Role of high tibial osteotomy in chronic injuries of posterior cruciate ligament and posterolateral corner

High tibial osteotomy (HTO) is a surgical procedure used to change the mechanical weight-bearing axis and alter the loads carried through the knee. Conventional indications for HTO are medial compartment osteoarthritis and varus malalignment of the knee causing pain and dysfunction. Traditionally, knee instability associated with varus thrust has been considered a contraindication. However, today the indications include patients with chronic ligament deficiencies and malalignment, because an HTO procedure can change not only the coronal but also the sagittal plane of the knee. The sagittal plane has generally been ignored in HTO literature, but its modification has a significant impact on biomechanics and joint stability. Indeed, decreased posterior tibial slope causes posterior tibia translation and helps the anterior cruciate ligament (ACL)-deficient knee. Vice versa, increased tibial slope causes anterior tibia translation and helps the posterior cruciate ligament (PCL)-deficient knee. A review of literature shows that soft tissue procedures alone are often unsatisfactory for chronic posterior instability if alignment is not corrected. Since limb alignment is the most important factor to consider in lower limb reconstructive surgery, diagnosis and treatment of limb malalignment should not be ignored in management of chronic ligamentous instabilities. This paper reviews the effects of chronic posterior instability and tibial slope alteration on knee and soft tissues, in addition to planning and surgical technique for chronic posterior and posterolateral instability with HTO

Outcomes and Complications of Total Ankle Replacement in Patients with Post-traumatic, Primary, and Inflammatory Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement has been evolved and proven to be an effective treatment for varieties of ankle arthritis. Previous literatures reported higher complications in patients who underwent total ankle replacement resulted from post-traumatic and inflammatory arthritis compared to primary arthritis. However, there is a lack of comparative studies to demonstrate outcomes and complications among the three groups of patients who underwent total ankle replacement. Methods: Retrospective chart review of 247 consecutive patients with 268 ankles who were diagnosed with end-stage ankle arthritis from primary (73 patients /86 ankle), post-traumatic (149 patients/154 ankle), and inflammatory arthritis (25 patients/ 28 ankle) and underwent total ankle replacement between October 1997 and May 2015. Data was collected prospectively and minimum follow-up was 6 months to allow comparison of early complications and longer term survival in all groups (mean, 41.6 months (range, 6 to 132 months), mean 43.4 months (range, 6 to 180 months), and mean 75.1 months (range, 12-162 months) for primary, post-traumatic, and inflammatory arthritis, respectively). The primary outcome was Visual Analogue Scale (VAS), Foot Function Index (FFI, pain, disability, activity limitations, and total scores), Short Form-36 (SF-36, PCS and MCS), and the secondary outcomes included 5-year and 10-year survival rate, the length of hospital stay, time to return to work, sport activity, and activity daily living, ankle range of motion at final post-operative visit, and complications. Results: There were post-traumatic (57.5%), primary (32.1%) and inflammatory arthritis (10.4%). Total ankle replacement of all three groups demonstrated significant improvement in the VAS, FFI, SF-36(p 0.05). Ankle range of motion was significantly improved in both dorsiflexion and plantarflexion in all groups(p 0.05). Tibial subsidence was significantly higher in the inflammatory group compared to the post-traumatic group (p=0.036), but others complications were similar among the three groups. Conclusion: Total ankle replacements demonstrated significant improvement in term of functional outcomes, clinical outcomes, and pain relief as measured with FFI, SF-36, VAS scores, and range of motion of the ankle joint for treatment of end-stage ankle arthritis. The functional outcomes and complications were comparable among the primary, post-traumatic, and inflammatory groups except the talar implant subsidence was significant higher in the inflammatory group. Further prospective clinical study is indicated

