Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Introduction: An ankle fracture represents the most frequent osseous injury in both the elderly and non-elderly population. To date, only a limited number of retrospective studies have addressed medium-term outcome following ankle Open Reduction and Internal Fixation (ORIF). The purpose of this study was to assess residual pain and functional outcome 10 to 20 years after operative treatment of ankle fractures and to evaluate the incidence of symptomatic and radiographic ankle osteoarthritis (OA). Methods: We designed a retrospective study including all consecutive patients who underwent ankle ORIF between January 1988 and December 1997 in a University Hospital setting. Pilon and talus fracture as well as pediatric patients were excluded. Patients were seen by two senior residents 10–20 years after their index surgery. Residual pain was measured using the Visual Analog pain Scale. Function and general health status were assessed using the Olerud and Molander Ankle Score, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the 12-item short-form health survey (SF-12). Ankle OA on standard radiographs was scored according to the revised Kellgren and Lawrence (K& L) scale. Results: 374 patients (56% men) underwent ankle surgery during the defined period. 10% of the patients had a Weber A fracture, 57% a Weber B and 33% a Weber C fracture. Mean age at the time of operation was 42.9 years (+/− 17.1; range 16–86 years). 10–20 years after surgery, 47 patients had died, 126 had left the country and were lost to follow-up, 99 did not respond or refused to participate, and 102 patients were seen at the follow-up visit. These patients did not differ in terms of age, gender distribution, BMI and type of fracture from those who were not seen. The mean duration of follow up was 17.3 years (+/− 3.3). Advanced radiographic OA (K& L grade 3 and 4) was present in 34.3 % of the patients. Symptomatic OA was reported by 34.3 % of the patients (AOFAS pain score < 40). Both clinically symptomatic and radiographic ankle OA was found in 18 patients (17.6%). Function was good in 85% of the cases (total AOFAS hindfoot score between 80 and 100 points; mean total AOFAS hindfoot score 89.9, +/−14.6). The mean Olerud and Molander ankle score was 86.5 (+/−18.7). The general health status (SF-12) was similar to representative values of the general population with a similar mean age. Conclusion: 10–20 years after operative treatment of an ankle fracture, the incidence of advanced radiographic post-traumatic ankle OA was 35%, symptomatic OA was present in one third of the patients and about one fifth had both. The majority of the patients reported good function

Background. Acquired flatfoot deformity goes ahead with a partial or complete rupture and thus insufficiency of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medial displacement calcaneal osteotomy to reconstruct the acquired deformity. Material & Methods. Twenty two patients (24 feet) with an average age of 58 (36–75) years were operated on for acquired flexible flatfoot deformity. Two patients had a bilateral procedure. Patients were seen pre-and postoperatively in order to evaluate following parameters: AOFAS hindfoot score, visual analogue scale for pain (0–10), the tarsometatarsal angle on lateral and ap standing x-rays, the cuneiform heights and talocalcaneal angle on lateral standing x-rays and subjective postoperative satisfaction score (1-worst to 5-best). Average time of follow-up was 24.7 months (12–48). Results. The AOFAS hindfoot score could be increased from 46.4 to 89.5 points, the visual analogue scale for pain decreased from 6.6 to 1.1. The average satisfaction score was 4.5 points with one patient scoring 2 and another one scoring 3. All the other patients scored either 4 or 5. All radiological parameters could be improved. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. The calcaneal screws had to be removed in 3 patients. Conclusion. Flexor digitorum longus transfer together with medial displacement calcaneal osteotomy gave satisfactory results for the treatment of acquired flatfoot deformity. All radiologic parameters were improved

Background: While several studies in the last years tried to identify clinical limitations of patients suffering from end-stage ankle osteoarthritis (OA), very few attempted to assess foot and ankle function in a more objective biomechanical way, especially using dynamic pedobarography. The aim of the study was therefore to explore plantar pressure distribution characteristics in a large cohort of posttraumatic end-stage ankle OA. Method: 120 patients (female, 54; male, 66; 120 cases) suffering from posttraumatic end-stage ankle OA were included. The clinical examination consisted of assessment of the AOFAS hindfoot score, a pain score, the range of motion (ROM) for ankle dorsiflexion and plantar flexion, and the body mass index (BMI, kg/m2). Radiological parameters included the radiological tibiotalar alignment and the radiological ankle OA grading. Plantar pressure distribution parameters were assessed using dynamic pedobarography. Results: Intra-individual comparison between the affected and the opposite, asymptomatic ankle revealed significant differences for several parameters: maximum pressure force and contact area were decreased in the whole OA foot, such was maximum peak pressure in the hindfoot and toes area. No correlations could be found between clinical parameters, such as AOFAS hindfoot score, VAS for pain, and ROM, and the pedobarographic data. However, there was a positive correlation between dorsiflexion and the pedobarographic parameters for the hindfoot area. Conclusion: In conclusion, posttraumatic end-stage ankle OA leads to significant alterations in plantar pressure distribution. These might be interpreted as an attempt of the patient to reduce the load on the painful ankle. Other explanations might be bony deformity and ankle malalignment as a consequence of either the initial trauma or of the degenerative process itself, pain related disuse atrophy of surrounding muscles, and scarred soft tissue

Summary: The SF-36, FFI, AOS and the AOFAS AHS were recorded pre and post-operatively in patients with end-stage ankle arthritis. Comparison of responsiveness shows the AOFAS score to be completely unresponsive. Introduction: Outcome studies should include both general health and disease specific measures. The Short Form 36 (SF36) is validated and widely used in musculoskeletal disease. A number of disease specific scores are available for the foot and ankle but, at present there is no widely agreed and validated score used specifically in end-stage ankle arthritis (EAA). Methods: 555 sets of pre and post-operative data on 239 EAA patients undergoing definitive treatment have been collected. The SF36 and three widely used Foot and Ankle scores (Foot Function Index (FFI), AOFAS Ankle Hindfoot Score (AHS) and Ankle Osteoarthritis Scale (AOS)) were recorded. We assessed the responsiveness (Standardized Response Mean (SRM) and Effect Size (ES)) and correlation (Spearman Rank Correlation) of each of the above scores. Results: The SF36, FFI and AOS responded to change and correlated in sub-scale and total scores. The AHS did not respond to change in pain or total scores and did not correlate with any other score. Using the three responsive scores there was a significant improvement in outcome with operative intervention (p< 0.0001) with each score. Using the SRM and the ES, the AOS showed the highest level of responsiveness. It also showed an increased response rate suggesting that patients find it more useable. Conclusion: In future studies we would recommend the use of the SF36 and the AOS for assessment of patients with EAA. We would also discourage use of the AOFAS Ankle Hindfoot Score which we have demonstrated to be unresponsive to change

