Sjoerd A. S. Stufkens

Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view

BackgroundHindfoot malalignment is a recognized cause of foot and ankle disability. For preoperative planning and clinical follow-up, reliable radiographic assessment of hindfoot alignment is important. The long axial radiographic view and the hindfoot alignment view are commonly used for this purpose. However, their comparative reliabilities are unknown. As hindfoot varus or valgus malalignment is most pronounced during mid-stance of gait, a unilateral weight-bearing stance, in comparison with a bilateral stance, could increase measurement reliability. The purpose of this study was to compare the intra- and interobserver reliability of hindfoot alignment measurements of both radiographic views in bilateral and unilateral stance.Materials and methodsA hindfoot alignment view and a long axial view were acquired from 18 healthy volunteers in bilateral and unilateral weight-bearing stances. Hindfoot alignment was defined as the angular deviation between the tibial anatomical axis and the calcaneus longitudinal axis from the radiographs. Repeat measurements of hindfoot alignment were performed by nine orthopaedic examiners.ResultsMeasurements from the hindfoot alignment view gave intra- and interclass correlation coefficients (CCs) of 0.72 and 0.58, respectively, for bilateral stance and 0.91 and 0.49, respectively, for unilateral stance. The long axial view showed, respectively, intra- and interclass CCs of 0.93 and 0.79 for bilateral stance and 0.91 and 0.58 for unilateral stance.ConclusionThe long axial view is more reliable than the hindfoot alignment view or the angular measurement of hindfoot alignment. Although intra-observer reliability is good/excellent for both methods, only the long axial view leads to good interobserver reliability. A unilateral weight-bearing stance does not lead to greater reliability of measurement.

Medium- to Long-Term Outcome of Ankle Arthrodesis

Background: Despite improvement in outcome after ankle arthroplasty, fusion of the ankle joint is still considered the gold standard. A matter of concern is deterioration of clinical outcome as a result of loss of motion and advancing degeneration of adjacent joints. We performed a long-term study to address these topics. Methods: Between 1990 and 2005 a total of 121 ankle arthrodeses were performed at our institute. Thirty-five cases were excluded because of simultaneous subtalar arthrodesis. Ten had died and ten were lost to followup. Six had a bilateral ankle arthrodeses, leaving 60 patients (66 ankles) eligible for followup. There were 40 males and 26 females with a mean age at surgery of 47 years. In 60 ankles, fusion was obtained using a two-incision, three-screw technique. All patients were assessed using validated questionnaires and clinical rating systems: Short Form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Foot and Ankle Ability Measure (FAAM) and a subjective satisfaction rating. Radiological progression of osteoarthritis of the adjacent joints was assessed. Results: Fusion was achieved in 91% after primary surgery. In six patients rearthrodesis was needed to obtain fusion. The mean SF-36 score was 63 (SD, 22) for the physical component scale and 81 (SD, 15) for the mental component scale. The mean FAAM score was 69 (SD, 17) and the mean AOFAS Ankle Hindfoot score was 67 (SD, 12). Ninety-one percent were satisfied with their clinical result. Infection occurred once. No other serious adverse events were encountered. In all contiguous joints significant progression of arthritis was appreciated. Conclusion: Ankle arthrodesis using a two-incision, three-screw technique was a reliable and safe technique for the treatment of end-stage osteoarthritis of the ankle. It resulted in a good functional outcome at a mean followup of 9 years. Progressive osteoarthritis of the contiguous joints was clearly appreciated but the functional and clinical importance of these findings remains unclear. Level of Evidence

Effect of supramalleolar varus and valgus deformities on the tibiotalar joint: a cadaveric study

Background: Distal tibia coronal plane malalignment predisposes the ankle joint to asymmetric load. The purpose of this cadaveric study was to quantify changes in pressure and force transfer in an ankle with a supramalleolar deformity. Materials and Methods: Seventeen cadaveric lower legs were loaded with 700 N after creating supramalleolar varus and valgus deformities. The fibula was left intact in 11 specimens and osteotomized in six. Tekscan© sensors were used to measure the tibiotalar pressure characteristics. Results: In isolated supramalleolar deformity, the center of force and peak pressure moved in an anteromedial direction for valgus and posterolateral direction for varus deformities. The change was in an anteromedial direction for varus and in a posterolateral direction for valgus deformities in specimens with an osteotomized fibula. Conclusion: Two essentially different groups of varus and valgus deformities of the ankle joint need to be distinguished. The first group is an isolated frontal plane deformity and the second group is a frontal plane deformity with associated incon-gruency of the ankle mortise. Clinical Relevance: Our findings underline the complexity of asymmetric osteoarthritis of the ankle joint. 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.

