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. This is a single-centre retrospective review of patients who underwent primary total ankle arthroplasty (TAA) with a Vantage implant between November 2017 and February 2020, with a minimum of two years’ follow-up. Four surgeons contributed patients. The primary outcome was reoperation and revision rate of the Vantage implant at two years. Secondary outcomes included radiological alignment, peri-implant complications, and pre- and postoperative patient-reported outcomes.Aims
Methods
Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up.Aims
Methods
Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded.Aims
Methods
This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients’ clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up.Aims
Methods
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. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up.Aims
Methods
Aims . This is the first prospective study to report the pre- and post-operative
patient reported outcomes and satisfaction scores following excision
of interdigital Morton’s neuroma. Patients and Methods. Between May 2006 and April 2013, we prospectively studied 99
consecutive patients (111 feet) who were to undergo excision of
a Morton’s neuroma. There were 78 women and 21 men with a mean age
at the time of surgery of 56 years (22 to 78). Patients completed
the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12
(SF-12) and a supplementary patient satisfaction survey three months
pre-operatively and six months post-operatively. Results. Statistically significant differences were found between the
mean pre- and post-operative MOXFQ and the physical component of
the SF-12 scores (p = 0.00081 and p = 0.00092 respectively). Most
patients reported their overall satisfaction as excellent (n = 49,
49.5%) or good (n = 29, 29.3%), but ten patients were dissatisfied,
reporting poor (n = 8, 8.1%) or very poor (n = 2, 2.0%) results.
Only 63 patients (63%) were pain-free at follow-up: in eight patients (8.1%),
the MOXFQ score worsened. There was no statistically significant
difference in outcome between surgery on single or multiple sites.
However, the MOXFQ scores were significantly worse after revision
surgery (p = 0.004). Conclusions. The patient-reported outcomes after
In distal fibular
To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA). A consecutive series of 811 ankles (789 patients) that underwent TAA between May 2003 and December 2013 were enrolled. The influence of age on clinical outcome, including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and pain according to the visual analogue scale (VAS) was assessed. In addition, the risk for revision surgery that includes soft tissue procedures, periarticular arthrodeses/osteotomies, ankle joint debridement, and/or inlay exchange (defined as minor revision), as well as the risk for revision surgery necessitating the exchange of any of the metallic components or removal of implant followed by ankle/hindfoot fusion (defined as major revision) was calculated.Aims
Methods
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
Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function.Aims
Methods
The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon. We reviewed 205 consecutive patients (210 ankles) who had undergone mobile-bearing TAA (205 patients) for osteoarthritis of the ankle between January 2005 and December 2015. Their mean follow-up was 6.4 years (2.0 to 13.4). Functional outcome was assessed using the Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, 36-Item Short-Form Health Survey (SF-36) score, visual analogue scale, and range of movement. Implant survivorship and complications were also evaluated.Aims
Patients and Methods
We examined seven patients with tarsal tunnel syndrome in one foot caused by talocalcaneal coalition and a ganglion. We excised the coalition and the ganglion in six of them. All the patients had pain, sensory disturbance in the sole, and a positive Tinel’s sign. Older patients with a long history showed atrophy and weakness of the plantar muscles. Talocalcaneal coalition can be diagnosed on a plain lateral radiograph and an anteroposterior radiograph externally rotated 20°, and confirmed by CT. MRI is also useful for diagnosis. The coalitions were medial, and the ganglion had developed from the incomplete part of the coalition; it was multilocular in some patients. After
The pathogenesis of intraneural ganglion cysts is controversial.
Recent reports in the literature described medial plantar intraneural
ganglion cysts (mIGC) with articular branches to subtalar joints.
