Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study.

BACKGROUND: Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT. METHODS: A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant. RESULTS: The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023. CONCLUSION: Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT. LEVEL OF EVIDENCE: Level III, retrospective cohort comparative study.

Diagnostic Accuracy of Harris Imprint Index, Chippaux-Smirak Index, Staheli Index Compared With Talar-First Metatarsal Angle for Screening Arch of Foot.

OBJECTIVE: To determine the diagnostic accuracy and reliability of the Harris imprint index (HII), Chippaux-Smirak index (CSI), and Staheli index (SI) compared with the talar-first metatarsal angle. METHODS: Data was collected at the orthotic and prosthetic clinic, Thammasat University Hospital from January 1, 2016 to August 31, 2020. The three footprints were measured by the rehabilitation physician and the orthotist. The talar-first metatarsal angle was measured by the foot and ankle orthopaedist. RESULTS: The data from 198 patients with 274 feet was analyzed. The diagnostic accuracy of the footprint triad showed that CSI was the most accurate in pes planus prediction, followed by HII and SI (area under the receiver operating characteristic curve [AUROC]=0.73, 0.68, 0.68, respectively). In pes cavus, HII was the most accurate, followed by SI and CSI (AUROC=0.71, 0.61, 0.60, respectively). For pes planus, the intra-observer reliability by Cohen's Kappa was 0.92 for HII, 0.97 for CSI, and 0.93 for SI, the inter-observer reliability 0.82, 0.85, and 0.70, respectively. For pes cavus, the intra-observer reliability was 0.89 for HII, 0.95 for CSI, and 0.79 for SI, inter-observer reliability of 0.76, 0.77, and 0.66, respectively. CONCLUSION: The accuracy of HII, CSI, and SI was fair in screening of pes planus and pes cavus. The intra- and inter-observer reliability were in the moderate to almost perfect range by Cohen's Kappa.

Conventional vs Accelerated Rehabilitation Protocol Following Reattachment of Achilles Tendon for Insertional Achilles Tendinopathy.

BACKGROUND: No studies have compared early vs conventional postoperative weightbearing following suture bridge Achilles tendon reattachment. We, therefore, evaluated postoperative functional outcomes in these patients. METHODS: We collected data on 49 patients who underwent surgical treatment of insertional Achilles tendinopathy using a central Achilles tendon-splitting approach and reattachment with suture bridge technique by a single surgeon. Functional outcomes were measured by a visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36) at 3, 6, and 12 months postoperatively. The differences in outcomes were analyzed using multiple linear regression. RESULTS: Eighteen and 31 patients underwent the conventional and accelerated protocols, respectively; their corresponding mean ages were similar, 53 and 57 years, as were all other baseline characteristics. The mean scores (conventional vs accelerated group) for VAS for pain, FAAM, and SF-36 in the conventional group at 3 months postoperatively were 4 ± 1 vs 3 ± 1 points, 53 ± 8 vs 68 ± 3 points, and 57 ± 15 vs 67 ± 10 points (P < .05 for each comparison). There were no statistically significant differences between the groups at 6 and 12 months postoperatively. All patients could perform the single heel raise test at 6 months, and none experienced complications. CONCLUSION: In this small study, short-term functional outcomes were better in the accelerated group. More data are needed before the accelerated program can be recommended. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Radiographic parameters in gravity stress view of the ankle: Normative data.

BACKGROUND: In rotational ankle injury with isolated fibular fracture, deltoid integrity is important for determining stability of ankle. Medial clear space and superior clear space in gravity stress view are parameters widely used to predict deltoid ligament tear. The purpose of this study is to report radiographic parameters in gravity stress view in normal population. METHODS: 120 persons were enrolled. Non weight-bearing ankle mortise and gravity stress view were obtained. Radiographic measurements were made by 2 investigators, including medial clear space (MCS), superior clear space (SCS), tibiofibular overlaps, tibiofibular clear space and talocrural angle. Statistical analysis included mean, mean difference, SD, 95%CI, paired T-test were calculated and subgroup analysis by foot length. Intraclass correlation coefficients were used to determine intra/interobserver reliability of measurement. RESULTS: Mean MCS in gravity stress view was 3.19mm (95%CI 3.1-3.31). This compared to mean MCS of 3.01mm (95%CI 2.9-3.12) in mortise view which was statistically significant (P=0.02). Mean difference was 0.18mm (95%CI 0.07-0.3). SCS in gravity stress view was 3.29mm (95%CI 3.19-3.39) and when compared to MCS in gravity stress view, no statistical significance was found (P=0.158). Mean difference was 0.1mm (95%CI 0.03-0.21). In subgroup analysis by foot length, no significant difference was found in any parameters. CONCLUSIONS: This study provides normative radiographic data for a gravity stress radiograph and supports that if measurable MCS >4mm on gravity stress view, it should be aware of an unstable ankle in supination-external rotation injury.

