Emerging National Trends in Ankle Prosthesis: A 15-Year Analysis of the Italian National Hospital Discharge Records.

Total ankle replacement (TAR) has gained popularity in recent years becoming the mainstream treatment for conditions like rheumatoid arthritis, posttraumatic arthritis and severe osteochondral lesions of the talus. The aim of the study was to assess the nationwide number of implants performed in a 15-year period (2001-2016) and to identify trends like patients' interregional migratory flows and their accessibility to this procedure. Data for this study were obtained from the Italian National Hospital Discharge records (SDO), obtained from the National Ministry of Health. The selected SDOs were evaluated for demographic data, like the patient's age and gender, for geographical data, including the region of hospitalization and the region of origin of the patient, and for hospitalization data, like the hospital stay length and the principal source of payment. In a 15-year span, a sharp increase in the number of TARs was observed with a 600% growth. The incidence was 0.16 per 100,000 persons in 2001 and increased to 0.915 per 100,000 persons in 2016. Most TAR were performed in northern Italy (73.9%), followed by central Italy (16.7%) and lastly southern Italy (9.4%). The rates of utilization of TAR increased every year from 2001 to 2016, indicating that demand for ankle arthroplasties is growing faster regarding to other procedures performed in Italy. The surgical cost was covered, in the majority of cases, by the National Health System and may play a role in the rising rates of TAR.

Posterior Tibial Tendon Dislocation: A Case Report.

Isolated posterior tibial tendon dislocation is a rare condition. Diagnosis can be challenging, especially in the acute clinical setting. Predisposing factors include shallow posterior tibial tendon groove and tear of the flexor retinaculum. We report the case of traumatic subluxation of the posterior tibial tendon, illustrating imaging findings and surgical technique. Posterior tibial tendon dislocation was detected using dynamic ultrasound, while magnetic resonance was essential for a comprehensive evaluation that included underlying predisposing anatomic abnormalities and associated pathologic conditions. Conservative treatment is often unsuccessful thus surgical approach was needed. Under ampliscopic guidance, a bone tunnel was created behind the retromalleolar groove. The posterior tibial tendon was located into the new groove and the retinaculum was re-attached and tightened by anchors and absorbable sutures at the anterior margin of the sulcus. At 12-month follow-up, the patient did not complain any residual pain and he was able to perform normal daily activities without any limitations and with no further tendon dislocations.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses.

PURPOSE: No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses. METHODS: Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes. RESULTS: Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters. CONCLUSION: Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

Return to sport activities after subtalar arthroereisis for correction of pediatric flexible flatfoot.

The aim of this study was to establish whether children treated with subtalar arthroereisis for flexible flatfoot were able to return to sport activities. We reviewed 49 patients with a mean age at the time of surgery of 10.7 years. The type of sport activities, the number of sessions per week, the time dedicated to each session, and the level achieved were assessed preoperatively and at the last follow-up. Overall, 45 patients returned to sports after surgery. Surgery did not alter the duration, frequency, and type of sporting activities, but the participation in physical activities as well as the emotional status and footwear issues improved.

Validation of the Italian version of the Oxford Ankle Foot Questionnaire for children.

PURPOSE: The purpose of this study was to translate the Oxford Ankle Foot Questionnaire (OAFQ) into Italian, to perform a cross-cultural adaptation and to evaluate its psychometric properties. METHODS: The Italian OAFQ was developed according to the recommended forward/backward translation protocol and evaluated in pediatric patients treated for symptomatic flatfoot deformity. Feasibility, reliability, internal consistency, construct validity [comparing OAFQ domains with Child Health Questionnaire (CHQ) domains] and responsiveness to surgical treatment were assessed. RESULTS: A total of 61 children and their parents were enrolled in the study. Results showed satisfactory levels of internal consistency for both children and parent forms. The test-retest reliability was confirmed by high ICC values for both child and parents subscales. Good construct validity was showed by patterns of relationships consistent with theoretically related domains of the CHQ. After surgery, the mean OAFQ scores improved in all the domains after treatment with the subtalar arthroereisis, for both children and parent scales (p < 0.01). Effect size ranged from small to moderate for almost all domains. CONCLUSIONS: The Italian version of the OAFQ might be a reliable and valid instrument in order to evaluate interventions used to treat children's foot or ankle problem, but needs further study on different clinical settings.

Recreational Sports Activities After Calcaneal Fractures and Subsequent Subtalar Joint Arthrodesis.

Subtalar joint arthrodesis is a common treatment for the management of hindfoot pathologic entities. Despite pain reduction, hindfoot stiffness is a common concern of active patients, who wish to continue or start exercising for fitness. The purpose of the present retrospective observational clinical study was to assess the rate and type of recreational sports activities in patients before and after subtalar joint arthrodesis and to correlate the clinical outcome and the level of sports activities. In 33 patients (22 males, 11 females) treated with subtalar joint arthrodesis, the pre- and postoperative participation in sports and recreational activities was evaluated. The American Orthopaedic Foot and Ankle Society hindfoot scale score, 36-item Short Form Health Survey, and a visual analog scale for pain were used as clinical outcome measures. The weekly session number, session time, and interval to activity recovery after surgery were registered. Patients with a subtalar joint arthrodesis returned to a satisfactory level of activity postoperatively. The sports participation almost reached levels similar to those preoperatively but with a shift from high- to low-impact activities.