The aim of the current study was to provide further support for
the principles underlying the articular theory, and to explain the
successes and failures of treatment of mICGs. Between 2006 and 2017, five patients with five mICGs were retrospectively
reviewed. There were five men with a mean age of 50.2 years (33
to 68) and a mean follow-up of 3.8 years (0.8 to 6). Case history,
physical examination, imaging, and intraoperative findings were
reviewed. The outcomes of interest were ultrasound and/or MRI features
of mICG, as well as the clinical outcomes.Aims
Patients and Methods
Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.Aims
Patients and Methods
Hindfoot arthrodesis with retrograde intramedullary nailing has
been described as a surgical strategy to reconstruct deformities
of the ankle and hindfoot in patients with Charcot arthropathy.
This study presents case series of Charcot arthropathy patients
treated with two different retrograde intramedullary straight compression
nails in order to reconstruct the hindfoot and assess the results
over a mid-term follow-up. We performed a retrospective analysis of 18 consecutive patients
and 19 operated feet with Charcot arthropathy who underwent a hindfoot
arthrodesis using a retrograde intramedullary compression nail.
Patients were ten men and eight women with a mean age of 63.43 years
(38.5 to 79.8). We report the rate of limb salvage, complications requiring
additional surgery, and fusion rate in both groups. The mean duration
of follow-up was 46.36 months (37 to 70).Aims
Patients and Methods
The aim of this study was to describe the technique of distraction
osteogenesis followed by arthrodesis using internal fixation to
manage complex conditions of the ankle, and to present the results
of this technique. Between 2008 and 2014, distraction osteogenesis followed by arthrodesis
using internal fixation was performed in 12 patients with complex
conditions of the ankle due to trauma or infection. There were eight
men and four women: their mean age was 35 years (23 to 51) at the
time of surgery. Bone healing and functional recovery were evaluated
according to the criteria described by Paley. Function was assessed
using the ankle-hindfoot scale of the American Orthopedic Foot and
Ankle Society (AOFAS).Aims
Patients and Methods
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:
The mainstay of surgical correction of hallux valgus is first
metatarsal osteotomy, either proximally or distally. We present
a technique of combining a distal chevron osteotomy with a proximal
opening wedge osteotomy, for the correction of moderate to severe
hallux valgus. We reviewed 45 patients (49 feet) who had undergone double osteotomy.
Outcome was assessed using the American Orthopaedic Foot and Ankle
Society (AOFAS) and the Short Form (SF) -36 Health Survey scores.
Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The
mean follow-up was 35.4 months (24 to 51).Aims
Patients and Methods
Injuries to the foot in athletes are often subtle
and can lead to a substantial loss of function if not diagnosed
and treated appropriately. For these injuries in general, even after
a diagnosis is made, treatment options are controversial and become
even more so in high level athletes where limiting the time away
from training and competition is a significant consideration. In this review, we cover some of the common and important sporting
injuries affecting the foot including updates on their management
and outcomes. Cite this article:
Few reports compare the contribution of the talonavicular articulation
to overall range of movement in the sagittal plane after total ankle
arthroplasty (TAA) and tibiotalar arthrodesis. The purpose of this
study was to assess changes in ROM and functional outcomes following
tibiotalar arthrodesis and TAA. Patients who underwent isolated tibiotalar arthrodesis or TAA
with greater than two-year follow-up were enrolled in the study.
