André Leumann

Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis.

In patients with asymmetric (varus or valgus) ankle osteoarthritis, realignment surgery is an alternative treatment to fusion or total ankle replacement in selected cases. To determine whether realignment surgery in asymmetric ankle osteoarthritis relieved pain and improved function, we clinically and radiographically followed 35 consecutive patients with posttraumatic ankle osteoarthritis treated with lower leg and hindfoot realignment surgery. We further questioned if outcome correlated with achieved alignment. The average patient age was 43 years (range, 26-68 years). We used a standardized clinical and radiographic protocol. Besides distal tibial osteotomies, additional bony and soft tissue procedures were performed in 32 patients (91%). At mean followup of 5 years (range, 3-10.5 years), pain decreased by an average of 4 points on a visual analog scale; range of ankle motion increased by an average of 5°. Walking ability and the functional parts of the American Foot and Ankle Society score increased by an average of 10 and 21 points, respectively, and correlated with achieved reversal of tibiotalar tilt and the score of Takakura et al. Revision surgery was performed in 10 ankles (29%), of which three ankles (9%) were converted to total ankle replacement. We believe the data support realignment surgery for patients with asymmetric ankle osteoarthritis. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Reconstruction of Osteochondral Lesions of the Talus With Autologous Spongiosa Grafts and Autologous Matrix-Induced Chondrogenesis

Background: Osteochondral lesions (OCLs) of the talus are a common entity in sports orthopaedics. There are several operative techniques with a good outcome on follow-up examinations. However, limitations such as sacrificing healthy cartilage (osteochondral autograft transfer system [OATS], mosaicplasty), multiple-stage operative procedures (matrix-induced autologous chondrocyte transplantation [MACI], autologous chondrocyte implantation [ACI]), high costs (ACI, allograft), and limited availability (allograft) do remain and reflect potential drawbacks of the currently used techniques. Purpose: To describe a novel operative technique for the treatment of OCLs of the talus in the form of an economically efficient, 1-step procedure combining OCL debridement, spongiosaplasty, and sealing of the OCL area with a collagen matrix. Study Design: Case series; Level of evidence, 4. Methods: Twenty-six patients underwent surgery receiving a modified autologous matrix-induced chondrogenesis (AMIC)–aided repair of OCLs of the talus consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold. Ligament repair was performed in 17 of 26 cases. A corrective calcaneal osteotomy was performed in 16 of 26 cases. Clinical and radiological assessment was performed before and a minimum of 24 months after surgery (mean, 31 months; range, 24-54 months). Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. Radiological imaging included single-photon emission computed tomography–computed tomography (SPECT-CT) and magnetic resonance imaging (MRI). The magnetic resonance observation of cartilage repair tissue (MOCART) score was applied, and sport activity was documented. Results: The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17-79 points) to 89 points (range, 61-100 points) postoperatively (P < .01). The preoperative pain score averaged 5 (range, 2-8), improving to an average of 1.6 (range, 0-7) postoperatively (P < .01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 62 points (range, 20-95 points). Complete filling of the defect at the level of the surrounding cartilage was found in 35%, and complete filling with a hypertrophic cartilage layer was found in 50% of the patients. Normal signal intensity of the repair tissue compared with the adjacent native cartilage was seen in 15%, with nearly normal activity in 69%. Nineteen patients (73%) participated in sports before the onset of symptoms compared with 3 (12%) at the time of surgery. The number increased to 16 patients (62%) at postoperative follow-up. Conclusion: The modified AMIC procedure is safe for the treatment of OCLs in the ankle with overall good clinical and MRI results.

Autologous matrix-induced chondrogenesis aided reconstruction of a large focal osteochondral lesion of the talus.

The aim of this case report is to describe a novel technique for treatment of large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III membrane.

Chronische Instabilität des oberen Sprunggelenks

ZusammenfassungDie chronische Sprunggelenkinstabilität ist eine typische Pathologie im Sport und entwickelt sich bei 20 bis 40% der Sportler nach erlittener akuter Sprunggelenkdistorsion. Man unterscheidet zwischen einer lateralen und medialen Sprunggelenkinstabilität, wobei die Kombination beider als Rotationsinstabilität des oberen Sprunggelenks bezeichnet wird. Des Weiteren kann pathophysiologisch eine mechanische oder funktionelle Sprunggelenkinstabilität unterschieden werden, die sich durch eine strukturelle Bandläsion bzw. durch eine Schwächung der neuromuskulären Kontrolle manifestiert. Durch die erschwerte Diagnose und eine komplexe Therapie, die oft eine operative Rekonstruktion bedingt, stellt die chronische Sprunggelenkinstabilität für den behandelnden Arzt eine vielschichtige Entität dar. Die vorliegende Übersichtsarbeit erörtert Pathomechanismen, Möglichkeiten der Diagnostik, Indikationen zur konservativen und operativen Therapie sowie potenzielle Langzeitschäden wie die posttraumatisch-ligamentäre Sprunggelenksarthrose.AbstractChronic ankle instability represents a typical sports injury. After an acute ankle sprain 20-40% of the injured develop chronic ankle instability. From an orthopaedic point of view chronic ankle instability can be subdivided into lateral and medial instability or a combination of both, the so-called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of neuromuscular control. For the physician chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy often surgical. This review on chronic ankle instability deals with the pathomechanisms, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, such as ligamentous osteoarthritis.

Direkte anatomische Rekonstruktion des lateralen Bandapparats bei chronischer lateraler Instabilität des oberen Sprunggelenks

F Chronische laterale Sprunggelenksinstabilität mit rezidivierenden lateralen Distorsionsereignissen des oberen Sprunggelenks (OSG), F Versagen einer extensiven konservativen Therapie, F Reduktion der Sportfähigkeit und Lebensqualität, F pathologischer Schubladentest und lateraler Aufklappbarkeitstest, F arthroskopisch nachgewiesene pathologische laterale OSG-Aufklappbarkeit, F elongierte oder rupturierte laterale OSG-Ligamente mit genügend ortständigem Bandmaterial.

