Total Ankle Replacement in Cavovarus Deformity: How Far Can We Go?

Because of the good functional results and satisfactory implant survival achieved with modern models, total ankle replacement (TAR) has become a legitimate alternative to ankle fusion. However, alignment and balance are mandatory for implant survival. Satisfactory results can be achieved in patients with significant preoperative deformity if alignment and balance were obtained. If not, a staged procedure involving deformity correction and secondary TAR is possible. The authors describe the principal aspects of this concept and illustrate their current approach to TAR in cavovarus deformity.

C-Nail® locking nail versus conventional plate for thalamic calcaneal fractures.

BACKGROUND: Surgery for displaced intra-articular calcaneal fractures (DIACFs) is often followed by skin complications that adversely impacts the functional outcomes. Minimally invasive techniques have been developed to decrease the risk of skin complications. The objective of this study was to compare C-Nail® locking-nail fixation to conventional plate fixation for DIACFs. HYPOTHESIS: C-Nail® fixation restores calcaneal anatomy similarly to conventional plate fixation and decreases the frequency of skin complications compared to conventional plate fixation, while providing satisfactory functional outcomes. MATERIAL AND METHODS: In this case-control study of DIACFs, fixation was with a non-locking plate in 30 patients treated between January 2016 and June 2017 and with the C-Nail® in 25 patients treated between April 2017 and April 2018. Computed tomography was performed before surgery then bilaterally after surgery for measurements of the following calcaneal parameters: height, length, width, joint-surface step-off and inter-fragmentary distance. The values of these parameters were compared between the two groups. Postoperative skin complications were recorded. The functional outcome was assessed by determining the AOFAS score 1 year after the injury. RESULTS: The two groups showed no significant differences for age, sex or fracture type. Wound healing was delayed in 3 patients in the plate group. The mean postoperative values of the calcaneal parameters were not significantly different between the two groups. The mean AOFAS score was 85.3±10.4 (range, 50-100) in the plate group and 87.0±12.0 (range, 64-100) in the C-Nail® group (p>0.05). DISCUSSION: Minimally invasive C-Nail® fixation provides similar restoration of calcaneal anatomy as does conventional plate fixation. LEVEL OF EVIDENCE: III, retrospective case-control study.

Ankle surgery in 2022: What do the scientific articles say, and what do the patients?

LEVEL OF EVIDENCE: V.

Posteromedial structure protection during ankle replacement: Surgical technique.

Residual pain after ankle replacement may implicate lesions in posteromedial structures, including the posterior tibial pedicle and tendon. The technique described here protects these structures, by positioning a malleable plate via a medial retromalleolar counter-approach. The technique seems not to cause any specific iatrogenicity. We advocate systematic implementation of this kind of protection in ankle replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Impact of preoperative varus on ankle replacement survival.

INTRODUCTION: The severity of a foot or ankle deformity is a major prognostic factor for the success of ankle replacement. Varus deformity is at once the most arthrogenic and the most frequent. HYPOTHESIS: The severity of preoperative varus is a negative factor for ankle replacement survival. MATERIAL AND METHOD: A retrospective study compared results in a continuous series of 57 Salto-Talaris® ankle replacements according to preoperative varus: 31 moderate (5-15̊) and 26 severe (> 15̊). Radiological and clinical assessment at a minimum 1 year focused on complications, revision and implant exchange and on AOFAS score, range of motion and tibiotalar angle at last follow-up. RESULTS: At a mean 2.4 years' follow-up, implant survival in the moderate and severe varus groups was respectively 83% and 92%. Postoperative AOFA score and range of motion improved significantly in both groups, without significant difference. Analysis of cumulative survival showed no significant intergroup difference. DISCUSSION: Severity of preoperative varus did not impact implant survival. Only postoperative alignment and stability emerged as survival factors. These results were related to the quality of associated procedures aiming to reduce deformity and to achieve ligament balance. LEVEL OF EVIDENCE: IV, retrospective comparative study.

Calcaneal osteotomy for hindfoot deformity.

Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis. Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation. We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with: medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot; Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge; lateralizingosteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted. Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited. LEVEL OF EVIDENCE: V; expert opinion.

Ankle dorsiflexion after isolated medial versus complete proximal gastrocnemius recession: A cadaveric study.

