Open Ankle Arthrodesis With a Fibular-Sparing Technique

Background: Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique. Methods: A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring. Results: At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being “completely satisfied” with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment. Conclusion: This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores. Level of Evidence: Level IV, retrospective case series. </jats:sec

The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation

BACKGROUND: Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported normal values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the lateral tibial line (LTL). METHODS: The relationship of the LTL to the superolateral talus was assessed by three reviewers on 99 standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. In addition, the interobserver reliability of the LTL measurement was recorded and compared with that of the MCS. RESULTS: The median value for the distance between the superolateral talus and LTL was -0.50 mm with an interquartile range of -1.4 to 0.0 mm. The LTL was within 1 mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or at most 1 mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good interobserver reliability (0.764, 95% confidence interval, 0.670 to 0.834), similar to the measurement of MCS (0.742, 95% confidence interval, 0.539 to 0.846). CONCLUSIONS: The relationship between the LTL and superolateral talus is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. The LTL uncommonly fell more than 1 mm medial to the superolateral talus, as might be seen with displaced ankle fractures. These findings will hopefully serve as a basis for future studies evaluating its role in assessing lateral displacement and stability of isolated fibula fractures. LEVEL OF EVIDENCE: Level III, retrospective review

Associated Joint Pain with Controlled Ankle Movement (CAM) Walker Boot Wear

Category: Ankle Introduction/Purpose: A controlled ankle movement (CAM) walker boot is often prescribed for patients with a lower extremity injury or disorder. CAM boot wear, however, may cause gait alterations and leg-length discrepancy, which are commonly associated with joint pain. This study evaluates the location, frequency and duration of secondary site pain relating to immobilization in a CAM walker boot. Methods: Patients wearing a CAM walker boot for treatment of a foot or ankle injury were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate the presence of secondary site pain, its severity, and its impact on overall function. Results: The final study population included 46 patients (mean age 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported secondary site pain either new or worse than baseline with an average of 1.6 secondary pain sites. The secondary sites most susceptible to pain were the lower back, contralateral hip, and ipsilateral knee. A majority (84%) of these pains began within the first two weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month, 15 patients (33%) at 3 months. The mean VAS for secondary site pains at transition out of boot was 51.2. Statistical significance was found correlating secondary site pain and a history of chronic pain (P=.04). Conclusion: Secondary site pain after CAM walker boot wear was common. The frequency and severity of pain lessened with time after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain three months after cessation of boot wear

The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation

Category: Ankle; Trauma Introduction/Purpose: Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported “normal” values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the “lateral tibial line” (LTL). Methods: The relationship of the LTL to the superolateral talus was assessed and characterized on ninety-nine standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. Additionally, the inter-observer reliability of the LTL measurement, determined by three reviewers, was recorded and compared to medial clear space measurements. Results: The median value for the lateral tibial line was -0.50 mm with an interquartile range of -1.4mm - 0.0mm. The LTL was within 1mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or was at most 1mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good inter-observer reliability (0.764, 95% CI: 0.670-0.834), similar to the measurement of MCS (0.742, 95% CI: 0.539-0.846). Conclusion: The LTL is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. It uncommonly fell more than 1 mm medial to the superolateral talus. In other words, it was uncommon for the talus to shift lateral to this line, as might be seen with displaced ankle fractures. These findings will hopefully serve as a standard for future studies evaluating the role of the LTL in assessing lateral displacement and stability of isolated fibula fractures

The Fate of Delayed Unions After Isolated Ankle Fusion

Category: Ankle Arthritis Introduction/Purpose: Despite advancements in surgical techniques, implants, and biologics, nonunion remains the most common major complication of ankle arthrodesis. While previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. We sought to better understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography (CT) was associated with outcomes. Methods: Delayed union was defined as incomplete ( < 75%) fusion seen on CT scan between 2 and 6 months postoperative. A total of 36 patients met inclusion criteria: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained and patients were asked about satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction with the procedure. Failure was defined as patients who progressed to revision or reported being not satisfied. Fusion was assessed by measuring the percent of osseous bridging across the joint on CT scan. The extent of bony bridging was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). Results: We determined the clinical outcome in 28 of the 36 eligible patients (78%) with mean follow-up of 5.6 years (range, 1.3 to 10.2 years). The majority (71%) of patients failed. A mean of 3.9 months (standard deviation, 1) elapsed between time of surgery and CT scan. Patients with minimal or moderate fusion on CT were more likely to succeed clinically than those with ‘absent’ fusion (X2 = 4.215, p = 0.040). Of those with absent ( < 25%) fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. Conclusion: We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% osseous bridging on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion