The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (. sd. 13.59) in the intact screw group, 92.40 (. sd. 12.69) in the broken screw group, and 85.80 (. sd. 11.33) in the removed screw group (p = 0.0466). There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw

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

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

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

Triple arthrodesis is the most effective treatment resource for restoring shape and stability to the hind-foot. It is used in order to achieve a plantigrade foot, aligned, stable and painless, in the treatment of various pathologies. However, it has the effect of changing the dynamic mobility of the foot and diminishes the adapting ability to uneven ground, influencing the outcome. Opinions differ on the necessity of internal fixation to maintain the proper alignment of the hind-foot and improve consolidation, influencing the results. The authors reviewed the patients who underwent triple arthrodesis between 01/01/1998 and 31/12/2008. Of a total of 46 patients 28 were reviewed, corresponding to 29 feet that underwent 36 interventions (7 recurrences). Patients were divided into two groups according to whether or not the placement of internal fixation. They were evaluated according to the AOFAS ankle and hindfoot score and correlated with the radiologic result. The most frequent indications for surgery were osteoarthrosis of the tarsus and sequelae of fractures of the calcaneus. In the group without fixation 68% had radiological signs of consolidation. 24% required revision for non consolidation. In the group with internal fixation there was 72.7% consolidation and 9.1% required revision surgery. Bone graft was more often used in internal fixation group (72.7% vs 40%). Group without fixation vs group with internal fixation:. AOFAS mean score: 74.5% vs 61.6%, patients without pain: 50% vs 20%; plantigrade foot with good alignment: 66.7% vs 40% without pain: 50% vs 20%; tibiotarsal arthritis: 48% vs 63.6%; Lisfranc arthrosis: 44% vs 63.6%. There is a higher rate of consolidation in the group setting. However, the functional outcome seems to be better in the group without fixation. Fixation seems to be associated with better consolidation. The functional outcome is related to a plantigrade and well aligned foot

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured.

Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score.

Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups.

At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture.

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.