Revision options for a failed Total ankle arthroplasty (TAA) have historically been limited to complex hindfoot fusions, bespoke ankle arthroplasty revision or amputation. The patient outcomes of these procedures has been felt to be poor. The introduction of the INBONE-II and INVISION ankle arthroplasty revision systems has created a range of revision arthroplasty options, with the possibility of improved patient outcomes. We aim to report on the early results of 20 sequential revision TAA. All patients undergoing revision TAA with INBONE-II or INVISION had prospective collection of pre-operative and post-operative MOx-FQ and EQ-5D scores. Between September 2013 and June 2019 23 patients underwent revision TAA with mean time from implantation of 35 months (6 to 74). Those with greater than 1 year follow-up had scores included. Other outcomes included radiographic assessment for loosening and revision. 13 patients had INBONE-II and 10 INVISION. None required revision at the time of review. Pre-operative MOx-FQ averaged 40.6 (13.4 pain, 21 walking, 6.2 social). Post-operative MOx-FQ averaged 17.4 (6.2 pain, 8.1 walking, 3.1 social). Average EQ-5D improved from 8 to 6.6 and average EQ-VAS from 60 to 80. On radiograph review one patient had radiolucent lines around their INBONE-II stem evident at 1 year. This had not progressed by 4 years total follow-up. Another patient had uncoupling of part of the stem of her INBONE-II but had not required revision. This was attributed to surgeon error. Revision TAA using the INBONE-II and INVISION systems shows promising early results relating to loosening and revision and good maintained improvement in MOx-FQ and EQ-5D scores. This provides further evidence that patients with a failed TAA can safely have revision rather than having to commit to complex ankle/hindfoot fusion. This provides surgeons with flexibility particularly in those patients with other hindfoot arthritis or arthrodesis

Introduction. Fusion represents an effective treatment option in patients affected by end-stage arthritis. To minimise the risk of non-union following fusion, biological preparations such as bone marrow aspirate concentrate (BMAC) are commonly used intra-operatively. Mechanotransduction represents an emerging field of research whereby physical stimuli can be used to modulate the behaviour and differentiation of cells. Blast waves (a subtype of shock waves) are one such physical stimulus. The aim of this study was to investigate whether the osteogenic potential of BMAC can be enhanced using a blast wave, and thus improve its efficacy in fusion surgery. Methods. Human BMAC samples were obtained from three healthy patients and exposed to a single blast wave (peak overpressure= 50psi), before being placed in a suspension of mesenchymal stem cells, to represent the biological environment of the fusion site. Three test groups were used: MSC (the experimental control); MSC + BMAC; MSC + BMAC + blast wave. Calcium mineralisation assays were performed on the MSCs on Day 7 and 14 to assess for osteoblastic transformation. Results. Calcium mineralisation on Day 7 was significantly increased in the MSC + BMAC group compared to the MSC group (mean percentage change 42.12 vs 0.0, p=0.012). The MSC + BMAC + blast wave group also demonstrated significantly increased levels compared to the MSC + BMAC group (84.56 vs. 42.14, p = 0.039). The difference in calcium mineralisation between the MSC and MSC + BMAC + blast wave groups was strongly significant (0.00 vs. 84.56, p = 0.003). Conclusion. Exposure of BMAC to a single blast wave enhances its osteogenic potential. This represents a potential novel way to improve healing following fusion surgery and reduce the rates of non-union

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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.

Aims. Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR. Methods. We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected. Results. The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review. Conclusion. We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220–226

Aims

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remains a challenge. A novel surgical technique named ‘tibial cortex transverse transport’ (TTT) has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In the present study, we explored the potential biological mechanisms of TTT surgery using various techniques in a rat TTT animal model.

Introduction. Arthroplasty for treatment of end stage hallux rigidus is controversial. Arthrodesis remains the gold-standard, but this procedure is not without complications, with up to 10% non-union, 14% re-operation and 10% transfer metatarsalgia rates reported. The aim of this study was to analyse the outcome of the double-stemmed silastic implant (Wright-Medical) for end stage hallux rigidus. Method. We conducted a retrospective review of a consecutive series of 108 silastic 1. st. MTPJ implanted in our Unit (January 2005 – December 2016). Data was collected from our research databases, patient notes, PACS and PROMS. No patient was lost to follow-up. Results. Average age was 60.1 years (range 42–42 years; 104F; 4M). Results show a 98.1% survivorship at an average 5.1 years follow up (range 6 months-12 years). Average pre- and post-operative MOXFQ scores were 78.8/100 and 11.0/100 respectively and VAS scores improved from 7/10 to 1.3/10, with an average post-operative range of movement of 26.3°. Overall satisfaction rate was 90.6%. 2 patients (1.9%) required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years). There were 15 complications (13.9%) in the group, 5 lateral metatarsalgia, 7 patients stiffness and ongoing pain in the index joint occurred in 2.7%. There was a 20% incidence of radiological cyst formation or demarcation, but this was neither progressive, symptomatic, nor affected clinical outcome. Conclusions. The authors believe these results are superior to results of other published implants for hallux rigidus (BioPro and Cartiva). Additionally, these results do not confirm progressive osteolysis, previously reported for this implant in other series, as being a mechanism of failure. Finally, these results suggest the double stemmed silastic 1. st. MTPJ replacement provides a reliable alternative, with at least comparable outcomes, to that of fusion, for the treatment of end stage hallux rigidus

