Geert Pagenstert

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.

Knee-to-Ankle Mosaicplasty for the Treatment of Osteochondral Lesions of the Ankle Joint

BACKGROUND Osteochondral lesions are frequently seen in athletes after ankle injuries. At this time, osteochondral autologous transplantation (OATS, mosaicplasty) is the only surgical treatment that replaces the entire osteochondral unit in symptomatic lesions. PURPOSE To evaluate the clinical and radiological midterm to long-term outcome of ankles treated with knee-to-ankle mosaicplasty. STUDY DESIGN Case series; Level of evidence, 4. METHODS Clinical evaluation consisted of patient satisfaction, pain evaluation (visual analog scale [VAS]), American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, sports activity score, range of motion, the radiological evaluation of magnetic resonance imaging (MRI), and single photon emission computed tomography-computed tomography (SPECT-CT) analysis of both the ankle and the knee joint. RESULTS Twelve of 21 patients (mean age, 43 years; male, 8; female, 4) were available for latest follow-up (mean, 72 months). At follow-up, patients reported a satisfaction rate of good to excellent in 92% (n = 11) and poor in 8% (n = 1). The average VAS pain score was 3.9 (preoperative, 5.9; P = .02), AOFAS ankle score significantly increased from 45.9 to 80.2 points (P < .0001), sports activity score remained significantly decreased with 1.25 (preinjury level, 2.3; P = .035), and ankle dorsiflexion was significantly reduced (P = .003). Knee pain was reported in 6 patients (50%). Radiologically, recurrent lesions were found in 10 of 10 cases (100%) and some degree of cartilage degeneration and discontinuity of the subchondral bone plate in 100%. CONCLUSION Indications for mosaicplasty with a plug transfer from the knee to the talus must be considered carefully, as at midterm, moderate outcome and considerable donor-site morbidity may be found.Background Osteochondral lesions are frequently seen in athletes after ankle injuries. At this time, osteochondral autologous transplantation (OATS, mosaicplasty) is the only surgical treatment that replaces the entire osteochondral unit in symptomatic lesions. Purpose To evaluate the clinical and radiological midterm to long-term outcome of ankles treated with knee-to-ankle mosaicplasty. Study Design Case series; Level of evidence, 4. Methods Clinical evaluation consisted of patient satisfaction, pain evaluation (visual analog scale [VAS]), American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, sports activity score, range of motion, the radiological evaluation of magnetic resonance imaging (MRI), and single photon emission computed tomography–computed tomography (SPECT-CT) analysis of both the ankle and the knee joint. Results Twelve of 21 patients (mean age, 43 years; male, 8; female, 4) were available for latest follow-up (mean, 72 months). At follow-up, patients reported a satisfaction rate of good to excellent in 92% (n 5 11) and poor in 8% (n 5 1). The average VAS pain score was 3.9 (preoperative, 5.9; P 5 .02), AOFAS ankle score significantly increased from 45.9 to 80.2 points (P< .0001), sports activity score remained significantly decreased with 1.25 (preinjury level, 2.3; P 5 .035), and ankle dorsiflexion was significantly reduced (P 5 .003). Knee pain was reported in 6 patients (50%). Radiologically, recurrent lesions were found in 10 of 10 cases (100%) and some degree of cartilage degeneration and discontinuity of the subchondral bone plate in 100%. Conclusion Indications for mosaicplasty with a plug transfer from the knee to the talus must be considered carefully, as at midterm, moderate outcome and considerable donor-site morbidity may be found.

Sports and Recreation Activity of Ankle Arthritis Patients Before and After Total Ankle Replacement