Overall arc of movement and talonavicular movement in the sagittal
plane were assessed with weight-bearing lateral maximum dorsiflexion
and plantarflexion radiographs. All patients completed Short Form-12
version 2.0 questionnaires, visual analogue scale for pain (VAS)
scores, and the Foot and Ankle Ability Measure (FAAM).Aims
Patients and Methods
The aim of this study was to report a single surgeon series of
consecutive patients with moderate hallux valgus managed with a
percutaneous extra-articular reverse-L chevron (PERC) osteotomy. A total of 38 patients underwent 45 procedures. There were 35
women and three men. The mean age of the patients was 48 years (17
to 69). An additional percutaneous Akin osteotomy was performed
in 37 feet and percutaneous lateral capsular release was performed
in 22 feet. Clinical and radiological assessments included the type
of forefoot, range of movement, the American Orthopedic Foot and
Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients
were lost to follow-up.Aims
Patients and Methods
While many forefoot procedures may be performed
as a day case, there are no specific guidelines as to which procedures
are suitable. This study assessed the early post-operative pain
after forefoot surgery performed a day case, compared with conventional
inpatient management. A total of 317 consecutive operations performed by a single surgeon
were included in the study. Those eligible according to the criteria
of the French Society of Anaesthesia (SFAR) were managed as day
cases (127; 40%), while the remainder were managed as inpatients. The groups were comparable in terms of gender, body mass index
and smoking status, although the mean age of the inpatients was
higher (p <
0.001) and they had higher mean American Society
of Anaesthesiologists scores (p = 0.002). The most severe daily
pain was on the first post-operative day, but the levels of pain
were similar in the two groups; (4.2/10, Apart from the most complicated cases, forefoot surgery can safely
be performed as a day case without an increased risk of pain, or
complications compared with management as an inpatient. Cite this article:
Macrodactyly of the foot is a rare but disabling
condition. We present the results of surgery on 18 feet of 16 patients, who
underwent ray amputation and were followed-up for more than two
years at a mean of 80 months (25 to 198). We radiologically measured the intermetatarsal width and forefoot
area pre-operatively and at six weeks and two years after surgery.
We also evaluated the clinical results using the Oxford Ankle Foot
Questionnaire for children (OxAFQ-C) and the Questionnaire for Foot
Macrodactyly. The intermetatarsal width and forefoot area ratios were significantly
decreased after surgery. The mean OxAFQ-C score was 42 (16 to 57)
pre-operatively, improving to 47 (5 to 60) at two years post-operatively
(p = 0.021). The mean questionnaire for Foot Macrodactyly score
two years after surgery was 8 (6 to 10). Ray amputation gave a measurable reduction in foot size with
excellent functional results. For patients with metatarsal involvement,
a motionless toe, or involvement of multiple digits, ray amputation
is a clinically effective option which is acceptable to patients. Cite this article:
Limited forefoot amputation in diabetic patients
with osteomyelitis is frequently required. We retrospectively reviewed
diabetic patients with osteomyelitis, an unhealed ulcer and blood
pressure in the toe of >
45 mmHg who underwent limited amputation
of the foot with primary wound closure. Between 2006 and 2012, 74
consecutive patients with a mean age of 67 years (29 to 93), and
a median follow-up of 31 months, were included. All the wounds healed
primarily at a median of 37 days (13 to 210; mean 48). At a median
of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered
a further ulceration. Of these, 12 patients (16% of the total) required
a further amputation. We conclude that primary wound closure following limited amputation
of the foot in patients with diabetes is a safe and effective technique
when associated with appropriate antibiotic treatment. Cite this article:
Charcot neuro-osteoarthropathy (CN) of the midfoot
presents a major reconstructive challenge for the foot and ankle
surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and
recommended for patients who have a deformity of the medial column
of the foot due to CN. We present the results from the first nine
patients (ten feet) on which we attempted to perform fusion of the
medial column using this bolt. Six feet had concurrent hindfoot fusion
using a retrograde nail. Satisfactory correction of deformity of
the medial column was achieved in all patients. The mean correction
of calcaneal pitch was from 6°
(-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively;
the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and
the mean talometatarsal angle on dorsoplantar radiographs from 27°
(1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse.