PURPOSE: Gastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: (1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk's technique; (2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession. METHODS: A cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro-Wilk test, then measurements were compared in the three conditions with appropriate statistical tests. RESULTS: After isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, -2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, -4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements). CONCLUSION: In this study, isolated medial gastrocnemius head recession performed according to LS Barouk's technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change. LEVEL OF EVIDENCE: Level V, cadaveric study.

Impact of intertibiofibular graft on the ankle joint: Medium-term radiologic and clinical assessment.

HYPOTHESIS: Intertibiofibular graft (ITFG) bridges tibial non-union, but blocks bimalleolar mortise opening, leading to loss of ankle dorsiflexion. The aim of the present study was to assess dorsiflexion loss and to determine whether it was associated with secondary osteoarthritis. Material and method A 2-center retrospective study included cases of tibial non-union, without initial involvement of the ankle, treated by ITFG with more than 2 years' consolidation. Clinical, functional and radiographic parameters were analyzed. Dorsiflexion stiffness was defined as<10° flexion. Symptomatic osteoarthritis was defined by radiologic joint impingement and/or osteophytosis associated with pain>4/10 on visual analog scale (VAS) restricting walking distance to less than 1 kilometer. RESULTS: Thirty-one cases were analyzed at a mean 7±2.8 years' follow-up. Mean pain on VAS was 3±2.6. Mean AOFAS score was 62.3±20.5 and mean SEFAS was 28.3±10.5. Mean dorsiflexion was significantly lower on the ITFG side, at 6.6±7.9° versus 15.1±4.8° on the healthy side. There was dorsiflexion stiffness in 26 cases. No correlation emerged between dorsiflexion stiffness and onset of osteoarthritis. CONCLUSION: Dorsiflexion was the most severely impacted motion. The rate of osteoarthritis was too low for any implication of dorsiflexion loss to be demonstrated, especially in traumatic contexts. LEVEL OF EVIDENCE: IV; retrospective study.

Weight-bearing CT in foot and ankle pathology.

Cone-beam scanners (CBCT) enable CT to be performed under weight-bearing - notably for the foot and ankle. The technology is not new: it has been used since 1996 in dental surgery, where it has come to replace panoramic X-ray. What is new is placing the scanner on the ground, so as to have 3D weight-bearing images, initially of the foot and ankle, and later for the knee and pelvis. This saves time, radiation and money. It is now increasingly used, but is unfortunately limited by not having specific national health insurance cover in France, and by the psychological reticence that goes with any technological breakthrough. A review of the topic is indispensable, as it is essential to become properly acquainted with this technique. To this end, we shall be addressing 5 questions. What biases does conventional radiography incur? Projecting a volume onto a plane incurs deformation, precluding true measurement. Conventional CT is therefore often associated with an increased dose of radiation. What is the impact of CBCT on radiation dose, costs and the care pathway? The conical beam turns around the limb (under weight-bearing if so desired) in less than a minute, making the radiation dose no greater than in standard X-ray. What does the literature have to say about CBCT, and what are the indications? CBCT is indicated in all foot and ankle pathologies, and indications now extend to the upper limb and the knee, and will soon include the pelvis. How are angles measured on this 3D technique? The recently developed concept of 3D biometry uses dedicated software to identify anatomic landmarks and automatically segment the bones, thereby enabling every kind of measurement. What further developments are to be expected? CBCT may become indispensable to lower-limb surgical planning. Artificial Intelligence will reveal novel diagnostic, prognostic and therapeutic solutions. LEVEL OF EVIDENCE: V; expert opinion.

Acute and Chronic Syndesmotic Injury: The Authors' Approach to Treatment.

Ankle injuries are a common traumatic injury. Rupture to the syndesmosis may occur as a result of these injuries. Strategies for the treatment of both acute and chronic syndesmotic repair are reviewed in detail. Significance of Chaput, Wagstaffe, and posterior malleolus fractures on syndesmotic stability are reviewed. Treatment considerations for total ankle arthroplasty are discussed, and correction of coronal plane deformity as a result of late syndesmotic injury at the time of ankle arthroplasty is outlined.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up.

INTRODUCTION: A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ. HYPOTHESIS: The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair. MATERIALS AND METHODS: A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected. RESULTS: Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair. CONCLUSION: Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair. STUDY DESIGN: Review of the literature; level of proof IV.

Patellofemoral joint replacement, an evolving concept.

Isolated patellofemoral arthritis is a rare disease, whose management is challenging and controversial. Patellofemoral joint replacement can be an effective treatment for this condition. The very concept of a patellofemoral implant has evolved throughout the years, resulting in more anatomic designs and reproducible surgical techniques. The clinical outcomes of this procedure are strictly related to surgical indications, implant design and appropriate surgical technique.