Background Total ankle replacement is a possible treatment for ankle arthritis; however, participation in sports after this procedure has not yet been analyzed. Hypotheses There is a significant increase of sports activity after total ankle replacement in patients with arthritis. There is a significant correlation between sports activity and American Orthopaedic Foot and Ankle Society hindfoot score in patients after total ankle replacement. Study Design Case series; Level of evidence, 4. Methods A clinical evaluation was performed preoperatively and at follow-up after total ankle replacement in 147 patients (152 ankles) with ankle arthritis (mean age, 59.6 years; range, 28-86 years). Ankle arthritis origin, patient satisfaction, range of motion, American Orthopaedic Foot and Ankle Society hindfoot score, radiologic assessment, and rate, level, and type of sports activity were documented at both evaluations. The mean follow-up was 2.8 years (range, 2-4 years). Results Preoperative diagnosis was posttraumatic osteoarthritis in 115 cases (76%). At total ankle replacement follow-up, excellent and good outcomes were reported in 126 cases (83%); 105 cases (69%) were pain free. The mean range of motion preoperatively was 21° (range, 0°-45°); after total ankle replacement, it was 35° (range, 10°-55°; P < .05). The preoperative American Orthopaedic Foot and Ankle Society score was 36 points; after total ankle replacement, it was 84 points (P < .001). Before surgery, 36% of the patients were active in sports; after surgery, this percentage rose to 56% (P < .001). After total ankle replacement, sports-active patients showed a significantly higher hindfoot score than did patients not active in sports: 88 versus 79 points (P < .001). The 3 most frequent sports activities were hiking, biking, and swimming. Conclusion There was a significant increase of sports activity by treating ankle arthritis patients with total ankle replacement. Sports-active total ankle replacement patients showed better functional results than did inactive ones.

SPECT‐CT compared with conventional imaging modalities for the assessment of the varus and valgus malaligned hindfoot

The combined single‐photon emission computed tomography and conventional computed tomography (SPECT/CT) technique has increased the sensitivity and specificity of bone scans. We examined the value of using SPECT/CT for the assessment of coronal plane hindfoot deformities. Twenty‐seven patients with varus (11 patients) or valgus (16 patients) malalignment of the hindfoot were assessed using radiography, conventional CT, bone scintigraphy, and SPECT/CT. The amount of deformity, stage of osteoarthritis, and level of activation on bone scans and SPECT/CT were measured. Activation was assessed in 12 regions of interest. The stage of osteoarthritis seen on plain radiographs correlated significantly with the level of activation detected on bone scans (p < 0.05). No correlation was observed between the amount of deformation and activity, and between bone scan activation and signs of osteoarthritis on CT scans. The varus malaligned ankles showed higher radioisotope uptake in the medial areas, while the valgus malaligned ankles showed increased uptake in the lateral areas (p < 0.05). SPECT/CT may be a valuable tool for the assessment and staging of osteoarthritis. Our findings underline the adverse effects of coronal plane deformity of the hindfoot. In addition, results from this study provide useful information for future basic research on coronal plane deformity of the hindfoot and for determining appropriate surgical approaches.

