Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Introduction. Anterior ankle arthroscopy currently provides the best chance of restricting local anatomy damage during ankle surgery. The anterior working area (AWA) of the ankle is restricted by the Dorsalis Pedis Artery (DPA) and the extensor muscle tendons when the procedure is conducted both in dorsiflexion and plantarflexion. During surgery, iatrogenic damage to the DPA can lead to the formation of a pseudoaneurysm, which can be difficult to identify intraoperatively. Our study investigates whether dorsiflexion or plantarflexion provides variability in the movement of the DPA to determine the positions at which anterior ankle arthroscopy provides the greatest anterior working area (AWA) without causing vascular damage. The current study expects the distance of the DPA from the inferior border of the medial malleolus (IBMM) (ankle joint) to be greater on ankle dorsiflexion than in ankle plantarflexion. Materials and Methods. Twelve cadaver ankles embalmed with a mixture of phenol and glycerol, allowing greater motion, were dissected to access the DPA. The ankles, while in a distracted position (in accordance with common surgical practice), were forced into dorsiflexion from a plantarflexion position at 5° intervals. The distance between the IBMM and the DPA was measured at the 5° intervals. Results. The mean amount of ankle flexion achieved was 24.58° (Range = 20–35). All twelve ankles showed positive range of movement (ROM) anteriorly from the IBMM with a mean ROM of 3.58mm (SE = 0.29mm) dorsiflexion. Discussion and Conclusion. Anterior movement of the Dorsalis Pedis Artery during dorsiflexion puts it at a lower risk of iatrogenic damage in a dorsiflexed position compared to plantarflexion. The increased AWA allows the surgeon more manoeuvrable space, possibly allowing the use of larger diameter surgical instruments

We describe a medial midline portal between the tendons of extensor hallucis longus and tibialis anterior for arthroscopy of the ankle. We dissected 20 cadaver specimens to compare the risk of neurovascular injury using this approach with that of using standard arthroscopic portals. Compared with the anterocentral portal, the medial midline was a mean of 11.2 mm further from the nearest branch of the superficial peroneal nerve and 10.3 mm further from the dorsalis pedis artery. This portal allows good access to the joint surface and intra-articular structures and has a lower risk of injury to the dorsalis pedis artery, deep peroneal nerve or the medial branch of the superficial peroneal nerve

Aims

The aim of this study was to evaluate antegrade autologous bone grafting with the preservation of articular cartilage in the treatment of symptomatic osteochondral lesions of the talus with subchondral cysts.

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

Introduction. Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. Methods. A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. Results. A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion. Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair

Background. MRI is the preferred modality for the diagnosis of ankle joint pathology. Musculoskeletal radiologists aim to determine and report both chondral and/or osseous stability/instability of each lesion. The aim of this study was to specifically analyse the reliability of MRI reported findings in predicting the stability of OCL's in symptomatic patients. Methods. A single centre, single surgeon consecutive series of patients who had undergone an ankle arthroscopy procedure preceded by an MRI scan for symptomatic ankle pathology were included in this retrospective clinical study. All MRI scans were reported by a musculoskeletal radiologist. MRI reports and arthroscopic findings were extracted and analysed. Arthroscopy findings were taken as the gold standard. Results. Between April 2012 and July 2016, 48 patients who fulfilled the above criteria were included. There were 27 male and 21 female patients, the average age was 43.4 (SD 14.1). The average time interval between MRI scan and arthroscopy was 9 months (2–49 months), 28 patients (58.3%) had a right sided pathology. There was a significant negative relationship between OCL's reported as stable on MRI to arthroscopic findings, r=−.31, p=0.03. Of the 21 patients who had OCL's reported as stable on the MRI scan, all had unstable lesions on arthroscopic evaluation (100%). One patient had an unstable OCL reported on the MRI scan and it was also found unstable arthroscopically. In 27 patients, where there was no mention of the stability of the reported OCL on the MRI, 22 patients (81.5%) had unstable lesions and 5 patients (18.5%) had stable lesions on intra-operative arthroscopic findings. Conclusion. This study demonstrates that MRI has a poor predictive value for the stability of OCL's of the ankle. Therefore we recommend that in the symptomatic patient an arthroscopy is indicated irrespective of MRI findings. Evidence. retrospective case review, level IV

Aims

The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival.

