Aims. The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. Methods. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results. Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion. Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting. Cite this article: Bone Joint J 2024;106-B(5):475–481

Aims. The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques. Methods. We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates. Results. The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes. Conclusion. The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results. Cite this article: Bone Jt Open 2024;5(3):227–235

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

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

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The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

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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.

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This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.

Introduction:. Charcot arthropathy is a complex condition affecting diabetic patients with neuropathy. Diagnosis of acute Charcot arthropathy particularly in absence of any perceptible trauma is very challenging as clinically it can mimic osteomyelitis and cellulitis. Delay in recognition of Charcot arthropathy can result in gross instability of foot and ankle. Early diagnosis can provide an opportunity to halt the progression of disease. We report the role of SPECT /CT in the early diagnosis and elucidation of the natural progression of the disease. Methods:. Our multidisciplinary team analysed the scans of neuropathic patients presented with acute red, hot, swollen foot with normal radiological findings (Eichenholtz stage 0), attending the diabetic foot clinic from 2009–2013. The patients were selected from our database, clinic and nuclear medicine records. Initial workup included the assessment of peripheral neuropathy, temperature difference, between the feet, serum inflammatory markers and weight bearing dorsoplantar, lateral and oblique x-rays. All patients had three dimensional triple Phase Bone Scan using 800Mbq . 99m. Tc HDP followed by CT scan. Those patients with obvious radiological findings and signs of infection were excluded. Results:. We evaluated 193 scans in 189 patients. One hundred and forty nine patients showed increase in focal radionuclide uptake at ligament insertion or subchondral bone with a positive predictive value of 77 percent. Forty four out of 193 were negative for Charcot changes and they were not treated as Charcot. These patients did not develop any Charcot changes in the mean follow up of 8 months, indicating a clinically false positive rate of 23%. Conclusion:. SPECT/CT scan is a highly sensitive and specific tool for early diagnosis and accurate localisation of Charcot neuroarthropathy as clinical examination results in high false positive rate. SPECT/CT also helps to understand the natural progression of this disease

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

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In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

In this retrospective study, using the prospectively collected database of the AO-Documentation Centre, we analysed the outcome of 57 malunited fractures of the ankle treated by reconstructive osteotomy. In all cases the position of the malunited fibula had been corrected, in several cases it was combined with other osteotomies and the fixation of any non-united fragments. Patients were seen on a regular basis, with a minimum follow-up of ten years. The aim of the study was to establish whether reconstruction improves ankle function and prevents the progression of arthritic changes. Good or excellent results were obtained in 85% (41) of patients indicating that reconstructive surgery is effective in most and that the beneficial effects can last for up to 27 years after the procedure. Minor post-traumatic arthritis is not a contraindication but rather an indication for reconstructive surgery. We also found that prolonged time to reconstruction is associated negatively with outcome

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To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

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A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. . We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus. Cite this article: Bone Joint J 2015; 97-B:802–8

Introduction:. Failure to adequately treat an injury of the syndesmosis leads to poor functional outcomes and posttraumatic arthritis. Many techniques have been proposed to salvage chronic instability. We report on the largest series of chronic syndesmotic injuries to be managed by syndesmotic arthrodesis from Europe to date. Aim:. To determine the radiographic and clinical outcomes for this technique at our institute. Methods:. Patients were followed-up prospectively. Relevant radiological and clinical data were obtained from electronic and case note review. The AOFAS score was utilised. Results:. A total of 6 patients were found. The average age was 33 years and the mean length of follow-up was 20 months. Arthrodesis was radiologically successful in all cases. Mean pre-operative and post-operative AOFAS scores were 70 and 82 respectively. All patients had some persistent ankle pain. One third had radiological progression of ankle osteoarthritis. Complications consisted of one patient with scar sensitivity. Conclusions:. This technique has a role in the salvage of chronic ankle syndesmotic instability. However patients must be counselled to the likelihood of ongoing symptoms

Introduction:. This study evaluates the mid-term results of first metatarsophalangeal joint replacement (MTPJR) for hallux rigidus using the Toefit-Plus™ prosthesis. Methods:. We prospectively studied the outcomes of 86 MTPJR in 73 patients using the AOFAS-HMI score and radiological follow up over a period from 2006 to 2013, with surgeries performed by a single surgeon at two centres. Patients were reviewed, scored and radiographs obtained pre-operatively and then at intervals of 6 weeks, 6 months, 12 months and then yearly. The mean follow up was 33 months (2–72). Results:. The mean AOFAS score of the patients not requiring revision at 1 year was 92, at 2 years was 94, at 3 years was 91, at 4 years was 99, at 5 years was 93, at 6 years was 100 and at 7 years was 97. 18 joints have either been revised or listed for revision giving a revision rate of 21%; this occurred at a mean of 33 months post-surgery. Reasons for revision included loosening of components in 13, infection in 1, dislocation in 2, malalignment in 1 and persistent pain in 1. Eight patients sustained intra-operative fractures requiring circlage wiring, of which 7 went on to union and one required revision. 25 patients had evidence of radiological loosening of which 22 were around the phalangeal component and 3 were around the metatarsal component. Conclusions:. First MTPJ replacement resulted in improved outcomes in patients with hallux rigidus who do not require revision in the medium term, however the revision rate is unacceptably high and as such we have discontinued use of this prosthesis. Radiological loosening of the components is high and needs monitoring for progression which may necessitate revision