Safety and efficiency of a 2-portal lateral approach to arthroscopic subtalar arthrodesis: a cadaveric study.

PURPOSE: To investigate the safety and efficiency of a 2-portal lateral (anterior and middle) approach to arthroscopic subtalar arthrodesis. METHODS: A cadaveric study was performed on 30 feet of 15 fresh cadaveric bodies (15 right and 15 left; 21 female specimens and 9 male specimens). The mean age at death was 78 ± 6.7 years. The procedure was performed with the specimen in the supine position through 2 lateral (anterior and middle) sinus tarsi portals by use of a 4.0-mm arthroscope. A 3.5-mm synovial shaver was used for debridement, and a 4.5-mm shielded bur was used to resect posterior subtalar facets. The feet were then dissected. The primary outcomes were the percentage of resected joint surface and the distances between portals and both sural and superficial peroneal nerves. The secondary outcomes were injury of sinus tarsi ligaments and lateral arterial network, calcaneofibular ligament, peroneal tendons, flexor hallucis longus tendon, and posterior tibial neurovascular bundle. RESULTS: The mean percentages of resected talar and calcaneal posterior subtalar facets were 94% ± 7.2% and 91% ± 6.8%, respectively. The minimum distance of either subtalar portal to the nerves was 4 mm. No nerve injury was observed. In 28 of 30 cases, the lateral sinus tarsi arterial network was found intact. In all cases the inferior retinaculum extensor was transfixed by the portals. In all cases both cervical and interosseous talocalcaneal ligaments were found intact. In 3 cases a shaving lesion was observed on the peroneus brevis tendon. CONCLUSIONS: According to this cadaveric study, more than 90% freshening of the posterior subtalar articular facets can be achieved through a 2-portal lateral (anterior and middle) approach. This technique is reproducible and safe with regard to the surrounding nerves. CLINICAL RELEVANCE: The 2 lateral portals may offer a safe and effective alternative approach for arthroscopic arthrodesis of the posterior subtalar joint.

PTT functional recovery in early stage II PTTD after tendon balancing and calcaneal lengthening osteotomy.

BACKGROUND: The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure. METHOD: The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years. RESULTS: One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation. CONCLUSIONS: The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.

Influence of offset stem couplers in femoral revision knee arthroplasty: a radiographic study.

We questioned whether the use of offset femoral stem would result in modifying the posterior femoral condylar offset (PFCO) in revision knee arthroplasty (RTKA). We measured both PFCO and stem alignment on lateral radiographs of two cohorts: 91 knees with straight stems and 35 knees with offset coupled stems. A higher PCOR was observed in knees with an offset stem compared to knees with straight stem. Knees with an offset stem had a better alignment within the intramedullary canal. Our conclusion is that the use of a modular offset coupler with femoral stem in RTKA compared to a modular straight stem both increases the posterior condylar offset and improves alignment of the stem within the intramedullary canal.

Posteriorly offset femoral component to restore anteroposterior position of the distal femur in revision total knee arthroplasty.

This study is based on a radiographic analysis of 50 cadaveric femurs (26 males, 24 females). The position of a press-fit stemmed revision total knee arthroplasty femoral component was simulated with templates. A diaphyseal engaging stem was templated in 74% of the subjects (23 males, 14 females). Every diaphyseal engaging stem required the use of a posterior offset coupler to achieve engagement in the femoral isthmus. In 26% of femurs (3 males, 10 females), anterior bowing of the distal metaphysis prevented the use of a diaphyseal engaging stem. Our results suggest that males have less flexion of the distal femur than females and can be templated effectively with a diaphyseal engaging posteriorly offset stem, whereas a metaphyseal flexed stemmed component templates better in females.

Measuring patellar height using the lateral active flexion radiograph: Effect of total knee implant design.

Patellar position during knee flexion was studied in 41 patients with bicruciate substituting (BCS), 41 patients with posterior cruciate retaining (CR) and 41 patients with posterior stabilized (PS) TKA's. The perpendicular height of the patella above the tibial tubercle was compared to the length of the patellar tendon on maximum flexion lateral radiographs. BCS knees had greater active flexion compared to PS and CR knees (BCS=124+/-9.8, PS=112+/-9.5, CR=110+/-10.9). In flexion, apparent patella infera (API) or the height of the patella above the tibial tubercle was 3.5% lower than the patellar tendon length for BCS knees, 1.7% lower in PS knees and 0.5% lower in CR knees. API in PS and BCS knees correlated with active knee flexion, but not in CR knees. Our findings indicate that an apparent inferior position of the patella occurs in BCS knees during deep flexion which is not caused by significant patellar ligament shortening or joint line elevation, but associated with normal posterior rollback of the femur.