The bolt migrated in six feet, all of which showed progressive radiographic
osteolysis, which was considered to indicate loosening. Four of
these feet have undergone a revision procedure, with good radiological
evidence of fusion. The medial column bolt provided satisfactory correction
of the deformity but failed to provide adequate fixation for fusion
in CN deformities in the foot. In its present form, we cannot recommend the routine use of this
bolt. Cite this article:
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:
Moderate to severe hallux valgus is conventionally
treated by proximal metatarsal osteotomy. Several recent studies
have shown that the indications for distal metatarsal osteotomy
with a distal soft-tissue procedure could be extended to include
moderate to severe hallux valgus. The purpose of this prospective randomised controlled trial was
to compare the outcome of proximal and distal Chevron osteotomy
in patients undergoing simultaneous bilateral correction of moderate
to severe hallux valgus. The original study cohort consisted of 50 female patients (100
feet). Of these, four (8 feet) were excluded for lack of adequate
follow-up, leaving 46 female patients (92 feet) in the study. The
mean age of the patients was 53.8 years (30.1 to 62.1) and the mean
duration of follow-up 40.2 months (24.1 to 80.5). After randomisation,
patients underwent a proximal Chevron osteotomy on one foot and
a distal Chevron osteotomy on the other. At follow-up, the American Orthopedic Foot and Ankle Society
(AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score,
patient satisfaction, post-operative complications, hallux valgus
angle, first-second intermetatarsal angle, and tibial sesamoid position
were similar in each group. Both procedures gave similar good clinical
and radiological outcomes. This study suggests that distal Chevron osteotomy with a distal
soft-tissue procedure is as effective and reliable a means of correcting
moderate to severe hallux valgus as proximal Chevron osteotomy with
a distal soft-tissue procedure. Cite this article:
We report the outcomes of 20 patients (12 men,
8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction
of deformities of the ankle and hindfoot using retrograde intramedullary
nail arthrodesis. The mean age of the patients was 62.6 years (46
to 83); their mean BMI was 32.7 (15 to 47) and their median American
Society of Anaesthetists score was 3 (2 to 4). All presented with
severe deformities and 15 had chronic ulceration. All were treated
with reconstructive surgery and seven underwent simultaneous midfoot
fusion using a bolt, locking plate or a combination of both. At
a mean follow-up of 26 months (8 to 54), limb salvage was achieved
in all patients and 12 patients (80%) with ulceration achieved healing
and all but one patient regained independent mobilisation. There was
failure of fixation with a broken nail requiring revision surgery
in one patient. Migration of distal locking screws occurred only
when standard screws had been used but not with hydroxyapatite-coated
screws. The mean American Academy of Orthopaedic Surgeons Foot and
Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22
to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical
Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7
to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved
from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary
hindfoot arthrodesis nail is a good form of treatment for patients
with severe Charcot hindfoot deformity, ulceration and instability
provided a multidisciplinary care plan is delivered. Cite this article:
Van Nes rotationplasty may be used for patients
with congenital proximal focal femoral deficiency (PFFD). The lower
limb is rotated to use the ankle and foot as a functional knee joint
within a prosthesis. A small series of cases was investigated to
determine the long-term outcome. At a mean of 21.5 years (11 to
45) after their rotationplasty, a total of 12 prosthetic patients
completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris
hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires,
as did 12 age- and gender-matched normal control participants. A
physical examination and gait analysis, computerised dynamic posturography
(CDP), and timed ‘Up &
Go’ testing was also completed. Wilcoxon
Signed rank test was used to compare each PFFD patient with a matched
control participant with false discovery rate of 5%. There were no differences between the groups in overall health
and well-being on the SF-36. Significant differences were seen in
gait parameters in the PFFD group. Using CDP, the PFFD group had
reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high
level of function and quality of life at long-term follow-up, but
presented with significant differences in gait and posture compared
with the control group. Cite this article:
Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy. The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one. With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.
We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.
There are few reports of the surgical treatment for late stage Freiburg’s disease with flattening of the metatarsal head and osteoarthritis. We describe the results of the surgical treatment of ten consecutive patients with advanced stage Freiburg’s disease (Smillie’s stage V), using a technique that has not been published previously.
