The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution. All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments. Cite this article: Bone Joint J 2015; 97-B:662–7

Introduction. The purpose of this study was to examine trends in patient characteristics and clinical outcomes that occur with age as a statistical variable when performing autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT). Methods. A retrospective cohort study for AOT procedures on 78 patients from 2006 to 2019. was conducted Clinical outcomes were evaluated via FAOS scores. A multivariable linear regression was used to assess the independent factors predictive of the first post-operative FAOS after AOT. The independent variables included pre-operative FAOS, age, defect size, shoulder lesion, cystic lesion, prior traumatic injury, and history of microfracture surgery. A p-value <.05 was considered significant and 95% confidence limits (95% CL) for regression coefficient estimates (est.) were calculated. Results. 78 patients were included with a mean age of 35.5 ± 13.6years at a mean follow-up was 54.4 ± 18.9 months. The mean pre-operative FAOS was 54.3 ± 19.4 and the mean post-operative FAOS was 83.4 ± 13.6. The mean defect size was 109.3±62.4 mm2. The multivariable linear regression showed that the pre-operative FAOS was associated with a higher post-operative FAOS (est., 95% CL: 0.16, 0.012 – 0.307; p=0.034). Defect size (est., 95% CL: −0.05, −0.097 – −0.003; p=0.0358), having a shoulder lesion (est., 95% CL: −9.068, −15.448 – −2.688; p=0.006), or having a prior microfracture surgery (est., 95% CL: −7.07, −13.118 – −1.021; p=0.0226) were associated with a lower post-operative FAOS. Conclusion. Patient age was not an independent risk factor for inferior clinical outcomes after AOT for OLT. Additionally, cystic lesions, or lesions with a traumatic aetiology were not significantly associated with post-operative FAOS. Having a shoulder lesion had the largest marginal effect on post-operative FAOS. These findings provide important information for providers when counseling and selecting patients for AOT procedure for treatment of OLT

Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. Methods. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Results. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. Conclusion. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229–1241

Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm. 2. ) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm. 2. or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm. 2. 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested

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

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. Methods. We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum one-year follow-up. Standard preoperative radiography and MRI were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately one-year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain visual analogue scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results. All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 (SD 1.53) to 63.5 (SD 22.60) (p = 0.025) in ten patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and two patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (p ≤ 0.003). Conclusion. PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study. Cite this article: Bone Jt Open 2023;4(12):942–947

Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales. This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56. We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003). As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist

Introduction. Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. Methods. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

Introduction. Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up. Methods. All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up. Results. 33 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 31 patients were included in the study. 4 patients declined participation for completing questionnaires. We received 15/27 (55.5%) completed questionnaires. The mean MOX-FQ average domain score for pain was (50.6 ± 26.9), walking/standing (62.4 ± 36.5) and social function was (43.7± 31.0). The mean FAOS scores were (52.5 ± 30.6; pain), (54.5 ± 29.2; symptoms), (62.1 ± 30.5; ADL) and (35.5 ± 28.2; for quality of life). The mean overall health score today for EQ-5D was 73.9/100. 50% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 57% were satisfied with the improved in daily activities. 78.5% were overall satisfied with the results from surgery. Conclusion. Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery

The effect of BMI on patient-reported outcomes following total ankle replacement (TAR) is uncertain and the change in BMI experienced by these patients in the 5 years following surgery has not been studied. We report a series of 106 patients with complete 5-year data on BMI and patient-reported outcome scores. Patients undergoing TAR between 2006 and 2009, took part in the hospital joint registry, which provides routine clinical audit of patient progress following total joint arthroplasty; therefore, ethics committee approval was not required for this study. Data on BMI, Foot and Ankle Score (FAOS) and SF-36 score were collected preoperatively and annually postoperatively. Patients who were obese (BMI >30) had lower FAOS scores pre-operatively and at 5 years, however this did not reach significance. Both obese (p = 0.0004) and non-obese (p < 0.0001) patients demonstrated a significant improvement in FAOS score from baseline to 5 years. This improvement was more marked for the non-obese patients. No significant differences were seen for SF36 scores between obese and non-obese patients either at baseline or 5 years. There was a trend for improved score in both groups. Mean pre-operative BMI was 28.49. Mean post-operative BMI was 28.33. The mean difference between pre- and post-operative BMI was −0.15, which was not statistically significant (p=0.55). There were no significant differences in revisions in the obese (2) and non-obese (1 and one awaited) groups at 5 years. This data supports use of TAR in the obese population, as significant increases in mean FAOS score were seen in this group at 5 years. Obesity did not have a significant influence on patients' overall health perceptions, measured by the SF36 and a trend for improvement was seen in both obese and non-obese patients. TAR cannot be relied upon to result in significant post-operative weight-loss without further interventions

Aims. The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure. Patients and Methods. A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs. Results. The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon. Conclusion. The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183–9

Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm. 2. or failed alternative therapies. This cohort study describes a 5 year review of the outcomes of talar lesions treated with MAST. A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was conducted to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. 32 patients were identified in this cohort. There were 10 females, 22 males, with an average age of 35. 01. 73% had returned and continued playing active sport. 23 patients underwent MAST in the setting of a failed previous operative attempt, with just 9 having MAST as a first option. 9 patients out of 32 had a further procedure. Two patients had a further treatment directed at their OCL. Two patients had a fusion, 2 had a cheilectomy at > 4 years for impingement, one had a debridement of their anterolateral gutter, one had debridement for arthrofibrosis, one patient had a re alignment calcaneal osteotomy with debridement of their posterior tibial tendon. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “failed microfracture” cohort

Purpose. To evaluate the clinical results of arthroscopic repair and open Ahlgren Larsson method in patients with chronic lateral ankle instability. Methods. We retrospectively evaluated 87 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. 16 patients with osteochondral lesion, 5 patients with rheumatoid arthritis, 4 patients with ankle fractures of the same side, 2 patients with a history of active or previous malignancy were excluded. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS and VAS scores. Results. Sixty patients with chronic lateral ankle instability were evaluated. 28 patients, treated with Ahlgren-Larsson method and 32 patients, treated with arthroscopic repair. 36 of the patients were female and 24 were male; the mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, VKI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in pain and satisfaction of VAS in favor of arthroscopy group. Conclusions. Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid

Aims. The aim of this study was to report the outcome following primary fixation or a staged protocol for type C fractures of the tibial plafond. Patients and Methods. We studied all patients who sustained a complex intra-articular fracture (AO type C) of the distal tibia over an 11-year period. The primary short-term outcome was infection. The primary long-term outcome was the Foot and Ankle Outcome Score (FAOS). Results. There were 102 type C pilon fractures in 99 patients, whose mean age was 42 years (16 to 86) and 77 were male. Primary open reduction internal fixation (ORIF) was performed in 73 patients (71.6%), whilst 20 (19.6%) underwent primary external fixation with delayed ORIF. There were 18 wound infections (17.6%). A total of nine (8.8%) were deep and nine were superficial. Infection was associated with comorbidities (p = 0.008), open fractures (p = 0.008) and primary external fixation with delayed ORIF (p = 0.023). At a mean of six years (0.3 to 13; n = 53) after the injury, the mean FAOS was 76.2 (0 to 100) and 72% of patients were satisfied. Conclusion. This is currently the largest series reporting the outcome following fixation of complex AO type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated that a satisfactory outcome can be achieved in the appropriate patients using primary ORIF. Cite this article: Bone Joint J 2016;98-B:1106–11

Of those foot and ankle injuries requiring radiographs based on the Ottawa Foot and Ankle Rules only approximately 22% will have a fracture. This diagnostic cohort study examined if ultrasound could detect acute non-bony foot and ankle injuries. Ottawa Rules positive patients over 16 years were eligible. An ED member performed scans for injury of tendons and ligaments blind to radiograph findings. Patients without fracture were re-scanned at 2 weeks. The Foot and Ankle Outcome Score (FAOS), a validated, patient-reported outcome measure, was completed at baseline (based on pre-injury status), 2 and 6 weeks. 110 subjects participated. 99 did not have significant radiological fractures. FAOS scores were significantly different at 2 weeks compared with baseline across all subscales (p< 0.000). At 6 weeks a significant difference persisted between scores for the ‘Pain’, ‘Sport’ and ‘QOL’ subscales (p<0.043, p<0.000, p<0.000 respectively) compared with baseline. Initial post-injury USS Anterior Talofibular Ligament (ATFL) findings were significantly predictive of FAOS Subscale results for ‘Symptoms’, ‘Sport’ and ‘QOL’ - respective p values being p<0.004 95% CI (−20.184, −4.402), p<0.029 95% CI (−31.857, −1.896) and p<0.008 95% CI (−32.118, −5.561). ATFL ultrasound status at the time of injury predicts patient perceived sporting function at 6 weeks

