Novel Double Osteotomy Technique of Distal Tibia for Correction of Asymmetric Varus Osteoarthritic Ankle

Category: Ankle, Ankle Arthritis Introduction/Purpose: A most challenging condition for balancing a varus arthritic ankle is the presence of a defect in the medial tibial plafond. After our initial results with a medial tibial plafond plasty did not fulfill our expectations of success, we hypothesized that adding a correcting supramalleolar osteotomy of the distal tibia would move the loading force to the tibiotalar joint more medially and thus act as an evertor force to the talus. In this study we asked (1) what surgical technique was used in detail; (2) what complications were observed; (3) what is the postoperative pain relief; (4) what is the patients’ mid-term functional outcome including range of motion; (5) what is the patients’ mid-term radiographic outcome including hindfoot alignment and progression of ankle osteoarthritis? Methods: Twenty consecutive patients were included into this study, no patients were lost for follow-up with a 4-year minimum required by the study. The mean age of the patients was 44 ± 12 years (range, 17-60 years). Followup averaged 5.9 ± 2.1 years (range, 4-11.2 years). All intraoperative and postoperative complications were recorded. The postoperative pain relief was assessed using a visual analog scale (VAS). Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and by measuring the ankle’s range of motion. Weight-bearing radiographs were used to assess osteotomy union and hindfoot alignment. Hindfoot alignment was assessed by measurement of the tibial ankle surface (TAS) angle, the tibiotalar (TT) angle, tibial lateral surface (TLS) angle, the tibiotalar tilt, and the moment arm of the calcaneus. Osteoarthritis grading was performed preoperative and postoperatively according to Takakura et al. Results: There were no intraoperative or perioperative complications. All patients had osseous fusion within 6 postoperative months. The average VAS pain score decreased significantly from 7.9 ± 1.3 (range, 6-10) to 1.3 ± 1.6 (range, 0-7). The average AOFAS hindfoot score increased significantly from 49 ± 15 points (range, 36-68) preoperatively to 86 ± 12 points (range, 66-96) postoperatively. The mean preoperative and postoperative ankle range of motion were comparable with 39° ± 11° (range, 25°- 46°) and 38° ± 9° (range, 28°-46°). The varus tilt improved significantly from 19.4° ± 8.2° (range, 6°-32°) to 6.9° ± 3.9° (range, 1°- 12°). According to Takakura’s classification, three ankles deteriorated by one stage, 11 ankles improved by one stage, and six ankles showed no changes. Conclusion: The novel double osteotomy was found to be an efficient and successful method to restore tibiotalar joint congruency and to normalize hindfoot alignment. The key of success of medial tibial plafond plasty may be the move of the joint load medially by the additional supramalleolar correcting osteotomy, thus creating an eversion force to the talus. Further in vitro studies are needed to evaluate these hypotheses

Syndesmotic Instability After Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) evolved over the last decades and has been shown to be an effective concept in the treatment of ankle osteoarthritis (OA). In three-component designs, the second interface between polyethylene insert (PI) and tibial component allows the PI to find its position according the individual physiological properties. This was believed to decrease shear forces within the ankle joint. However, it is not clarified to which extent such an additional degree of freedom may overload the ligamentous structures of the ankle joint over time. This may in particular be the case for the syndesmotic ligaments. Therefore, the purpose of this study was to analyze all ankles after TAR that showed a symptomatic overload of the syndesmotic ligaments and to determine the potential consequences. Methods: Between 2003 and 2017, 31 ankles (females, 17; males 14; mean age 60 [40-79] years) were treated with a tibio-fibular fusion for a symptomatic instability of the syndesmosis. The indication for TAR was posttraumatic OA in 27 (87%), primary OA in 3 (10%), and hemochromatosis in one ankle (3%). The 31 ankles included 23 primary TAR (74%), 6 revision TAR (19%), and two take-down of a fusion and conversion to TAR (7%). Criteria for fusion were the presence of at least two of the followings: (1) tenderness over the syndesmosis, (2) pain while compressing the fibula against the tibia (squeeze test), (3) pain while rotating the foot externally (external rotation test), (4) widening of the syndesmosis on an anteroposterior view. Alignment of TAR (tibial articular surface [TAS] angle) and hindfoot alignment were measured on standard radiographs. Intraoperatively, the syndesmotic instability was confirmed before fusion. The wear of PI was documented. Results: After a mean of 63 (range, 4 – 152) months after TAR, all patients evidenced pain at the level of the syndesmosis of at least 3 months. 25 ankles (81%; 24 after posttraumatic OA) showed a widening of the syndesmotic space and 22 ankles (71%) of the medial clear space with lateral translation of the talus. The PI was seen to overlap the tibial component in 15 ankles (48%). Nine ankles (29%) evidenced cyst formation, and eight ankles (26%) showed a decrease in height of the PI; whereas, in 3 ankles (10%) a fracture of the PI was found. A valgus misalignment of the heel was found in 25 ankles (81%), a valgus TAS in 16 (52%) and a varus TAS in 11 ankles (36%). Conclusion: A syndesmotic instability after a three-component TAR apparently occurred mostly after posttraumatic OA, in particular if the heel was left in valgus. If the talus starts to move lateralward, the PI seems to be at risk for increased wear and finally mechanical failure (Figure 1). Therefore, a valgus misaligned heel should always be corrected during TAR implantation. If there is any sign of syndesmotic instability, a fusion should be considered. Further studies must proof whether in cases with a syndesmotic instability the use of a two-component design will be superior, as it stabilizes the talus in the coronal plane