Aims

This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

Aims

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

Introduction. Mesenchymal stem cells (MSCs) are a potential source of cells for the repair of articular cartilage and osteochondral defects (OCD) in the ankle. Synovial tissue has been shown to be a rich source of MSCs with the ability to undergo chondrogenic differentiation. Although these cells represent a heterogenous population, clonal populations have not been previously studied. Methods. MSCs were isolated from synovial tissue of a patient undergoing joint arthroplasty and expanded in culture. Six clonal populations were also isolated and expanded. The cells from the mixed parent population and the derived clonal populations were characterised for stem cell surface epitopes, and then cultured in chondrogenic mediums. Various assays were determined to analyse for features of differentiation. Results. Cells from the mixed parent population and the derived clonal populations stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic marker CD34 and for the neural and myogenic marker CD56. Interestingly, a variable number of cells were also positive for the pericyte marker 3G5 both in the mixed parent and clonal populations. The clonal populations exhibited a variable chondrogenic response. Conclusion. Pericytes are a candidate stem cell in many tissues and our results show that all six clonal populations derived from the heterogenous synovium population express the pericyte marker 3G5. The chondrogenic potential of synovial tissue could be optimised by the identification of clonal populations with a propensity to differentiate down particular differentiation pathways. Our study demonstrates a role for MSCs in of osteochondral defects (OCDs) and areas of focal cartilage damage in the ankle joint

Aim. To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1. st. metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. Methods. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes. Results. 2 patients required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years 1 month). 5 patients reported lateral metatarsalgia, 2 patients reported neuropathic pain, 6 patients developed superficial infection which fully responded to oral antibiotics, and 1 patient developed interphalangeal joint pain. 2 patients died in the cohort. Pre-operative mean MOXFQ was 44, mean EQ5D Index was 0.564 and VAS was 6.97. At mean follow-up of 5.3 years, the mean MOXFQ was 12.7 (0–57), the mean EQ5D Index was 0.851 (−0.02–1) and the mean VAS was 1.67 (0–8). The mean range of motion was 35° (30° dorsiflexion and 5° plantarflexion). The overall satisfaction rate was 90.2%. The implant survival rate was 97.6%. Conclusions. The silastic big toe arthroplasty offers excellent clinical mid term survival and functional outcomes and could be considered as an attractive alternative to traditional fusion for end stage hallux rigidus

Introduction. Freiberg's infarction poses a challenge to foot and ankle surgeons. Several surgical and non surgical treatment methods are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps in bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage via subchondral stem cells. Materials and Methods. Total of 15 patients (12F, 3M) underwent the above surgery between year 2002 and 2008. Mean age was 35yrs (range14-60). All of them had an extraarticular dorsal closing wedge osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head. Patients had a mean follow up of 2.5 yrs (Range 1-6). All patients were assessed using subjective patient satisfaction scores (scale 0-10) and AOFAS scores. Results. 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a mean period of 10 weeks (range6-18). The mean patient satisfaction score was 8 (range5-10). The mean pre and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which resolved spontaneously. No other complications noted. Conclusions. A combination of dorsal closing wedge osteotomy, debridement and microfracture is a simple, reproducible and effective method of treating Freiberg's disease with no major complications

Objectives

The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits.

Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger patients. 9-14. . Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration. 15. , distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By mounting the fixator components to the bone on each side of the joint, and then lengthening the rods connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage regeneration during distraction are not yet understood. A possible negative consequence of joint fixation is cartilage degeneration due to immobilization during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be detrimental to articular cartilage. 16-18. . Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage cartilage regeneration. 19-22. Toward this end, considerable effort has been invested in the application of hinges to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in distraction treatment, as well. 10. This is borne out by data from an RCT comparing the use of a rigid vs motion external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of symptoms

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the ankle. However, the longevity of the implants is still far from that of total knee and hip arthroplasties.

The aim of this review is to outline a diagnostic and treatment algorithm for the painful TAA to be used when considering revision surgery.

Cite this article: Bone Joint J 2017;99-B:5–11.

Aims

A failed total ankle arthroplasty (TAA) is often associated with much bone loss. As an alternative to arthrodesis, the surgeon may consider a custom-made talar component to compensate for the bone loss. Our aim in this study was to assess the functional and radiological outcome after the use of such a component at mid- to long-term follow-up.

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Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle.

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.

We performed a retrospective review of a consecutive series of 178 Mobility total ankle replacements (TARs) performed by three surgeons between January 2004 and June 2009, and analysed radiological parameters and clinical outcomes in a subgroup of 129 patients. The mean follow-up was 4 years (2 to 6.3). A total of ten revision procedures (5.6%) were undertaken. The mean Ankle Osteoarthritis Scale (AOS) pain score was 17 (0 to 88) and 86% of patients were clinically improved at follow-up. However, 18 patients (18 TARs, 14%) had a poor outcome with an AOS pain score of > 30. A worse outcome was associated with a pre-operative diagnosis of post-traumatic degenerative arthritis. However, no pre- or post-operative radiological parameters were significantly associated with a poor outcome. Of the patients with persistent pain, eight had predominantly medial-sided pain. Thirty TARs (29%) had a radiolucency in at least one zone.

The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. However, there is a significant incidence of persistent pain, particularly on the medial side, for which we were unable to establish a cause.

Cite this article: Bone Joint J 2013;95-B:1366–71.