Aims

Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques.

One assumed function of Total Ankle Replacement (TAR) is that by maintaining ankle joint motion we can protect the other hind foot joints from further degredation. 1. However, there is no work to our knowledge that compares hindfoot outcomes between TAR and arthrodesis. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. 2. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. We performed a retrospective review of all patients at our centre who had had a TAR or ankle arthrodesis since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patients were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. 214 arthrodesis cases and 302 TAR were eligible. The average age was 57. Average time to follow up was 13 years (4–21). At the time of abstract submission 107 sets of notes had been reviewed fully. Full analysis will be performed by conference. 14% of TAR patients went on to have further procedures to the hindfoot joints while 35% of arthrodesis patients had further procedures (p=0.014). There was also a significant difference in the number of patients progressing to fusion of a further hindfoot joint between groups (TAR- 4%, arthrodesis- 20%, p=0.01). These data suggest that TAR are protective of symptomatic change of hindfoot joints. Patients with TAR had fewer hindfoot fusions than those with arthrodesis and also fewer procedures of any form, including injections

Background

Lateral ankle instability is a common problem, but the precise role of the lateral ankle structures has not been accurately investigated. This study aimed to accurately investigate lateral ankle complex stability for the first time using a novel robotic testing platform.

Background. Total ankle replacements (TARs) are becoming increasingly more common in the treatment of end stage ankle arthritis. As a consequence, more patients are presenting with the complex situation of the failing TAR. The aim of this study was to present our case series of isolated ankle fusions post failed TAR using a spinal cage construct and anterior plating technique. Methods. A retrospective review of prospectively collected data was performed for 6 patients that had isolated ankle fusions performed for failed TAR. These were performed by a single surgeon (IW) between March 2012 and October 2014. The procedure was performed using a Spinal Cage construct and grafting in the joint defect and anterior plating. Our primary outcome measure was clinical and radiographic union at 1 year. Union was defined as clinical union and no evidence of radiographic hardware loosening or persistent joint lucent line at 1 year. Results. The mean follow-up was 37.3 months (SD 13.2). Union was achieved in 5 of the 6 patients (83%). One patient had a non-union that required revision fusion incorporating the talonavicular joint that successfully went on to unite across both joints. Another patient had radiographic features of non-union but was clinically united and asymptomatic and one required revision surgery for a bulky symptomatic lateral malleolus with fused ankle joint. Conclusion. The failing TAR presents a complex clinical situation. After removal of the implant there is often a large defect which if compressed leads to a leg length discrepancy and if filled with augment can increase the risk of non-union. Multiple methods have been described for revision, with many advocating fusion of both the ankle joint and subtalar joint. We present our case series using a spinal cage and anterior plating that allows preservation of the subtalar joint and a high rate of union

Aim. Surgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements. Method. A total of 18 revision TAR in 17 patients were performed in patients with aseptic loosening. The technique was performed by a single surgeon (CSK) over a 4 year period between July 2014 and August 2018 using the Inbone total ankle replacement system. Patient demographics and clinical outcomes were collected retrospectively using - MOXFQ, EQ5D, VAS pain score and patient satisfaction questionnaires. Results. 12 right and 6 left ankle replacements were revised in 17 patients (11 male/ 6 female). The mean age at revision was 69.1 years (range 56–81 years) with a mean BMI of 31. The mean surgical time was 171 minutes with 22% of cases requiring bone grafting. 6 patients had early wound complications, all superficial and settled with dressings. There were no deep infections, 2 patients had further surgery for exploration for possible nerve injuries. At a mean follow up of 20.6 months, 4 patients had mild/moderate ongoing pain with the majority of patients being satisfied with the outcome of their surgery. Conclusion. This study represents one of the largest group of patients reported to have undergone revision total ankle arthroplasty. Our experience shows that this results in acceptable level of complications and provides satisfactory function in most patients. We feel revision TAR is a viable option in patients with failed primary arthroplasty who wish to continue to maintain mobility at the ankle joint

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Aims

Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care.

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Aims

This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Syndesmotic ankle lesions involve disruption of the osseous tibiofibular mortise configuration as well as ligamentous structures stabilizing the ankle joint. Incomplete diagnosis and maltreatment of these injuries is frequent, resulting in chronic pain and progressive instability thus promoting development of ankle osteoarthritis in the long term. Although the pathogenesis is not fully understood, abnormal mechanics has been implicated as a principal determinant of ankle joint degeneration after syndesmotic ankle lesions. Therefore, the focus of this presentation will be on our recent development of a computationally efficient algorithm to calculate the contact pressure distribution in patients with a syndesmotic ankle lesion, enabling us to stratify the risk of OA development in the long term and thereby guiding patient treatment

Aims

Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT.

Aims

To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs.