Subtalar and Naviculocuneiform Fusion in Treating Adult Acquired Flatfoot Deformity with Medial Arch Collapse at the Level of the Naviculocuneiform Joint

Category: Midfoot/Forefoot Introduction/Purpose: A conflicting problem in treating acquired flatfoot deformities is the break-down of the arch at the naviculocuneiform (NC) joints. After having encountered problems with extended triple fusion, in particular increased stiffness of the foot, we established a rational to combine subtalar (ST) fusion with NC I-III fusion while preserving the talonavicular (TN) and calcaneo-cuboidal (CC) joint. Our hypothesis was that the break-down of the arch at the NC joint can be specifically addressed while sparing the Chopart Joint (TN and CC joint). This, in turn, will allow the patient to accommodate better to the ground while walking. The aim of the study was to analyze the radiographic correction and fusion rate, and to determine patient’s satisfaction with this procedure. Methods: Between 2009 and 2015, a consecutive series of 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated by combining a fusion of the subtalar joint with a NC fusion. Both joints were exposed through a medial approach. Two 7.5mm-screws were used for ST fusion, and two 5.5mm-screws were used for NC fusion. In addition an anatomically contoured plate was used as a medio-plantar tension bending support of the NC joint. In 15 patients, an additional medial sliding-osteotomy was done to fully correct valgus misalignment of the hindfoot. The following measures were taken on standard weight-bearing radiographs including hindfoot alignment view preoperatively and at 2 years: the talus-first metatarsal angle, the talocalcaneal angle, the calcaneal pitch, the talonavicular coverage angle, the talus-first metatarsal angle, and calcaneal offset. Bony fusion was confirmed on plain radiographs. If no trabeculation was visible, a CT scan was performed. Results: All radiographic parameters, except the calcaneal pitch, showed a statistically significant improvement (Table 1). Solid fusion at the arthrodesis site was observed between 8 and 12 weeks in all but 2 cases (94.1%). One nonunion occurred at the ST joint and one at the NC joint. No interventions were necessary as both cases were asymptomatic. One patient developed an avascular necrosis of the lateral talus with need for a total ankle replacement after one year. All patients were satisfied with the results of this procedure and stated that they would undergo the surgery again. All patients were able to wear normal shoes without insoles. Conclusion: Our results show that a combined fusion of the subtalar and NC joint is an effective and safe technique in treating the adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. The deformity was corrected in all three planes. Even though the TN joint was not fused, its subluxation was significantly reduced. Although our radiographic results are promising, a clinical follow-up study is necessary to quantify the clinical benefit of this procedure