Realignment Surgery for Valgus Ankle Osteoarthritis

ObjectiveImprovement of joint congruence, reduction of pain, slowdown of osteoarthritis progression, and prevention or delay of total ankle arthroplasty or ankle fusion.IndicationsActive patients with lateral valgus ankle joint degeneration.ContraindicationsPatients in poor general condition.Inability to adhere to postoperative non-weight-bearing rehabilitation.Distinct cartilage degeneration of more than half of tibiotalar joint surface.Systemic joint disease.Insufficiency of the deltoid ligament with tibiotalar subluxation malalignment.Surgical TechniqueDepending on stage of deformity:Stage I – collapse of the lateral tibia plafond and/or lateral malleolar gutter with subsequent valgus ankle arthritis: medial closing-wedge osteotomy of the distal tibia. Derotation- lengthening osteotomy in case of fibula malunion.Stage II – excessive calcaneus valgus: add medial sliding calcaneus osteotomy.Stage III – forefoot-induced hindfoot valgus (flatfoot deformity with forefoot abduction): add repair/augmentation of the posterior tibial tendon, superficial delta and spring ligaments; gastrocnemius/triceps release; flexion osteotomy of the first cuneiform or metatarsal bone or fusion of the first tarsometatarsal joint.Postoperative ManagementContinuous active and passive range of motion starting at the 2nd postoperative day. Removable short leg cast during nights. Partial weight bearing for 6–8 weeks until osseous healing has occurred, followed by gradual return to full weight bearing and activity.Results14 patients with stage I, three with stage II, and five with stage III valgus ankle osteoarthritis were treated. In two cases realignment surgery failed and progressive painful arthritis was treated by arthroplasty. The other 20 patients improved at an average follow-up of 4.5 years (range 3–6.5 years). Eight patients (41%) were free of pain. Tibiotalar arthritis and alignment (Takakura Score) improved significantly and correlated with significant improvement of pain (visual analog scale) and function (American Orthopaedic Foot and Ankle Society Score).ZusammenfassungOperationszielVerbesserte Gelenkkongruenz, Schmerzreduktion, Aufhalten des Arthroseprozesses und zeitliches Hinausschieben von Arthroplastik oder Versteifung des oberen Sprunggelenks (OSG).IndikationenAktive Patienten mit Valgusfehlstellung und lateraler Arthrose im OSG.KontraindikationenPatienten in schlechtem Allgemeinzustand.Unfähigkeit, das postoperative Rehabilitationsprogramm mit Entlastung durchzuführen.Fortgeschrittene Arthrose mit Degeneration von mehr als der Hälfte der tibiotalaren Gelenkfläche.Systemische GelenkerkrankungInsuffizienz des gesamten Ligamentum deltoideum mit tibiotalarer Subluxation.OperationstechnikIn Abhängigkeit vom Stadium der Deformität:Stadium I – Kollaps des lateralen Pilon tibiale und/oder des fibulotalaren Malleolargelenks mit konsekutiver Valgusarthrose: Medial zuklappende Osteotomie der distalen Tibia. Fibulaosteotomie zur Derotation und Verlängerung bei Pseudarthrose.Stadium II – Valgusfehlstellung der Ferse: Zusätzliche Durchführung einer medialen Verschiebeosteotomie des Tuber calcanei.Stadium III – Valgusfehlstellung der Ferse, induziert durch eine Vorfußabduktion bei Pes planovalgus: Zusätzliche Durchführung einer Naht/Augmentation der Tibialis-posterior-Sehne, des vorderen Ligamentum deltoideum und des Ligamentum calcaneonavicular, einer Verlängerung des Musculus gastrocnemius/Musculus triceps, einer Flexionsosteotomie des Os cuneiforme mediale/Metatarsale I oder einer Versteifung des ersten tarsometatarsalen Gelenks.WeiterbehandlungAktive und passive Bewegungsübungen im OSG ab dem 2. postoperativen Tag. Entfernbarer Unterschenkelgipsverband. Sohlenkontakt für 6–8 Wochen postoperativ bis zur Knochenheilung. Anschließend schrittweiser Übergang zur Vollbelastung.Ergebnisse14 Patienten im Stadium I, drei im Stadium II und fünf im Stadium III wurden Korrekturoperationen bei Valgusarthrose im OSG unterzogen. In zwei Fällen kam es zur Ausbildung einer progressiven schmerzhaften OSG-Arthrose, welche mittels OSG-Prothese therapiert wurde. Die übrigen 20 Patienten zeigten nach einer mittleren Nachkontrollzeit von 4,5 Jahren (3–6,5 Jahre) eine Verbesserung der Studienvariablen. Acht Patienten (41%) waren schmerzfrei. Tibiotalare Arthrose und Alignment (Takakura-Score) verbesserten sich signifikant und korrelierten mit der Verbesserung der Schmerzen (visuelle Analogskala) und der Funktion (Score der American Orthopaedic Foot and Ankle Society).

A Novel Imaging Method for Osteochondral Lesions of the Talus—Comparison of SPECT-CT With MRI

Background: Magnetic resonance imaging (MRI) is the current standard in noninvasive diagnostics of osteochondral lesions (OCLs) of the talus. Single-photon emission computed tomography–computed tomography (SPECT-CT) is a new technique that displays different imaging qualities. The influence of the aforementioned diagnostic information on treatment decision making in talar OCLs is not known. Purpose: The aim of the study was to evaluate SPECT-CT in comparison with MRI for image interpretation and decision making in OCLs of the talus. Study Design: Case series; Level of evidence, 4. Methods: Magnetic resonance imaging and SPECT-CT of 25 patients (average age, 32 years; range, 18-69 years) were analyzed by 3 independent orthopaedic surgeons blinded to the study. Raters had to analyze images for predefined criteria of cartilage, subchondral bone plate, and subchondral bone, including bone marrow edema on MRI and scintigraphic activity on SPECT-CT. For MRI alone, SPECT-CT alone, and their combination, the treatment decision had to be defined. Results: In comparison with MRI alone, treatment decision making changed in 48% of the cases with SPECT-CT alone and 52% with SPECT-CT and MRI combined. While cartilage showed good correlation for interpretation between MRI and SPECT-CT, the subchondral bone plate and subchondral bone showed substantial differences. Poor intrarater correlation highlighted the different information provided by the 2 imaging techniques. Poor interrater correlation showed a high heterogeneity in the treatment decision making of OCLs. Conclusion: Compared with MRI, SPECT-CT provides additional information and influences the decision making of OCL treatment. For thorough diagnostic evaluation in OCLs, performing both MRI and SPECT-CT is recommended. Further clinical investigation is needed to see if SPECT-CT in addition to MRI results in improved treatment outcomes.