Introduction Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. Methods The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibiais muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination (average 18 months). Results The AOFAS hindfoot score improved from 62/100 to 84/100. The subjective portion of the AOFAS hindfoot score improved from 31/60 to 49/60. Weight bearing pre-operative and post-operative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform or talo-navicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, six patients satisfied with minor reservations and one dissatisfied. No patient complained of donor defecit from the harvested FHL tendon. Conculsions Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial diplacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Introduction. Currently, a validate scale of ankle osteoarthritis (OA) is not available and different classifications have been used, making comparisons between studies difficult. In other joints as the hip and knee, the Kellgren-Lawrence (K&L) scale, chosen as reference by the World Health Organizations is widely used to characterize OA. It consists of a physician based assessment of 3 radiological features: osteophyte formation, joint space narrowing and bone end sclerosis described as follows: grade 0: normal joint; grade 1: minute osteophytes of doubtfull significance; grade 2: definite osteophytes; grade 3: moderate diminution of joint space; grade 4: joint space greatly impaired, subchondral sclerosis. Until now, the K&L scale has never been validated in the ankle. Our objective was to assess the usefulness of the K&L scale for the ankle joint, by determining its reliability and by comparing it to functional scores and to computerized minimal joint space width (minJSW) and sclerosis measurements. Additionally we propose an atlas of standardized radiographs for each of the K&L grades in the ankle. Methods. 73 patients 10 to 20 years post ankle ORIF were examined. Bilateral ankle radiographs were taken. Four physicians independently assessed the K&L grades and evaluated tibial and talar sclerosis on anteroposterior radiographs. Functional outcome was assessed with the AOFAS Hindfoot score. Bone density and minJSW were measured using a previously validated Ankle Image Digital Analysis software (AIDA). Results. The interobserver reliability, for the K&L stages was 0.60 (intraclass correlation coefficient) indicating moderate to good agreement. The mean AOFAS hindfoot score decreased substantially (p = 009) and linearly from 99.3 in K&L grade 0 to 79.5 points in K&L grade 4. The minJSW assessed by AIDA was similar among grades 0 to 2 (between 2 and 2.5mm), but significantly lower in grade 3 (1.8mm) and in grade 4 (1.1mm). A decreased minJSW less than 2mm, commonly used as a threshold for the assessment of hip and knee OA, was found in 77% of K&L grades 3–4 compared to 33% of grades 0–2, sensitivity 77.4% and specificity 66.7%. Physician based assessment revealed that subchondral sclerosis was present in 16% of K&L grade 1 patients, 52% of grade 2, 70% of grade 3 and 100% of grade 4 patients. No correlation could be found between physician based assessment and digital image analysis of subchondral sclerosis. Conclusions. Interobserver reliability in assessment of ankle OA using the K&L scale was similar to other previously described joints. OA progression correlated with functional diminution. Joint space narrowing assessed AIDA as well as the cut-off of 2mm correlated well with the K&L scale. Overall, we recommend the use of the K&L scale for the radiographic assessment of ankle OA

Purpose. Total Ankle Replacement (TAR) is increasingly being offered to patients as an alternative to arthrodesis for the operative management of debilitating end-stage ankle arthritis. The Mobility Total Ankle System is a third-generation design consisting of a three component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a multi-centre prospective study of the Mobility prosthesis. This is the first such report by independent researchers. Method. The senior authors implanted 86 consecutive Mobility prostheses. The underlying diagnosis was primary OA in 24 ankles, secondary OA in 47 ankles and inflammatory arthritis in 15 ankles. There were 41 males (Mean age 67 / Range 51–87) and 44 females (Mean age 60 / Range 29–72). The mean BMI was 28 (Range 22–36) for males, and 28 (Range 20–39) for females. Previous ankle operations were performed in 24 patients, 22 of which were for fracture fixation. Ankles were classified according to the COFAS end-stage ankle arthritis classification system. Coronal plane deformity was quantified pre-operatively. Clinical outcome was assessed using the AOFAS hindfoot score. Radiological assessment was performed from weight-bearing radiographs, documenting post-operative alignment, osseous integration, edge-loading and heterotopic bone formation. The mean follow-up time was 40 months (Range 30–60). Survival analysis was calculated according to the Kaplan-Meier method. Failure was defined as exchange of any component of the TAR, arthrodesis or amputation. Results. Type 1 ankle arthritis was demonstrated in 54 ankles (63%). No patient had pre-operative coronal plane angulation > 20. In 30 ankles (35%), the pre-operative coronal alignment was neutral, and in 32 ankles (37%), the deformity was < 10. The mean AOFAS hindfoot score improved from 37.4 (Range 12–59) pre-operatively to 77.9 (Range 51–100) post-operatively. 78 (90%) of prosthetic components were implanted within 5 of the optimal position. Bone-implant interface abnormalities were identified in 16 ankles (18%). In total, 5 TARs required revision, 4 for aseptic loosening and one for component malpositioning. There was one conversion to arthrodesis, and one BKA for CRPS. 30 simultaneous procedures were performed in 28 patients. The most common was gastrocnemius recession. There were 8 re-operations, most commonly for impingement due to peri-articular ossifications. Delayed wound healing occurred in 3 patients, and there was one case of deep infection. There were 5 patients that sustained fractures of the medial malleolus: 2 were intra-operative, and underwent internal fixation. There are 6 patients being investigated for ongoing pain. The 2-year survival was 96.4% (95% CI 89.4–99.1) and 3-year survival was 91.7% (95% CI 83.3–96.3). Conclusion. Although early results of the Mobility TAR are encouraging for independent researchers, they do not match those reported by designer surgeons. Most patients achieve good pain relief and improved function post-operatively

