Foot & ankle international最新文献

Background: Severe septic destruction of the ankle joint poses a therapeutic challenge but lacks a consensus optimal treatment. Tibiotalocalcaneal arthrodesis (TTCA) is considered a valuable salvage procedure, but the literature remains scarce. Conventional treatment approaches, including 2-stage procedures, have been associated with prolonged recovery times and varying success rates. Many authors prefer classical external fixation in these scenarios, citing concerns that internal implants might pose a risk for recurrent infection. To date, no study has investigated the outcomes of 1-stage surgery using a retrograde intramedullary (IM) nail. The main purpose was to assess the rate of recurrent infection at 2 years following 1-stage TTCA using a retrograde IM nail in severe septic destruction of the ankle joint. Fusion rates and functional outcomes were evaluated as secondary purposes.

Methods: The clinical and radiologic data of patients who underwent 1-stage TTCA with retrograde IM nail following severe septic destruction of the ankle joint with a minimal follow-up of 2 years were retrospectively analyzed. Reinfection rate, fusion rate, functional outcomes, and complications were evaluated.

Results: A total of 25 patients were included with a mean follow-up of 42 months (24-92 months). The mean age was 55 ± 18 years old. At the last follow-up, reinfection occurred in 6 patients (24%) and fusion was obtained in 19 patients (83%). Eight patients (32%) required revision surgery. The mean postoperative modified American Orthopaedic Foot & Ankle Society (AOFAS) score, 12-Item Short Form Health Survey physical and mental component summary scores were respectively 53 ± 19.5, 35.5 ± 11.4, and 46.7 ± 13.5 points.

Conclusion: One-stage TTCA with retrograde IM nail appears to be an acceptable alternative in severe septic destruction of the ankle joint, with a high eradication rate of infection and ankle fusion.

Background: Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries.

Methods: A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant.

Results: A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3.

Conclusion: In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

Background: Tibial pilon malreductions are challenging to correctively reconstruct, and the relevant literature is limited. This study aims to assess whether corrective intra-articular osteotomy is worthwhile to treat relatively younger (<55-year-old) patients with intra-articular malreductions of pilon fractures.

Methods: This is a retrospective observational study with a minimum follow-up of 2 years. From 2013 to 2021, 21 patients (mean age: 39.2 ± 11.2 years) with intra-articular pilon malreductions ≥6 weeks treated with intra-articular osteotomies were analyzed. The median interval time until intra-articular osteotomy was 76 (interquartile range [IQR], 49-149) days. Plain radiographs and computed tomography were used for radiographic assessments. Clinical outcomes were evaluated with visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short-Form Health Survey (SF-36) score, and ankle range of motion (ROM).

Results: The median follow-up duration was 34.6 (IQR, 26.1-74.3) months. The median articular displacement was reduced from 12.7 mm preoperatively to 2.7 mm postoperatively (P < .05). According to the Kellgren-Lawrence grading, 16 patients were assigned to stage II, 4 to stage III, and 1 to stage IV. In the 10 patients with available preoperative assessments, substantial improvement was found in the VAS score, from 5.90 to 2.0 at the final follow-up (P < .05). Similarly, the AOFAS ankle-hindfoot score and SF-36 scores improved (P < .05). Ankle ROM did not change a clinically meaningful amount. Progressive degenerative changes were noted in 2 of 10 patients who had adequate preoperative imaging. Four patients had VAS scores ≥4 including 1 patient who is scheduled for an arthrodesis.

Conclusion: In this small series, we found that the corrective osteotomies generally provided reasonable improvement at 3 years in patients <55 years old with intra-articular malreduction of pilon fractures. Prospective cohort studies are needed to determine if it is worthwhile in long-term outcome.

Background: This study investigated the impact of total knee arthroplasty (TKA) on the alignment of the ankle joint, focusing on changes in coronal alignment of both ankles.

Methods: This retrospective study, conducted at our hospital, included 64 patients older than 70 years who underwent TKA for varus knee osteoarthritis (OA). Using full-length standing radiographs of both lower extremities taken preoperatively and 6 months postoperatively, we assessed ankle OA grading based on the Takakura-Tanaka classification and measured mechanical hip-knee-ankle (mHKA) and the tibiotalar angle (TTA) on both the surgical and contralateral side. Additionally, we examined the impact of ankle OA on postoperative clinical scores, the Knee injury and Osteoarthritis Outcome Score, following TKA.