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

We report the incidence and intensity of persistent pain in patients with an otherwise uncomplicated total ankle replacement (TAR). Arthroscopic debridement was performed in selected cases and the clinical outcome was analysed. Among 120 uncomplicated TARs, there was persistent pain with a mean visual analogue scale (VAS) of 2.7 (0 to 8). The intensity of pain decreased in 115 ankles (95.8%). Exercise or walking for more than 30 minutes was the most common aggravating factor (62 ankles, 68.1%). The character of the pain was most commonly described as dull (50 ankles, 54.9%) and located on the medial aspect of the joint (43 ankles, 47.3%). A total of seven ankles (5.8%) underwent subsequent arthroscopy. These patients had local symptoms and a VAS for pain ≥ 7 on exertion. Impingement with fibrosis and synovitis was confirmed. After debridement, the median VAS decreased from 7 to 3 and six patients were satisfied. The median VAS for pain and the American Orthopaedic Foot and Ankle Society score of the ankles after debridement was similar to that of the uncomplicated TARs (p = 0.496 and p = 0.066, respectively). Although TAR reduces the intensity of pain, residual pain is not infrequent even in otherwise uncomplicated TARs and soft-tissue impingement is the possible cause. Cite this article: Bone Joint J 2013;95-B:378–83

Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management. Treatment. Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required. if the mortise is normal, even with external rotation stress test positive, conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling acutely, at regaining range of motion and strength subacutely, and then progressed to functional training and finally return to sport. The timeframe for these was in the range of 2 to 6 weeks without very specific progression criteria. In the athlete, pain with rotational stress, greater severity of sprain, may treat operatively to stabilize the syndesmosis and aggressive rehab with earlier return to sport. Tightrope vs screw fixation vs both. Use of arthroscopy. Chronic sprains with recalcitrant pain and functional instability usually require operative treatment. very poor evidence exists as to the timing or type of procedure. Arthroscopy is required to confirm the diagnosis, treat intraarticular problems, and provide fixation of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the same as the one used when treating an acute syndesmosis disruption. Tight rope vs Screw Fixation. clinical studies tightrope fixation has been acceptable and comparable to screw fixation. laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting. indications for tightrope fixation are becoming more clear with more experience. my indications:. syndesmotic sprains with complete or incomplete disruption. fractures with syndesmotic disruption augment with screws, leave in place following screw removal. Summary and Controversies. Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost from sport. The conclusion that can be drawn from the current evidence is that the current diagnostic process probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately predicting the time lost from sport. Syndesmosis sprains can be a significant injuries that result in an inability to play sports for significant periods of time(up to 137 days). We need to be able to identify the more severe ones earlier in order to improve their treatment, perhaps lead to operative stabilization. Tightrope fixation avoids screw removal, minimally invasive, permanent stabilization

This study investigated athletes presenting with grade II syndesmosis injuries and identified the clinical and radiological factors important in differentiating a stable from dynamically unstable injury and those findings associated with a longer recovery and return to sport. Sixty-four athletes were prospectively assessed with an average follow-up of 37 months (range 24–66 months). Athletes with an isolated distal syndesmosis (+/− medial deltoid ligament) injury were included. Those athletes with a concomitant ankle fracture were excluded. Those considered stable (grade IIa) were treated conservatively with a boot and progressive rehabilitation. Those with clinical signs of instability underwent arthroscopy and if instability was confirmed (grade IIb) the syndesmosis was stabilized surgically. The clinical assessment of injury to individual ligaments of the ankle and syndesmosis were recorded along with MRI findings, complications and time to return to play. All athletes returned to the same level of professional sport – 28 with IIa injuries returned at a mean of 45 days whereas the 36 with grade IIb injuries returned to play at a mean of 64 days (p< 0.001). Clinical assessment of injury to the ligaments of the syndesmosis correlated well with MRI findings. Those with a positive squeeze test were 9.5 times as likely and those with a deltoid injury 11 times more likely to have an unstable syndesmosis confirmed arthroscopically. The combination of injury to the AITFL and deltoid ligament was associated with a delay in return to sport. Concomitant injury to the ATFL indicated a different mechanism of injury with the syndesmosis less likely to be unstable and was associated with an earlier return to sport. Clinical and MRI findings may differentiate stable from dynamically unstable grade II injuries and identify which athletes may benefit from early arthroscopic assessment and stabilization. It also suggests the timeframe for expected return to play