Growth factors are reported to play an important role in healing after acute Achilles tendon rupture (ATR). However, the association between growth factors and patient outcome has not been investigated previously. The aim of this retrospective study is to identify growth factors and related proteins which can be used as predictors of healing after ATR, ethical approval was obtained from the Regional Ethical Review Committees in Sweden and followed the guidelines of the Declaration of Helsinki. The study included 28 surgically treated patients (mean age 39.11 ± 8.38 yrs) with acute ATR. Healing was assessed by microdialysate two weeks after the surgery and performed on both injured and contralateral un-injured leg. The microdialysates were analyzed by proteomics based on mass spectrometry (MS) to detect growth factor expressions in ATR patients. One year after the surgery, healing outcomes were evaluated by patient-reported Achilles tendon Total Rupture Score (ATRS), Foot and Ankle Outcome Score (FAOS), and functional outcomes by heel-rise test. A total of 1549 proteins were detected in the microdialysates of which 20 growth factor/ related proteins were identified. 7 of these were significantly up-regulated (IGFBP2, Fold change (FC) = 4.07, P = 0.0036; IGFBP4, FC = 3.06, P = 0.009; CTGF, FC = 15.83, P = 0.003; HDGF, FC = 4.58, P = 0.003; GRB2, FC = 14.8, P = 0.0004; LTBP1, FC = 12.08, P = 0.0008; TGFBI, FC = 5.54, P = 0.001) and 1 down-regulated (IGFBP6) in the injured compared to the contralateral healthy side. Linear regression analysis revealed that TGFB1 was positively associated with improved ATRS (r = 0.585, P = 0.04) as well to ATRS subscales: less limitation in running (r = 0.72, P = 0.004), less jumping limitation (r = 0.764, P = 0.001) and less limitation caused by decreased tendon strength (r = 0.665, P = 0.012). Interestingly, all 7 up-regulated proteins were positively associated with less jumping limitations (IGFBP2, r = 0.667, P = 0.015; IGFBP4, r = 0.675, P = 0.013; CTGF, r = 0.668, P = 0.015; HDGF, r = 0.672, P = 0.014; GRB2, r = 0.665, P = 0.016; LTBP1, r = 0.663, P = 0,016). No associations were observed among any of the growth factor and FAOS or patient's functional outcomes. We conclude that growth factors and related proteins play a crucial role in ATR healing. More specifically, TGFB1 may be used as prognostic biomarker of the patient-reported outcome 1-year post-surgery. These results may be used to develop more specific treatments to improve ATR healing

Introduction:. The role of total ankle replacements remains unproven within orthopaedic literature. We present a prospective series of patients who underwent a SALTO TAR (Tornier) between October 2006 and January 2014. Methods:. A cohort of 53 TAR (50 patients) were prospectively followed up and assessed clinically, radiologically and asked to complete FAOS, VAS and Modified AOFAS scores. Four patients had bilateral procedures. The mean age was 71 years old (range 42–92). The mean follow up was 55 months (range 6–92). Nineteen TARs (19 patients) have a follow up of more than 60 months. Results:. Our survival rate is 98% as one patient proceeded to have an ankle fusion at 12 months due to loosening. Three patients had ankle arthroscopies at 1 year post TAR; one for removal of a fibula cyst, one for synovitis in the lateral gutter and another for fibula impingement. One patient had an early postoperative infection. Mean overall FAOS scores were 73.4 for the entire cohort and 74.2 for the cohort with over 5 years follow-up. Mean modified AOFAS scores for the entire cohort and the cohort with over 5 years follow up was 71.5 and 78.9 respectively. Mean VAS scores for the entire cohort and the cohort with over 5 years follow-up was 18.8 and 25.8 respectively. Discussion:. Ankle joint arthrodesis has been shown to be a reliable in relieving pain and result in good patient satisfaction. However, total ankle replacement provides an alternative surgical option for the management of ankle arthritis. The improving survivorship of ankle replacements is making this an increasingly popular option. Our follow-up of almost five years as an entire cohort, but also those with over five years, show that these latest generations of TAR have excellent mid term survivorship, accompanied by high levels of patient satisfaction and function

Introduction:. Total Ankle Replacement is proving to be a viable option for younger patients with Post Traumatic Osteoarthritis of the Ankle. The aim of our study was to study the clinical and patient reported outcomes between patients of < 60 and > 60 years who underwent TAR. Method:. Patients who underwent a TAR between March 2006 and May 2009 were invited to take part in the hospital patient registry. They were divided into two groups based on Age (Group A-Age > 60 and Group B-Age < 60). Patient demographics, co-morbidities, Clinical (AOFAS) outcomes, patient reported outcomes (FAOS, SF-36, patient satisfaction) and complications were collected from patients pre-operatively and at 1, 2 and 3 years follow up. Comparisons were made between groups for all outcome measures. Results:. There were 56 patients in Group A and 32 patients in Group B. There was no difference in Gender, side of operation and diagnosis reported between the 2 groups (P>0.05). Group A reported higher number of co-morbidities than Group B (1.54 vs. 1.00); p=0.032. There was no difference in AOFAS scores and FAOS scores for pain and function at all follow up times (p>0.05). Although Group B reported worse scores for FAOS stiffness pre-operatively (p=0.002) and at 1 year (p=0.029); there was no difference between scores at 2 and 3 years follow up. There was no difference in SF-36 scores and patient satisfaction and complications between groups. We expect to have the 4 year results processed by October this year. Conclusion:. We have found satisfactory outcomes following TAR, both clinical and patient reported, irrespective of age of patient. Although long-term survivorship results for TAR are unavailable, we feel that younger age may not be a contra-indication to TAR as it provides good quality of life and potentially allows continuation of work