Results: Based on the classification, ankle OA stage 2 or higher was present in 13 cases on the surgical side and 13 cases on the contralateral side. On the surgical side, mHKA changed from 12.2 to 1.8 degrees varus (P < .001) and TTA from 1.7 to 1.0 degrees varus (P = .002). On the contralateral side, mHKA changed from 4.0 to 5.4 degrees varus (P = .04), and TTA from 2.7 to 3.0 degrees varus (P < .001). In ankle OA stage 2 or higher patients, contralateral TTA changed from 5.2 to 6.5 degrees varus (P < .001) and unchanged in stage 1 patients. Ankle OA stage 2 or higher patients had worse ADL outcomes than stage 1 patients (score: 67.2 and 78.3, respectively, P = .03).

Conclusion: This study suggests an apparent interrelationship between knee and ankle OA and the potential negative influence of TKA on ankle OA.

Background: Although an association between intercuneiform (C1-C2) joint instability and the recurrence of hallux valgus (HV) deformity after the modified Lapidus procedure has been suggested, there is currently no radiographic evidence to support it. This study aims to investigate radiographic changes in the C1-C2 joint after the modified Lapidus procedure for HV correction, using weightbearing computed tomography (WBCT).

Methods: This retrospective cohort study included 52 feet (50 patients) with HV who underwent modified Lapidus procedure and had preoperative and postoperative WBCT. Patients who had an additional transfixation screw between the first and second ray were excluded. The preoperative and average 6.5 months postoperative C1-C2 distance, C1-C2 angle, and C1-ground angle were measured on coronal multiplanar reconstructed WBCT images. Radiographic parameters between the recurrence group (n = 9) and nonrecurrence group (n = 43) were compared. Recurrence of HV deformity was characterized by a postoperative hallux valgus angle (HVA) greater than 20 degrees.

Results: Nine of 52 patients (17.3%) had recurrence of their HV deformity. The recurrence group had greater changes in the C1-C2 distance; the median widening in the recurrence group was 0.7 mm (IQR, 0.6-0.8), whereas the nonrecurrence group was 0.3 mm (IQR, 0.1-0.4, P < .001). Regression analysis showed that increase in the C1-C2 distance were significantly associated with recurrence (odds ratio, 1.79; 95% CI, 1.18-3.77; P = .0015). Although no preoperative imaging parameters were associated with a change in the C1-C2 distance, increasing postoperative sesamoid position (r = 0.32, P = .022) and HVA (r = 0.28, P = .046) were correlated with a greater change in the C1-C2 joint gapping.

Conclusion: Our study results suggest a possible association between early postoperative widening of the C1-C2 joint and the recurrence of the HV deformity following a modified Lapidus procedure. This raises, but does not answer, the question as to whether the routine stabilization of intercuneiform joint directly or indirectly may help reduce the rate of hallux valgus recurrence when performing the modified Lapidus procedure.

Background: Occupational exposure to high levels of noise increases the risk of noise-induced hearing loss (NIHL), resulting in significant long-term quality of life implications. Hearing protection is recommended if occupational noise exposure routinely exceeds 85 decibels (dB). The purpose of this study was to determine if foot and ankle surgeons are exposed to excessive levels of noise, thus putting them at an increased risk for NIHL.

Methods: A prospective review was conducted of intraoperative recordings during a variety of foot and ankle procedures. Recordings were categorized into 3 subgroups: trauma, deformity correction and degenerative conditions, and soft tissue procedures. Noise levels were reported as maximum dB level (MDL) and time-weighted average (TWA), defined as the average dB level projected over an 8-hour period. Dose was reported as the percentage of allowable daily noise, with projected dose reported as the measured dose projected over an 8-hour period.

Results: A total of 147 operative recordings consisting of 64 (44%) deformity correction and degenerative conditions, 40 (27%) soft tissue procedures, and 43 (29%) trauma cases were collected. Maximal and average noise exposures were similar for all procedures (P = .077; P = .090), with an average MDL of 98.9 dB (range, 87.9-109.2) and TWA of 60.5 dB. Procedures also did not significantly differ in dose (P = .273), even when projected over an 8-hour period (P = .362). The average MDL of total ankle arthroplasty (TAA) and hindfoot arthrodesis procedures was 101.5 dB (range, 93.9-109.2), with 52% of all deformity correction and degenerative procedures having an MDL over 100.0 dB.

Conclusion: Foot and ankle surgeons are typically not exposed to dangerous levels of occupational noise as per National Institute for Occupational Safety and Health recommendation; however, specific procedures, such as arthrodesis and TAA, routinely achieve noise levels that are above the recommended limits.

Background: Dorsal closing-wedge calcaneal osteotomy (DCWCO) is a treatment option for persistent Haglund exostosis-related heel pain after failed conservative management. In modifying the orientation of the calcaneal tendinous insertion site and reducing mechanical stress, the consequences of DCWCO-associated biomechanical changes on everyday foot function remain unknown.