Treatment of bone marrow edema of the talus with pulsed electromagnetic fields: outcomes in six patients.

BACKGROUND: Bone marrow edema (BME) of the talus is a rare, mostly self-limiting cause of foot and ankle pain. We sought to investigate in patients with idiopathic BME of the talus the effectiveness of pulsed electromagnetic fields and to determine the effect of this therapy on magnetic resonance imaging findings. METHODS: Six patients with BME of the talus confirmed by magnetic resonance imaging were enrolled. Pain was quantified with a visual analog scale from 0 (no pain) to 10 (the worst pain imaginable). The clinical outcome was assessed using the American Orthopaedic Foot and Ankle Society scoring system. Treatment consisted of pulsed electromagnetic field stimulation 8 h/d for 30 days. The device used generated pulses 1.3 milliseconds in duration, with a frequency of 75 Hz and a mean ± SD induced electric field of 3.5 ± 0.5 mV. RESULTS: The mean American Orthopaedic Foot and Ankle Society score improved from 59.4 (range, 40-66) before treatment to 94 (range, 80-100) at the last follow-up. The visual analog scale score decreased significantly from 5.6 (range, 4-7) before treatment to 1 (range, 0-2) at the last follow-up. Magnetic resonance imaging showed that BME improved after 1 month of treatment and resolved completely within 3 months in 5 patients, with normal signal intensity and no signs of progression to avascular necrosis. CONCLUSIONS: A significant reduction in BME area was associated with a significant decrease in pain within 3 months of beginning treatment.

Acute rupture of the tibialis posterior tendon without fracture: a case report.

The acute rupture of the tibialis posterior (TP) tendon, compared to an acute rupture of the Achilles tendon, is a quite uncommon disease to be diagnosed in the emergency department setting. In most cases symptoms related to a TP dysfunction, like weakness, pain along the course of the tendon, swelling in the region of the medial malleolus, and the partial or complete loss of the medial arch with a flatfoot deformity precede the complete rupture of the tendon. In this case report, we describe an acute rupture of the TP tendon following a pronation-external rotation injury of the ankle with no association of a medial malleolus fracture and with no history of a prior flatfoot deformity or symptoms.

Reliability, validity and responsiveness of the Italian version of the Foot Function Index in patients with foot and ankle diseases.

PURPOSE: The purpose of this study was to translate the Foot Function Index (FFI) into Italian, to perform a cross-cultural adaptation and to evaluate the psychometric properties of the Italian version of FFI. METHODS: The Italian FFI was developed according to the recommended forward/backward translation protocol and evaluated in patients with foot and ankle diseases. Feasibility, reliability [intraclass correlation coefficient (ICC)], internal consistency [Cronbach's alpha (CA)], construct validity (correlation with the SF-36 and a visual analogue scale (VAS) assessing for pain), responsiveness to surgery were assessed. The standardized effect size and standardized response mean were also evaluated. RESULTS: A total of 89 patients were recruited (mean age 51.8 ± 13.9 years, range 21-83). The Italian version of the FFI consisted in 18 items separated into a pain and disability subscales. CA value was 0.95 for both the subscales. The reproducibility was good with an ICC of 0.94 and 0.91 for pain and disability subscales, respectively. A strong correlation was found between the FFI and the scales of the SF-36 and the VAS with related content, particularly in the areas of physical function and pain was observed indicating good construct validity. After surgery, the mean FFI improved from 55.9 ± 24.8 to 32.4 ± 26.3 for the pain subscale and from 48.8 ± 28.8 to 24.9 ± 23.7 for the disability subscale (P < 0.01). CONCLUSIONS: The Italian version of the FFI showed satisfactory psychometric properties in Italian patients with foot and ankle diseases. Further testing in different and larger samples is required in order to ensure the validity and reliability of this score.

Current strategies of tissue engineering in talus chondral defects.

Due to the nature of articular cartilage of being poorly vascularized the capabilities of self repair are limited. Mesenchymal stem cells transplantation is a modern technique which has been developed after the high success rates obtained by microfracturing and drilling techniques which promote the release of growth factors and the infiltration of bone marrow derived cells in the lesion. In order to increase the concentration of bone marrow derived cells appropriate devices, the scaffolds, are necessary. These three dimensional constructs mimic the physiological ambient of chondrogenesis.The race for new scaffold materials, which will show high biocompatibility to prevent inflammatory response, high cellular adhesion properties with three dimensional architecture, high bioactivity to deliver growth factor appropriately and possibly high biodegrability has just begun. New studies will concentrate on the role, on the interaction and on the temporal sequence of growth factors to improve ostheocondral differentiation, but the necessity to increase the number of clinical studies with more patients and longer follow ups seems mandatory. The aim of this review is to update and summarise the evidence-based knowledge of treatment of talus chondral defect with new tissue engineering techniques.