We retrospectively reviewed 31 patients who underwent reconstruction procedure for PTT D (Type II Johnson). The surgery was mostly performed by the senior author. Fifty patients underwent 55 procedures, 31 patients were available for review (34 procedures). Clinical and functional outcome were assessed using AOFAS hindfoot score, and the SF-36 health assessment score. The patients had a calcaneal medialising (chevron) osteotomy to correct heel valgus, with or without a calcaneal lengthening osteotomy, and transfer of the FDL tendon to the navicular. All patients were immobilized in non-weight (to partial) bearing POP for 5 weeks, followed by CAM for 6 weeks. There were 7 males and 24 female, with an average age of 60.5 years. The average follow up was 54 months (range 11.5–111.2). The average hindfoot valgus deformity was 15 degrees preoperatively. Eight patients had and additional procedures including (TA lengthening, Lapidus). Four patients required bone graft for calcaneal column lengthening, and in 5 patients the posterior screw was removed due to continuous discomfort. The average AOFAS hindfoot score was 74 (47–100), the average pain score was 31/40 and the average subscore of the heel alignment was 7.9/10. Nineteen patients (61%) were able to perform single heel raise, and 27 patients (87%) were able to perform bilateral heel raise. 26 patients (83.8%) had no lateral impingement pain post operatively. The SF-36 health assessment showed similar functional outcome with age matched population. Two patients had superficial wound infection required oral antibiotics. Hindfoot and midfoot reconstructive surgery for type II PTTD after failed orthotic treatment is well established. However, the post operative care and rehabilitation period is lengthy and protracted. This must be emphasized during informed consent in order to fulfil realistic expectations