Haglund Excision and Suture Bridge Repair

Background: Haglund deformity and insertional Achilles tendinopathy involve a degenerative process demonstrating disorganized collagen and mucoid degenerative material causing pain and swelling. Indications: Operative management through a distally based midline incision should be explored if symptoms are refractory to nonoperative management (activity and shoewear modifications, heel lifts, physical therapy, and heel sleeves). Direct lateral approach with small longitudinal split and removal of lateral prominence “pump bump” is performed when a patient has pain isolated solely to the prominence. We feel that endoscopic removal does not allow for appropriate evaluative of degenerative tissue. Techniques: Through a distally based incision, we dissect to the level of the paratenon and make one smooth cut through paratenon and tendon. We then excise the mucoid, degenerative tissue. Removal of Haglund deformity and exostosis is carefully accomplished with a saw. We then utilize a rongeur to smooth Haglund deformity and any remaining medial/lateral calcaneal prominences. We then complete a dual-row speed bridge with 4 suture anchors (horizontal mattress) and a modified Mason-Allen technique. A Thompson test is then repeated and the longitudinal split is repaired. Postoperatively, we have patients weight bear as tolerated in a boot for with suture removal and transition to shoewear at the 2-week mark. We begin range of motion and activity once the wound has healed. We expect return to sport beginning at 3 months with full return by 6 months. Results: The current body of literature shows significant patient satisfaction and minimal risk of complication. Some authors have shown significant improvement in American Orthopaedic Foot and Ankle Score (AOFAS) scores, with only 1 patient requiring a flexor hallucis longus (FHL) transfer and no complications. Further studies identify early weight-bearing in Achilles suture bridge technique to have some promise with improvement in visual analog scale (VAS)/AOFAS scores, though there is risk of wound breakdown. Discussion/Conclusion: An Achilles suture bridge technique with early weight-bearing is a viable option for patients with Haglund deformity, and insertional Achilles tendinopathy who have failed conservative management. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication

Tarsal Tunnel Release

Category: Ankle Introduction/Purpose: Tarsal tunnel release is a standard surgical treatment for patients who have tarsal tunnel syndrome and failure of conservative treatment. However, there remains little evidence demonstrating the medium-term of functional outcomes and complications of tarsal tunnel release. The purpose of this study was to report functional outcomes and complications of tarsal tunnel release. Methods: Retrospective chart review with prospectively collected data of 79 consecutive patients with 87 feet (primary surgery = 74/80 and revision surgery = 5/5) who were diagnosed with tarsal tunnel syndrome and underwent tarsal tunnel release between 2008 and 2014. Diagnosis bases on history and physical examination. All patients were failure of conservative treatment at least 6 weeks and the minimum follow up to be included in the study was 12 months (mean, 32.2 months; range, 12 to 80 months). The primary outcome was visual analogue scale (VAS), Short Form-36 (SF-36); physical and mental component scores, and Foot Function Index (FFI); pain, disability, activity limitation, and total score. Pre- and post-operative SF-36, and Foot Functional Index (FFI), pain (Visual Analog Scale) were obtained and compared using pair t-test. The secondary outcomes were operative time, time to return to activity of daily living and work, and complications. Mann-Whitney U-test was used to compare non-parametric data and Wilcoxon signed ranks test was used to compare parametric data. Results: The VAS was significantly decrease from 7.6 to 2.0(p = 0.001) and SF-36 was significantly improved from 33.2 to 40.2, for PCS (p= 0.001) and 47.7 to 49.7 for MCS (p = 0.005). The FFI was significantly decreased from 63.0 to 36.0, 61.9 to 35, 72.5 to 34.9, and 65.8 to 35.3 for pain, disability, activity limitations, and total scores(p=0.001, all). Mean operative time was 36.1 minutes for primary surgery and 54.8 minutes for the revision surgery. There 45 of 87 feet (51.7%) had positive Tinel test pre-operatively and 9 of 87 feet (10.3%) post-operatively. Revision surgery demonstrated significantly worse outcomes (VAS,SF-36,and FFI) compared to primary surgery(p 12 months and Tinel sign did not affect the outcomes compared to duration >12 months and Tinel sign negative (p>0.05 all). An average time to return to activity of daily living and work was 8.1 and 9.5 weeks. Complications were painful scar(14.9%), wound infection(6.9%), CRPS(2.3%), and paresthesia on the foot(20.7%). Conclusion: Tarsal tunnel release demonstrated significant improvement of functional outcomes and pain relief in medium-term follow-up as measured with SF-36, FFI, and VAS. Revision surgery demonstrated less favorable outcomes while pre-operative Tinel test and duration of symptom more than 12 months did not affect the outcome. This procedure was effective and feasible for tarsal tunnel syndrome with minor complications

