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. Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans.Aims
Methods
This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA). A scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-based literature search was performed in PubMed, Embase, Cochrane trials, and Web of Science. Two reviewers independently performed title/abstract and full-text screening according to predetermined selection criteria. English-language original research studies reporting patient-related factors associated with a poorer outcome following TAA were included. Outcomes were defined as patient-reported outcome measures (PROMs), perioperative complications, and failure.Aims
Methods
Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb. We describe a technique for restoring talar height using an
Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°. A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded.Aims
Methods
We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44).Aims
Patients and Methods
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. 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.Aims
Patients and Methods
Total ankle arthroplasty (TAA) has become the most reliable surgical solution for patients with end-stage arthritis of the ankle. Aseptic loosening of the talar component is the most common complication. A custom-made artificial talus can be used as the talar component in a combined TAA for patients with poor bone stock of the talus. The purpose of this study was to investigate the functional and clinical outcomes of combined TAA. Ten patients (two men, eight women; ten ankles) treated using a combined TAA between 2009 and 2013 were matched for age, gender, and length of follow-up with 12 patients (one man, 11 women; 12 ankles) who underwent a standard TAA. All had end-stage arthritis of the ankle. The combined TAA features a tibial component of the TNK ankle (Kyocera, Kyoto, Japan) and an alumina ceramic artificial talus (Kyocera), designed using individualized CT data. The mean age at the time of surgery in the combined TAA and standard TAA groups was 71 years (Aims
Patients and Methods
The aim of this study was to present a series of patients with
aseptic failure of a total ankle arthroplasty (TAA) who were treated
with fusion of the hindfoot using a nail. A total of 23 TAAs, in 22 patients, were revised for aseptic
loosening and balloon osteolysis to a hindfoot fusion by a single
surgeon (NH) between January 2012 and August 2014. The procedure
was carried out without bone graft using the Phoenix, Biomet Hindfoot
Arthrodesis Nail. Preoperative investigations included full blood
count, CRP and ESR, and radiological investigations including plain
radiographs and CT scans. Postoperative plain radiographs were assessed
for fusion. When there was any doubt, CT scans were performed.Aims
Patients and Methods
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. 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.Aims
Patients and Methods
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. The study involved seven men and five women; their mean age was
35.9 years (14 to 70). All lesions included full-thickness articular
cartilage extending through subchondral bone and were associated
with subchondral cysts. Medial lesions were exposed through an oblique
medial malleolar osteotomy, and one lateral lesion was exposed by
expanding an anterolateral arthroscopic portal. After refreshing
the subchondral cyst, it was grafted with autologous cancellous
bone from the distal tibial metaphysis. The fragments of cartilage
were fixed with 5-0 nylon sutures to the surrounding cartilage.
Function was assessed at a mean follow-up of 25.3 months (15 to
50), using the American Orthopaedic Foot and Ankle Society (AOFAS)
ankle-hindfoot outcome score. The radiological outcome was assessed
using MRI and CT scans.Aims
Patients and Methods
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. A total of 12 patients (five women and seven men, mean age 53
years; 36 to77) with a failed TAA and a large talar defect underwent
a revision procedure using a custom-made talar component. The design
of the custom-made components was based on CT scans and standard
radiographs, when compared with the contralateral ankle. After the
anterior talocalcaneal joint was fused, the talar component was
introduced and fixed to the body of the calcaneum.Aims
Patients and Methods
Large osteochondral lesions (OCLs) of the shoulder
of the talus cannot always be treated by traditional osteochondral
autograft techniques because of their size, articular geometry and
loss of an articular buttress. We hypothesised that they could be
treated by transplantation of a vascularised corticoperiosteal graft
from the ipsilateral medial femoral condyle. Between 2004 and 2011, we carried out a prospective study of
a consecutive series of 14 patients (five women, nine men; mean
age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised
bone graft. Clinical outcome was assessed using a visual analogue
scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society
(AOFAS) hindfoot score. Radiological follow-up used plain radiographs
and CT scans to assess graft incorporation and joint deterioration. At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain
had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and
the mean AOFAS hindfoot score had increased from 65 (41 to 70) to
81 (54 to 92) (p = 0.003). Radiologically, the talar contour had
been successfully reconstructed with stable incorporation of the
vascularised corticoperiosteal graft in all patients. Joint degeneration
was only seen in one ankle. Treatment of a large OCL of the shoulder of the talus with a
vascularised corticoperiosteal graft taken from the medial condyle
of the femur was found to be a safe, reliable method of restoring
the contour of the talus in the early to mid-term. Cite this article:
Osteochondral lesions (OCLs) occur in up to 70%
of sprains and fractures involving the ankle. Atraumatic aetiologies have
also been described. Techniques such as microfracture, and replacement
strategies such as autologous osteochondral transplantation, or
autologous chondrocyte implantation are the major forms of surgical
treatment. Current literature suggests that microfracture is indicated
for lesions up to 15 mm in diameter, with replacement strategies
indicated for larger or cystic lesions. Short- and medium-term results
have been reported, where concerns over potential deterioration
of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of
OCLs, as they potentially enhance the biological environment for
a natural healing response. Further research is required to establish
the critical size of defect, beyond which replacement strategies
should be used, as well as the most appropriate use of biological augmentation.
This paper reviews the current evidence for surgical management
and use of biological adjuncts for treatment of osteochondral lesions
of the talus. Cite this article:
The purpose of this study was to evaluate the
clinical results of a newly designed prosthesis to replace the body
of the talus in patients with aseptic necrosis. Between 1999 and
2006, 22 tali in 22 patients were replaced with a ceramic prosthesis.
A total of eight patients were treated with the first-generation
prosthesis, incorporating a peg to fix into the retained neck and
head of the talus, and the remaining 14 were treated with the second-generation prosthesis,
which does not have the peg. The clinical results were assessed
by the American Orthopaedic Foot and Ankle Society ankle/hindfoot
scale. The mean follow-up was 98 months (18 to 174). The clinical results
of the first-generation prostheses were excellent in three patients,
good in one, fair in three and poor in one. There were, however,
radiological signs of loosening, prompting a change in design. The
clinical results of the second-generation prostheses were excellent
in three patients, good in five, fair in four and poor in two, with
more favourable radiological appearances. Revision was required
using a total talar implant in four patients, two in each group. Although the second-generation prosthesis produced better results,
we cannot recommend the use of a talar body prosthesis. We now recommend
the use of a total talar implant in these patients.
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:
In distal fibular resection without reconstruction,
the stabilising effect of the lateral malleolus is lost. Thus, the ankle
may collapse into valgus and may be unstable in varus. Here, we
describe a child who underwent successful staged surgical correction
of a severe neglected valgus deformity after excision of the distal
fibula for a Ewing’s sarcoma.
Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals. We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others. The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained. One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.
We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p <
0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55). At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p <
0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group). We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.
We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.