History and Background: The HINTEGRA. ®. Total Ankle Prosthesis was designed in 2000 by Dr. B. Hintermann (Basel, Switzerland); Dr. G. Dereymaeker (Pellenberg, Belgium); Dr. R. Viladot (Barcelona/Spain); and Dr. P. Diebold (Maxeville, France), and is manufactured by Newdeal SA in Lyon, France. Design Features: The HINTEGRA. ®. Total Ankle Prosthesis is a non-constrained, three-component system that provides inversion/eversion stability. Axial rotation and normal flexion/extension mobility are provided by a mobile bearing element. Limits of motion are dependent on natural soft-tissue constraints: no mechanical prosthetic motion constraints are imposed for any ankle movement with this device. The HINTEGRA. ®. ankle uses all available bone surface for support. The anatomically shaped, flat tibial and talar components essentially resurface the tibia and talar dome, respectively, and wings hemiprosthetically replace degenerate medial and lateral facets (a potential source of pain and impingement). No more than 2 to 3 mm of bone removal on each side of the joint is necessary to insert the tibial and talar components. On the tibial side, most importantly, the bony architecture remains intact, and in particular, the anterior cortex is preserved. Perfect apposition with the hard subchondral bone is achieved by the flat resection of the bone and the flat surface of the component. Primary stability for coronal plane motion is provided by two screws inserted into the anterior shield, in the upper part of oval holes so that the settling process of the component is not hindered by axial loading. On the talar side, additional anterior support is provided by a shield, and pressfit is provided by the slightly curved wings. Two pegs facilitate the insertion of the talar component and provide additional stability, particularly against anterior-posterior translation. Another advantage of this concept is the instrumentation that allows reliable implantation of components. Technique: The prosthesis is implanted through an anterior approach. In the case of malalignment, ligamentous instability, and concomitant osteoarthrosis of the distal joints, additional surgeries are considered before prosthetic implantation. Complications: In the beginning, a major concern was the positioning of the talar component, which tended to slide too posteriorly while impacting and press fitting. With the addition of two talar pegs, the current design may resist such translational forces during press fitting. There is evidence that positioning of the talar component too posteriorly may cause pain and limit dorsiflexion of the foot (probably because the posterior aspects of the deltoid ligament are over-tensioned), thereby the intrinsic forces are also increased which may cause unacceptable high shear forces at the bone-implant interface and/or component instability. In all but one of the seven revised talar components (out of the author’s first 400 cases), the component was positioned too posteriorly. There is a potential risk for dislocation of the meniscal component either laterally or medially as long as no appropriate alignment and/or ligament balancing have been achieved during surgery. The author encountered this problem only in two of the first twenty cases; thereafter, no such complications occurred probably because of better understanding alignment and balancing the ankle. A potential concern in uncemented resurfacing prostheses is the use of screws that may create stress shielding. The HINTEGRA. ®. ankle, however, uses oval holes on the tibial side so that some settling of the component during osteointegration is possible. As screw fixation is located eccentric to the load transfer area, the potential for stress shielding is in addition minimized. Salvage of Complications: Special revision implants are available for salvage of failed components. On tibial side, components with a thicker plateau may serve to replace loosed bone stock and to get firm bony support more proximally, thereby preserving the original joint line (that means, the ankle ligaments are supposed to be properly used for stabilizing and guidance of the joint). On talar side, components with a flat undersurface allow flat resection of the talus, thus providing a wide area of bone support to the revision component. Results: Between 05/2000 and 12/2006, 340 primary TAA were performed in 322 patients (females, 165; males, 157, age 57.3 ± 13.4 years). Underlying diagnosis was posttraumatic osteoarthritis in 272 ankles, primary osteoarthritis in 26 ankles and inflammatory arthritis in 42 ankles. All patients were clinically and radiologically assessed after 6.2 (1.1–7.5) years, and survivorship analysis was calculated. Revision of a metallic implant or conversion into ankle arthrodesis was taken as the endpoint. The AOFAS Hindfoot Score improved from 42.1 (14–61) points preoperatively to 78.6 (44–100) points at follow-up. 205 ankles (60.5%) were completely pain free. The average range of motion was clinically 32.2° (range, 15° to 55°), and under fluoroscopy (that is, true ankle motion) 30.4° (range, 7° to 62°). Four ankles were revised to TAA (component loosening, 3; pain, 1), and 2 ankles (component loosening and recurrent misalignment, 1; pain, 1) were revised to ankle arthrodesis. Overall survivorship at 6 years was 98.2%, being 97.9% for the talar component and 98.8% for the tibial component. Four ankles (1.2%) were successfully revised, and the obtained result at latest follow-up did not differ from those ankles without complications. Whereas, 2 ankles (0.6%) were revised to ankle arthrodesis. In another series of 37 patients (37 ankles: STAR, 26 ankles; HINTEGRA, 3 ankles; AGILITY, 3 ankles, Büchel-Pappas, 2 ankles; MOBILITY, 2 ankles; SALTO, 1 ankle) with failed total ankle arthroplasty, revision arthroplasty was performed with the HINTEGRA. ®. ankle. All but one surgery were successful. At a mean follow-up of 3.6 (1.2–6.4) years, 29 patients (78.4%) were satisfied with the obtained result. The AOFAS Hindfoot Score improved from 39.2 (23–58) points pre-operatively to 72.8 (54–95) points. All but on implants were radiographically stable; in one case, the tibial component showed, at one year, still a radioluscency which may be considered as loosening. As the patient is completely pain free, no revision surgery was done. In another series of 29 patients (30 ankles), a painful ankle fusion was taken down and ankle arthroplasty was performed with the HINTEGRA. ®. ankle. All surgeries were successful. At a mean follow-up of 3.4 (2–7.6) years, 24 patients (80%) were satisfied with the obtained result. The AOFAS Hindfoot Score improved from 34.1 (18–47) points preoperatively to 69.4 (48–90) points. The obtained motion for dorsi-/plantar flexion was clinically 23.5° (10°–40°) [52.6% of contra lateral ankle), and radiographically (“true ankle motion”) 24.5°(8°–24°) [54.4% of contra lateral ankle]. The author’s overall experience: more than 750 replacements with the HINTEGRA. ®. ankle in the last 8 years. The learning curve was rather long as some adjustments had to be performed, and there was need of some time to understand “ligament balancing” in ankle replacement in more detail. However, since then, an extremely high satisfaction rate was obtained, and most patients are doing very well. The revision rate has also turned down to < 2% despite, with increased experience, more complex cases may have been considered for ankle replacement. Conclusion: Obviously, TAA using a current anatomic design of 3-component prosthesis (HINTEGRA) have evolved to a safe procedure with reliable results at mid- to long-term. These encouraging results support our belief that TAA has become a viable alternative to ankle arthrodesis even for younger patients and more difficult conditions, as often the case in posttraumatic osteoarthritis

