Monika Horisberger

Ligamentous posttraumatic ankle osteoarthritis

Background Ankle sprains are the most common injuries in sports and recreational activities. Hypothesis Ankle osteoarthritis can be caused by ankle ligament lesions. Latency time between injury and osteoarthritis is influenced by the type and side of the injured ligaments. The side of the ligamentous lesion correlates with the hindfoot alignment. Study Design Case series; Level of evidence, 4. Methods Of a cohort of 247 patients with ankle arthritis, we reviewed data from 30 patients (33 ankles; mean age, 58.6 years) with ligamentous end-stage ankle osteoarthritis. The patients were evaluated etiologically, clinically, and radiologically. Results Etiologic analysis: 55% had a ligamentous lesion from sports injuries (soccer, 33%); 85% injured the lateral ankle ligaments, and 15% injured the medial and medial-lateral ligaments. The mean latency time between injury and osteoarthritis was 34.3 years. The survivorship rate for single severe ankle sprains was worse than that for chronic recurrent ligamentous lesions (mean latency time, 25.7 vs 38.0 years; P< .05), and the rate for medial sprains was worse than for lateral sprains (mean latency time, 27.5 vs 35.0 years; P< .05). At follow-up, the American Orthopaedic Foot and Ankle Society hindfoot score was 23.0 points, 52% had varus malalignment, 52% had persistent instability, and the mean ankle arthritis grade was 2.6 points. There was a correlation between chronic lateral ankle instability and varus malalignment. Conclusion Lateral ankle sprains in sports are the main cause of ligamentous posttraumatic ankle osteoarthritis and correlate with varus malalignment. At the time of end-stage ligamentous ankle osteoarthritis, persistent instability may be encountered.

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.

Sports and Recreation Activity of Patients with Femoroacetabular Impingement before and after Arthroscopic Osteoplasty

Background Hip arthroscopy represents a new and minimally invasive method of treating patients with femoroacetabular impingement (FAI). However, participation in popular sports after this procedure has not yet been analyzed. Hypotheses Arthroscopic treatment of FAI increases the level of popular sports activities, and this level of activity correlates with the clinical outcome in terms of pain and function. Study Design Case series; Level of evidence, 4. Methods Fifty-three patients (41 male, 12 female) were evaluated preoperatively and after a mean follow-up of 2.4 years (range, 2-3.2 years) after arthroscopic osteoplasty for cam and mixed FAI. Evaluation included the type and level of sports activities (sports frequency score [SFS]) as well as clinical outcome in terms of pain (VAS) and function (nonarthritic hip score [NAHS]). Results Forty-five of the 53 patients had regularly participated in popular sports until the first occurrence of FAI symptoms. Preoperatively, only 4 of these 45 patients had maintained their accustomed level of activity. At the final follow-up, 31 patients had returned to their full accustomed level of activity. None of the patients who had not been active in sports before the first occurrence of symptoms of FAI (n = 8) had begun participation in sports after arthroscopic osteoplasty. The SFS significantly increased from 0.78 to 1.84 (P < .001), and the mean VAS pain score significantly improved from 5.7 (range, 1-9) to 1.5 (range, 0-6) points (P < .001). The NAHS improved from 54.4 (range, 28.75-92.5) to 85.7 (range, 47.5-100) (P < .001). There was no significant correlation between SFS and NAHS (r = .051, P = .35), as well as between SFS and VAS pain score (r = .159, P = .140) preoperatively, but a significant correlation was seen at the time of the last postoperative follow-up (SFS/NAHS: r = .392, P = .003; SFS/VAS: r = .242, P = .049). The 3 most frequent sports activities postoperatively were biking, hiking, and fitness. Conclusion Arthroscopic osteoplasty can significantly improve the rate and level of popular sports activities in patients with FAI. The level of postoperative sports activity directly correlates with the clinical outcome in terms of pain and function.

Arthroscopic Treatment of Femoral Acetabular Impingement in Patients With Preoperative Generalized Degenerative Changes

PURPOSE The aim of this study was to evaluate the short-term results after arthroscopic femoroacetabular impingement (FAI) correction combined with additional procedures addressing labral and chondral damages in patients who showed generalized severe cartilage lesions intraoperatively. METHODS Between 2004 and 2007, 20 patients (16 men and 4 women) could be included in the study. Clinical parameters, the pain score on a visual analog scale, initial radiologic degenerative changes, the alpha angle, and the Nonarthritic Hip Score were prospectively documented. The study endpoint was the implantation of a total hip arthroscopy or the latest follow-up. RESULTS At a mean follow-up of 3.0 years, 10 patients (50%) had undergone, or planned to undergo, total hip replacement. The remaining patients showed a significant improvement in pain, Nonarthritic Hip Score, and hip flexion and internal rotation. CONCLUSIONS In patients with already marked generalized chondral lesions, arthroscopy does not have any effect beyond the short-term pain relief resulting from debridement. The study underlines the fact that FAI with advanced osteoarthrosis, particularly Tönnis grade III, is not an indication for arthroscopic FAI correction. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Cartilage lesions and the development of osteoarthritis after internal fixation of ankle fractures : a prospective study