Magnetic resonance imaging of in vivo patellofemoral kinematics after total knee arthroplasty.

Simulated partial weight bearing during magnetic resonance imaging of the knee was used to measure patellar tilt, medial-lateral patellar shift, and patellofemoral contact area in three groups of subjects; patients with posterior cruciate retaining (PCR) TKA, patients with bicruciate substituting (BCS) TKA, and healthy controls. Contact stress was also calculated based on the contact area and body weight-based estimates of contact force. Contact stress was significantly (p<0.05) higher in PCR knees (2.5+/-3.0 MPa) than in BCS knees (0.2+/-0.1 MPa) when knees were fully extended, but this difference was not significant (3.7+/-3.5 MPa for PCR knees vs. 1.4+/-1.9 MPa for BCS knees; p>0.05) in early flexion. The results also indicate that patellar tilt (normal=2.4 degrees +/-4.8 degrees, BCS=5.5 degrees +/-5.5 degrees, PCR=-3.0 degrees +/-6.9 degrees change in lateral tilt when moving from full extension to early flexion) and contact area (full extension: normal=267+/-111 mm(2), BCS=344+/-201 mm(2), PCR=83+/-80 mm(2); early flexion: normal=723+/-306 mm(2), BCS=417+/-290 mm(2), PCR=246+/-108 mm(2)) in BCS TKA mimic those in the normal knees more closely than PCR knees do. These results suggest that the patellar component in BCS TKA may be expected to experience less wear than the patellar component in PCR TKA over time.

Single medial approach to modified double arthrodesis in rigid flatfoot with lateral deficient skin.

BACKGROUND: Triple arthrodesis through a two-incision approach is the traditional surgical treatment of fixed flatfoot in adults. However, since it limits motion and forces the remaining joints to absorb more load, long-term studies report diminishing results over time from symptomatic breakdown of adjacent joints. In addition, wound-healing problems have been reported in up one-third of patients undergoing a major flatfoot reconstruction which are more commonly associated with the anterolateral approaches. Therefore, since 2003, we have been interested in selective arthrodesis of the subtalar and talonavicular joints sparing the uninvolved calcaneocuboid joint and the lateral skin. MATERIALS AND METHOD: We have performed this procedure in 11 patients (14 feet) who had deficient lateral skin and a fixed hindfoot valgus deformity where adequate correction may have led to lateral wound complication. They were followed in a prospective fashion and assessed at a minimum of 6 months followup. RESULTS: Wound healing occurred without any complications in all cases. Evaluation was performed at an average of 21.5 (range, 6 to 50) months. Significant radiographic improvements were observed on each measurement: anteroposterior talonavicular coverage angle improved from 38.5 degrees to 7 degrees, lateral talo-first metatarsal angle improved from 21 degrees to 0 degrees, hindfoot frontal alignment angle improved from 18 degrees to 7.5 degrees. All patients had an asymptomatic calcaneocuboid joint. CONCLUSION: Arthrodesis of the subtalar and talonavicular joints through a medial approach combined with peroneal lengthening is a reliable procedure for the treatment of rigid flatfoot with deficient lateral skin without calcaneocuboid joint degeneration.

Compartment syndrome with foot ischemia after inversion injury of the ankle.

This article reports the case of a 17-year-old girl who presented with compartment syndrome and acute ischemia of the foot after a minor ankle sprain. The suspected cause of compartment syndrome was secondary emergence of swelling and palsy of the foot. The posterior tibial and dorsalis pedis pulses were nonpalpable. The syndrome was confirmed by measurement of the pressures in the compartments of the foot, which were >30 mm Hg. Foot fasciotomy was successfully performed by using a three-incision technique. In contrast with previous case reports, no bone or vessel lesion was detected to explain the onset of a compartment syndrome. To our knowledge, this is the first case report compartment syndrome of the foot after an isolated minor ankle injury. Physicians should be aware of the possibility of compartment syndrome of the foot emerging irrespective of the severity of the initial trauma.