An Accuracy of Syndesmotic Reduction by Direct Visualization Technique

Category: Trauma Introduction/Purpose: Syndesmotic injury is commonly seen associated with acute ankle fracture. Syndesmotic malreduction was proven be a poor prognostic factor. Many methods have been purposed to assess the quality of reduction such as direct visualization, comparing radiographic parameters to contralateral ankle fluoroscopy, and intra-operative computed tomography. In this study, we demonstrated syndesmotic malreduction rate using bilateral CT after using direct visualization technique for syndesmotic fixation. Methods: A prospective case series of 34 patients (13 left and 21 right sides) with an average age of 42 years who had rotational ankle fractures with syndesmotic injury confirmed by arthroscopic examination. All patients were treated with an open reduction and internal fixation of distal fibula using either 1/3 tubular plate or distal anatomical locking plate. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. Before syndesmotic fixation, syndesmotic reduction is made by using a large point reduction clamp and quality of the reduction was checked by direct visualization at anterior tibiofibular line. The accuracy of syndesmotic reduction is then evaluated by post-operative bilateral CT. A widening of distance between anterior tibia and fibular at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: The accuracy of syndesmotic reduction was 97.1 percent (33/34) compare to contralateral ankle. An average of BMI was 27.2 and an average of operative time was 98.2 minutes. One malreduction, was diagnosed on the criteria of a 2 mm difference from the contralateral side occurred due to a small fragment interposition at the syndemosis. This patient underwent revision surgery to remove the fragment and then fixation of syndesmosis with same manner to achieve anatomical reduction. In all cases, the screws are removed at 12 weeks. Neither breakage nor migration of screws is observed and no wound or nerve complications following this technique. Conclusion: A syndesmotic fixation using direct visualization technique demonstrate lower rate of malreduction as demonstrated by poster-operative bilateral CT scan and no complications. This technique is effective, safe, and should be considered for treatment of syndesmotic injury associated ankle fracture

Outcomes and Complication Following Endoscopically-Assisted Percutaneous Achilles Tendon Repair

Category: Arthroscopy Introduction/Purpose: Open repair of acute Achilles tendon rupture is considered as a standard surgical treatment while percutaneous technique has gained increasing popularity especially under endoscopic control. However, there is a lack of currently research reporting outcomes and complications following this technique. Methods: The retrospective chart reviews with prospectively collecting data were performed in 32 patients with 32 legs who underwent endoscopically-assisted percutaneous Achilles tendon repair using 6-portal technique between 2008 and 2015. The minimum follow-up to be included in the study was 6 months (mean, 49.3 months; range, 6 to 76 months). The primary outcome was Foot and Ankle Ability Measure (FAAM); Activity and Sport, Short Form-36 (SF-36); physical and mental component scores, and Visual Analogue Scale (VAS). The secondary outcomes included tourniquet time, recovery time, and complications. Pre- and post-operative FAAM, SF-36, and Visual Analog Scale were obtained and compared using pair t-test. Results: There were 32 patients (26 male and 6 female) with a mean age of 36.7 years. An average of tourniquet time was 39.6 minutes (range, 23-67 minutes). There was significant improvement of VAS (7.1/10 to 0.1/10), SF-36 (PCS (38.8 to 49.9) and MCS (49.0 to 51.8)), FAAM (Activity, 19.0 to 88.4 and Sport, 0 to 65.6). An average time to return to activity of daily living, works, and sports were 6 weeks, 7 weeks, 3.6 months respectively. The complications included hypertrophic scar without pain (6.7%), superficial wound infection (3%). There was no re-rupture, deep vein thrombosis, sural nerve injury, and painful scar in this study. Conclusion: Endoscopically assisted percutaneous Achilles tendon repair demonstrated significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS. acute rupture of Achilles tendon. This technique is safe and feasible for treatment patients with acute rupture of Achilles tendon

Rigid Syndesmotic Fixation Alters Joint Contact Mechanics and Talar Kinematics

Category: Trauma Introduction/Purpose: The variety of methods available for performing syndesmotic fixation have led to significant controversy about the optimal method of surgical fixation, and the effects of syndesmotic fixation on the biomechanics of the ankle remain poorly understood. The purpose of the present study was to use a cadaveric model to evaluate the effects of progressively increasing syndesmotic fixation on talar motion and contact stress on the talar dome and in the medial and lateral gutters. Methods: Twelve fresh-frozen cadaveric specimens were dissected to expose the ankle joint while leaving ligaments, syndesmosis, and interosseus membrane intact, simulating a best-case fibular reduction. Rigid clusters of reflective markers were attached to the tibia, the distal fibula, and the talus for tracking with a motion capture system. A Tekscan pressure sensor was inserted into the tibiotalar joint (n=6) or into both gutters (n=6) for measuring contact stress. A 600N axial load was applied in a custom-built ankle simulator which permitted free internal/external rotation and inversion/eversion while holding either 20°plantar flexion, 10° plantar flexion, neutral, or 10° dorsiflexion. Specimens were tested without fixation, with one 3.5mm screw, and with two 3.5mm screws. Motion data were rotated into an anatomic reference frame and a fixed center of rotation (CoR) of the talus was calculated in the sagittal plane. Tekscan data were analyzed for changes in peak contact stress and changes in contact area. Results: Antero-posterior translation of the talus was variable with increasing fixation and specimen dependent. A single 3.5mm screw shifted the average CoR posteriorly 0.4 mm, and two 3.5mm screws shifted the average talar CoR anteriorly 1.6mm. Five specimens shifted posteriorly with fixation, while the other specimens moved anteriorly, resulting in extremely large standard deviations of AP movement. Peak contact stress on the talar dome decreased 10%-20% with the addition of syndesmotic fixation. Contact area on the talar dome decreased with increased syndesmotic fixation. Conversely, peak contact stress in the medial and lateral gutters increased with the addition of syndesmotic screws, although the magnitude was substantially lower than peak stresses in the talar dome. Contact areas in both gutters tended to increase with each syndesmotic screw. Conclusion: Fixation of the distal tibiofibular syndesmosis altered the biomechanical behavior of the ankle, generally shifting the talus slightly anteriorly, decreasing the load on the tibiotalar articulation, and increasing medial and lateral gutter contact stress. The specimen-to-specimen variability was noteworthy. While the variability lead to large standard deviations and prevented some mechanical trends from achieving statistical significance, it became very apparent that there are certain individuals who would suffer grossly abnormal ankle mechanics after rigid syndesmotic fixation, and a more aggressive fixation would amplify the mechanical abnormalities

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

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