Introduction. Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair. Methods. Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically. Results. The mean age at surgery was 53 years (22–83 years). Mean time from rupture to surgery was 7 months (1–36 months). Follow up ranged from 29–120 months (mean 73 months). Sixteen patients were completely satisfied and four moderately satisfied. The mean ATRS was 80 (range 25–100) and AOFAS 94 (range 82–100). Postoperative Tegner score showed a reduction by one level from pre-injury (mean 5.1 pre injury to 4.3 post surgery). No cases of re-rupture were encountered. Six patients had wound issues. The mean maximal strength of ankle plantar flexion on the operated leg 95Nm (41–163) was less than the non-operated leg 123 Nm (50–190Nm). The average difference in strength was 24%. The operated hallux had only 40% of strength in flexion of the contralateral toe. There were no floating toes. Conclusion. Transtendinous FHL transfer for late presenting Achilles tendon ruptures provides reliable long term function and reasonable ankle plantar flexion strength. Long FHL harvest has little morbidity and lack of a distal tenodesis did not result in any notable functional loss or alignment issues to the great toe

Background. The adult acquired flat foot is caused by a complete or partial tear of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medializing calcaneal osteotomy for recontruction of the deformity. Material & Methods. Twenty-six patients (31 feet) with an average age of 58 years (36–75) were operated for an acquired flat foot deformity. The patients were seen before surgery, one year after surgery and an average of 85 months after surgery to assess the following parameters: AOFAS Score, VAS Score for pain (0–10). Foot x-rays in full weightbearing position (dorsoplantar and lateral) were done at every visit in order to assess the following parameters: tarsometatarsale angle on the dorsoplantar and lateral x-ray, talocalcaneal angle on the lateral x-ray, calcaneal pitch angle and medial cuneiforme height on the lateral x-ray. Results. The AOFAS hindfoot score improved from 46.4 to 89.5 (max.: 100) points 1 year postoperatively und decreased to 87.8 points at the last follow-up. VAS for pain decreased from 6.6 to 1.1 at the one year follow-up and increased to 1.5 at the last follow-up. All radiologic parameters improved and stayed without significant changes over time. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. In six patients the screws had to be removed. Apart from that no other revision surgery had to be done. Conclusion. Flexor digitorum longus transfer together with medializing calcaneal osteotomy provides excellent results for the therapy of acquired flat foot deformity. The results did not change significantly over time