Purpose. Platelet Rich Plasma (PRP) has been shown to have positive effect in tendon regeneration in in-vitro and limited in-vivo animal studies. We aim to study PRP use in acute Achilles tendon rupture (ATR) regeneration in a purposely designed clinical trial. Methods. This is a prospective double-arm patient-blinded randomized controlled trial. ATR patients were randomized into PRP treatment or control groups. Non-operatively treated patients received PRP or control injection in clinic. In operatively treated patients, PRP gel was applied in the ruptured gap during percutaneous repair. Standard rehabilitation protocol was used and patients were followed up for 24 weeks. ATR, VISA-A and FAOS scores were used as subjective outcome measures. Functional ultrasound Elastography (FUSE) was performed at each follow-up to assess the mechanical properties of tendons. PRP analysis and tendon needle-biopsy were performed to study the histological differences during healing in both groups. Results. 20 patients were recruited with mean age 37.5±8.8 (8males and 7 females). Rupture location was 4.8±2.1 cm from insertion. PRP platelet count 1044±320 × 1000/μL with average platelet CD62p activation 68.42±4.5%. Mixed linear regression analysis revealed PRP treated tendon achieved better ATR and VISA-A outcome scores (p<0.05). FAOS score analysis showed that PRP group had better pain, ADL and symptoms scores with significant difference apparent from week 3 onwards. Strain mapping using FUSE scan in 4 patients showed bigger harder tendons in PRP group. Analysis of the remaining patients is on the way. To achieve the desired statistical power in pragmatic settings, recruitment will continue in a multi-centre trial. Conclusion. Our preliminary findings show that PRP application in Achilles tendon rupture may lead to faster regeneration and return to function as supported by a combination of objective and subjective outcome measures

After catastrophic failure of first generation, joint replacement as treatment option for ankle osteoarthritis is undergoing a revival with improved second generation designs. Short to mid-term results reportedly equal those of ankle arthrodesis in terms of complications and revision, but preserving joint motion and protecting neighbouring midfoot joints from overuse and consecutive osteoarthritis. However, most reports derive from developers centres excluding the learning curve. We present clinical results and subjective outcome of an initial patient series undergoing ankle replacement in an independent centre. From January 2004 to January 2008 a Hintegra. ®. prosthesis was implanted in 39 consecutive patients (41 ankles), average age 60.7 years (range 36.6–85.0), 13 males and 25 females. Repeated clinical follow up was done for an average of 2.2 years (range 0.5–4.3). All patients whose operation had been more than 0.7 years before were sent the FAOS (Foot and Ankle Outcome Score) in order to record the subjective outcome. Pre-operative diagnoses were posttraumatic osteoarthritis in 26 cases (63.4%), primary osteoarthritis in 9 cases (22%) and rheumatoid arthritis in 6 cases (14.6%). Clinical examination did not show significant improvement of mean range of motion, dorsiflexion and plantarflexion compared with the preoperative status. The change in motion highly correlated with the preoperative mobility (r=0,8; p< 0.001): patients with the largest preoperative range of motion were the ones to lose most mobility, whereas patients with low preoperative motion gained mobility. About 60% of the patients achieved 25° to 30° total range of motion regardless of their preoperative mobility. Early postoperative complications occurred in 14 patients (34.1%). In all five subclasses of the FAOS a significant improvement was achieved within the observation period. Reduction of pain had the greatest impact on the improvement of quality of life, whereas change in mobility did not have any influence. Joint replacement is a valuable treatment option for ankle osteoarthritis. There are however a series of early complications and restrictions of subjective outcome a surgeon has to be aware of when selecting an individual patient for ankle replacement. Further studies are needed to detect in which cases arthrodesis or prosthesis is preferable

