Foot & ankle international最新文献

Background: End-stage hallux rigidus is currently being treated by total joint arthrodesis rather than arthroplasty more commonly. However, there is an advancing number of joint prosthesis being employed either as hemiarthroplasty or total joint replacement. One such total joint replacement is the ToeFit Plus joint.

Methods: A retrospective cohort study over 20 years was undertaken to assess functional outcomes. Seventy total joint replacements were performed between 2006 and 2013. Fifty-seven patients (46 females, 11 males), mean age 62.1 years (range 42-82). Thirteen patients had bilateral replacements. Mean follow-up was 98.2 months (range 13-216, SD 61.3). Survival analysis used Kaplan-Meier methodology with best-case (excluding lost to follow-up) and worst-case (assuming all lost to follow-up were failures) scenarios.

Results: Mean Manchester-Oxford Foot Questionnaire score at the latest follow-up telephone consultation was 7.4 (range 0-59, SD 14). Twelve of 70 joints were revised to arthrodesis because of phalangeal component loosening, with 24 joints lost to follow-up. Best-case scenario showed 81% survival at mean 11.0 years, whereas worst-case scenario showed only 48.2% survival. The mean age of patients who had revision surgery was 62.5 years (range 51-73, SD 6.9). The mean age for nonrevised patients was 62.0 years (range 42-82, SD 9.0), with no significant correlation between patients' age and the implant longevity or revision. In the first 5 years following TJR, there was a 15% chance of revision.ConclusionRevision was mainly caused by phalangeal component loosening. Even in the best-case scenario, the 19% revision rate at 10 years is concerning, but the potential 52% failure rate in worst-case analysis is unacceptably high. We recommend discontinuing the use of the ToeFit Plus arthroplasty.

Background: This study aimed to evaluate the efficacy and safety of an accelerated postoperative rehabilitation protocol (APRP), which emphasizes immediate full weightbearing (FWB), muscle strength and balance training as early as possible, after arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI).

Methods: Patients with CLAI who underwent modified ATFL lasso-loop repair procedures between December 2019 and November 2022 were retrospectively screened. Based on their postoperative rehabilitation protocols, subjects were divided into the APRP group and the conventional postoperative rehabilitation protocol (CPRP) group using 1:2 propensity score matching. Clinical outcome measures comprised the Karlsson score, visual analog scale (VAS) for pain, Tegner score, anterior drawer test findings, complications, and magnetic resonance imaging-based ATFL Quality Score (ATFLQS). A receiver operating characteristic curve analysis was employed to investigate the association between preoperative ATFLQS and clinical outcomes in the APRP group.

Results: The APRP group demonstrated comparable improvements in Karlsson score (31.8 ± 17.6 vs 36.0 ± 13.4, P = .267) and Tegner score (2 [-1 to 6] vs 2 [0 to 5], P = .168) to the CPRP group. Although the APRP group showed statistically superior VAS pain score improvement (3.5 ± 2.3 vs 2.2 ± 0.7, P < .001), the clinical significance of this 1.3-point difference remains uncertain given the lack of validated minimal clinically important difference thresholds for VAS pain in ankle ligament surgery populations. The overall complication rates between the 2 groups showed no statistically significant difference (10/54 vs 7/28, P = .492). Comparable ATFL quality was also found between the 2 groups based on the ATFLQS. The optimal ATFLQS threshold value for predicting functional outcomes was determined to be 2.5, based on the maximal Youden index, demonstrating a sensitivity of 82.4% and specificity of 83.3%.

Conclusion: Comparable outcomes between the 2 groups were found following arthroscopic ATFL repair for CLAI, with no recurrence observed. FWB, muscle strength, and balance training as early as possible demonstrates both efficacy and safety after surgery. However, patients with preoperative ATFLQS <2.5 receiving APRP may have a significantly increased risk for suboptimal functional recovery.

Background: Accurate evaluation can be challenging in subtle Lisfranc injuries. Although weightbearing computed tomography (WBCT) provides 3-dimensional assessment under physiological load, its role in diagnosing subtle Lisfranc instability and guiding treatment thresholds remains undefined. Currently there is no consensus on the optimal timing, measurement protocol, or stability threshold with WBCT.

Methods: We prospectively recruited patients with nondisplaced (<2 mm), intra-articular fractures and/or avulsion fractures in the tarsometatarsal 1-3 area. To assess Lisfranc joint stability, patients underwent bilateral, single-leg WBCT scans. Medial cuneiform (C1) and second metatarsal (M2) measurements, evaluating the integrity of both the dorsal and interosseous Lisfranc ligament, were combined and compared to the contralateral, healthy side to create a difference score. Threshold of instability was defined as >3 mm C1-M2 difference score. Measurements were tested for agreement using the intraclass correlation coefficient (ICC).