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

This paper outlines a valid and reliable, clinical method of assessing the amount of deformity in the congenital clubfoot. Clinical & MRI clubfoot scoring systems were developed to score the amount of deformity clinically & to image & score osteochondral pathology of the club-foot -MRI Total Score (MTS), MRI Hindfoot Contracture Score (MHCS), & MRI Midfoot Contracture Score (MMCS), Clinical Total Score (CTS), Clinical Hindfoot Contracture Score (CHCS), Clinical Midfoot Contracture Score (CMCS). Three independent observers tested the Clinical scoring systems Inter-observer reliability (Kappa Statistic) over one hundred consecutive clubfeet. Kappa values were CTS-0.92, CMCS-0.91, and CHCS-0.86- (almost perfect inter-observer reliability). Nineteen clubfeet were scored clinically and by thirty-eight MRI evaluations during treatment. Validity was evaluated by correlating the MRI and clinical scores (Pearson Correlation). The Pearson Correlations between clinical & MRI scores were CTS: MTS = 0.786 (P< 0.01), CHCS: MHCS = 0.712 (P< 0.01) & CMCS: MMCS = 0.651 (P< 0.01). All correlations were highly significant confirming validity. There is neither reliability nor validity in current methods of clubfoot assessment. This paper outlines a method of assessing the amount of deformity in the congenital clubfoot deformity using six well-described simple clinical signs that has been tested & found to be both valid and reliable. A clinical clubfoot scoring system was created- Clinical Total Score (CTS)- comprised of a Clinical Hind-foot Contracture Score (CHCS) & a Clinical Midfoot Contracture Score (CMCS). One hundred consecutive congenital clubfeet were scored for clinical deformity each week during cast treatment by three independent observers. Inter-observer reliability (Kappa Statistic) of this clinical scoring system was evaluated. A clubfoot MRI protocol & scoring system were developed to visualise & score osteochondral pathology of the clubfoot -MRI Total Score (MTS)- comprised of a MRI Hindfoot Contracture Score (MHCS) and a MRI Midfoot Contracture Score (MMCS). Nineteen clubfeet were scored clinically and by thirty-eight MRI evaluations during treatment. All MRI films were scored for amount of osteochondral pathology. Validity of this clinical scoring system was evaluated by correlating the MRI and clinical scores (Pearson Correlation). The Kappa values for inter-observer reliability were CTS-0.92, CMCS-0.91, and CHCS-0.86. All scores showed almost perfect inter-observer reliability. The Pearson Correlations between clinical & MRI scores were CTS: MTS = 0.786 (P< 0.01), CHCS: MHCS = 0.712 (P< 0.01) & CMCS: MMCS = 0.651 (P< 0.01). All correlations were highly significant confirming validity of the clinical scores. We have developed a clinical scoring system for club-feet that is reliable and valid

Introduction:. The Scandinavian Total Ankle Replacement (STAR) is a three-component, uncemented implant in widespread use throughout Europe. STAR has achieved encouraging results with short and medium term outcome. We present the long term (13–19 year) results of a consecutive series of 200 STAR ankles. Methods:. Between November 1993 and February 2000, a total of 200 consecutive STARs were carried out in 184 patients. Patients were followed up both clinically and radiologically, until death or failure, with time to decision to revision or fusion as the endpoint. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. Results:. Of the 200 STARs, 109 (105 patients) were alive at latest review. 12 STARs (11 patients) were lost to follow-up, leaving 97 ankles for clinical review. Of these, 76 ankles were surviving and 21 ankles had failed [13 underwent arthrodesis, 4 had an exchange of poly insert, and 4 had a revision TAR], with mean time to failure 82 months (2–156 months). For the 91 ankles in 79 patients who died during the study, 8 had failed [6 underwent revision TAR and 2 had an arthrodesis]. The implant survival at 15 years with endpoint of revision for any reason was 76.9% [95% CI 66.4 to 87.3]. The mean AOFAS score was 72 [20 to 96]. The mean annual failure rate was 1.5%, which was steady across the study period. Conclusion:. The 15 year survivorship for the STAR prosthesis was 76.9%, which provides a benchmark for other later design ankle prostheses. We found no drop off in failure rate or function over the study period