Researchers and clinicians measuring outcomes following total ankle replacement (TAR) are challenged by the wide range of outcome measures used in the literature without consensus as to which are valid, reliable, and responsive in this population. This review identifies region- or joint-specific outcome measures used for evaluating TAR outcomes and synthesises evidence for their measurement properties. A standard search strategy was conducted of electronic databases MEDLINE, EMBASE and CINAHL (to June 2015) to identify foot/ankle measures in use. A best evidence synthesis approach was taken to critically appraise measurement properties [COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of identified measures. The review was restricted to English publications and excluded cross-cultural adaptations. Measurement properties collected from each article were coded for validity, reliability, responsiveness, or interpretability. Clinimetric evidence exists for identified measures tested in non-TAR populations, but were not the focus of this review. The search identified 14 studies to include in the best evidence synthesis with 32 articles providing clinimetric evidence for eight of the measures (one CBO, seven PRO), however only five measures were tested in a TAR population (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale [AOFAS], Foot and Ankle Outcome Score, Self-Reported Foot and Ankle Score). Five studies provided clinimetric evidence in a TAR population and their methodological quality was assessed: (1) Validity—two good quality studies examining different measures provide moderate evidence supporting construct validity (FFI, AOS, AOFAS self-reported items; SEFAS); (2) Reliability—two good quality studies examining different measures provide moderate evidence supporting internal consistency and test-retest reliability (FFI, AOS, AOFAS self-reported items; FAOS, SEFAS); (3) Responsiveness—three poor quality studies, thus unknown evidence for responsiveness; (4) Interpretability—two studies provide interpretability values (AOS, FFI, AOFAS self-reported items; AOS). This review offers a basis for choosing the most appropriate instrument for evaluating TAR outcomes. Numerous outcome measures were identified with evidence supporting their use in populations with various foot/ankle conditions, but none have strong evidence supporting use in a TAR population. Measures must have adequate clinimetric properties in all patient groups in which they are applied. Evidence supporting or critiquing an instrument should not be based on studies with poor quality methodology, as identified by this review. Further testing in a TAR population would benefit identified measures with emphasis on adequate sample sizes, testing a priori hypotheses, and evaluating their content validity for a TAR population

Background:. Achilles pathology is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional achilles tendinopathy. We report on the outcomes after excision of the plantaris tendon in elite athletes. Aim:. To assess whether or not excising the plantaris tendon improves the symptoms of Achilles tendinopathy in elite athletes. Methods:. A group of 32 elite athletes who underwent plantaris tendon excision to treat medially located pain associated with non-insertional Achilles tendinopathy were investigated. Outcomes were assessed with pre and post-operative Visual Analogue Scores (VAS) for pain and the Foot and Ankle Outcome Score (FAOS) as well as time to return to sport and satisfaction scores. Results:. At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. 30/32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Conclusions:. The plantaris tendon may be responsible for symptoms in some patients with non-insertional Achilles tendinopathy. Excision using a mini-incision technique carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite level sports

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome. There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied. This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases

Aims

This systematic review and meta-analysis was conducted to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA) in the treatment of Lisfranc injuries, regarding patient-reported outcome measures (PROMs), and risk of secondary surgery. The aim was to conclusively determine the best available treatment based on the most complete and recent evidence available.

Introduction. Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options. Materials and methods. In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty. Results. Most of patients with mild pain and low AOFAS score during first year improved by the 2 year review. The pain was localised to the medial aspect of the ankle in 10 patients, lateral side in 8 patients, and both medial and lateral side in 1 patient and global in 1 patient with complex regional pain syndrome. 8 patients with medial or lateral pain needed a re-operation. 5 patients with medial pain were treated by complete release of deltoid ligament along with bony decompression of the medial compartment. None of the above implants were loose intra-operatively. 2 AA with lateral pain needed subtalar arthrodesis. 1 patient needed removal of metalwork from the calcaneum for relief of symptoms. A significant improvement of pain and AOFAS scores was observed in 3 out of the 5 patients who underwent medial compartment decompression and both patients who underwent subtalar arthrodesis. Conclusion. There are 10–13% of low AOFAS scores following Ankle Arthroplasty due to pain. In our series, the pain did not co-relate to implant loosening. Our treatment protocol of mapping of pain and re-do surgery could improve the long term outcome in a significant proportion of the patients

Aim. We aimed to study the effect of BMI on clinical and patient-reported outcomes in patients with TAR with a minimum follow-up of three years. Method. Patients who underwent a TAR between March 2006 and May 2009 were invited to take part in the hospital patient registry. Patients were divided into two groups based on BMI (Group A – BMI <30 and Group B – BMI >30). Patient demographics, co-morbidities, clinical (AOFAS), patient reported outcomes (FAOS, SF-36, patient satisfaction) and complications were collected pre-operatively and at 1, 2 and 3 years and comparison made between groups. Results. There were 50 patients in group A and 31 in group B. There was no significant difference between age (Mean 64.5 (A) and Mean 61.3 (B), gender and side of operation between the groups (p>0.05). Group A had higher percentage of patients with OA and RA compared to Group B (p=0.027). Group B (1.16) reported higher co-morbidites than Group A (1.81); p=0.012. There was no difference in AOFAS scores, FAOS scores (for pain, function and stiffness) and SF-36 scores reported between groups at 1, 2 and 3 years post-operatively (p>0.05). At 3 years, Group B reported less patient satisfaction with return to ADL 84.6 %(A) vs. 50.1%(B) and recreational activities 73.1 %(A) vs. 43.8 %(B); p<0.05. There was no significant difference in overall satisfaction and pain relief and also in the number of reported complications between Groups A and B (p>0.05). Conclusion. Patients with BMI > 30 reported higher co-morbidities pre-operatively and less patient satisfaction (return to ADL and recreation) at 3 years when compared to patients with BMI <30. There was no difference in clinical, complications and patient reported outcomes between these groups