In a retrospective study we compared 32 HINTEGRA
total ankle replacements (TARs) and 35 Mobility TARs performed between
July 2005 and May 2010, with a minimum follow-up of two years. The
mean follow-up for the HINTEGRA group was 53 months (24 to 76) and
for the Mobility group was 34 months (24 to 45). All procedures
were performed by a single surgeon. There was no significant difference between the two groups with
regard to the mean AOFAS score, visual analogue score for pain or
range of movement of the ankle at the latest follow-up. Most radiological
measurements did not differ significantly between the two groups.
However, the most common grade of heterotopic ossification (HO)
was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade
2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025).
Although HO was more frequent in the HINTEGRA group (40.6%) than
in the Mobility group (20.0%), this was not statistically significant
(p = 0.065).The difference in peri-operative complications between
the two groups was not significant, but intra-operative medial malleolar
fractures occurred in four (11.4%) in the Mobility group; four (12.5%)
in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed
(p = 0.185). Cite this article:
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.
The purpose of this study was to compare the
results of proximal and distal chevron osteotomy in patients with moderate
hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without
lateral release (PCO group) and 33 distal chevron osteotomies (DCO
group) performed sequentially by a single surgeon. There were no
differences between the groups with regard to age, length of follow-up,
demographic or radiological parameters. The clinical results were
assessed using the American Orthopaedic Foot and Ankle Society (AOFAS)
scoring system and the radiological results were compared between
the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant
differences in the mean AOFAS scores between the DCO and PCO groups
(93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176).
The mean hallux valgus angle, intermetatarsal angle and sesamoid
position were the same in both groups. The metatarsal declination
angle decreased significantly in the PCO group (p = 0.005) and the
mean shortening of the first metatarsal was significantly greater
in the DCO group (p <
0.001). We conclude that the clinical and radiological outcome after
a DCO is comparable with that after a PCO; longer follow-up would
be needed to assess the risk of avascular necrosis. Cite this article:
The aim of this study was to identify the incidence of post-operative symptomatic deep-vein thrombosis (DVT), as well as the risk factors for and location of DVT, in 665 patients (701 ankles) who underwent primary total ankle replacement. All patients received low-molecular-weight heparin prophylaxis. A total of 26 patients (3.9%, 26 ankles) had a symptomatic DVT, diagnosed by experienced radiologists using colour Doppler ultrasound. Most thrombi (22 patients, 84.6%) were localised distally in the operated limb. Using a logistic multiple regression model we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT. The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement.
Severe hallux valgus deformity is conventionally
treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy
with an associated soft-tissue procedure can also be used in moderate
to severe deformity. We compared the clinical and radiological outcomes
of proximal and distal chevron osteotomy in severe hallux valgus deformity
with a soft-tissue release in both. A total of 110 consecutive female
patients (110 feet) were included in a prospective randomised controlled
study. A total of 56 patients underwent a proximal procedure and
54 a distal operation. The mean follow-up was 39 months (24 to 54)
in the proximal group and 38 months (24 to 52) in the distal group.