The Effect of Age in Total Ankle Replacement

Category: Ankle Introduction/Purpose: Over the last decades, total ankle replacement (TAR) emerged as a reliable treatment option in end-stage ankle osteoarthritis (OA) while preserving motion and physiological load. As these are strong arguments for TAR from an active patient’s perspective, it appears obvious that young patients show great interest in it. In the late 90s, 2nd generation implants showed a high revision rate, which has led to great cautiousness for TAR in young and active patients. Despite recently published data on 3rd generation implants showed a comparable outcome within different age groups, the question to debate remains whether TAR is advised in younger patients. The purpose of this study was to compare the clinical outcome and revision rate after TAR in patients younger and older than 50 years. Methods: A consecutive series of 813 primary TARs (3rd generation HINTEGRA, 446 male, 367 female), performed between May 2003 and December 2013, were enrolled. 129 patients (16%) were younger than 50 years and 784 (84%) were older than 50 years at time of surgery. The clinical outcome (AOFAS hindfoot score) and survivorship (revision of a metallic component as endpoint, or ankle fusion) of patients aged 50 years and 18.4% for patients aged ≥ 50 years. Conclusion: Beside of the higher incidence of posttraumatic OA in younger cohort, the high activity level and biomechanical demands may lead to a greater subjective limitation, which explains their significantly lower baseline AOFAS score. However, both groups showed similar clinical improvement and overall revision rates. Our findings support and back up recently published data from 3rd generation TARs to be an effective and reliable treatment option in end-stage ankle OA in young patients. However, a long-term follow-up and individual analysis of all failures leading to revision is of high importance

Subtalar Joint Arthritis After Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: It has been shown that total ankle replacement (TAR) is effective in reducing pain and maintaining function in posttraumatic ankle osteoarthritis (OA). Compared to ankle fusion, TAR restores hindfoot kinematics more physiological. However, the assumption that the maintenance of ankle motion has a protective effect on the subtalar joint is still a matter of debate. Only a scarce number of long-term studies exist to support this statement.The purpose of this study was (1) to evaluate to which extent the integrity of the subtalar joint can be preserved by treating patients with a TAR, (2) to determine the rate of subtalar fusion following TAR, and (3) to determine whether the need of subsequent subtalar fusion was predictable at time of TAR. Methods: A consecutive series of 1140 primary TAR (508 female, 632 male, median age 63.5 years), performed between May 2000 and December 2015, were prospectively documented. The indication for TAR was posttraumatic OA in 78%, primary and systemic OA in 10% each, and other secondary OA in 3% of the cases. 199 subtalar joints were either fused before (n=73) or during TAR surgery (n=126), leaving 941 subtalar joints available for analysis. Radiographs before implantation and at latest follow-up were classified using the Kellgren and Lawrence Grading Score (KLS). In case of a subtalar fusion, the radiograph prior to the fusion was classified. Results: After a median radiographic follow-up of 6.1 years, the KLS remained unchanged in 66% of all cases. While it was increased by one stage in 30%, it was increased by two stages in 3%; whereas, signs of OA decreased by one stage in 1%. Cases with an increase of two stages on the KLS had a longer follow-up compared to cases without increase (p=0.047).37 cases (3.9%) underwent a subtalar joint fusion, of which the indication was progressive OA in 19 cases (51%), instability in 10 cases (27%) and others in 8 cases (22%). Subtalar joints that required a fusion after TAR did not show higher preoperative KLS than the group which did not need a subtalar joint fusion. Conclusion: Apparently, TAR protects the subtalar joint from secondary degeneration, as found in 67% with no increase in KLS. Although 33% showed an increase in the KLS, only 2% required a subtalar fusion due to progressive OA. Overall, the rate of subtalar joint fusion after TAR was low and comparable to the rates reported in the literature. Subtalar joints requiring fusion after TAR did not show higher preoperative rates of OA. Therefore, the KLS classification of subtalar OA on conventional radiographs provides only limited information about the need for postoperative subtalar fusion, and thus need to be interpreted with caution

Ligament Balancing During TAR in Varus Deformity by Open Wedge Osteotomy of the Medial Malleolus