The new intra-articular calcaneal fracture classification system in term of sustentacular fragment configurations and incorporation of posterior calcaneal facet fractures with fracture components of the calcaneal body.

OBJECTIVE: The aim of this study was to develop a new calcaneal fracture classification system which will consider sustentacular fragment configuration and relation of posterior calcaneal facet to calcaneal body. METHODS: The new classification system used sustentacular fragment configuration and relation of posterior calcaneal facet fracture with fracture components of calcaneal body as key aspects of main types and subtypes. Between 2000 and 2014, 126 intraarticular calcaneal fractures were classified according to the new classification system by using computed tomography images. The new classification system was studied in term of reliability, correlation to choices of treatment, implant fixation and quality of fracture reduction. RESULTS: Types of sustentacular fragment comprised type A, B and C. Type A sustentacular fragment included sustentacular tali containing middle calcaneal facet. In Type B and C fractures sustentacular fragment included medial aspect and entire posterior calcaneal facet as a single unit, respectively. The fractures with type A, B and C sustentacular fragments were classified as main type A, B and C intra-articular calcaneal fractures. The main type A and B comprised 4 subtypes. Subtypes A1, A3, B1, and B3 associated with avulsion and bending fragments of calcaneal body. Subtype A2, B2, and B4 associated with burst calcaneal body. Subtype B4 was not found in the study. Main type C had no subtype and associated with burst calcaneal body. The data showed good reliability. CONCLUSION: The study showed that our new intra-articular calcaneal fracture classification system correlates to choices of treatment, implant fixation and quality of fracture reduction. LEVEL OF EVIDENCE: Level IV, Study of Diagnostic Test.

Validity and Reliability of Thai Version of the Foot and Ankle Ability Measure (FAAM) Subjective Form.

BACKGROUND: Self-administered questionnaires have become an important aspect for clinical outcome assessment of foot and ankle-related problems. The Foot and Ankle Ability Measure (FAAM) subjective form is a region-specific questionnaire that is widely used and has sufficient validity and reliability from previous studies. OBJECTIVE: Translate the original English version of FAAM into a Thai version and evaluate the validity and reliability of Thai FAAM in patients with foot and ankle-related problems. MATERIAL AND METHOD: The FAAM subjective form was translated into Thai using forward-backward translation protocol. Afterward, reliability and validity were tested. Following responses from 60 consecutive patients on two questionnaires, the Thai FAAM subjective form and the short form (SF)-36, were used. The validity was tested by correlating the scores from both questionnaires. The reliability was adopted by measuring the test-retest reliability and internal consistency. RESULTS: Thai FAAM score including activity of daily life (ADL) and Sport subscale demonstrated the sufficient correlations with physical functioning (PF) and physical composite score (PCS) domains of the SF-36 (statistically significant with p < 0.001 level and ≥ 0.5 values). The result of reliability revealed highly intra-class correlation coefficient as 0.8 and 0.77, respectively from test-retest study. The internal consistency was strong (Cronbach alpha = 0.94 and 0.88, respectively). CONCLUSION: The Thai version of FAAM subjective form retained the characteristics of the original version and has proved a reliable evaluation instrument for patients with foot and ankle-related problems.

Validation and reproducibility of a biplanar imaging system versus conventional radiography of foot and ankle radiographic parameters.