Background. Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years. Methods. Retrospective review of 68 patients treated by a single surgeon over the last 6 years. Injuries were diagnosed on plain Xrays, clinic examination. Any suspicious injury were further assessed by a CT scan, all injuries were confirmed by EUA and treated with open reduction and internal fixation within 4 weeks of injury. Post-operative immobilisation in full cast for 6 weeks then a removal boot with non-weight bearing for a total of 3months. They were followed up regularly initially at 3, 6 and 12months. At final review the following data was collected: clinical examination, plain x-ray looking for: late deformity, signs of OA in Lisfranc joint, Auto fusion rate, rate of metal work failure. The x-rays findings were correlated with: (1) type of fixation. (2) The following scores: FAOS, AOFAS-M, specially designed new foot and ankle score. Results. 43 males: 25 females. 37 right: 31 left sided injuries. 90% were fully weight bearing with minimal discomfort after 6months. In 12 months all of them returned to their normal daily life activities. Wound complications: 2 of them had initial wound complications which were treated successfully with 2 weeks of oral antibiotics, 2 had lateral scar tenderness. One had loosened metal work, revised to fusion. Conclusion. Early operative intervention with good anatomical reduction can minimise the potential chronic disability associated with these injuries. This is a largest series of Lis-franc injuries of a single surgeon with good clinical outcome following surgical fixation

Introduction. Osteochondral lesions of the talus are common injuries following acute and chronic ankle sprains and fractures, the treatment strategies of which include both reparative and restorative techniques. Recently, restorative techniques (i.e., autologous osteochondral transplantation) have been become increasingly popular as a primary treatment strategy, in part due to the potential advantages of replacing “like with like” in terms of hyaline cartilage at the site of cartilage repair. The current study examines the functional results of autologous osteochondral transplantation of the talus in 72 patients. Methods. Between 2005 and 2009, 72 patients underwent autologous osteochondral transplantation under the care of the care of the senior author. The mean patient age at the time of surgery was 34.19 years (range, 16–85 years). The mean follow-up time was 28.02 months (range, 12–64 months). Patient-reported outcome measures were taken pre-operatively and at final-follow-up using the Foot and Ankle Outcome Score and Short-Form 12 general health questionnaire. Quantitative T2-mapping MRI was also performed on select patients at 1-year post-operatively. Results. The mean FAOS scores improved from 52.67 points pre-operatively to 86.19 points post-operatively (range, 71–100 points). The mean SF-12 scores also improved from 59.40 points pre-operatively to 88.63 points post-operatively (range, 52–98 points). Three patients reported donor site knee pain after surgery. Quantitative T2-mapping MRI demonstrated relaxation times that were not significantly different to those of native cartilage in both the superficial and deep halves of the repair tissue. Discussion and Conclusion. Autologous osteochondral transplantation is a reproducible and primary treatment strategy for large osteochondral lesions of the talus and provides repair tissue that is biochemically similar to that of native cartilage on quantitative T2-mapping MRI. This may ultimately allow the ankle joint to function adequately over time

There is no optimal treatment for osteochondral defects of the talus after failed primary surgical treatment. To treat these patients, a 15-mm diameter metal implant was developed for the medial talar dome. The present study was undertaken to evaluate the clinical effectiveness of the metal implantation technique for osteochondral lesions of the medial talar dome. This is a prospective case series. The inclusion criteria were the combination of a large OCD (ϕ >12 mm) of the medial talar dome, persistent complaints >1 year after treatment, and clinically relevant pain levels. The exclusion criteria were: age <18 years, OCD size >20 mm, ankle osteoarthritis grade 2 or 3, concomitant ankle pathology, and diabetes. The primary outcome measure was the Numeric Rating Scale pain (NRS) rest, walking, running, and stair climbing. Secondary outcome measures were: Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. The Wilcoxon signed ranks test was used to calculate p-values. Between October 2007 and March 2009 10 patients were included. The median follow-up was 2 years (range, 2–3 years). On preoperative CT scanning, the median lesion size was 15 (range, 12–20) × 11 (range, 8–14) mm. The NRS rest improved from a median of 3 (0–7) preoperatively to 0.5 (0–2) at final follow-up (p = 0.017), NRS walking from 6.5 (4–8) to 1 (0–4) (p = 0.005), NRS running from 9 (6–10) to 3 (0–10) (p = 0.024), and NRS stair climbing from 6 (4–8) to 1 (0–7) (p = 0.012). The FAOS improved significantly on four of five subscales. The AOFAS improved from a median of 70 (47–75) before surgery to 89 (69–100) at final follow-up (p = 0.008). There were three temporary complications: hyposensibility about the scar in two and a superficial wound infection in one. There were no radiographic complications

