Kazuya Sugimoto

Long-term results of arthrodesis for osteoarthritis of the ankle.

A bone graft in the shape of a triangular prism was taken from the anterior surface of the tibia and used in the arthrodesis in 43 joints of 42 patients with primary and secondary osteoarthritis of the ankle. The modified anterior sliding inlay graft method was used. The average period of external immobilization was 5.8 weeks (range, 27-84 days), and followup ranged from 2 years 4 months to 14 years 11 months (average, 7 years 2 months). Nonunion was detected in three (7%) patients: one patient returned to work without additional treatment, and the other two patients underwent followup surgery within 7 months, and bony union was achieved. The final rate of nonunion was 2.3%. After the operation, excellent alleviation of pain was obtained. However, dorsiflexion of the foot decreased from the preoperative average value of 10.5 degrees to the postoperative value of 4.2 degrees, and plantar flexion also decreased from the preoperative value of 24.7 degrees to the postoperative value of 14 degrees. In addition, the range of motion of the subtalar and Chopart joints gradually improved with little effect on daily living activities. The most appropriate position of arthrodesis of the ankle appears to be in the neutral position between dorsal and plantar flexion. In addition, the varus and valgus angle of the hindfoot should be in a neutral or slightly valgus position. Degenerative arthritis developed and advanced in the subtalar joint in 32.5% of the patients, and these degenerative changes were exacerbated in many patients if such changes were present before surgery. Tibial stress fracture occurred in two (4.7%) patients as a complication that was specific to the current surgical method. Thus, the surgical procedure was modified to prevent the onset of tibial stress fracture.

Low tibial osteotomy for varus-type osteoarthritis of the ankle

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications. We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months). Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a.

Ankle arthroplasty : a comparative study of cemented metal and uncemented ceramic prostheses

From 1975 to 1980, total ankle arthroplasty was performed using a metal and polyethylene prosthesis on 30 ankles in 28 patients with painful arthritis. However, because loosening and sinking of the prosthesis were significant, a ceramic total prosthesis was designed in 1980 to be used without cement. Between 1980 and 1987, 39 ankles in 35 patients with osteoarthritis, rheumatoid arthritis, and hemophilic arthritis were replaced using the ceramic prosthesis. Out of 39 ankles, nine were replaced with cement and 30 without cement. The follow-up period for the cemented metal and ceramic cases ranged from 13.4 to 6.2 years, with an average of 8.1 years, and for uncemented ceramic cases from 1.2 to 6.4 years, with an average of 4.1 years. Based on a rating scale for ankle evaluation, 27% of the cemented cases and 67% of the uncemented cases are satisfactory. Five metal ankles and one ceramic ankle were reoperated upon, with one revision and five arthrodeses performed. Ceramic total ankle arthroplasty, performed without cement, has to date provided mostly excellent stable results.

Tarsal tunnel syndrome. Causes and results of operative treatment

From 1975 to 1988, operative treatment was performed on 50 feet in 45 patients with tarsal tunnel syndrome. The causes of this syndrome were correlated with operative findings and included ganglia in 18, and a bony prominence from talocalcaneal coalition in 15. Five feet had sustained an injury, tumours were found in three and there was no obvious cause in nine. In most cases in need of operative treatment, there was a space-occupying lesion. Classifying the results according to causes, those with coalition or a tumour fared better, and idiopathic and traumatic cases had a worse outcome. In cases with a definite lesion, an excellent result can be expected from surgical treatment carried out soon after onset of the condition.

Chondral injuries of the ankle with recurrent lateral instability: an arthroscopic study.

BACKGROUND Prolonged lateral instability of the ankle after ligament injury has been believed to be a major cause of osteoarthritis of the ankle, yet the rate of development of osteoarthritis of the ankle is relatively low. Clarifying the relationship between patient factors and chondral damage of the ankle with prolonged instability is essential to identify the important risk factors underlying osteoarthritis of the ankle. METHODS Arthroscopic examination was performed to assess the condition of the articular cartilage in a series of patients with prolonged lateral instability of the ankle. There were ninety-three patients with ninety-nine involved ankles. Their mean age was 28.7 years (range, fifteen to fifty-nine years). The relationships between the severity of the chondral damage and patient factors, the number and combination of torn ligaments, and mechanical instability and alignment of the ankle mortise were studied. RESULTS Twenty-three ankles were classified as grade 0 (normal cartilage); thirty-five, as grade 1 (superficial softening, fibrillation, or fissuring of the cartilage); twenty-four, as grade 2 (a cartilage defect without exposure of the subchondral bone); and seventeen, as grade 3 (exposure of the subchondral bone). Patient age, the talar tilt angle, and varus inclination of the ankle plafond were significantly associated with more severe chondral changes. CONCLUSIONS Patient age, the talar tilt angle, and varus inclination of the ankle are risk factors for severe chondral damage of the ankle in patients with a prolonged history of lateral ankle instability.

Reconstruction of the Lateral Ankle Ligaments with Bone-Patellar Tendon Graft in Patients with Chronic Ankle Instability A Preliminary Report

Background Unsatisfactory long-term results have been reported after use of a Broström repair for patients with chronic ankle ligament insufficiency. Hypothesis Repair or reconstruction of both the anterior talofibular and calcaneofibular ligaments is essential for normal kinematics of the ankle-hindfoot. Study Design Case series. Methods Thirteen patients with chronic instability of the ankle were found at operation to have injuries of both the anterior talofibular and calcaneofibular ligaments, with a lack of healthy ligament margins suitable for suturing. Reconstruction of the ligaments was performed with bone-patellar tendon graft. The score devised by Good et al. was used to assess the patients’ clinical condition before the operation and at final follow-up. Results Before the operation, six patients had a grade 3 clinical condition and seven had a grade 4 condition. At a mean follow-up of 26.5 months, all patients had a grade 1 condition. The average talar tilt of the patients was improved from 18.4° ± 5.5° to 4.9° ± 2.6°, and the average anterior drawer sign was improved from 9.1 ± 2.6 mm to 5.8 ± 1.6 mm. Conclusion In cases of combined injuries, short-term results of reconstruction of the anterior talofibular and calcaneofibular ligaments using bone-split patellar tendon graft were good, with a low frequency of complications.

Symptomatic talocalcaneal coalition. Its clinical significance and treatment.

The clinical significance of symptomatic talocalcaneal coalition was described subjectively, objectively, and identified roentgenographically after examining 67 feet of 42 patients between 1977 and 1987. Computed tomographic examinations, conducted on 29 of 42 patients, were useful in recognizing the extent of coalition, the condition of union, and the postoperative results. Tarsal tunnel syndrome was present in 23 feet with the coalition. Thirty-one feet (24 patients) were treated conservatively and 36 feet (29 patients) surgically. Of the surgically treated feet, the coalition was excised in 33 and talocalcaneal fusion was performed in three. Follow-up examinations were performed at an average of 5.3 years (range, 2.25-11.2 years). In the excision group, the results were excellent in 24 feet, good in seven, and fair in two. The results were good in three feet treated by arthrodesis.

Long-term results of Watson-Jones tenodesis of the ankle clinical and radiographic findings after ten to eighteen years of follow-up

Thirty-seven chronically unstable ankles in thirty-six patients were operated on with use of a Watson-Jones tenodesis. Thirty-four ankles (thirty-three patients) were followed for a mean duration of thirteen years and eight months (range, ten to eighteen years) after the operation. There were nine male and twenty-four female patients. The mean age of the patients was thirty-one years (range, fourteen to fifty-seven years) at the time of the operation and forty-four years (range, twenty-eight to seventy years) at the time of the latest follow-up. At the time of the most recent follow-up evaluation, twenty-seven patients (twenty-eight ankles) were examined directly by one of us and twenty-five patients (twenty-six ankles) also were evaluated radiographically. The other six patients were interviewed, with use of a questionnaire, by telephone. Of the thirty-four ankles, nineteen had an excellent result (grade 1), eleven had a good result (grade 2), three had a fair result (grade 3), and one had a poor result (grade 4) according to the rating system of Good et al. The mean score (and standard deviation) on the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society for the twenty-eight ankles that were examined directly by one of us was 90 ± 9.3 points (range, 68 to 100 points). Progression of an exostosis at the edge of the joint was detected in eighteen (69 percent) of the twenty-six ankles that were examined radiographically, but narrowing of the joint space was not seen in any ankle. No relationship was detected between the clinical results and radiographic osteoarthrotic changes or the duration of follow-up. The results did not deteriorate over the long term.

Varus Tilt of the Tibial Plafond as a Factor in Chronic Ligament Instability of the Ankle

The authors performed a radiographic study of 136 patients with acute ligament sprains and 85 patients with chronic lateral ligament instability of the ankle. Varus angulation of the tibial plafond, varus angulation of the line passing both malleolar ends, and varus angulation of the medial malleolus were measured on the AP views, and dorsal angulation of the tibial plafond was measured on the lateral views. The varus angles of the tibial plafond, the line passing both malleolar ends, and the medial malleolus were larger as mean values in patients with chronic ligament instability than in the patients with acute ligament sprain. The varus tilt of the tibial plafond is more often seen in patients with chronic ligament instability of the ankle than in patients with acute ligament sprains.

Precise Anatomic Configuration Changes in the First Ray of the Hallux Valgus Foot

To detect precise anatomical configuration of the first ray in feet with hallux valgus, a two-dimensional coordinate system was devised for evaluation of a weight-bearing dorsoplantar radiograph. The radiographs, taken from 229 feet of 114 patients with symptomatic hallux valgus and 94 normal feet, were investigated. A comparative study showed the first metatarsal head of a foot with hallux valgus was located on the medial side of that of the normal foot and the base of the proximal phalanx of the hallux valgus foot was located on the same point of that of the normal foot. Lateral translation of the base of the proximal phalanx occurred only in cases with overlap toes. Our study shows that subluxation of the metatarsophalangeal joint in hallux valgus is primarily caused by metatarsus primus varus. This study indicated that first metatarsal osteotomies should be given the first priority in consideration for bunion surgery, because these procedures could move the first metatarsal heads laterally in a more normal position.