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.

Korrekturoperationen bei Valgusarthrose im oberen Sprunggelenk

ObjectiveImprovement of joint congruence, reduction of pain, slowdown of osteoarthritis progression, and prevention or delay of total ankle arthroplasty or ankle fusion.IndicationsActive patients with lateral valgus ankle joint degeneration.ContraindicationsPatients in poor general condition.Inability to adhere to postoperative non-weight-bearing rehabilitation.Distinct cartilage degeneration of more than half of tibiotalar joint surface.Systemic joint disease.Insufficiency of the deltoid ligament with tibiotalar subluxation malalignment.Surgical TechniqueDepending on stage of deformity:Stage I – collapse of the lateral tibia plafond and/or lateral malleolar gutter with subsequent valgus ankle arthritis: medial closing-wedge osteotomy of the distal tibia. Derotation- lengthening osteotomy in case of fibula malunion.Stage II – excessive calcaneus valgus: add medial sliding calcaneus osteotomy.Stage III – forefoot-induced hindfoot valgus (flatfoot deformity with forefoot abduction): add repair/augmentation of the posterior tibial tendon, superficial delta and spring ligaments; gastrocnemius/triceps release; flexion osteotomy of the first cuneiform or metatarsal bone or fusion of the first tarsometatarsal joint.Postoperative ManagementContinuous active and passive range of motion starting at the 2nd postoperative day. Removable short leg cast during nights. Partial weight bearing for 6–8 weeks until osseous healing has occurred, followed by gradual return to full weight bearing and activity.Results14 patients with stage I, three with stage II, and five with stage III valgus ankle osteoarthritis were treated. In two cases realignment surgery failed and progressive painful arthritis was treated by arthroplasty. The other 20 patients improved at an average follow-up of 4.5 years (range 3–6.5 years). Eight patients (41%) were free of pain. Tibiotalar arthritis and alignment (Takakura Score) improved significantly and correlated with significant improvement of pain (visual analog scale) and function (American Orthopaedic Foot and Ankle Society Score).ZusammenfassungOperationszielVerbesserte Gelenkkongruenz, Schmerzreduktion, Aufhalten des Arthroseprozesses und zeitliches Hinausschieben von Arthroplastik oder Versteifung des oberen Sprunggelenks (OSG).IndikationenAktive Patienten mit Valgusfehlstellung und lateraler Arthrose im OSG.KontraindikationenPatienten in schlechtem Allgemeinzustand.Unfähigkeit, das postoperative Rehabilitationsprogramm mit Entlastung durchzuführen.Fortgeschrittene Arthrose mit Degeneration von mehr als der Hälfte der tibiotalaren Gelenkfläche.Systemische GelenkerkrankungInsuffizienz des gesamten Ligamentum deltoideum mit tibiotalarer Subluxation.OperationstechnikIn Abhängigkeit vom Stadium der Deformität:Stadium I – Kollaps des lateralen Pilon tibiale und/oder des fibulotalaren Malleolargelenks mit konsekutiver Valgusarthrose: Medial zuklappende Osteotomie der distalen Tibia. Fibulaosteotomie zur Derotation und Verlängerung bei Pseudarthrose.Stadium II – Valgusfehlstellung der Ferse: Zusätzliche Durchführung einer medialen Verschiebeosteotomie des Tuber calcanei.Stadium III – Valgusfehlstellung der Ferse, induziert durch eine Vorfußabduktion bei Pes planovalgus: Zusätzliche Durchführung einer Naht/Augmentation der Tibialis-posterior-Sehne, des vorderen Ligamentum deltoideum und des Ligamentum calcaneonavicular, einer Verlängerung des Musculus gastrocnemius/Musculus triceps, einer Flexionsosteotomie des Os cuneiforme mediale/Metatarsale I oder einer Versteifung des ersten tarsometatarsalen Gelenks.WeiterbehandlungAktive und passive Bewegungsübungen im OSG ab dem 2. postoperativen Tag. Entfernbarer Unterschenkelgipsverband. Sohlenkontakt für 6–8 Wochen postoperativ bis zur Knochenheilung. Anschließend schrittweiser Übergang zur Vollbelastung.Ergebnisse14 Patienten im Stadium I, drei im Stadium II und fünf im Stadium III wurden Korrekturoperationen bei Valgusarthrose im OSG unterzogen. In zwei Fällen kam es zur Ausbildung einer progressiven schmerzhaften OSG-Arthrose, welche mittels OSG-Prothese therapiert wurde. Die übrigen 20 Patienten zeigten nach einer mittleren Nachkontrollzeit von 4,5 Jahren (3–6,5 Jahre) eine Verbesserung der Studienvariablen. Acht Patienten (41%) waren schmerzfrei. Tibiotalare Arthrose und Alignment (Takakura-Score) verbesserten sich signifikant und korrelierten mit der Verbesserung der Schmerzen (visuelle Analogskala) und der Funktion (Score der American Orthopaedic Foot and Ankle Society).