Category: Ankle Arthritis Introduction/Purpose: After reducing the tilted talus during total ankle replacement (TAR) in severe varus deformities, the surgeon is faced to a contract medial joint and an abducted medial malleolus leaving a wide gutter. A sliding osteotomy will release the deltoid ligament but the “horizontal” position of the medial malleolus remains and bony containment of the ankle joint is not restored. We propose an open wedge osteotomy, which will both lengthen and adduct the medial malleolus and restore ligament balancing. Fixation is done by either screw or plate fixation. We present our primary results with this new technique. Methods: From 2008-2015 Total Ankle Replacement combined with open wedge medial malleolar osteotomy was done in 50 ankles (48 patients). Inclusion criteria: Takakura stages 3 and 4 ankle arthritis. Minimum follow-up was defined as one year. Results: Neutral alignment was achieved in all ankles at last follow-up. AOFAS score increased from 36 preoperative to 82 at last follow-up. In 15 Ankles an additional bony procedure was done during the TAR surgery (Calcaneus Osteotomy: 5, Dorsiflexion Osteotomy of first ray: 6, Fibula Osteotomy: 4, peritalar fusion: 4) Complications included one non-union of the medial malleolus, which resolved after revision. One deep infection that was treated in a staged procedure with reimplantation of a TAR and no recurrence of infection. Two luxations of the polyethylene due to insufficient lateral ligaments and syndesmotic dehiscence, both were stable at final follow-up after revision (ligament reconstruction and tight-rope Fixation). Conclusion: Open wedge osteotomy of the medial malleolus restores the bony containment of the ankle joint and decreases the tension of the deltoid ligament. It is a valuable tool for ligament balancing during TAR

The Syndesmotic Insufficiency in Mobile Bearing TAR – A Challenging and Underestimated Problem

Category: Ankle Arthritis Introduction/Purpose: The consequence of a missed syndesmotic insufficiency during mobile bearing total ankle replacement (TAR) surgery is subsequent valgus deformity leading to dissociation of the distal tibiofibular joint and failure of the TAR. The purpose of this study was to retrospectively review the patients who developed a syndesmotic insufficiency, which lead to a revision surgery, after primary TAR in our centre. The primary goal was to identify red-flags for possible syndesmotic insufficiency in preoperative planning of TAR, in order to reduce this type of complication. Methods: We identified twenty patients (12 females and 8 males) with a missed instability of the distal tibio-fibular joint appearing 3.5 years (range 0.8-9.5 years) after primary TAR. Patient’s records, preoperative and postoperative radiographs and intraoperative fluoroscope images were reviewed especially with regard to previous ankle or lower leg fractures. Functional outcome was assessed with the use of the American Orthopaedic Foot&Ankle (AOFAS) hindfoot score. Results: The mean follow-up after last revision surgery was 3.5 years. The median AOFAS Score at last follow-up was 72.5. We could identify 3 risk factors for possible failure: (a) The nature of trauma: Weber-C-Type fractures or Maisonneuve-Type fractures were found in 13 of 20 cases. (b) A defect in the lateral tibial plafond after for example, a pilon fracture or arising due to cyst formation, was found in 3 cases. Here we concluded that the defect lead to a subsequent valgus tilt of the tibial component, acting as a stress riser in the distal tibio-fibular joint. (c) The remaining 4 cases showed a high tibial resection probably leading to an iatrogenic lesion of the anterior and posterior distal tibio-fibular ligaments. Conclusion: Knowing the etiology of posttraumatic osteoarthritis of the ankle joint is mandatory to identify a syndesmotic insufficiency in the preoperative work-up for mobile bearing three-component TAR. Due to these findings, our surgical protocol for TAR was adapted accordingly. If one or more of the risk factors are present during surgery we suggest performing distal tibio- fibular fusion

Invisible Injuries in Ankle Fractures

Category: Ankle, Trauma, Biomechanical Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5 mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all? Methods: The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700 N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10 Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden’s classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results: During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700 N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion: Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise

Supramalleolar Osteotomy for Tibial Component Malposition in Total Ankle Replacement

Category: Ankle Introduction/Purpose: A key for success in total ankle replacement is a balanced ankle joint. If the tibial component is misaligned, the ligamentous structures, the malleoli and the tendons may be overused, which, may lead to pain and impairment during gait. A misaligned tibial component can be revised using a corrective bone resection and re-insertion of a new component or using a corrective osteotomy of the distal tibia above the stable implant. The aim of this study was to review a series of patients, in whom a corrective supramalleolar osteotomy was performed to realign a misaligned tibial component in total ankle replacement. Methods: Twenty-two patients (nine male; 13 female; mean age, 62.6 years; range, 44.7 – 80.0) were treated with a supramalleolar osteotomy to correct a painful dysbalanced ankle, following a varus implanted tibial component. Following radiological and clinical outcomes were recorded preoperatively and at the follow-up examination within the first 24 months: the tibial anterior surface angle (TAS), the tibial lateral surface angle (TLS), patient’s pain measured with the Visual Analogue Scale (VAS), the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score, range of motion (ROM) of the ankle and patient’s satisfaction. Furthermore, postoperative complications were reviewed. Results: The TAS changed on average from 85.2 ± 2.5 degrees preoperatively to 91.4 ± 2.9 degrees postoperatively (p < 0.0001), the AOFAS score increased from 46 ± 14 to 66 ± 16 points (p < .0001) and the VAS pain score decreased from 5.8 ± 1.9 to 3.3 ± 2.4 (p < .001). No statistical difference was found in the TLS and the range of motion. The osteotomy healed in 19 patients (86%), re-osteosynthesis was successful in the remaining three patients. In one of these three patients, a chronic infection of the ankle joint led to a below-knee amputation. Fifteen patients (68%) were (very) satisfied, four (18%) moderately satisfied and three (14 %) patients were not satisfied with the obtained postoperative result. Conclusion: The supramalleolar osteotomy was found to be an efficient alternative to correct the misaligned tibial component in total ankle replacement. Pain could be successfully addressed in the majority of the patients. The treatment of a malpositioned, well anchored tibial component with a supramalleolar osteotomy, instead of exchanging the tibial component, allows preservation of the bone stock. However, non-union should be mentioned as a possible complication of this surgery. Nonetheless, this method might be a feasible treatment option, especially for younger patients

Subtalar Joint Alignment in Ankle Osteoarthritis

Category: Ankle Arthritis, Hindfoot Introduction/Purpose: The influence of the subtalar joint on the evolution of ankle joint osteoarthritis is still a matter of debate. Although subtalar joint compensation of deformities above the ankle joint was proposed until mid-stage of ankle osteoarthritis, the evidence of this assumption is weak. In this study, we investigated the subtalar joint alignment in different stages of ankle joint osteoarthritis using weightbearing CT scans. The influence of the tibio-talar tilt and presence of subtalar joint osteoarthritis was additionally assessed. We hypothesized, that the subtalar joint compensates for deformities above the ankle joint in early- to mid-stage of ankle osteoarthritis. We also hypothesized, that subtalar joint compensation increases with a pronounced tibio-talar tilt and decreases with the presence of subtalar joint osteoarthritis. Methods: We included patients with ankle joint osteoarthritis treated in our institution from January 2013 to April 2016. A control group of 28 patients was additionally assessed. Varus and valgus ankles were subdivided according to the modified Takakura classification, the tilt of the talus in the ankle mortise and stage of subtalar joint osteoarthritis. The type of ankle osteoarthritis was diagnosed on a plain weightbearing anterior to posterior radiograph of the ankle. The medial distal tibial angle (TAS) and the angle between the tibial shaft and the surface of the talar dome (TTS) were measured. The subtalar joint alignment was assessed using weightbearing CT scans. Two angles were assessed: The subtalar inclination angle (SIA) was measured to investigate the subtalar compensation. For assessment of the morphology of the talus, the inftal-subtal angle (ISA) was determined. Results: This analysis showed significant differences of the subtalar inclination between varus feet and the controls (SIA, P=.001). Regarding the talar morphology, significant differences were found between varus/ valgus feet and the controls (ISA, P=.001 and .036, respectively). No significant differences of the subtalar joint inclination and talar morphology could be identified comparing different stages of ankle joint osteoarthritis inside the varus or valgus group. No relationship between the tilt of the talus in the ankle joint mortise and the subtalar joint inclination or talar morphology was identified. Neither presence nor absence of subtalar joint osteoarthritis influenced the subtalar joint inclination and talar morphology. Conclusion: Varus ankles compensate in the subtalar joint for deformities above the ankle joint. Compensation had no influence on the stage of ankle osteoarthritis, extent of the tibio-talar tilt and stage of subtalar joint osteoarthritis. Consequently, the progression of ankle joint osteoarthritis is more depended on the supramalleolar alignment and integrity of the periarticular structures (i.e. ligaments and tendons) than on the osseous alignment of the subtalar joint