Introduction:. The National Joint Registry has been capturing data on ankle replacement surgery since April 2010. This currently represents the largest cohort of ankles replacements captured worldwide and is a valuable resource to give us short term outcome of ankle replacement surgery. Methods:. All the ankle replacements on the NJR were linked to the HES database using deterministic methods. The results were then anonymised. We then looked at Hopital admissions after the ankle replacement had taken place. Results:. There were just over 1600 ankles on the NJR and linking to HES gave 2065 records. 1437 of these were relevant to TAR. There were 12 malleolar fractures post-op and 6 DVT/PE which required readmission. there were 49 reoperations other than revision, 12 of which were ankle arthroscopies, and 14 removal of metalwork. Conclusion:. Ankle replacement is a effective procedure but does carry with it the risk of short term reoperation

Aim:. Ankle sprains are one of the most common sports injuries. Around 10–20 % of the acute ankle sprains may lead to the sequelae of chronic ankle instability. Around 15–35% of the patients have residual pain following successful lateral ligament reconstruction. One of the reasons suggested for the persistent symptoms following lateral ligament reconstruction has been the presence of intra-articular pathology. Methods and materials:. We performed ankle arthroscopy on all patients undergoing the modified Brostrom repair and compared patients with associated intra-articular pathology to those without any intra-articular pathology. Results:. A total of 35 patients underwent the modified Brostrom procedure during the study period. 11/25 patients were found to have associated intra-articular pathology. The average age for both the groups was 33 years. The average follow-up duration was 75 months and 71 months for the intra-articular pathology group and the normal articular groups respectively. The difference in the SAFAS (Sports athlete foot and ankle score) was statistically better in the group without any intra-articular pathology (93.7 compared to 71.6, p-value < 0.05). Conclusions:. The patients who have an associated intra-articular pathology whilst undergoing the stabilisation of lateral ligament instability of the ankle have a slightly poorer outcome compared to those without any intra-articular pathology. Secondly, the SAFAS scoring system seems to overcome the ceiling effect seen in other scoring systems when used for the athletic population

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. Single photon emission computed tomography (SPECT) can be used to create a three dimensional image of a radiopharmaceutical bone scan. This combined with high resolution CT scan (SPECT-CT) with bone windows allows the linking of the information obtained in both investigations. The multiplanar anatomical information provided by CT is therefore linked with the functional, biological information of bone scintigraphy. The painful total ankle replacement has a number of potential causes of discomfort including impingement and loose components. Correct identification of the source of pain will assist surgeons in treating the source of the pain while avoiding unnecessary surgery. We present our experience of the use of SPECT-CT to investigate patients with ongoing pain following Total Ankle Replacement (TAR). Materials and Methods. A retrospective analysis of all patients having SPECT-CT for continuing pain following TAR. Scans were requested in addition to plain radiographs, joint aspiration and blood testing. Results: A total of 12 patients were identified. The scan proved helpful in all cases. 5 patients showed increased uptake around one or both prostheses signifying loosening which was not apparent on plain films. Gutter impingement was identified in 4 patients. One patient had a talo-navicular non-union, one patient demonstrated sub-talar joint arthrosis and one patient showed no bony abnormality but soft tissue impingement at arthroscopy. Discussion. SPECT-CT provides a useful adjunctive investigation in the work-up of the patient with ongoing pain in a TAR, particularly in the cases of component loosening where plain x-rays may be limited. The SPECT-CT assists in the correct anatomical localization of the pain and has assisted in identifying the correct surgical treatment. Disadvantages include cost and availability of scanners

Introduction. We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications. Methods. Between July 2010 & April 2012, 39 isolated closed intra-articular calcaneal fractures were admitted to St Mary's Hospital. All Sanders type 2 and type 3 fractures were included. Undisplaced fractures (13) were treated non-operatively and comminuted type 4 fractures (4) were treated with primary arthroscopic fusion. Surgery was performed on the next list with no delay for swelling. All patients had pre and post op CT scans. Patients were discharged in a temporary cast with routine follow up at 2, 6 and 12 weeks. Technique. Arthroscopy was performed in the lateral position with a 4.0mm arthroscope, using two sinus tarsi portals and a posterolateral portal. The fracture fragments were reduced percutaneously, held with wires before definitive fixation. Results. There were 10 three-part fractures (Sanders 3AB) and 12 two part (Sanders 2A/2B). Bohler's angle improved from 9.9 (7–18) to 27.7 (23–32) P <0.001. The mean time to surgery was 4 days (1–7), mean post-op stay was 1.9 days. Mean articular step of 0.9mm (0.4–1.9mm) on post-op CT. There were no deep wound infections. Conclusions. PACO is an accurate and reliable technique for fixation of calcaneal fractures, with a low complication rate, and minimal pre and post-operative delay

