot arthropathy

Charcot medial column and midfoot deformities are associated with rocker bottom foot, recurrent plantar ulceration, and consequent infection. The primary goal of surgical intervention is to realign and stabilize the plantar arch in a shoe-able, plantigrade alignment. Different fixation devices, including screws, plates, and external fixators, can be used to stabilize the Charcot foot; however, each of these methods has substantial disadvantages. To assess the effectiveness of rigid, minimally invasive fixation of the medial column and midfoot, 8 cases of solid intramedullary bolt fixation for symptomatic Charcot neuroarthropathy were reviewed. The patients included 6 males (75%) and 2 females (25%), with a mean age of 63 (range 46 to 80) years. The Charcot foot deformity was caused by diabetic neuropathy in 7 cases (87.5%) and alcoholic neuropathy in 1 (12.5%). The mean duration of postoperative follow-up period was 27 (range 12 to 44) months. The mean radiographic correction of the lateral talar-first metatarsal angle was 15° (range 3° to 19°), and the mean radiographic correction of the dorsal midfoot dislocation was 9 (range -4 to 23) mm. The mean loss of correction of the lateral talar-first metatarsal angle and midfoot dislocation after surgery was 7° (range 0° to 26°) and 1 (range 0 to 7) mm, respectively. No bolt breakage was observed, and no cases of recurrent or residual ulceration occurred during the observation period. Bolt removal was performed in 3 cases (37.5%), 2 (25%) because of axial migration of the bolt into the ankle joint and 1 (12.5%) because of infection. The results of the present review suggest that a solid intramedullary bolt provides reasonable fixation for realignment of the medial column in cases of Charcot neuroarthropathy.

Reconstruction of a large osteochondral lesion of the distal tibia with an iliac crest graft and autologous matrix-induced chondrogenesis (AMIC): a case report

Isolated osteochondral lesions (OCL) of the distal tibia are rare and lack clear treatment guidelines. With the case we present here, we suggest a novel surgical approach and report the successful use of autologous matrix-induced chondrogenesis-aided reconstruction for OCL of the distal tibia. A 29-year-old male patient complained about persisting pain of the left ankle joint and a restricted activity level 12 months after an ankle sprain. Imaging revealed edema of the subchondral bone and thinning of the cartilage above the osseous defect at the lateral distal tibia. The OCL was debrided followed by microfracturing of the underlying sclerotic bone. A cancellous bone plug was harvested from the iliac crest and impacted into the defect. A collagen matrix was then fixed on the defect. After 12 months, the patient was free of pain and returned to full activity. Conventional radiographs at 1 year showed successful osseous integration of the plug and a nearly anatomic shape of the tibial joint line. Delayed gadolinium-enhanced MRI of cartilage scans at 36 months showed an intact cartilage layer over the defect and glycosaminoglycan content, indicating hyaline-like cartilage repair. This case demonstrates autologous matrix-induced chondrogenesis-aided reconstruction of large osteochondral lesions of distal tibia to be a promising treatment method. Our aim was to describe the case of a patient with a large isolated osteochondral lesion of the distal tibia treated by a novel operative technique using cancellous bone from the iliac crest and a collagen I/III matrix.

Revision of failed osteochondral autologous transplantation procedure for chronic talus osteochondral lesion with iliac crest graft and autologous matrix-induced chondrogenesis: a case report

This article describes a novel technique for treatment of recurrent large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III matrix.

Intramedullary fixation of the medial column of the foot with a solid bolt in Charcot midfoot arthropathy: a case report

Medial column fixation for rocker-bottom deformity in Charcot arthropathy is commonly performed. However, implant failure is commonly encountered because of uncontrolled weight bearing by the patient. The aim of this case report is to describe the use of a large solid bolt for fusion of the medial column of the foot in a patient with collapse of the midfoot due to diabetic neuroarthropathy.

Linear bearing device as a solution for optical navigation of fine needle procedures

BACKGROUND

Optical navigation of needles < 1 mm diameter remains a challenging task. Bending of these tools is the limiting factor.