Introduction. There is less literature reporting outcomes following total ankle replacement (TAR) in patients presenting with a coronal plane deformity preoperatively. This study compares clinical and patient reported outcomes at 1 year between TAR patients with and without coronal plane deformity. Methods. Patients from single centre prospective cohort (132) who underwent TAR between 2006 and 2010 were included. They were divided into 2 groups based on preoperative coronal plane deformity. Groups 1 and 2 had a coronal plane deformity of <10 and >10 respectively. Assessments included American Orthopaedic Foot and Ankle Score (AOFAS), Foot and Ankle Outcome Score (FAOS), SF-36 (Generic Health Measure) and complications recorded preoperatively and 3, 6 and 12 months postoperatively. Results. There were 102 ankles (77.2%) in group 1 and 30 ankles (22.7%) in group 2. There was no difference in age and BMI between groups (p > 0.05). AOFAS, FAOS and SF-36 scores showed improvement for both groups from pre-op to 1 year (p < 0.01) with no difference between groups (p > 0.05) at all assessment times; except for mental health scores (SF-36 component) which showed no significant improvement (p > 0.05) and no difference between groups (p > 0.05). There was no difference in patient satisfaction for overall outcomes, pain relief, improvement in ADL and recreational activities between groups at 1 year (p > 0.05). There was no incidence of DVT/PE in both groups. The incidence of peri-prosthetic fractures was 8 (7.8%) for group 1 and 2 (6.6%) in group 2. Discussion and Conclusion. These early results of total ankle replacement demonstrate that patients with >10 degrees coronal plane deformity had equivalent outcomes to patients with <10 degrees of coronal plane deformity. Our surgical techniques for correction of deformity are reliable to reduce the requirement of ankle fusion

Total Ankle Arthroplasty (TAA) using the uncemented three component mobile design has shown encouraging results. There is limited literature on the optimal postoperative management. In our centre, TAA patients are mobilised 48 hours after surgery without a short leg plaster. The aim of this prospective audit was to measure the outcomes of these patients to ascertain if this is a safe and effective protocol. Patients who underwent primary TAA between March 2006 and March 2008 were invited to participate in the audit. Assessment included patient questionnaires which collected demographics, height and weight, Foot and Ankle Outcome Score (FAOS) and Short-Form-36 (SF-36). Clinical examination collected American Orthopaedic Foot and Ankle Score (AOFAS). Data was collected pre-operatively and at 3 and 6 months after surgery. A total of 48 ankle replacements in 46 patients were included. Primary diagnosis was osteoarthritis (25), post-traumatic osteoarthritis (9), and rheumatoid arthritis (12). Mean age was 63 years (range 33 to 83) and the majority were males (29, 60%). The average body mass index was 28 (SD 5.3). There were significant improvements to 3-months after surgery for AOFAS (mean 29 to 76, p< 0.0001), FAOS (mean scores changes: Pain 36 to 72, Function 41 to 68, Stiffness 38 to 65, p< 0.001) and physical domains of the SF-36 (means score changes: Physical Functioning 25 to 39, Role Physical 27 to 40, Bodily Pain 29 to 48 and Vitality 42 to 50, p< 0.05). All outcome scores were maintained with a non-significant trend for better scores from 3 to 6 months. These early results demonstrate encouraging outcomes for TAA patients who are mobilised early after surgery without a short leg plaster. Further studies of post-operative management are needed to compare outcomes after TAA between patients undergoing this protocol and patients who are immobilised in plaster