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

Introduction. End-stage ankle osteoarthritis is a debilitating condition that results in functional limitations and a poor quality of life. Ankle arthrodesis (AAD) and total ankle replacement (TAR) are the major surgical treatment options for ankle arthritis. The purpose of the present study was to compare preoperative and postoperative participation in sports and recreational activities, assesses levels of habitual physical activity, functional outcome and satisfaction of patients who underwent eighter AAD or TAR. Methods. 41 patients (mean age: 60.1y) underwent eighter AAD (21) or TAR (20) by a single surgeon. At an average follow-up of 30 (AAD) and 39 (TAR) months respectively activity levels were determined with use of the University of California at Los Angeles (UCLA) activity scale. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, patients's satisfaction and pre- and postoperative participation in sports were assessed as well. Results. In the AAD group 90% and in the TAR group 76% were active in sports preoperatively. Postoperatively in both groups 76% were active in sports (AAD p=0.08). The UCLA score was 7.0 (± 1.9) in the AAD group and 6.8 (± 1.8) in the TAR group (p=0.78). The AOFAS score reached 75.6 (± 14) in the AAD group and 75.6 (± 16) in the TAR group (p=0.97). Conclusion. Our study revealed no significant difference between the groups concerning activity levels, participation in sports activities, UCLA and AOFAS score. After AAD the number of patients participating in sports decreased. However, this change was not statistically significant

Between 2000 and 2004 we used subtalar arthrodesis to treat 44 patients for continued pain after intra-articular calcaneal fracture. All the fractures were due to laboral accidents. Average time to union was 3 month(2 to 4 months). Complications were minor in 12 patients and major in 10 patients. Lenght of follow-up was 23 months. Hindfoot scores (clinical rating system of the American Orthopaedic Foot and Ankle Society)improved from 35,11 to 67,22. The results were excelent in 7 patients, good in 24, fair in 7 and bad in 6 patients. Return to previous activities was possible in 26 pacients. We concludes that subtalar arthrodesis represents a rather effective treatment of the subtalar arthritis due to inta-articular calcaneal fractures. The majority of patients can have improvement with surgical reconstruction but pain relief is usually not complete

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no studies to show the effectiveness of such a procedure for plantar fasciitis. Fourteen patients with plantar fasciitis with failed conservative treatment underwent. TOPAZ RF treatment for their symptoms between 2007 and 2008. The RF-based microdebridement was performed using the TOPAZ Microdebrider device (ArthroCare, Sunnyvale, CA). They were followed-up for up to six months thereafter. Pre-operative, three and six months post-operative VAS, AOFAS ankle-hindfoot and SF-36 scores were analysed. There were six men and eight women, with an average age of 44.0 years (23–57). There were 15 feet, with six right and nine left feet. They were followed up for six months post-operatively. There was a significant improvement in mean pre-op and six-month VAS scores from 8.13 to 3.27(p=0.00), and AOFAS hindfoot scores from 34.37 to 71.33 (p=0.00). There was a significant decrease in SF-36 for bodily pain, and significant increases in physical and social function scores. Twelve out of 14 (85.7%) patients reported ‘good’ to ‘excellent’ satisfaction results at six months, and 11 out of 14 (78.6%) patients had their expectations met from the procedure at six months follow-up. TOPAZ RF coblation is a good and effective method for the treatment of plantar fasciitis. Early results are encouraging, and we believe that the pain experienced by the patients in the follow-ups will subsequently improve