Medium-Term Outcomes Using Fresh Osteochondral Allograft Transplantation for Treatment of Large Osteochondral Lesion of the Talus

Category: Ankle Introduction/Purpose: Osteochondral allograft has been proven to be successful surgical option for treatment of large osteochondral defect of the talus. However, there are currently limited literatures reported outcomes of this technique. Methods: Retrospective Chart review with prospectively collected data of 26 patients with 26 ankles who had been diagnosed with large osteochondral lesion of the talus and underwent fresh osteochondral allograft transplantation 2004 and 2011 in single institution. All patients had failure of conservative treatment and minimum follow-up to be included in this study was 1 year (mean 40.9 months, range, 12 to 123 months). Pre- and post-operative pain (Visual Analog Scale (VAS)), SF-36 (PCS and MCS), and Foot Functional Index (FFI) were obtained and compared using Wilcoxon Singed-Ranks test. Results: Twenty-six patients (13 male and 13 female) with mean age of 31.7 years and an average of BMI of 29.0 were included in this study. Complete pre-operative and 1-year post-operative pain (VAS) (n=19/26) and functional outcome scores (SF-36 and FFI)(n=12/26) were collected. The mean pain (VAS) decrease from 6.9/10 to 4.8/10 post-operatively (p = 0.007). The mean SF-36 (PCS and MCS) were 41.3 and 54.7 pre-operatively which improved to 47.2 and 56.0 post-operatively, p = 0.084 and p = 0.875, respectively. The mean FFI (pain, disability, activity limitations, and total score) were 48.0, 48.8, 57.6, and 45.8 pre-operatively which changed to 53.4, 57.6, 68.5, and 54.6 post-operatively (p = 0.674, 0.575, 0.110, and 0.859, respectively). There were 61.8% patient satisfaction with this surgery and 82.7% of the patients will do the surgery again and they will recommend this type of surgery to their friends and family. There were 100% survival rate at 5-year (8 of 8) and 10-year (1 of 1). Conclusion: Osteochondral allograft demonstrated significant relief of pain in medium-term of follow-up as measured with VAS. This procedure was successful for treatment of large osteochondral lesion of the talus

