Keith L. Wapner

Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results

Background: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. Materials and Methods: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. Results: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. Conclusion: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Level of Evidence: II, Prospective Controlled Comparative Surgical Trial

Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients : The effect of tendo-Achilles lengthening and total contact casting

Between 1993 and 1995, 93 neuropathic diabetes mellitus patients with foot ulcers underwent a total contact cast (TCC) protocol. A randomly chosen group of 21 patients (Group I) demonstrated ulcer healing in a mean time of 43.5 days. Despite 9 weeks of TCC, 15 patients (Group II) with forefoot ulcers failed to heal. Physical examination of Group I revealed plantarflexion/dorsiflexion range of motion of the ankle of 33.8 degrees / 1.9 degrees compared to 32.3 degrees / -10.5 degrees of Group II, demonstrating an ankle equinus deformity and limited joint motion. Group II patients underwent a correction of the equinus deformity with percutaneous tendo-Achilles lengthening (TAL), followed by a TCC. All but one ulcer (93.3%) healed within 39.4 days. Four (19.0%) ulcers recurred (at the same site) in Group I, compared to none in Group II at the latest follow up of 17.3 months. Surgical correction with percutaneous TAL and TCC results in healing of forefoot ulcer and helps prevent ulcer recurrence.

Operative Treatment for Peroneal Tendon Disorders

Peroneal tendon disorders are rare, are frequently missed, and can be a source of lateral ankle pain. Magnetic resonance imaging is the standard method of radiographic evaluation of peroneal tendon disorders; however, diagnosis and treatment are based primarily on the history and physical examination. Peroneal tenosynovitis typically responds to conservative therapy, and operative treatment is reserved for refractory cases. Operative treatment is frequently required for peroneal tendon subluxation and consists of anatomic repair or reconstruction of the superior peroneal retinaculum with or without deepening of the retromalleolar groove. Operative treatment of peroneal tendon tears is based on the amount of remaining viable tendon. Primary repair and tubularization is indicated for tears involving <50% of the tendon, and tenodesis is indicated for tears involving >50% of the tendon.

MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals.

Abstract Objective: To differentiate MR imaging characteristics of symptomatic as compared with asymptomatic Achilles tendons. Design: 1.5 T MR images of 94 feet (88 patients) with ”abnormal” MR examinations were retrospectively evaluated and clinically correlated. Two masked, independent observers systematically evaluated for intratendon T2 signal, tendon thickness, presence of peritendonitis, retrocalcaneal bursal fluid volume, pre-Achilles edema, bone marrow edema at the Achilles insertion, and tears (interstitial, partial, complete). These findings were correlated with symptoms (onset and duration) and physical examination results (tenderness, palpable defects, increased angle of resting dorsiflexion). Results: Of the 94 ankles, 64 ankles (32 females, 29 males) were clinically symptomatic. No relationship between Achilles tendon disorders and age or gender was identified. Asymptomatic Achilles tendons frequently demonstrated mild increased intratendon signal (21/30), 0.747 cm average tendon thickness, peritendonitis (11/30), pre-Achilles edema (12/30), and 0.104 ml average retrocalcaneal bursal fluid volume. Symptomatic patients had thicker tendons (0.877 cm), greater retrocalcaneal fluid volume (0.278 ml), more frequent tears (23/64), a similar frequency of peritendonitis (22/64) but less frequent pre-Achilles edema (18/64). Sixty-four percent of the Achilles tendon tears were interstitial. Except for two interstitial tears in control patients, the majority of Achilles tears were in symptomatic patients (14/16). Only symptomatic tendons demonstrated partial or complete tendon tears. In addition, calcaneal edema was found almost exclusively in actively symptomatic patients. Thicker tendons were associated more often with chronic symptoms and with tears. When present in symptomatic patients, peritendonitis was usually associated with acute symptoms. The presence of pre-Achilles edema, however, did not distinguish acute from chronic disorders. Conclusion: There is significant overlap of MR findings in symptomatic and asymptomatic Achilles tendons. Furthermore, there is apparently a spectrum of disease in symptomatic tendons ranging from subtle intratendinous and peritendinous signal to partial and complete tendon tear.

MR imaging of inflammatory joint diseases of the foot and ankle.

Abstract Pain affecting the foot and ankle is a common complaint frequently attributable to inflammatory joint diseases. Although conventional radiography is regarded as the initial step in the diagnostic investigation, MR imaging may contribute to further evaluation of these patients due to the direct visualization of the inflammatory soft tissue formed in the disease and its effects on bone, cartilage and para-articular structures. The high spatial resolution of MR imaging combined with tissue characterization often allows initial detection of inflammatory joint abnormalities at a stage that precedes radiographic evaluation. The typical MR appearance of certain inflammatory joint disorders may be helpful in narrowing the wide differential diagnosis. Furthermore, MR imaging can be used for an exact assessment of the extent of the disorder as well as its complications. Accurate diagnostic information can guide the clinician in further diagnostic tests and implementation of proper therapeutic treatment.