BACKGROUND: Diagnosis of foot deformities is frequently supported by objective measures of bony alignment made on AP and lateral weight-bearing radiographs. The EOS biplanar imaging system has the capability of simultaneously capturing orthogonal AP and lateral images of the foot during weight-bearing with reduced radiation exposure. The purpose of this study was to evaluate the validity and reproducibility of common foot and ankle radiographic measurements made on images acquired with the EOS biplanar imaging system. METHODS: Fifty consecutive patients indicated for foot and ankle realignment surgeries were enrolled. Radiographic studies included conventional AP and lateral ankle weight-bearing radiographs and long-leg AP and lateral weight-bearing images acquired using the EOS system with both a staggered feet and a nonstaggered feet position. Sixteen radiographic parameters of foot, ankle, and lower limb alignment were measured by 2 blinded observers, with 1 observer repeating all measurements 6 weeks later. Inter- and intraobserver reliability was assessed using intraclass correlation coefficients. Between-group comparison was assessed using Pearson correlation coefficients, ANOVA, and paired t-tests. RESULTS: There was no statistically significant difference in any commonly used foot and ankle radiographic parameters measured on conventional radiographs or EOS images acquired with staggered and nonstaggered feet (ANOVA P = .792 to .997 and paired t tests P = .067 to .977). However, the staggered foot position resulted in significantly different limb length measurements in the rear leg (P = .000 to .049). Intra- and interrater reliabilities of limb alignment measurements from EOS system images were excellent in both foot positions (ICC = .938 to 1.000). CONCLUSION: Images acquired using EOS biplanar imaging system allowed for valid and reliable measurement of commonly used foot and ankle radiographic parameters; however, the staggered foot position required for simultaneous imaging of both feet in the lateral view affected limb length measurements in the rear leg. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Endoscopic Gastrocnemius Recession for the Treatment of Isolated Gastrocnemius Contracture: A Prospective Study on 320 Consecutive Patients.

BACKGROUND: Endoscopic gastrocnemius recession has been proposed as a minimally invasive technique for the treatment of isolated gastrocnemius contracture. We report on the safety and efficacy of endoscopic gastrocnemius recession, as an isolated procedure or combined with other concomitant procedures in terms of improvement in ankle dorsiflexion, functional outcome, and postoperative morbidities. METHODS: The data were prospectively collected in this case series. Endoscopic gastrocnemius recession was performed by a single surgeon in 320 consecutive patients (344 feet) who were diagnosed with isolated gastrocnemius contracture and failed nonoperative treatments between March 2009 and December 2012. There were 180 women and 140 men with mean age, 47.1 ± 15.7 years. The minimum follow-up was 1 year (mean, 18 months; range, 12 to 53 months). Pre- and postoperative ankle dorsiflexion, pain (Visual Analog Scale [VAS]), SF-36, and Foot Function Index (FFI) were obtained and compared using paired sample t test and Wilcoxon signed-rank test. RESULTS: The mean ankle dorsiflexion significantly improved from -0.8 ± 5.4 degrees preoperatively to 11.0 ± 6.6 degrees at average of 13 months postoperatively (n = 294) (P < .001). Complete preoperative and 1-year postoperative pain (VAS) (n = 274) and functional outcome scores (n = 185) were collected when possible. The mean pain (VAS) decreased from 7/10 to 3/10 postoperatively (all P < .01). The mean SF-36 including physical component summary score (PCS) and mental component summary score (MCS) increased from 34 and 44 to 45 and 51, respectively (P < .01 for both PCS and MCS). The mean FFI improved from 63 to 42 for pain, 63 to 43 for disability, 68 to 44 for activity limitation, and 61 to 41 for total score postoperatively (all P < .01). Postoperative morbidity included weakness of ankle plantarflexion (N = 11/320; 3.1% respectively) and sural nerve dysesthesia (N = 10/320; 3.4%). Wound complications or Achilles tendon rupture did not occur. There was no difference in the average improvement in ankle dorsiflexion, outcome scores, and rate of complications between the isolated and combined procedures. CONCLUSION: Endoscopic gastrocnemius recession demonstrated promising results in the treatment of isolated gastrocnemius contracture. Ankle dorsiflexion was significantly improved with minimal morbidity. The procedure was found effective in improving functional outcomes and relieving pain as a sole operative treatment and as a part of combined procedures in our patients. LEVEL OF EVIDENCE: Level IV, case series.

Tripod Index: diagnostic accuracy in symptomatic flatfoot and cavovarus foot: part 2.

BACKGROUND: The Tripod Index (TI) has been created to allow assessment of complex foot deformities. It utilizes tripod relationship between center of the heel, medial/lateral borders of the forefoot, and compare it to the center of the talar head. This study aimed to verify diagnostic accuracy of the TI in symptomatic flatfoot and cavovarus foot. METHODS: Weightbearing radiographs including foot AP with a hemispherical marker around the heel, lateral, and hindfoot alignment views were obtained on 91 patients (110 feet) presenting with medial foot and ankle pain and on 89 patients (90 feet) presenting with lateral foot and ankle pain between June 2010 and May 2011. Radiographs were evaluated blindly for the TI, AP talonavicular coverage angle, lateral talo-first metatarsal angle, calcaneal pitch angle, medial cuneiform-fifth metatarsal height, and coronal plane hindfoot alignment. The sensitivity, specificity, likelihood ratios, and predictive values were calculated. Clinically diagnosed flatfoot and cavovarus foot deformity indicated for surgical reconstruction by one of our foot and ankle orthopaedic surgeons was used as the accepted standard for diagnosis. RESULTS: In flatfoot, sensitivity of the TI was 100%, comparable with lateral talo-first metatarsal angle (100%), and medial cuneiform-fifth metatarsal height (100%). Specificity of the TI was 93%, comparable with coronal plane hindfoot alignment (98%), but superior to other parameters. Positive likelihood ratio of the TI was 14.29, which was less than coronal plane hindfoot alignment (47.5), but more than other parameters. In cavovarus foot, sensitivity of the TI was 96%, comparable with coronal plane hindfoot alignment (100%), but superior to other parameters. Specificity of the TI was 95%, comparable with lateral talo-first metatarsal angle (94%), but superior to other parameters. Positive likelihood ratio of the TI was 19.2, which was more than other parameters. CONCLUSION: The Tripod Index showed high accuracy as a quantitative assessment in diagnosis of a symptomatic flatfoot and cavovarus foot.

Replication of chronic abnormal cartilage loading by medial meniscus destabilization for modeling osteoarthritis in the rabbit knee in vivo.

Medial meniscus destabilization (MMD) is a surgical insult technique for modeling osteoarthritis (OA) by replicating chronic abnormal cartilage loading in animal joints in vivo. The present study aimed to characterize the immediate biomechanical effects (ex vivo) and short-term histological consequences (in vivo) of MMD in the rabbit knee. In a compressive loading test, contact stress distribution in the medial compartment was measured in eight cadaver rabbit knees, initially with all major joint structures uninjured (Baseline), after MMD, and finally after total medial meniscectomy (TMM). Similarly, the effects on sagittal joint stability were determined in an anterior-posterior drawer test. These biomechanical (ex vivo) data indicated that both MMD and TMM caused significant (p < 0.001), distinct (>1.5-fold) elevation of peak local contact stress in the medial compartment, while leaving whole-joint stability nearly unchanged. Histological consequences in vivo were assessed in a short-term (8-week) survival series of MMD or TMM (five animals for each group), and both caused moderate cartilage degeneration in the medial compartment. The MMD insult, which is feasible through posterior arthrotomy alone, is as effective as TMM for modeling injurious-level chronic abnormal cartilage loading in the rabbit knee medial compartment in vivo, while minimizing potential confounding effects from whole-joint instability.

Tripod index: a new radiographic parameter assessing foot alignment.

BACKGROUND: No single radiographic measurement takes into account complete foot alignment. We have created the Tripod Index (TI) to allow assessment of complex foot deformities using a standing anteroposterior (AP) radiograph of the foot. We hypothesized that TI would demonstrate good intraobserver and interobserver reliability and correlate with currently accepted radiographic parameters, in both flatfoot and cavovarus foot deformities. METHODS: Three groups of patients were studied: 26 patients (30 feet) with flatfoot, 29 patients (30 feet) with cavovarus foot, and 51 patients (60 feet) without foot deformity as controls. Weight-bearing radiographs were obtained: foot AP with a hemispherical marker around the heel plus standard lateral and hindfoot alignment views. Radiographic measurements were made by 2 blinded investigators. Statistical analysis included intraclass correlation coefficients (ICCs), correlation of the TI with existing radiographic measurements using Pearson coefficients, and comparison between patient groups using analysis of variance. RESULTS: Intraobserver and interobserver ICCs of TI (0.99 and 0.98, respectively) were excellent. In the flatfoot group, TI significantly correlated with AP talonavicular coverage angle (r = 0.43), medial cuneiform-fifth metatarsal height (r = -0.59), coronal plane hindfoot alignment (r = 0.53), and clinical hindfoot alignment (r = 0.39). In the cavovarus foot group, TI correlated significantly with AP talonavicular coverage angle (r = 0.77), calcaneal pitch angle (r = 0.39), medial cuneiform-fifth metatarsal height (r = -0.65), coronal plane hindfoot alignment (r = 0.55), and clinical hindfoot alignment (r = 0.61). Statistically significant differences between flatfoot-control and cavovarus foot-control were found in TI, AP talonavicular coverage angle, lateral talo-first metatarsal angle, calcaneal pitch angle, medial cuneiform-fifth metatarsal height, coronal plane hindfoot alignment, and clinical assessment of hindfoot alignment (all with P < .001). CONCLUSION: The TI was demonstrated to be a valid and reliable radiographic measurement to quantify the magnitude of complex foot deformities when evaluating flatfoot and cavovarus foot. CLINICAL RELEVANCE: The TI may be helpful as an integrated assessment of complex foot deformities. Further clinical studies are recommended. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Level of undercarboxylated osteocalcin in hip fracture Thai female patients.

The undercarboxylated osteocalcin (ucOC) level is increased in the elderly and postmenopausal women compared with the young, healthy, and reproductive women. The high level of serum UcOC reflects the vitamin K2 deficiency which not only results in high skeletal turnover, low bone quality, and low bone density, but also increases a risk of fracture. The objective of the study is to measure the ucOC level, the 25-hydroxy vitamin D (25(OH)D) levels, and the prevalence of vitamin K2 and vitamin D deficiency in Thai female patients with hip fracture. The serum UcOC and 25(OH)D levels of the 40 female patients with hip fracture (the mean age 77.2 +/- 9.7 years) were measured and compared to the control group of the 47 randomly selected female volunteers (the mean age 75.2 +/- 8.1 years) without osteoporosis-related problems. The serum level of UcOC (median) in the female patients with hip fracture was significantly higher than the control group (p = 0.0001). Fifty-three percent had the serum UcOC level above the cut-off point at 2.314 ng/ml and 83% had lower serum 25(OH)D than the cut-off point at 30 ng/ml. The serum UcOC levels; however, were not correlated with 25(OH)D levels (r = 0.191, p = 0.237). The high prevalence of vitamin K2 and vitamin D deficiency was found in the Thai female patients with hip fracture. The additional treatment with vitamin K2 supplement besides calcium and vitamin D is a beneficial effect for osteoporosis.

Arthroscopic loose body removal after hip fracture dislocation: experiences in 7 cases.

OBJECTIVE: The aims of the present study were to describe the technique of hip arthroscopy for osteochondral loose body removal after posterior hip dislocation and report its preliminary results. MATERIAL AND METHOD: We reported consecutive patients undergoing hip arthroscopy for osteochondral fragment after sustaining fracture-dislocations. Seven patients who sustained traumatic hip dislocation with incarcerated osteochondral were included in this study. All patients had standard AP pelvis x-rays and 3D-CT scans. After closed reduction, all patients underwent hip arthroscopy in which loose bodies were removed and labral pathology debrided. RESULTS: The mean follow-up was 15.7 months. The average Harris Hip Score was 89.8. No patient developed any of the complications commonly associated with arthrotomy including avascular necrosis, heterotopic ossification, and nerve injury. CONCLUSION: Arthroscopic treatment of intra-articular loose bodies after hip fracture-dislocations allows excellent visualization of the joint and facilitated straightforward removal of the fragment.

The accuracy of preoperative templating in total knee arthroplasty.

OBJECTIVE: Radiographic templates have been developed to assist with the preoperative planning process. However, the clinical usefulness of preoperative templating in total knee replacement is still lacking. The present study aims to evaluate the accuracy of preoperative templating in primary total knee replacement. MATERIAL AND METHOD: A retrospective study of 98 patients and 113 knees was carried out. Both the anteroposterior and lateral radiographic views were templated using the templates for DePuy Sigma PFC, fixed bearing total knee system and the template size was documented for each patient pre-operatively. The operative records were then reviewed to determine the size of the implant used during the operation. RESULTS: The overall accuracy between the preoperative template size and the final implant size was 50.4% for the femoral component and 55.8% for the tibial component. The highest prediction for tibial assessment was the anteroposterior view and the lateral intercondylar view for femoral assessment. CONCLUSION: Approximately 50% of the patients had a preoperative template size that matched the actual implant used. Many factors influence the final choice of the prosthesis used during total knee replacement; therefore, the preoperative template size can only be used as a rough guide.