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In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

Introduction. Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative. Methods. We studied a consecutive cohort of patients with Morton's neuroma that had failed non-operative treatment. Instead of undergoing surgical excision, these patients were referred for RFA. Under a local anaesthetic nerve block, RFA was performed under ultrasound-guidance, as an out-patient procedure, by a single radiologist. The procedure was repeated after 4 weeks if necessary. We followed patients for a minimum of 6 months to assess their change in visual analogue pain scores (VAS), overall symptom improvement, complications and progression to surgical excision. Results. 30 feet in 25 patients were studied. There were 4 males and 21 females with an average age of 55 years (range 33–73 y). All had tried previous methods of non-operative management. 40% presented with 2. nd. space neuromas and 60% with 3. rd. space. The average number of treatment sessions was 1.6 (range 1–3, mode 1). Prior to treatment, all patients had pain on activity (VAS average: 6.0, range 3–9). At 6 months post treatment, there was a statistically significant reduction in pain scores (post RFA VAS average: 1.7, range 0–8, p<0.001). The average overall symptom improvement was 76%. There was one minor complication of temporary nerve irritation. 3 neuromas (10%) have progressed to surgical excision. 1 patient has ongoing, unchanged pain with no obvious cause. At 6 months, 26 out of 30 feet had a satisfactory outcome. Conclusion. RFA has potentially reduced the need for surgical excision of Morton's neuromas by >85%

Introduction. The standard practice of uncomplicated total ankle replacement (TAR) involves postoperative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the postoperative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs. Materials and Methods. We have 133 TARs with 3 to 48 months' follow-up. 28 patients were excluded for the following reasons: other major procedure performed concurrently (osteotomy or tendon transfer), custom prosthesis, revision surgery, fusion conversions, or patients involved in a separate RCT (n = 16). We do not routinely immobilise patients postoperatively but allow partial to full weight-bearing as able. Outcome scores were compared to those without fractures. Results. 105 patients were included in the study. Nine (8.6%) patients sustained a periprosthetic fracture with no history of significant trauma. One of these was intraoperative; this was a posterior tibial fracture noticed on postoperative radiographs. The remainder (n = 8) were tibial metaphyseal stress fractures, all occurring within the first three months, most (n = 6) within six weeks. One occurred on the sixth post-op day and was managed in cast. Seven were asymptomatic at diagnosis and managed nonoperatively; one was fixed at three months due to radiological medial migration of the talus and one was fixed at seven months due to progression to symptomatic non-union. The remainder united. Between those with and without fractures, there was no significant difference in age (mean 61.4 vs. 62.1, p = 0.387), diagnosis leading to arthroplasty (OA, RA, PTOA), or outcome scores (12 months: 83 vs. 78, p = 0.237). Conclusion. Periprosthetic fracture remains a significant complication of total ankle arthroplasty. However, in our series, they do not lead to increased morbidity or worse outcome scores than patients without fractures and most can be managed nonoperatively

Introduction. The literature remains controversial on treatment of advanced stages of first metatarsophalangeal (MTP) arthritis and frequently favors arthrodesis. However, complications and suboptimal outcomes in active patients still remain with fusion of the first MTP joint. This study reports results of patients who underwent metallic resurfacing of the metatarsal side of the MTP joint. Materials and Methods. Twenty seven patients (31 implants) with stage II or III hallux rigidus underwent resurfacing with a fourth generation (screw fixation) contoured MTP implant and were willing to participate in a follow up study comparing pre- and postoperative radiographs, range of motion, AOFAS and SF-36 scores. The average age of these patients was 51 years (range 35-74) and the average follow up was 54 months (range 45-66). Results. The postoperative assessment demonstrated statistically significant improvements in range of motion, AOFAS, and SF-36 scores (P<0.05) when compared to baseline. The mean preoperative AOFAS scores improved from 51.5(range 35-74) to 94.1 (range 82-100). The mean preoperative active range of motion improved from 19.7 degrees (range 5-50) to 47.9 degrees (range 25-75). The mean preoperative passive range of motion improved from 28.0 degrees (range 10-60) to 66.3 degrees (range 40-90). The mean SF-36 score improved from 71.2 (range 60.6-80.0) to 88.2 (range 69.6-99.1), physical health sub scores improved from 66.8 (range 40-87) to 90.1 (range 70-98). The average time for return to work was 7 days (range 3-20). There was one implant revision due to phalangeal disease progression. All other patients were satisfied and willing to have the procedure performed again. Conclusion. Current 4 and 5 year results are very promising. Preservation of joint motion, alleviation of pain and functional improvement data are very encouraging. Because minimal joint resection is performed, conversion to arthrodesis or other salvage procedures is relatively simple if further intervention is necessary