Radiographic evaluation of frontal talar edge configuration for osteochondral plug transplantation.

For successful reconstruction of osteochondral lesions of the talus, the anatomic configuration of the talar edge must be respected. This study evaluated the radiographic configuration of the talar edge in the anterior‐posterior (AP) view by analyzing medial and lateral talar edge angles and radii in 81 patients with a true AP view and without ankle pathology. The mean lateral talar edge angle was 91.8°, and the mean medial talar edge angle was 110.0°. The medial frontal talar edge radius was 4.8 mm and the lateral 3.5 mm, respectively. No correlation between angle and radius was found. These results revealed a significant difference between the medial and the lateral talar edge configuration. This may be due to the three‐dimensional function of the human ankle joint. No study so far has addressed these differences radiologically. These differences should be addressed in the reconstruction of osteochondral lesions and be included in the preoperative planning. Clin. Anat. 22:261–266, 2009.

Direct anatomic repair of the lateral ankle ligaments in chronic lateral ankle instability

F Chronische laterale Sprunggelenksinstabilität mit rezidivierenden lateralen Distorsionsereignissen des oberen Sprunggelenks (OSG), F Versagen einer extensiven konservativen Therapie, F Reduktion der Sportfähigkeit und Lebensqualität, F pathologischer Schubladentest und lateraler Aufklappbarkeitstest, F arthroskopisch nachgewiesene pathologische laterale OSG-Aufklappbarkeit, F elongierte oder rupturierte laterale OSG-Ligamente mit genügend ortständigem Bandmaterial.

Altered cell metabolism in tissues of the knee joint in a rabbit model of Botulinum toxin A‐induced quadriceps muscle weakness

Quadriceps muscle weakness is frequently associated with knee injuries in sports. The influence of quadriceps weakness on knee joint homeostasis remains undefined. We hypothesized that quadriceps weakness will lead to tissue‐specific alterations in the cell metabolism of tissues of the knee. Quadriceps weakness was induced with repetitive injections of Botulinum toxin A in six 1‐year‐old New Zealand White rabbits for 6 months. Five additional animals served as controls with injections of saline/dextrose. Muscle weakness was assessed by muscle wet mass, isometric knee extensor torque, and histological morphology analysis. Cell metabolism was assessed for patellar tendon, medial and lateral collateral ligament, and medial and lateral meniscus by measuring the total RNA levels and specific mRNA levels for collagen I, collagen III, MMP‐1, MMP‐3, MMP‐13, TGF‐β, biglycan, IL‐1, and bFGF by reverse transcription and polymerase chain reaction. While the total RNA levels did not change, tissue‐specific mRNA levels were lower for relevant anabolic and catabolic molecules, indicating potential changes in tissue mechanical set points. Quadriceps weakness may lead to adaptations in knee joint tissue cell metabolism by altering a subset of anabolic and catabolic mRNA levels corresponding to a new functional and metabolic set point for the knee that may contribute to the high injury rate of athletes with muscle weakness.

Computer tomographic evaluation of talar edge configuration for osteochondral graft transplantation

To successfully surgically reconstruct osteochondral lesions of the talus, the exact three‐dimensional (3D) configuration of the upper articular surface of the talus has to be respected. We assessed the talar geometry by measuring the coronal and sagittal talar edge radius and the frontal talar profile in multiplanar reconstructions of computer tomographic (CT) studies of 79 patients (83 feet) with a healthy ankle joint. An image visualization software designated for coordinate measurement was used to perform the measurement. In the coronal plane, the mean lateral talar edge radius was 4.0 mm and the medial 4.5 mm. In the sagittal planes the mean lateral talar edge radius was 20.3 mm, the radius of the sulcus 20.7 mm and the medial talar edge radius 20.4 mm. The talus showed a concave shape in coronal cuts. These results show a significant difference between medial and lateral talar edge configuration in coronal planes. The measurements of the lateral and medial sagittal radius and the mid‐sagittal radius in the sulcus tali show no statistically significant difference. The depth of the talar sulcus shows no correlation to age or sex. Different sizes of custom‐made tissue‐engineered grafts according to the location of the osteochondral lesion at the talus are needed for exact surgical reconstruction of the anatomy. Osteochondral lesions are three dimensional; therefore, a 3D preoperative planning tool by CT scan or MRI is mandatory. Clin. Anat. 25:773–780, 2012.

Distinctive pain course during first year after total ankle arthroplasty : a prospective, observational study

Background: Patients and health care professionals alike are often surprised by the course of pain after total ankle arthroplasty (TAA). The current study aimed to determine the baseline patterns of postoperative symptoms during the first year following uncomplicated TAA. Materials and Methods: In a prospective observational study 28 patients with unilateral posttraumatic osteoarthritis were tested for pain with a visual analogue scale, swelling (min grade, 0; max grade, 4), ankle range of motion, and AOFAS ankle score. Assessments were performed preoperatively and 6 weeks, 3, 6, 9, and 12 months after TAA. Results: At 6 weeks all variables had improved significantly. However, at 3 months a relapse with deterioration of mean variables was found. These improved asymptotically during assessments at 6, 9, and 12 months. Conclusion: Our data suggest patients undergoing uncomplicated TAA have to overpass what we believe is an adaptive inflammatory phase with increased periarticular pain and swelling about 3 months after surgery. This distinctive course may influence patient education and increase confidence of healthcare professionals involved in the rehabilitation of TAA patients. Level of Evidence: II, Prospective Observational Study