OBJECTIVE

To use a conventional optical navigation system for interventional fine needle procedures.

MATERIALS AND METHODS

A novel custom-made device was constructed to guide the needle in the direction of the planned trajectory. Accuracy of this device was analyzed with two setups (A = ballistic gelatin; B = used pork meat). For both setups, a Plexiglas cube with integrated Plexiglas reference arrays was used. Metal targets of 1 mm diameter were placed in the center. Images were acquired using a 3D fluoroscope connected to a conventional optical navigation system. After trajectory planning, ten navigated injections were performed freehand and with the linear bearing device for each setup. A 3D scan was performed to measure the distance between contrast medium and metal target after each injection.

RESULTS

Freehand navigation with a needle of 0.9 mm in diameter was not accurate with either setup (Setup A: mean 33.4 mm; range, 3-63 mm; Setup B: mean 40.1 mm; range, 12-75 mm). Linear bearing navigation was significant more precisely (Setup A: mean 0.7 mm; range, 0-0.75 mm; Setup B: mean 0.29 mm, range 0-1.3 mm) than freehand navigation.

CONCLUSION

The linear bearing device reduced all bending. Optical fine needle navigation was accomplished with precision comparable to electromagnetic navigation. This device may provide useful for minimally-invasive clinical applications. Follow-up studies should compare electromagnetic and optical navigation systems in the same setup.

Pain in osteochondral lesions

Pain is the key symptom of patients suffering from osteochondral lesions (OCLs) of the ankle joint. Routine radiographic imaging methods for diagnosis and staging of OCL fail to visualize the pain-inducing focus within the joint. SPECT-CT (Single-photon emission computed tomography-computed tomography) is a new hybrid imaging technique allowing exact digital fusion of scintigraphic and computer tomographic images. This allows precise localization and size determination of an OCL within the joint. Using this novel imaging method, we conducted a study to evaluate the correlation between pathological uptake within an OCL and pain experienced by patients suffering from this condition; 15 patients were assessed in the orthopaedic ambulatory clinic for unilateral OCL of the ankle joint. Pain status was measured with the Visual Analogue Scale (VAS). A SPECT-CT was performed. All patients underwent CT-guided ankle injection with a local anesthetic and iodine contrast medium. The VAS score assessed immediately postinfiltration was compared with the preinterventional VAS score obtained in the outpatient clinic. Pain relief was defined as a reduction of the VAS score to ≤50% of the preinterventional score, if expected immediately after infiltration. Pain relief was found in all 15 patients. The results of our study show that there is a highly significant correlation between pain and pathological uptake seen on SPECT-CT, indicating that pathologically remodeled bone tissue is an important contributor to pain in OCL. Adequate addressing of involved bone tissue needs to be taken into consideration when choosing a surgical treatment method.

Autologous matrix-induced chondrogenesis aided reconstruction of a large focal osteochondral lesion of the talus

The aim of this case report is to describe a novel technique for treatment of large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III membrane.

Distinctive pain course during first year after total ankle arthroplasty: a prospective, observational study

BACKGROUND

Patients and health care professionals alike are often surprised by the course of pain after total ankle arthroplasty (TAA). The current study aimed to determine the baseline patterns of postoperative symptoms during the first year following uncomplicated TAA.

MATERIALS AND METHODS

In a prospective observational study 28 patients with unilateral posttraumatic osteoarthritis were tested for pain with a visual analogue scale, swelling (min grade, 0; max grade, 4), ankle range of motion, and AOFAS ankle score. Assessments were performed preoperatively and 6 weeks, 3, 6, 9, and 12 months after TAA.

RESULTS

At 6 weeks all variables had improved significantly. However, at 3 months a relapse with deterioration of mean variables was found. These improved asymptotically during assessments at 6, 9, and 12 months.

CONCLUSION

Our data suggest patients undergoing uncomplicated TAA have to overpass what we believe is an adaptive inflammatory phase with increased periarticular pain and swelling about 3 months after surgery. This distinctive course may influence patient education and increase confidence of healthcare professionals involved in the rehabilitation of TAA patients.