BACKGROUND The role of the location and severity of the initial cartilage lesions associated with an ankle fracture in the development of posttraumatic osteoarthritis has not been established, to our knowledge. METHODS We performed a long-term follow-up study of a consecutive, prospectively included cohort of 288 ankle fractures that were treated operatively between June 1993 and November 1997. Arthroscopy had been performed in all cases in order to classify the extent and location of cartilage damage. One hundred and nine patients (47%) were available for follow-up after a mean of 12.9 years. The main outcome parameters were the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score for clinical evaluation and a modified Kannus osteoarthritis score for radiographic assessment of the development of posttraumatic osteoarthritis. RESULTS Cartilage damage anywhere in the ankle joint was associated with a suboptimal clinical outcome (odds ratio, 5.0 [95% confidence interval = 1.3 to 20.1]; p = 0.02) and with a suboptimal radiographic outcome (odds ratio = 3.4 [95% confidence interval = 1.0 to 11.2]; p = 0.04). An association was also found between the development of clinical signs of osteoarthritis and a deep lesion (>50% of the cartilage thickness) on the anterior aspect of the talus (odds ratio = 12.3 [95% confidence interval = 1.4 to 108.0]; p = 0.02) and a deep lesion on the lateral aspect of the talus (odds ratio = 5.4 [95% confidence interval = 1.2 to 23.5]; p = 0.02). A deep lesion on the medial malleolus was associated with the development of clinical signs of osteoarthritis (odds ratio = 5.2 [95% confidence interval = 1.9 to 14.6]; p < 0.01) and radiographic signs of osteoarthritis (odds ratio = 2.9 [95% confidence interval = 1.1 to 7.9]; p = 0.03) of osteoarthritis. There was no significant correlation between cartilage lesions on the fibula and the long-term outcome. CONCLUSIONS Our findings show that initial cartilage damage seen arthroscopically following an ankle fracture is an independent predictor of the development of posttraumatic osteoarthritis. Specifically, lesions on the anterior and lateral aspects of the talus and on the medial malleolus correlate with an unfavorable clinical outcome.

Evaluation of a Computed Tomography-Based Navigation System Prototype for Hip Arthroscopy in the Treatment of Femoroacetabular Cam Impingement

PURPOSE The purpose of this study was to investigate the impact of a new computed tomography-based computer navigation system on the accuracy of arthroscopic offset correction in patients with cam type femoroacetabular impingement (FAI), and to evaluate if the accuracy of offset restoration compromises the early clinical outcome. METHODS We prospectively treated 50 patients (25 navigated and 25 non-navigated) by hip arthroscopy and arthroscopic offset restoration for cam FAI. The patients were a mean age 42.9 years, and the average follow-up was 26.7 months, with no patients lost to follow-up. Magnetic resonance imaging scans were performed preoperatively and 6 weeks postoperatively. A postoperative alpha angle of less than 50 degrees or a reduction of the alpha angle of more than 20 degrees was considered to be successful offset restoration. Outcomes were measured with a visual analogue scale for pain, range of motion, and the nonarthritic hip score. RESULTS The mean alpha angle improved from 76.5 degrees (range, 57 degrees to 110 degrees) to 54.2 degrees (range, 40 degrees to 84 degrees). In both the navigated and the non-navigated groups, 6 patients (24%) showed insufficient offset correction. Range of motion, visual analogue scale for pain scores, and nonarthritic hip scores significantly improved in all subgroups. Statistical analysis showed no significant difference regarding the clinical outcome between patients with sufficient and insufficient correction of the alpha angle. CONCLUSIONS In this series, a significant percentage of patients (24%) showed an insufficient correction of the alpha angle after hip arthroscopy for cam FAI. This study shows that the presented navigation system could not improve this rate and that the insufficient accuracy of reduction of the alpha angle does not appear to compromise the early clinical outcome. LEVEL OF EVIDENCE Level II, prospective comparative study.

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.

A New Z-shaped Calcaneal Osteotomy for 3-plane Correction of Severe Varus Deformity of the Hindfoot

Surgical treatment of varus hindfoot deformity may necessitate bony and soft-tissue corrections, as it is often associated with a cavovarus deformity of the foot. Different procedures have been suggested; most of the authors, however, recommend a calcaneal osteotomy to address the varus deviation of the heel, particularly if a rigid deformity is present. The popular Dwyer osteotomy shortens the heel and allows only limited correction in only 1 plane, and therefore, several modifications of the classic Dwyer osteotomy have been described. This article describes an attractive alternative procedure with a Scarf-like osteotomy, allowing to correct the heel in a frontal and transversal plane.

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.

Bone augmentation for revision total ankle arthroplasty with large bone defects

Until recently, revision arthrodesis was the standard salvage procedure for failed total ankle arthroplasty (TAA) (Groth and Fitch 1987, Kotnis et al. 2006, Culpan et al. 2007, Doets and Zurcher, 2010, Henricson and Rydholm 2010). However, recent studies have investigated the efficacy of revision TAA (Espinosa and Wirth 2013, Hintermann et al. 2013 , Zgonis 2013) but most of them have not specifically addressed the problem of deficient bone stock. This technical note shows how to perform revision TAA in patients with substantial bone loss.