Epidemiology and Outcomes of Achilles Tendon Ruptures in the National Football League

The purpose of this study is to document the epidemiology of Achilles tendon ruptures in the National Football League (NFL) and to quantify the impact of these injuries on player performance. A retrospective review of several online NFL player registries identified 31 Achilles tendon ruptures in NFL players between 1997 and 2002. Nineteen percent of injuries occurred during preseason play, while another 18% occurred during the first month of the official season. There was a postinjury reduction of 88%, 83%, and 78% in power ratings for wide receivers, running backs, and tight ends, respectively, over a 3-year period. There was a 95%, 87%, and 64% postinjury reduction in power ratings for linebackers, cornerbacks, and defensive tackles over a 3-year period. On average, players experienced a greater than 50% reduction in their power ratings following such an injury. Thirty-two percent (n = 10) of NFL players who sustained an Achilles tendon rupture did not return to play in the NFL.

Complications of achilles and posterior tibial tendon surgeries.

Surgery of the Achilles and posterior tibial tendons requires finesse to achieve optimal function. Although superficial in anatomic location, various critical neurovascular structures exist in close proximity. The superficial blood supply is fragile, requiring a delicate touch to prevent problems with wound healing. Damaged tendon tissue often is friable, making it difficult to sew or anchor. Adjusting the tendon length to the appropriate tension requires good judgment and affects long-term outcome through power and range of motion. Finally, surgery on these two tendons significantly affects function of the ankle and longitudinal arch, where small changes are magnified into large changes in maintaining normal gait. The current authors review the complications encountered in various common surgeries of the Achilles and posterior tibial tendons.

Anatomy of Second Muscular Layer of the Foot: Considerations for Tendon Selection in Transfer for Achilles and Posterior Tibial Tendon Reconstruction

Controversy exists regarding tendon choice to substitute for a ruptured posterior tibial tendon. A similar debate about late Achilles tendon reconstruction also persists. To establish priorities and aid the surgeons decision-making process, we studied 85 en bloc dissections of the second muscular layer of the sole. Muscular and tendinous interconnections were evaluated. Location and minimal donor deficit following harvest of the flexor digitorum longus make it the transfer of choice for posterior tibial tendon reconstruction. We suggest that relative strength, anatomic location, and available length of tendon make the flexor hallucis longus the superior choice for late Achilles tendon reconstruction.

Triple arthrodesis in adults.

&NA; Surgical fusion of the subtalar, talonavicular, and calcaneocuboid joints historically evolved for the treatment of paralytic deformities of the foot where there was often notable bone deformity. Today most of these procedures are performed in adults for posttraumatic arthritis, rheumatoid arthritis, or end‐stage posterior tibial tendon rupture with fixed bone deformity. Triple arthrodesis is a technically demanding procedure that generally involves a prolonged recovery time. When proper alignment is obtained, predictable and significant improvement in symptoms occurs, but the resultant loss of hindfoot motion is not without consequence. Residual discomfort and secondary arthrosis of the ankle and tarsometatarsal joints should be expected. Because of the complications of residual deformity, pseudarthrosis, avascular necrosis of the talus, and ankle and midtarsal arthritis, it has been recommended that it be used only as a salvage operation in older patients who have a painful, fixed deformity or disabling instability refractory to other treatment options. Despite these caveats, most patients who undergo triple arthrodesis for appropriate indications report significant improvement in their symptoms and level of function.

Surgical treatment for chronic disease and disorders of the achilles tendon

&NA; Chronic Achilles tendon disorders range from overuse syndromes to frank ruptures. Numerous forms of treatment have been used, depending on the nature of the disorder or injury. Ultrasonography and magnetic resonance imaging are commonly used for evaluation. The spectrum of disease comprises paratenonitis, tendinosis, paratenonitis with tendinosis, retrocalcaneal bursitis, insertional tendinosis, and chronic rupture. However, there is no clear consensus on what defines a chronic Achilles disorder. Nonsurgical therapy is the mainstay of treatment for most patients with overuse syndromes. Surgical techniques for overuse syndromes or chronic rupture include débridement, local tissue transfer, augmentation, and synthetic grafts. Local tissue transfer most commonly employs either the flexor hallucis longus or flexor digitorum longus tendon to treat a chronic rupture. Reports on long‐term outcomes are needed before useful generalizations can be made regarding treatment.