The December 2023 Foot & Ankle Roundup³⁶⁰ looks at: Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis; 3D-printed modular endoprosthesis reconstruction following total calcanectomy; Percutaneous partial bone excision in the management of diabetic toe osteomyelitis; Hemiepiphysiodesis is a viable surgical option for Juvenile hallux valgus; Ankle arthroplasty vs arthrodesis: which comes out on top?; Patient-related risk factors for poorer outcome following total ankle arthroplasty; The Outcomes in Ankle Replacement Study.

Abstract. Objectives. The fidelity of a 3D model created using image segmentation must be precisely quantified and evaluated for the model to be trusted for use in subsequent biomechanical studies such as finite element analysis. The bones within the ankle joint vary significantly in size and shape. The purpose of this study was to test the hypothesis that the accuracy and reliability of a segmented bone geometry is independent of the particular bone being measured. Methods. Computed tomography (CT) scan data (slice thickness 1 mm, pixel size 808±7 µm) from three anonymous patients was used for the development of the ankle geometries (consisting of the tibia, fibula, talus, calcaneus, and navicular bones) using Simpleware Scan IP software (Synopsys, Exeter, UK). Each CT scan was segmented 4 times by an inexperienced undergraduate, resulting in a total of 12 geometry assemblies. An experienced researcher segmented each scan once, and this was used as the ‘gold standard’ to quantify the accuracy. The solid bone geometries were imported into CAD software (Inventor 2023, Autodesk, CA, USA) for measurement of the surface area and volume of each bone, and the distances between bones (tibia to talus, talus to navicular, talus to calcaneus, and tibia to fibula) were carried out. The intra-class coefficient (ICC) was used to assess intra-observer reliability. Bland Altman plots were employed as a statistical measure for criteria validity (accuracy) [1]. Results. The average ICC score was 0.93, which is regarded as a high reliability score for an inexperienced user. The talus to navicular and talus to tibia separations, which had the smallest distances, showed a slight decrease in reliability and this was observed for all separations shorter than 2 mm. According to the Bland-Altman plots, more than 95% of the data points were inside the borders of agreement, which is an excellent indication of accuracy. The bias percentage (average error percentage) varied between 1% and 4% and was constant across all parameters, with the proportion rising for short distance separations. Conclusions. The current study demonstrates that an inexperienced undergraduate, with access to software manuals, can segment an ankle CT scan with excellent reliability. The present study also concluded that all five bones were segmented with high levels of accuracy, and this was not influenced by bone volume or type. The only factor found to influence the reliability was the magnitude of distance between bones, where if this was smaller than 2 mm it reduced the reliability, indicating the influence of CT scan resolution on the segmentation reliability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. This abstract provides an update on the Open Ankle Models being developed at the University of Bath. The goal of this project is to create three fully open-source finite element (FE) ankle models, including bones, ligaments, and cartilages, appropriate musculoskeletal loading and boundary conditions, and heterogeneous material property distribution for a standardised representation of ankle biomechanics and pre-clinical ankle joint analysis. Methods. A computed tomography (CT) scan data (pixel size of 0.815 mm, and slice thickness of 1 mm) was used to develop the 3D geometry of the bones (tibia, talus, calcaneus, fibula, and navicular). Each bone was given the properties of a heterogeneous elastic material based on the CT greyscale. The density values for each bone element were calculated using a linear empirical relation, ρ= 0.0405 + (0.000918) HU and then power law equations were utilised to get the Young's Modulus value for each bone element [1]. At the bone junction, a thickness of cartilage ranging from 0.5–1 mm, and was modelled as a linear material (E=10 MPa, ν=0.4 [2]). All ligament insertions and positions were represented by four parallel spring elements, and the ligament stiffness and material attributes were applied in accordance with the published literature [2]. The ankle model was subjected to static loading (balance standing position). Four noded tetrahedral elements were used for the discretization of bones and cartilages. All degrees of freedom were restricted at the proximal ends of the tibia and fibula. The ground reaction forces were applied at the underneath of the calcaneus bone. The interaction between the cartilages and bones was modelled using an augmented contact algorithm with a sliding elastic contact between each cartilage. A tied elastic contact was used between the cartilages and the bone. FEbio 2.1.0 (University of Utah, USA) was used to construct the open-source ankle model. Results. When the double-legged stance phase loading condition was taken into consideration, stress at the antero-medial tibial wall (ranged from 1 to 7 MPa) was found to be similar to the prior work [2], indicating bulk of the load transfer was through this region. The maximum principal strain was predicted at the different regions on bones around the ankle joint. The proximal surface of the talus, and tibial distal surface were shown to have the highest maximum principal strains followed by antero-medial walls of the tibia bone, at the proximal location. Conclusions. The present open 3D FE model of the ankle will assist researchers in better understanding ankle biomechanics, precisely predicting load transfer, and examining the ankle to address unmet clinical needs for this joint. The results of the current investigation are realistic in terms of load transfer and stress-strain distribution across the ankle joint and well comparable to those reported in the literature [2]. However, sensitivity and ankle instability simulations will be performed in future work to investigate the model's reliability and robustness. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims

The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals.