Jochen Paul

Chronic Ankle Instability

Chronic 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.

Mobile- and Fixed-Bearing Total Ankle Prostheses: Is There Really a Difference?

Approximately 1% of the worlds adult population is affected by ankle osteoarthritis (OA). Therapeutic options include conservative and surgical measures. Because of substantial progress in total ankle replacement, ankle fusion is no longer the gold standard therapy for end-stage ankle OA. Various ankle prostheses have been designed and are currently available. This article reviews the inxa0vitro studies addressing the biomechanics and kinematics of the replaced ankle. Furthermore, a systematic literature review was conducted to assess possible differences in clinical outcomes, including prosthesis survivorship and postoperative range of motion between mobile- and fixed-bearing total ankle prostheses.

Commercially Available Trabecular Metal Ankle Interpositional Spacer for Tibiotalocalcaneal Arthrodesis Secondary to Severe Bone Loss of the Ankle

Retrograde tibiotalocalcaneal nailing arthrodesis has proved to be a viable salvage procedure; however, extended bone loss around the ankle has been associated with high rates of nonunion and considerable shortening of the hindfoot. We present the surgical technique and the first 2 cases in which a trabecular metal™ interpositional spacer, specifically designed for tibiotalocalcaneal nailing arthrodesis, was used. The spacer can be implanted using either an anterior or a lateral approach. An integrated hole in the spacer allows a retrograde nail to be inserted, which provides excellent primary stability of the construct. Trabecular metal™ is a well-established and well-described material used to supplement deficient bone stock in surgery of the spine, hip, and knee. It has shown excellent incorporation and reduces the need for auto- and allografts. The trabecular metal™ interpositional ankle spacer is the first trabecular metal spacer designed specifically for ankle surgery. Its shape and variable size will make it a valuable tool for reconstructing bone loss in tibiotalocalcaneal nailing arthrodesis.

Increased Osseous 99mTc-DPD Uptake in End-Stage Ankle Osteoarthritis Correlation Between SPECT-CT Imaging and Histologic Findings

BACKGROUNDnWe analyzed the histopathologic findings in end-stage osteoarthritic ankle joint tissue that display increased uptake of bone-seeking radiotracer in single-photon emission computed tomography-computed tomography (SPECT-CT) imaging.nnnMETHODSnSix consecutive patients with end-stage osteoarthritis undergoing total ankle replacement received preoperative SPECT-CT imaging using (99m)Technetium dicarboxypropane diphosphonate ((99m)Tc-DPD). Using imaging data for stratification, osteochondral tissue sections were prepared from SPECT-positive (+) and -negative (-) areas of tibial and talar resection specimens. Histomorphometric analyses of osteoblast numbers, collagen deposition, and cartilage degeneration were performed on hematoxylin and eosin, van Giesons and Safranin-O stained tissue sections. Osteoclast activity was visualized using tartrate-resistant acid phosphatase (TRAP) staining.nnnRESULTSnIncreased (99m)Tc-DPD uptake was observed exclusively subjacent to the subchondral bone plate of tibial and talar joint compartments. SPECT(-) tissues displayed typical fatty marrow morphology containing mainly collagen-positive blood vessels and few marrow and bone-lining cells. SPECT(+) tissues were characterized by increased numbers of active bone-lining osteoblasts depositing collagen fibers. Collagen area fraction of subchondral bone marrow was significantly increased in SPECT(+) (0.52 ± 0.21) compared with SPECT(-) (0.29 ± 0.13) tissues (P = .30). Multinucleated TRAP(+) osteoclasts were absent from bone formation sites, but associated with vascular structures invading articular cartilage through the subchondral bone plate. Increased (99m)Tc-DPD uptake was specifically and strongly correlated with increased osteoblast numbers (P = .011), and with collagen area fraction (P = .030) but not with Mankin score (P = .202), or with osteoclast number (P = .576).nnnCONCLUSIONnSubchondral bone tissues in SPECT(+) areas of end-stage ankle osteoarthritis were histologically characterized by increased osteoblast-mediated bone formation in the absence of functional osteoclasts, and increased cellularity and collagen deposition in marrow tissues.nnnCLINICAL SIGNIFICANCEnOur findings suggest a pathologic bone-remodeling process in end-stage ankle OA areas with increased (99m)Tc-DPD uptake.Background: We analyzed the histopathologic findings in end-stage osteoarthritic ankle joint tissue that display increased uptake of bone-seeking radiotracer in single-photon emission computed tomography–computed tomography (SPECT-CT) imaging. Methods: Six consecutive patients with end-stage osteoarthritis undergoing total ankle replacement received preoperative SPECT-CT imaging using 99mTechnetium dicarboxypropane diphosphonate (99mTc-DPD). Using imaging data for stratification, osteochondral tissue sections were prepared from SPECT-positive (+) and -negative (–) areas of tibial and talar resection specimens. Histomorphometric analyses of osteoblast numbers, collagen deposition, and cartilage degeneration were performed on hematoxylin and eosin, van Gieson’s and Safranin-O stained tissue sections. Osteoclast activity was visualized using tartrate-resistant acid phosphatase (TRAP) staining. Results: Increased 99mTc-DPD uptake was observed exclusively subjacent to the subchondral bone plate of tibial and talar joint compartments. SPECT(–) tissues displayed typical fatty marrow morphology containing mainly collagen-positive blood vessels and few marrow and bone-lining cells. SPECT(+) tissues were characterized by increased numbers of active bone-lining osteoblasts depositing collagen fibers. Collagen area fraction of subchondral bone marrow was significantly increased in SPECT(+) (0.52 ± 0.21) compared with SPECT(–) (0.29 ± 0.13) tissues (P = .30). Multinucleated TRAP(+) osteoclasts were absent from bone formation sites, but associated with vascular structures invading articular cartilage through the subchondral bone plate. Increased 99mTc-DPD uptake was specifically and strongly correlated with increased osteoblast numbers (P = .011), and with collagen area fraction (P = .030) but not with Mankin score (P = .202), or with osteoclast number (P = .576). Conclusion: Subchondral bone tissues in SPECT(+) areas of end-stage ankle osteoarthritis were histologically characterized by increased osteoblast-mediated bone formation in the absence of functional osteoclasts, and increased cellularity and collagen deposition in marrow tissues. Clinical Significance: Our findings suggest a pathologic bone-remodeling process in end-stage ankle OA areas with increased 99mTc-DPD uptake. Level of Evidence: Level IV, case series.

Mid- to Long-term Clinical Outcome and Gait Biomechanics After Realignment Surgery in Asymmetric Ankle Osteoarthritis

Background: Joint-preserving, realignment surgical procedures have gained increasing popularity as treatment of asymmetric early- and mid-stage ankle osteoarthritis. The aim of the present study was to quantify bilateral gait biomechanics in patients who underwent ankle realignment surgery by supramalleolar osteotomies. Methods: Eight patients, a minimum of 7 years after realignment surgery, and 8 healthy controls were included in this study. Three-dimensional instrumented gait analysis was used to assess spatiotemporal parameters, bilateral joint angles, and moments. Furthermore, a clinical evaluation on pain, ankle function, and quality of life was performed. Results: Compared with the healthy controls, the patients walked more slowly, had a smaller sagittal hindfoot range of motion on their affected leg, and had a lower peak ankle dorsiflexion moment (P < .05). There were no significant differences compared with controls for the ranges of motion in the foot segments of the nonaffected foot and for the knee and hip joint ranges of motion and peak moments of both legs. Additionally, patients and controls did not differ in the quality of life score. However, in the pain subscore, the patients reported significantly more pain than the healthy persons. Conclusion: Despite different gait biomechanics of the affected foot after ankle realignment surgery, the quality of life for patients was comparable to that of healthy controls. Therefore, supramalleolar osteotomies should be considered as a promising treatment option in patients with asymmetric non-end-stage ankle osteoarthritis. Level of Evidence: Level III, comparative study.

Joint-Preserving Surgery of Valgus Ankle Osteoarthritis

Patients with posttraumatic ankle osteoarthritis (OA) typically present with asymmetric involvement of the tibiotalar joint, resulting in valgus or varus deformity of the ankle and hindfoot. Without appropriate treatment, patients with asymmetric ankle OA typically develop full end-stage ankle OA. Ankles with valgus deformities suffer from a lateral joint overload with subsequent lateral tibiotalar joint degeneration, which causes further lateral load shift. In these cases patients may benefit from joint-preserving realignment surgery to unload the degenerated lateral area and normalize joint biomechanics. This article describes the authors algorithm for the treatment of patients with asymmetric valgus ankle OA.

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

Background: For the treatment of osteochondral lesions of the talus (OCLTs), autologous matrix-induced chondrogenesis (AMIC) is a safe 1-step procedure with good clinical and radiological results. However, data regarding postoperative sports activity after AMIC are limited. Purpose: To identify significant factors influencing the rate of postoperative sports and recreational activities. Study Design: Case series; Level of evidence, 4. Methods: The sports and recreational activities of 60 patients (mean age, 34.9 ± 11.5 years) undergoing the AMIC procedure were retrospectively analyzed at a mean of 46.9 ± 17.8 months (range, 24.5-87.0 months) postoperatively. The visual analog scale (VAS) for pain score, Tegner activity scale score, activity rating scale (ARS) score, and satisfaction with surgery outcomes were assessed. Results: Corrective calcaneal osteotomy was performed in 38 of 60 (63.3%) patients. Ligament repair was performed in 41 of 60 (68.3%) patients. The mean VAS score improved significantly from 6.9 ± 1.6 points (range, 5-10 points) preoperatively to 2.3 ± 1.9 points (range, 0-6 points) at latest follow-up (P < .001). No significant change in the mean Tegner activity scale score (3.3 ± 2.0 preoperatively to 3.4 ± 2.2 postoperatively; P = .526) and the mean ARS score (2.6 ± 4.3 preoperatively to 2.3 ± 3.4 postoperatively; P = .874) was noted. The percentage of patients involved in sports activity before the onset of symptoms became significantly lower at the time of surgery (from 95.0% to 53.3%; P < .001); no significant difference was noted postoperatively (from 53.3% to 58.3%; P = .663). No significant difference of the weekly sports frequency and the duration of sports activity was found postoperatively. Conclusion: Patients undergoing AMIC repair of an OCLT participate at a similar low postoperative sports and recreational activity level compared with the preoperative level.

Ankle Salvage Surgery with Autologous Circular Pillar Fibula Augmentation and Intramedullary Hindfoot Nail

Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.

Supramalleolar Osteotomies for Ankle Osteoarthritis

Asymmetric ankle osteoarthritis (OA) may develop in patients with varus or valgus deformities. Pathologically altered load distribution in the tibiotalar joint leads to medial (varus) or lateral (valgus) tibiotalar joint degeneration. However, as more than half of the tibiotalar joint surface remains preserved, joint sacrificing procedures including total ankle replacement or ankle arthrodesis may not be the most appropriate treatment options. The short-term and mid-term results after realignment surgery, published in the current literature, are very promising with substantial pain relief and functional improvement observed postoperatively. Herein we describe our experience with supramalleolar realignment surgery in patients with asymmetric varus or valgus ankle osteoarthritis.

Retrograde Synovial Biopsy of the Knee Joint Using a Novel Biopsy Forceps

Synovial biopsies of the knee joint are commonly performed arthroscopically with the patient under full or regional anesthesia. To overcome the effort, costs, and potential risks of surgery, we developed an office-based technique for retrograde synovial biopsy using a designated novel biopsy forceps. Using this technique, no arthroscopic or radiologic control is needed to perform rapid synovial biopsies of the knee joint. Concomitant aspiration of synovial fluid can be performed. A technical description of the procedure is given.