Outcomes and Complications of Four Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement has been proven to be effective method for treatment of patient with end-stage ankle arthritis alternative to ankle fusion. STAR implant was initially used followed by SALTO, INBONE and ZIMMER implants. While four implants are currently used, there is a paucity of evidence in literature to compare outcomes and complications between them. Methods: Retrospective chart review of 247 consecutive patients with 258 arthritic ankles who were diagnosed with end-stage ankle arthritis and underwent total ankle replacement using STAR (98 ankles, 38.0%), SALTO (121 ankles, 46.9%), INBONE (24 ankles, 9.3%), and Zimmer (15 ankles, 5.8%) implants between October 1997 and May 2015. There was prospectively collected data and minimum follow-up for inclusion was 6 months with an average of follow-up of 101.2 months (range, 18 to 211 months), 52.3 (range, 6 to 90 months), 15.3 (range, 6 to 27 months), and 13.7 months (range, 6 to 26 months) for STAR, SALTO, INBONE, and ZIMMER, respectively). The primary outcome was Visual Analogue Scale (VAS), Foot Function Index (FFI, pain, disability, activity limitations, and total scores), Short Form-36 (SF-36, PCS and MCS), and the secondary outcomes included 2- year, 5-year, and 10-year survival rate, ankle range of motion at the final post-operative visit, and complications. Analysis of VAS, SF-36, and FFI was performed between the four groups using one-way ANOVA. Independent Sample T-test, Wilcoxon Rank Sum Test, and Chi-square test were used to compare other parameters and complications. Results: All four implants demonstrated significant improvement of functional outcomes (SF-36,FFI,VAS) (p 0.05, all). The 2-year survival rates were 98.9%, 100%, 100%, and 100% for STAR, SALTO, INBONE, and Zimmer implants respectively. The 5-year survival rates were 91.7% and 96.2% and for STAR and SALTO implants respectively but 10-year survival was 86.1% for the STAR implant. Short- term complication for STAR, SALTO, INBONE, and ZIMMER implants were superficial wound infection (8.4%, 8.5%, 0%, and 0%), deep wound infection (2.1%, 1.7%, 0%, and 0%), medial malleolar fracture (6.3%, 6.8%, 0%, and 0%), lateral malleolar fracture (0%, 2%, 0%, and 0%), numbness on the incision (5.3%, 1.7%, 0%, and 0%), stiffness of the ankle joint (1.1%, 1.7%, 0%, and 0%), gutter impingement (14.7%, 2.5%, 0%, and 13.3%), talar component subsidence (9.5%, 0.8%, 0%, and 0%), and tibia component subsidence (4.2%, 3.4%, 0%, and 0%), polyethylene fracture (6.3%, 0%, 0%, and 0%). Conclusion: Based on our findings, all implants demonstrated significant improvement in term of functional outcomes, clinical outcomes, and pain relief as measured with FFI, SF-36, VAS scores, and range of motion of the ankle joint for treatment of end- stage ankle arthritis. The functional outcomes were comparable in all four types. Short-term complications were comparable in all groups but long-term complications of INBONE and Zimmer implants required longer follow-up time. Further prospective clinical investigation is important

Arthroscopic Plafond Access for Osteochondral Lesions- The Effect of Limited Ankle Range of Motion on Anterior and Posterior Arthroscopic Accessibility

Category: Arthroscopy. Introduction/Purpose: Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. Arthroscopic treatment has been described after failure of initial nonoperative treatment. However, the ideal appropriate approach for OLTPs is controversial, and it is not known if ankle positioning or joint distraction affects the accessibility of these lesions. The purpose of this study was to determine the effects of predetermined ankle flexion angles on arthroscopic accessibility of the distal tibial articular surface through either the anterior or posterior approach. The effects of non- invasive joint distraction were also analyzed. Methods: Fourteen below-knee cadaver specimens were subjected to pre-operative range of motion measurements. Joint distraction was measured using sizing rods with the precision of 1 mm. The accessible areas at the tibial plafond were marked using a curette at predetermined ankle positions. Arthroscopy was performed using a 30-degree 2.7 mm camera via standard anterior and posterior approaches in randomized fashion in all specimens. Following arthroscopic accessibility, each cadaveric ankle was disarticulated and arthroscopic accessibility was quantified using a surface laser scan. Statistical analyses were performed to determine the correlation between pre-operative ankle range of motion and amount of distraction on arthroscopic accessibility of the tibial plafond. Results: The average accessibility of the tibial plafond was 56 percent and 68 percent for the anterior and posterior approaches, respectively (p = 0.056). There was no difference in accessibility from the anterior approach with increasing level of plantarflexion (p >0.05). Increasing dorsiflexion during the posterior approach significantly reduced ankle accessibility (p = 0.028). There was a significant increase in accessibility through either anterior or posterior approach with increasing level of ankle distraction; (parameter estimates ±SE): anterior= 14.2±3.34, p < 0.01 and posterior= 10.6±3.7, p < 0.05). Conclusion: Arthroscopic accessibility for the treatment of OLTPs was vastly dependent on the amount of intra-operative joint distraction achieved. Posterior approach had more joint distraction and wider plafond accessibility. Increasing ankle distraction significantly improved arthroscopic plafond accessibility for both anterior and posterior approaches while ankle joint position did not influence accessibility from either approach

Osteoarthritis Classification Scales: Interobserver Reliability and Arthroscopic Correlation

The MARS Group* Background: Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. Methods: As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45°of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. Results: Overall, 45°posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass continue