Long-term outcome after 1822 operatively treated ankle fractures: A systematic review of the literature

Abstract The aim of this literature review is to systematically gather the highest level of available evidence on the long-term outcome after operatively treated ankle fractures in the English, German and Dutch literature. A search term with Boolean operators was constructed. The search was limited to humans and adults and the major databases were searched from 1966 to 2008 to identify studies relating to functional outcome, subjective outcome and radiographic evaluation at least 4 years after an operatively treated ankle fracture. Of the 42 initially relevant papers, 18 met our inclusion criteria. A total of 1822 fractures were identified. The mean sample-size weighted follow-up was 5.1 years. The initial number of patients that were included in the studies was 2724, which results in a long-term follow-up success rate of 66.9%. Regarding the fracture reduction we found 4 papers reporting on 106 fractures. Of the fractures that were classified according to Danis–Weber, 736 were eligible for correlation with the long-term outcome. In 442 fractures a comparison was possible between supination–external rotation stage 2 and 4 of the Lauge-Hansen classification. Only one study reported on the influence of initial cartilage lesions on the outcome. Regarding the involvement of the posterior malleolus, two studies reported on the long-term outcome. None of the studies addressed the influence of hindfoot varus or valgus on the long-term outcome after ankle fracture. Only 79.3% of the optimally reduced fractures show good to excellent long-term outcome. The Weber A type fractures do not show a better long-term outcome than Weber B type fractures. Recommendations for future research were formulated.

The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review.

The supination–external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.

Posterior Malleolar Fracture Patterns.

Objective: To characterize posterior malleolar fracture morphology using Cole fracture mapping and to study reliability of quantification of 3-dimensional computed tomography (CT)–modeling for posterior malleolar fractures with respect to quantification of fragment size (in cubic millimeter) and true articular involvement (in square millimeter). Methods: CT scans of a consecutive series of 45 patients with an ankle fracture involving the posterior malleolus were reconstructed to calculate (1) fracture maps, (2) fragment volume, (3) articular surface of the posterior malleolar fragment, (4) articular surface of intact tibia, and (5) articular surface of the medial malleolus by 3 independent observers. Three-dimensional animation of this technique is shown on www.traumaplatform.org. Results: Fracture mapping revealed (1) a continuous spectrum of posterolateral oriented fracture lines and (2) fragments with posterolateral to posteromedial oriented fracture lines extending into the medial malleolus. Reliability of measurements of the volume and articular surface of posterior malleolar fracture fragments was defined as almost perfect according to the categorical system of Landis (interclass coefficient, range, 0.978–1.000). Conclusions: Mapping of posterior malleolar fractures revealed a continuous spectrum of Haraguchi III to I fractures and identified Haraguchi type II as a separate pattern. Quantification of 3-dimensional CT–modeling is reliable to assess fracture characteristics of posterior malleolar fracture fragments. Morphology might be more important than posterior malleolar fracture size alone for clinical decision making.

Long-term outcome of pronation-external rotation ankle fractures treated with syndesmotic screws only.