Objectives. Osteochondral ankle defects (OCDs) mainly occur in a young, active population. In 63% of cases the defect is located on the medial talar dome. Arthroscopic debridement and microfracture is considered the primary treatment for defects up to 15 mm. To treat patients with a secondary OCD of the medial talar dome, a 15-mm diameter metal implant (HemiCAP ®) was developed. The set of 15 offset sizes was designed to correspond with the anatomy of various talar dome curvatures. Recently, two independent biomechanical cadaver studies were published, providing rationale for clinical use. The present study was undertaken to evaluate the clinical effectiveness and safety of the metal implantation technique for osteochondral lesions of the medial talar dome in a prospective study. Material and methods. Since October 2007, twenty patients have been treated with the implant. Four patients who did not meet the inclusion criteria and four patients who had less than one-year follow-up at the time of writing were left out of this analysis. Twelve patients are reported with one year (n=8) or two years (n=4) follow-up. All patients had had one or two earlier operations without success. On preoperative CT-scanning, the mean lesion size was 16 × 11 (range, 9–26 × 8–14) mm. Outcome measures were: Numeric Rating Scale pain (NRS) at rest and when walking, Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. Data are presented as median and range. The Wilcoxon signed ranks test was used to calculate p-values. Results. All patients recovered well from surgery. The NRS at rest improved from 3 (0–7) preoperatively, to 0.5 (0–4) after 1 year and 1 (0–1) after 2 years follow-up (p < 0.05). The NRS when walking was 6.5 (4–8) preoperatively, improving to 1.5 (0–5) at 1 year and 1 (0–2) at 2 years follow-up (p < 0.05). The five subscales of the FAOS improved from 14–64 preoperatively, to 53–91 after 1 year and 63–100 after 2 years (p < 0.05). The AOFAS improved from 70 (42–75) before surgery to 86 (58–100) at 1 year, and 89 (82–90) at 2 years follow-up (p < 0.05). There were no clinical or radiographic complications. Conclusion. The metallic implantation technique appears to be a promising treatment for secondary OCDs of the talus, but more patients and longer follow-up are necessary to draw firm conclusions

It is now well established that operative repair of Tendo Achilles (TA) ruptures reduces re-rupture rate compared with conservative treatment. Operative repair has been reported to be associated with significant morbidity in 11–29% of cases, in particular wound related complications. In 1977 Ma and Griffith described a percutaneous repair of the TA, however initial results showed a disappointingly high re-ruputre rate of approximately 10%. The senior author has modified the technique initially described in attempt to reduce the re-rupture rate. After marking out the course of the sural nerve, a 2 Ethibond suture is passed into the ruptured tendon end via a stab incision, and passed proximally as in a modified Kessler suture. The suture is then passed first proximally and then back distally in a criss-cross pattern via further stab incisions and brought out at the tendon stump. A second suture is passed into the distal stump in a similar fashion and the sutures tied with the foot in equinus. We recruited a cohort of patients who had undergone percutaneous repair in the last 5 years, and a cohort of age and sex matched controls who had undergone open repair. Both groups of patients were managed postoperatively in equinus cast for 8 weeks. Subjective outcome was measured using the Foot and Ankle Outcome Score (FAOS). Statistical analysis was performed using the Mann-Whitney U-test for non-parametric data. Fifteen patients, mean age of 41.3, underwent percutaneous repair. There were 9 men and 6 women. The median time from injury to repair was 2 days in the percutaneous group and 1 day in the open group. Post-operatively there was no statistically significant difference between the two groups in relation to time taken to return to work (12 (percutaneous) versus 10 (open) weeks). However the percutaneous group returned to sport sooner 6 (percutaneous) versus 12 (open) months; p=0.6). There were no re-ruptures in either group. There were two sural nerve injuries in the percutaneous group and none in the open group. There was no significant difference in mean FAOS between the two groups (466 percutaneous versus 468 open). Percutaneous repair of TA ruptures results in a similar functional outcome as the traditional open repair. The increased incidence of sural nerve injury may be associated with the learning curve of the procedure as both of these cases were early in the series. We propose that percutaneous repair is safe and effective. The avoidance of a large skin incision may reduce wound related complications

Aims

Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing.

Aims

Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction.

The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus.

A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively.

In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10).

In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Cite this article: Bone Joint J 2015; 97-B:668–74.

It has previously been suggested that among unstable ankle fractures, the presence of a malleolar fracture is associated with a worse outcome than a corresponding ligamentous injury. However, previous studies have included heterogeneous groups of injury. The purpose of this study was to determine whether any specific pattern of bony and/or ligamentous injury among a series of supination-external rotation type IV (SER IV) ankle fractures treated with anatomical fixation was associated with a worse outcome.

We analysed a prospective cohort of 108 SER IV ankle fractures with a follow-up of one year. Pre-operative radiographs and MRIs were undertaken to characterise precisely the pattern of injury. Operative treatment included fixation of all malleolar fractures. Post-operative CT was used to assess reduction. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and the range of movement of the ankle.

There were no clinically relevant differences between the four possible SER IV fracture pattern groups with regard to the FAOS or range of movement. In this population of strictly defined SER IV ankle injuries, the presence of a malleolar fracture was not associated with a significantly worse clinical outcome than its ligamentous injury counterpart. Other factors inherent to the injury and treatment may play a more important role in predicting outcome.

We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.

Cite this article: Bone Joint J 2013;95-B:1650–5.

The December 2013 Foot & Ankle Roundup³⁶⁰ looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.