Results: 38 patients were included in the study and were able to fully weightbear after a median of 9 days postinjury. Eight patients (21%) had a C1-M2 difference score >3 mm (95% CI, 3.8-5.8) while loading. Instability was confirmed in all 8 patients during a fluoroscopic stress test. The remaining 30 patients, with a C1-M2 difference score <3 mm (95% CI, 0.6-1.1), were classified as stable and received conservative treatment. These patients were followed up with an additional WBCT scan after 12 weeks, and none had signs of Lisfranc instability with a median different score 0.6 mm (95% CI, 0.4-0.7). Our measurement method demonstrated excellent interrater (ICC 0.95, 95% CI, 0.93-0.96) and intrarater agreement (ICC 0.97, 95% CI, 0.96-0.98).

Conclusion: For subtle Lisfranc injuries, adequate WBCT can be performed 9 days postinjury. In our study population, using our dual-measuring method, a C1-M2 difference >3 mm on WBCT reliably identified subtle Lisfranc instability.

Background: Soft tissue defects around the ankle are common for orthopaedic surgeons in clinical practice. This study aimed to compare the modified sural flaps and free anterolateral thigh (ALT) flaps in terms of their ability to cover soft tissue defects, patient satisfaction, infection rates, flap ischemia, and flap sensation.

Methods: This comparative study included 40 patients (24 males and 16 females) aged 5-60 years with defects in the lower one-fifth of their leg or foot, and less than 15 cm × 15 cm in size. Group A (20 patients) underwent a modified sural flap, whereas group B (20 patients) underwent free ALT flap. The study was performed in our specialized hand and reconstructive microsurgery unit from 2021 to 2023.

Results: The operation time was significantly longer for the free ALT flap group compared with the modified sural flap group (P value < .01). Patient satisfaction was higher with the modified sural flap. There were no significant differences in flap ischemia or donor site complications between the 2 groups. The sensation of the flap after 1 year favored the free anterolateral thigh flaps due to sensory nerve anastomosis, but after 1.5 years, good sensation was present in both flaps.

Conclusion: The modified sural flap demonstrated superior efficiency with shorter operative times and higher patient satisfaction, whereas the free ALT flap provided better short-term sensory outcomes because of nerve micro-anastomosis capability. Both techniques achieved equivalent sensation recovery at 18 months, suggesting the modified sural flap may be preferable for most small to medium-sized defects foot and ankle defects.

Background: Patients with progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA) could benefit from a bone-block tarsometatarsal (TMT) arthrodesis. The allograft wedge, producing distraction and plantarflexion, provides a stable medial column while correcting the deformity, but with increased risk of pseudoarthrosis. The objective of this study was to report the clinical nonunion and results of the bone-block first-TMT arthrodesis in collapsed feet.

Methods: In this short-term prospective cohort (mean follow-up 17 months) we evaluated patients with PCFD, HV, and MA who underwent allograft bone-block first-TMT fusion between August 2020 and November 2022. Patients were kept nonweightbearing for 6 weeks and followed, having a WBCT at 3 months and subsequent follow-ups. Bone healing was determined by at least 50% of bone trabeculae crossing both graft interfaces. Complications were documented. Forefoot arch angle (FAA), Meary angle, talonavicular coverage angle (TNCA), middle facet subluxation (MFS), and foot and ankle offset (FAO) were obtained, as well as PROs.

Results: Sixty-four patients (67 feet) were included, mean age 54.0 (18-77), body mass index 31.6 (29.6-33.6), 17.3 months (6-33) follow-up. Median allograft size was 8 mm (5-19 mm). Clinical nonunion rate was 11.9%, minor complications 2.9%, and major complications 5.9%. Tomographic healing at 3 months occurred in 86.4% and 66.7% at the most recent WBCT (mean: 10.1 months; 6-29). Improvement (P < .001) in FAA of 6.9 degrees (5.8-7.9), MFS of 22.6% (19.8-25.4), TNCA of 13.5 (12.1-14.3), Meary angle of 8.1 degrees (6.7-9.5), and FAO of 3.8% (3.1-4.6) were found. PROs improved for VAS, PROMIS-PH, PROMIS-PI, Pain Catastrophic Scale, and EFAS (P < .001).

Conclusion: Although the first-TMT bone-block arthrodesis restored many markers associated with foot collapse and alignment, the clinical nonunion rate was 11.9%, which is in the top range of the literature for TMT fusions. The use of allograft wedges can explain our findings. Tomographic healing, initially 86.4% at 3 months, decreased to 66.7% at the most recent follow-up.

Background: This study investigates revision surgery rates in patients with Ehlers-Danlos Syndrome (EDS) or hypermobility spectrum disorder (HSD) following ankle surgery for instability compared to matched controls.

Methods: A retrospective cohort study was conducted using the PearlDiver Mariner 170 Database. Patients undergoing ankle ligament repair procedures were identified using Current Procedural Terminology (CPT) codes. The experimental cohort included patients with EDS or HSD with at least 2 years of follow-up data, excluding other connective tissue disorders and confounding conditions. Propensity score matching was used to create a matched control group. The primary outcome was the rate of revision ankle ligament repair within 2 and 5 years. The secondary outcome was the effect of patient risk factors associated with revision. Revision rates were compared between cohorts using multivariable logistic regression. Statistical significance was set at P < .05.