At follow-up the hallux valgus angle, intermetatarsal angle, distal
metatarsal articular angle, tibial sesamoid position, American Orthopaedic
Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal
score, patient satisfaction level, and complications were similar
in each group. Both methods showed significant post-operative improvement
and high levels of patient satisfaction. Our results suggest that
the distal chevron osteotomy with an associated distal soft-tissue
procedure provides a satisfactory method for correcting severe hallux
valgus deformity. Cite this article:
We investigated 60 patients (89 feet) with a
mean age of 64 years (61 to 67) treated for congenital clubfoot deformity,
using standardised weight-bearing radiographs of both feet and ankles
together with a functional evaluation. Talocalcaneal and talonavicular
relationships were measured and the degree of osteo-arthritic change
in the ankle and talonavicular joints was assessed. The functional
results were evaluated using a modified Laaveg-Ponseti score. The
talocalcaneal (TC) angles in the clubfeet were significantly lower
in both anteroposterior (AP) and lateral projections than in the
unaffected feet (p <
0.001 for both views). There was significant
medial subluxation of the navicular in the clubfeet compared with
the unaffected feet (p <
0.001). Severe osteoarthritis in the
ankle joint was seen in seven feet (8%) and in the talonavicular
joint in 11 feet (12%). The functional result was excellent or good
(≥ 80 points) in 29 patients (48%), and fair or poor (<
80 points)
in 31 patients (52%). Patients who had undergone few (0 to 1) surgical
procedures had better functional outcomes than those who had undergone
two or more procedures (p <
0.001). There was a significant correlation
between the functional result and the degree of medial subluxation
of the navicular (p <
0.001, r2 = 0.164), the talocalcaneal
angle on AP projection (p <
0.02, r2 = 0.025) and extent of osteoarthritis
in the ankle joint (p <
0.001). We conclude that poor functional outcome in patients with congenital
clubfoot occurs more frequently in those with medial displacement
of the navicular, osteoarthritis of the talonavicular and ankle
joints, and a low talocalcaneal angle on the AP projection, and
in patients who have undergone two or more surgical procedures. However,
the ankle joint in these patients appeared relatively resistant
to the development of osteoarthritis.
The Bologna–Oxford (BOX) total ankle replacement
(TAR) was developed with the aim of achieving satisfactory pain-free
movement of the ankle. To date, only one single multicentre study
has reported its clinical results. The aim of this study was to
conduct an independent review of its mid-term results. We retrospectively reviewed a total of 60 prospectively followed
patients in whom 62 BOX TARs had been implanted between 2004 and
2008. We used the American Orthopedic Foot and Ankle Society (AOFAS)
score to assess the clinical results. Standardised radiographs taken
at the time of final follow-up were analysed by two observers. The
overall survival was 91.9% at a mean follow-up of 42.5 months (24
to 71). The mean AOFAS score had improved from 35.1 points (
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 allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).
Our study describes the clinical outcome of total ankle replacement (TAR) performed in patients with moderate to severe varus deformity. Between September 2004 and September 2007, 23 ankles with a varus deformity ≥ 10° and 22 with neutral alignment received a TAR. Following specific algorithms according to joint congruency, the varus ankles were managed by various additional procedures simultaneously with TAR. After a mean follow-up of 27 months (12 to 47), the varus ankles improved significantly in all clinical measures (p <
0.0001 for visual analogue scale and American Orthopaedic Foot and Ankle Society score, p = 0.001 for range of movement). No significant differences were found between the varus and neutral groups regarding the clinical (p = 0.766 for visual analogue scale, p = 0.502 for American Orthopaedic Foot and Ankle Society score, p = 0.773 for range of movement) and radiological outcome (p = 0.339 for heterotopic ossification, p = 0.544 for medial cortical reaction, p = 0.128 for posterior focal osteolysis). Failure of the TAR with conversion to an arthrodesis occurred in one case in each group. The clinical outcome of TAR performed in ankles with pre-operative varus alignment ≥ 10° is comparable with that of neutrally aligned ankles when appropriate additional procedures to correct the deformity are carried out simultaneously with TAR.
We describe the early results of a prospective study of 100 total ankle replacements (96 patients) at a single centre using the Mobility Total Ankle Replacement. At final review, six patients had died and five ankles (5%) had been revised, two by fusion and three by exchange of components. All remaining patients were reviewed at a minimum of three years. The mean follow-up was 43 months (4 to 63). The three-year survival was 97% (95% confidence interval (CI) 91 to 99). The four-year survival was 93.6% (95% CI 84.7 to 97.4). The portion of bony interface that was visible on plain radiograph was divided into 15 zones and a radiolucent line or osteolytic cavity was seen in one zone in 14 ankles. It was not seen in more than one zone. In five ankles it was >
10 mm in width. This study suggests that the early outcome of ankle replacement is comparable to that of other total joint replacements.
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.
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was <
5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.
Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated.
A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis.