Posterior Ankle Impingement: Clarification and Confirmation of the Pathoanatomy

Abstract The diagnosis of posterior hindfoo

Medium to Long-Term Results of Non-anatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity with Severe Abduction Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Spring ligament reconstruction (SLR) has been proposed as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity. However, most clinical reports present short-term follow-up data and include only a small number of patients. Recent cadaveric studies have demonstrated that the spring ligament maintains medial tibiotalar stability by forming a large confluent (tibiospring) ligament with the superficial deltoid ligament. Therefore, the purpose of this study was to investigate the medium to long-term results of our nonanatomic tibiospring ligament complex reconstruction using allograft tendon, as an adjunct to other reconstructive procedures in PCFD with severe abduction deformity. This study to our knowledge represents the largest number of patients and the longest follow-up to date. Methods: This study retrospectively reviewed prospectively collected data of 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5- 13.4). The SLR was performed when bony correction with lateral column lengthening (LCL) achieved at least 50% of abduction correction but failed to provide adequate abduction correction under intraoperative fluoroscopy. The tendon graft was positioned from the inferior navicular to the medial malleolus via bone tunnels and screw posts (Figure 1). Radiographic evaluation consisted of five parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure. Results: Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction (Table 1). All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except one patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and one (3.7%) developed non-union of the LCL osteotomy. No patient required conversion to talonavicular or subtalar fusion. Conclusion: This study demonstrates favorable medium- to long-term outcomes, as well as maintenance of the correction, following a nonanatomic tibiospring ligament complex reconstruction using allograft tendon augmentation in addition to other corrective procedures for the surgical treatment of PCFD with severe abduction deformity. As there is growing evidence of the potential for excessive foot stiffness following LCL, a remaining question is whether it is reasonable to use SLR to reduce the amount of LCL needed, as long as the bony procedure achieves at least 50% of the required abduction correction, as described in the current study

Comparison of Juvenile Allogenous Articular Cartilage and Bone Marrow Aspirate Concentrate versus Microfracture in Arthroscopic Treatment of Talar Osteochondral Lesions

Category: Ankle Introduction/Purpose: There are few prior investigations that report the clinical and radiographic outcomes of juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate in the ankle. Reports that do exist have offered conflicting results and suggest that this relatively new technique has no significant advantage over current repair techniques. The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate for treatment of talar osteochondral lesions with those of patients who underwent microfracture. Methods: After approval was obtained from our institutional review board, the institution’s foot and ankle registry was searched using relevant Current Procedural Terminology codes for all patients who underwent either microfracture or juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate for an osteochondral lesion of the talus between 2006 and 2014. Ninety-six patients fit the inclusion criteria and composed the study cohort. Of these 96 patients, 50 had undergone microfracture treatment and 46 had received DeNovo NT for juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate treatment, composing the microfracture (MF) and JACI-BMAC groups, respectively. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Postoperative magnetic resonance (MR) images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Results: The average followup was 40.0 (range 5.0 to 113.6) months with the MF group having an average followup of 40.3 months (range 5 to 133.6) and the JACI-BMAC group averaging a 18.6 month followup (range 9.1 to 39.6). Both the JACI-BMAC and MF groups had significant pre-to-postoperative improvements in Pain, Daily Activities, Sports, Quality of Life, and overall FAOS Scores; however, there were no significant differences in any patient reported outcomes between the groups. SF-12 scores were improved in both JACI-BMAC and MF groups, however the MF change from pre- to-postoperative did not reach significance (p = 0.214). Radiographically, both the JACI-BMAC and MF groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group tended to have more patients with hypertrophy exhibited on MR imaging than the MF group (p = 0.030). Conclusion: Juvenile allogenic chondrocyte implantation and microfracture resulted in improved functional outcomes. However, none of the differences in FAOS scores between groups achieved the minimal clinically important difference, suggesting there may not be enough of a difference between these treatments to distinguish them in terms of patient outcomes in the short term. Both techniques produced reparative tissue that exhibited fibrocartilage composition radiographically. Based on our results, juvenile allogenous cartilage has not demonstrated a significant advantage over the microfracture technique in the treatment of talar osteochondral lesions. Longer term studies will be needed to see if these findings are maintained over time

Cervical Ligament Insufficiency in Progressive Collapsing Foot Deformity: It May Be More Important Than We Know

Category: Hindfoot; Midfoot/Forefoot Introduction/ Purpose: Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if its integrity of it changes with increasing axial plane deformity. We hypothesized that there will be a higher prevalence of cervical ligament insufficiency in a PCFD cohort compared to that of a control group. Additionally, we hypothesized that those with higher degrees of cervical ligament insufficiency will have a more severe abduction deformity and talocalcaneal subluxation. Methods: This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender- matched controls. A radiologist specializing in musculoskeletal disorders evaluated the structural derangement of the cervical ligament into five grades (Grade 0 indicating normal and Grade 4 indicating a tear greater than 50% of the cross-sectional area), as previously described. To compare its involvement in PCFD, two commonly involved ligaments (spring and interosseous) in PCFD were also evaluated. Plain radiographic parameters, including the talonavicular coverage angle (TNC), lateral talo-1st metatarsal (Meary’s) angle, calcaneal pitch, and hindfoot moment arm, as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal), were correlated with the cervical ligament MRI grading system. Results: The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P < .001, Table 1). MRI evidence of a tear (Grades 3 or 4) in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and greater than that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modelling demonstrated a predictive ability of TM-Calc (Odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.06-1.30, p=.004), Diff Calc- Tal (OR: 1.15, 95% CI: 1.06-1.26, p=.002), TNC (OR: 1.08, 95% CI: 1.03-1.13, p=.003), and Meary’s angle (OR: 1.05, 95% CI: 1.02-1.10, p=.006) in determining higher cervical ligament grade on MRI (Figure 1). Conclusion: We found that cervical ligament insufficiency is a significant component of PCFD and is more common than anticipated in this study. Based on the radiographic findings in the current study, cervical ligament insufficiency appears to be primarily associated with axial plane midfoot and hindfoot deformity. If its biomechanical properties are established in the future studies, we think the reconstruction of the cervical ligament may be a potential adjunct surgical procedure for PCFD patients with significant axial plane deformity