Treating Patella Instability in Skeletally Immature Patients

PURPOSE The purpose of this study was to comprehensively and systematically review the current evidence for orthopaedic treatment of immature and adolescent patients with acute and chronic patellar instability. METHODS We searched the online databases PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for relevant publications on patellar instability. All dates and languages were included. RESULTS Twenty articles reporting on a total of 456 knees in 425 patients (131 male patients, 294 female patients) followed-up for 56.7 ± 42.2 months on average were included in the analysis. Two studies focused specifically on conservative versus surgical treatment in acute dislocations and reported no difference in outcomes after 7 and 14 years, even in the face of slight trochlear dysplasia. For recurrent instability, we found consistent beneficial effects from surgical stabilization on clinical scores, postoperative stability, and radiographic assessment. There is no evidence for growth disturbance with surgical patellar stabilization in immature patients. CONCLUSIONS The current best evidence does not support the superiority of surgical intervention over conservative treatment in an acute patellar dislocation. However, anatomic variations and their effect on healing should be considered and included in decision making. In recurrent patellar instability in pediatric and adolescent patients with normal or restored knee anatomy, reconstruction of the medial patellofemoral ligament (MPFL) is the most effective treatment option and can be done safely, together with extensor realignment as needed. LEVEL OF EVIDENCE Level IV, systematic review of mixed-level studies.

Open Lateral Patellar Retinacular Lengthening Versus Open Retinacular Release in Lateral Patellar Hypercompression Syndrome: A Prospective Double-Blinded Comparative Study on Complications and Outcome

PURPOSE To compare complication rates and outcome of open lateral retinacular (LR) lengthening and open LR release in the treatment of lateral patellar hypercompression syndrome (LPHS). METHODS In a prospective double-blinded study, 28 patients (mean age, 48 years; 21 women and 7 men) received either LR release (14 patients) or LR lengthening (14 patients) in alternating fashion over the same lateral parapatellar skin incision for LPHS (blinding of patients to surgical procedure [i.e., single blinding]). Strict inclusion criteria (retinacular pain, tight retinaculum, decreased patellar mobility) were used to exclude other reasons for anterior knee pain (patellar instability, leg malalignment or maltorsion, trochlear dysplasia, patella alta). The surgeon and postsurgical rehabilitation were the same. Preoperatively and at 3, 6, 12, and 24 months postoperatively, complications, muscle atrophy, and Kujala patellofemoral outcome score were documented by examiners blinded to the surgical procedure (double blinding). All patients completed 2 years of follow-up. RESULTS The results of 2 years of follow-up showed that recurrence of LPHS, as indicated by the patellar tilt test and decreased medial patellar glide test, developed in 2 cases after LR release and 1 case after LR lengthening (P > .999). Medial patellar subluxation, as indicated by the gravitation-subluxation test and increased medial patellar glide test, developed in 5 cases after LR release and no case after LR lengthening (P = .041). Quadriceps atrophy, as indicated by the mean circumference difference compared with the healthy contralateral side, was significantly higher (P = .001) in the LR release group (1.8 cm) than in the LR lengthening group (0.2 cm). The mean Kujala score was significantly lower (P = .035) in the LR release group (77.2 points) than in the LR lengthening group (88.4 points). CONCLUSIONS In this prospective double-blinded study, retinacular lengthening showed less medial instability, less quadriceps atrophy, and a better clinical outcome at 2 years compared with retinacular release. We believe that this may be explained by the controlled preservation of the lateral patellar muscle-capsuloligamentous continuity after retinacular lengthening. LEVEL OF EVIDENCE Level II, prospective double-blinded comparative study.