The purpose of this study was to evaluate the early functional outcome of this new modification of the Brostrom-Gould lateral ligament reconstruction using suture anchors and triple breasting of ATFL. AOFAS hindfoot scoring system was the primary outcome measure used. Between January 2008 and May 2011, data was collected prospectively, pre and postoperatively. Surgery for all patients included ankle arthroscopy plus whatever other minor procedure was indicated and was performed by the senior author. Postoperatively at 3 months and 12 months and in May 2011 patients were asked to attend a research clinic and their scores were obtained. Anterior drawer laxity and patient satisfaction, activity resumption and complications were some of the other information recorded. A mean follow up of 25 months on 18 ankles is presented which is amongst the longest in the literature for this procedure. Comparing pre and postoperative AOFAS scores revealed a statistically significant mean improvement of 39 points p < 0.05 with mean preoperative score being 53 and at 25 months being 89. All ankles felt clinically stable on repeated anterior drawer testing. 8 patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity and 2 did not carry out physical prior to operation. One patient complained of scar tenderness otherwise no complications were noted. 13 patients were extremely satisfied with results of surgery, 4 were very satisfied and 1 was moderately satisfied. The mid-term results of our modification show it to be safe, reproducible and highly successful in producing clinically and functionally stable ankles with high patient satisfaction. This includes a statistically significant improvement in AOFAS scores. This exceeds the results in the published literature

The saphenous nerve is classically described as innervating skin of the medial foot to the first MTP joint and thus is at risk in surgery to the medial ankle and foot. However, it has previously been demonstrated that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, and therefore previous descriptions of the saphenous nerve maybe erroneous. We undertook a cadaveric study to assess the presence and variability of this nerve. 21 cadaveric feet were dissected from a level 5 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 16 specimens (76%), a saphenous nerve was present, of which 14 were anterior to the saphenous vein. Two of 16 nerves terminated above the medial malleolus. Therefore, only 14 of 21 specimens (66%) had a saphenous nerve present at the level of the medial malleolus. In seven of these 14 specimens (50%), the nerve terminally branched before the level of the tip of the malleolus. The mean distance reached in the foot was 46mm. Only two nerves reached the forefoot, at 97mm and 110 mm from the ankle joint respectively. At the ankle, the mean distance of the nerve from the tibialis anterior tendon was 9mm, and the saphenous vein 1.2mm. Discussion. Our study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 40mm of the ankle. Only 10% reach the first MTP joint. These findings are inconsistent with standard surgical text descriptions. The saphenous nerve is at risk in distal tibial screw placement and arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a small proportion of nerves supply sensation to the medial forefoot

Technique, inducations, complications and early outcomes with posterior ankle and subtalar arthroscopy. A. ANKLE ARTHROSCOPY: Tips and Pearls on Avoiding Complications. a. Introduction. i. understanding of the anatomy of the foot and ankle is critical to safe performance of arthroscopic procedures and prevention of complications. ii. understanding of the surface and intra-articular anatomy of the ankle/subtalaar region is essential. iii. topographical anatomy serves as a guide to the successful placement of arthroscopic portals in the ankle. iv. neurovascular and tendinous structures are most at risk. b. Indications for Posterior/Subtalar Arthroscopy. i. Posterior ankle/ST Impingement. ii. OLT Ankle (usually posteromedial). iii. Assist operative reduction of calc or post mal fractures. iv. Arthrodesis ankle/ST or both. c. Portals. i. Know the anatomy, use blunt dissection, minimize re-entry. ii. Preoperative plan for access, pathology, visualization. d. Prone Position. a. Posteromedial. b. Posterolateral. c. Accessory posterolateral. e. Set-up/instrumentation. i. Positioning -. ii. posterior, prone. iii. Distraction- non-invasive vs invasive (trans-calcaneal thin wire). iv. Equipment - general set-up/instruments. - scopes (4.0 for outside joint or fusions; 2.7 otherwise). - irrigation/pump (run at lowest flow possible). f. Tips on Avoiding Complications. i. Patient selection and education. ii. Careful preoperative planning, evaluation. iii. Know/respect your anatomy. iv. Meticulous portal placement/care. v. Limit operative time/distension/tissue damage. vi. Use mini C-arm to monitor. vii. Plan, plan and plan, if you are prepared, all will work out. viii. Rehabilitation protocol and follow up