Methods: This retrospective cohort study analyzed routinely collected clinical data as well as data from our foot and ankle registry. One hundred twenty patients (66 males, 54 females, 17-77 years) who underwent DCWCO from January 2016 to December 2019 were included. Adverse events were collected from the patient files. Foot Function Index (FFI) scores were collected before (baseline) and at 6, 12, and 24 months postsurgery. Radiographic parameters including the Achilles tendon moment arm and X/Y ratio were evaluated from standard preoperative and 6-week postoperative radiographs. Correlations between FFI and biomechanical changes were calculated for men and women separately with the Pearson correlation coefficient and Bonferroni correction.

Results: One intra- and 18 postoperative adverse events were documented. Mean baseline FFI pain decreased from 47.9 ± 17.2 to 12.0 ± 17.5 points at 24 months with an average decrease of -21.8 ± 21.3 points occurring within the first 6 months postsurgery. A similar trend was also seen with the FFI disability score (49.6 ± 20.3 to 12.8 ± 17.6 points). The mean decrease in Achilles tendon moment arm was -8.1 ± 3.8 mm and mean X/Y ratio increased from 2.6 ± 0.3 to 3.8 ± 1.0. There were no significant correlations between the FFI score and radiographic changes.

Conclusion: DCWCO effectively alleviates exostosis-related heel pain and associated disabilities. Improvements can still be expected up to 2 years after surgery. Radiographic changes of the foot and ankle are significant but do not correlate with patient-reported outcome measures.

Background: There are few reports on the intra- and interobserver agreement and parameters for the diagnostic accuracy of ultrasound (US) imaging for chronic lateral ankle instability (LAI). The purpose of this study was to investigate the reliability and validity of US imaging for identifying anterior talofibular ligament (ATFL) remnants in patients with LAI.

Methods: A total of 547 ankles from 406 patients underwent surgery for LAI between 2019 and 2022. If ligament fibers remained in US images, they were evaluated as positive. If the ligament was not visualized, it was evaluated as negative. Two observers performed repeated measurements. Arthroscopic findings were considered the "gold standard" for validity and diagnostic test accuracy purposes. The intra- and interobserver agreements and parameters for diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative US imaging as intraoperative arthroscopic findings were used as reference standards.

Results: The intraobserver agreement was substantial, with an agreement of 98.54% and a kappa coefficient of 0.76. The interobserver agreement was also substantial, with an agreement of 98.72% and a kappa coefficient of 0.75. The sensitivity, specificity, and accuracy of preoperative US imaging were 98.7%, 100%, and 98.7%, respectively. The PPV and NPV of US imaging were 100% and 61.1%, respectively. In the arthroscopic evaluation of the 7 cases in which US imaging showed false negative results, the ATFL ruptured at the fibular attachment and ran in contact with the talus.

Conclusion: A US examination finding of an intact ATFL is highly likely to be correct. An US examination finding of a ruptured ATFL can be false and may require arthroscopic confirmation.

Background: The talus is more internally rotated within the ankle mortise in progressive collapsing foot deformity (PCFD) patients. However, no studies have investigated the change in talar axial rotation (AR) in PCFD postoperatively. The primary aim was to investigate the change in talar AR following PCFD reconstruction. Secondary aims were to determine whether talar AR changes were associated with other radiographic measurements or specific procedures, and whether postoperative talar AR was associated with 2-year patient-reported outcome scores.

Methods: Twenty-seven patients older than 18 years who underwent flexible PCFD reconstruction with preoperative and at least 5-month postoperative weightbearing computed tomographic (WBCT) scans and radiographs and had preoperative and at least 2-year postoperative PROMIS scores were included. Patients with talonavicular fusions were excluded. Talar AR was the angle between the transmalleolar axis and talar axis on WBCT scans, with smaller angles representing more internal rotation as described by Kim et al. Hindfoot moment arm, Meary angle, fibulocalcaneal and talocalcaneal distance, subtalar middle facet uncoverage, and talonavicular angle were measured on radiographs.

Results: Postoperative talar AR was 49.7 degrees (IQR, 45.9, 57.3), which was more externally rotated than preoperative AR by a median of 8.3 degrees (IQR, 2.2, 15.7) (P > .001). The change in talar AR was not associated with changes in any radiographic parameter. Increasing external talar AR was associated with an increase in postoperative PROMIS pain intensity (r_s = 0.38, 95% CI 0.00, 0.67). Lateral column lengthening and subtalar fusion procedures were not associated with changes in talar AR (P > .10).

Conclusion: PCFD reconstruction results in external rotation of the talus within the ankle mortise. Kim et al found that control patients had approximately 40 to 60 degrees of talar AR, which is similar to this study's corrected position of the talus. However, increasing talar external rotation resulted in worse postoperative PROMIS pain intensity, suggesting the possibility of overcorrecting the internal AR deformity.