Results: The 2-year cohort included 805 patients with EDS/HSD and 805 matched controls, whereas the 5-year cohort consisted of 480 patients in each group. Procedures primarily involved modified Brostrom repair, lateral ankle ligament reconstruction, and arthroscopic-assisted repairs. Patients with EDS/HSD had significantly higher revision rates at 2 years (13.8% vs 6.3%) and 5 years (19.4% vs 7.3%) (P < .0001). Multivariate analysis identified EDS/HSD as an independent risk factor for revision surgery, with adjusted odds ratios of 2.41 (95% CI 1.71-3.45; P < .0001) at 2 years and 3.11 (95% CI 2.07-4.77; P < .0001) at 5 years.

Conclusion: This study highlights the significant challenges in surgical management of ankle instability in patients with EDS and HSD. The risk of surgical failure increases over time, with a 3.1-fold increase in revision surgery rates at 5 years postoperatively compared with matched controls. These findings emphasize the need for specialized surgical approaches and comprehensive perioperative care to address the unique risks in this population. Future work should compare specific repair techniques and graft choices in this high-risk cohort.

Background: Progressive collapsing foot deformity (PCFD) is a complex condition characterized by progressive ligamentous and osseous changes in the hindfoot, midfoot, and forefoot. Although osseous changes at the subtalar and transverse tarsal joints have been well studied, ligamentous anatomy in PCFD is less understood. This study evaluates the cervical, interosseous talocalcaneal, and superomedial fibers of the spring ligament in patients with PCFD vs controls using magnetic resonance imaging (MRI) analysis.

Methods: Nonweightbearing MRI and weightbearing radiographs of 39 patients (23 PCFD, 16 controls) were retrospectively reviewed. MRIs measured the coronal plane orientation of the interosseous talocalcaneal, cervical, and superomedial spring ligaments relative to the subtalar joint middle facet. Radiographic data included anteroposterior (AP) talonavicular coverage percentage, AP talocalcaneal angle (Kite), lateral talar-first metatarsal angle (Meary), talar declination angle, and calcaneal pitch. Two observers measured each radiographic and MRI angle. Statistical analysis included an independent t test and intraclass correlation coefficient (ICC) to assess interobserver reliability.

Results: PCFD patients demonstrated significantly more horizontal ligament orientations than controls, with reduced cervical (25.5 vs 45 degrees, P < .001), superomedial spring (11.5 vs 23.1 degrees, P < .001), and interosseous talocalcaneal ligament angles (39.5 vs 49.0 degrees, P = .005). Radiographically, PCFD patients had decreased talonavicular coverage (64.5% vs 80.9%, P < .001), increased Meary angle (22.2 vs -2.3 degrees, P < .001), increased talar declination (37.0 vs 20.6 degrees, P < .001), increased Kite angle (20.7 vs 17.2 degrees, P = .079), and decreased calcaneal pitch (15.5 vs 24.6 degrees, P < .001). Interobserver reliability was excellent, with ICC values exceeding 0.94 for all measurements except interosseous talocalcaneal ligament angle (ICC = 0.83).

Conclusion: On nonweightbearing MRI, PCFD patients showed more horizontal orientation of key subtalar ligaments than controls; whether these differences persist under physiologic load should be confirmed with weightbearing imaging.

Background: Previous studies have shown that fibular osteotomy can enhance correction of varus talar tilt (TT) in ankle osteoarthritis (OA) when combined with supramalleolar osteotomy (SMO). This study introduces a simplified and universally applicable oblique sliding fibular osteotomy (OSFO) technique suitable for joint-preserving procedures.

Methods: This retrospective study included 22 patients with varus ankle OA and TT >10 degrees who underwent OSFO with SMO between January 2019 and June 2024, with a minimum of 1-year follow-up. For comparison, 42 patients who underwent SMO with either a medial opening wedge or lateral closing wedge fibular osteotomy were analyzed. Radiographic and clinical outcomes were compared across the 3 groups.

Results: Postoperatively, with the numbers available, TT showed a significant decrease (P = .012), the relative fibular length to the tibia decreased by approximately 7.5 mm (P = .01), and fibular valgization averaged 6.4 degrees (P = .01) in all 22 patients. All clinical outcome measures improved significantly (P = .001). In the comparative analysis of the 3 types of fibular osteotomy, the decrease in talocrural angle was significantly greater in the OSFO and lateral closing wedge groups than in the medial opening wedge group (P = .013). The degree of shortening of the relative fibular length to the tibia was smaller in the medial opening wedge group than in the OSFO and lateral closing wedge groups (P = .017). We did not detect a significant difference in the degree of fibular valgization among the groups (P = .591). Notably, improved TT, hindfoot alignment angle, and hindfoot alignment ratio outcomes were observed only in patients undergoing additional inframalleolar procedures in conjunction with OSFO.

Conclusion: The OSFO technique appears to offer correction comparable to conventional fibular osteotomy techniques when combined with SMO. Although its clinicoradiographic correction is similar to that of conventional lateral closing-wedge fibular osteotomy, the OSFO technique could offer intraoperative adjustability and eliminate the need for plate fixation, providing distinct surgical advantages.