BACKGROUND There is sparse information in the literature on the outcome of Maisonneuve-type pronation-external rotation ankle fractures treated with syndesmotic screws. The primary aim of this study was to determine the long-term results of such treatment of these fractures as indicated by standardized patient-based and physician-based outcome measures. The secondary aim was to identify predictors of the outcome with use of bivariate and multivariate statistical analysis. METHODS Fifty patients with pronation-external rotation (predominantly Maisonneuve) fractures were treated with open reduction and internal fixation of the syndesmosis utilizing only one or two screws. The results were evaluated at a mean of twenty-one years after the fracture utilizing three standardized outcomes instruments: (1) the Foot and Ankle Ability Measure (FAAM), (2) the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, and (3) the Center for Epidemiologic Studies-Depression (CES-D) Scale. Osteoarthritis was graded according to the van Dijk and revised Takakura radiographic scoring systems. Bivariate and multivariate analyses were performed to identify predictors of long-term outcome. RESULTS Forty-four (92%) of forty-eighty patients had good or excellent AOFAS scores, and forty-four (90%) of forty-nine had good or excellent FAAM scores. Arthrodesis for severe osteoarthritis was performed in two patients. Radiographic evidence of osteoarthritis was observed in twenty-four (49%) of forty-nine patients. Multivariate analysis identified pain as the most important independent predictor of long-term ankle function as indicated by the AOFAS and FAAM scores, explaining 91% and 53% of the variation in scores, respectively. Analysis of pain as the dependent variable in bivariate analyses revealed that depression, ankle range of motion, and a subsequent surgery were significantly correlated with higher pain scores. No firm conclusions could be drawn after multivariate analysis of predictors of pain. CONCLUSIONS Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. The most important predictor of long-term functional outcome was patient-reported pain rather than physician-reported function or posttraumatic osteoarthritis. There was no significant association between radiographic signs of posttraumatic osteoarthritis and perceived pain in the present series.

Modifizierte Arthrodese nach Lambrinudi mit zusätzlichem Transfer der Tibialis-posterior-Sehne zur Behandlung des adulten Fallfußes

OBJECTIVE Treatment of adult instable drop foot by modified Lambrinudi arthrodesis (removal of a wedge between the talus and calcaneus), followed by a posterior tibial tendon transfer to the medial cuneiform in order to provide active dorsiflexion. INDICATIONS Severe drop foot (of various etiologies) in combination with hindfoot instability. Sufficient function of the posterior tibial muscle. CONTRAINDICATIONS Neurologic dysfunction of the posterior tibial muscle, infection of foot/hindfoot, Charcot arthropathy, and insufficient patient compliance. RELATIVE CONTRAINDICATIONS: Previous surgery of posterior tibial tendon, critical soft tissues/skin conditions, insufficient neurovascular conditions. SURGICAL TECHNIQUE Lateral skin incision. Debridement of sinus tarsi and removal of the bifurcate ligament to expose the subtalar, calcaneocuboidal, and talonavicular joints. Resection of a bone wedge from the calcaneus and talus (25-30°) to correct the drop foot deformity. Cartilage removal from the calcaneocuboid joint. Debridement of both the talar head and the navicular to allow adequate fitting. After reduction (neutral dorsiflexion and 10° foot abduction), preliminary fixation with Kirschner wires. Final fixation with canulated screws (talonavicular, calcaneocuboidal, and subtalar joints). Medial skin incision at the navicular tuberositas to deattach the posterior tibial tendon with a bony fragment. The tendon stump is harvested 10 cm proximal to the tibiotalar joint. Small skin incision at the anterolateral aspect of the distal lower leg. The posterior tibial tendon is transferred through the interosseous membrane and reattached to the medial cuneiform with a screw. POSTOPERATIVE MANAGEMENT Immobilization with a removable short leg cast for 2-4 days. Ambulation with full weightbearing in a cast for 8 weeks. Radiographic assessment 8 weeks postoperatively. After bony healing, mobilization in normal shoes is allowed. Intensive physiotherapy to train the dorsiflexion. RESULTS The average correction of drop foot deformity was 18.7°. Active dorsiflexion increased significantly from 30° preoperatively to 10° postoperatively.

Articular Gap and Step-off Revisited: 3d Quantification of Operative Reduction for Posterior Malleolar Fragments

Objectives: Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT). Methods: Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. “Classic” maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm2) and multidirectional 3D-displacement (mm). Results: “Classic” measurements showed a median maximum step-off of 1.1 mm [interquartile range (IQR) 0.0–1.8 mm] on 2DCT versus a median step-off of 0.6 mm (IQR 0.0–1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0–3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm2 (IQR 4.7–30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0–1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79–0.98) for gap surface and good (ICC 0.64, 95% CI 0.28–0.88) for 3D-displacement. Conclusions: Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to “classic” gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Peroneus Quartus Muscle in a Locking Phenomenon of the Ankle: A Case Report

We present the case of a 64-year-old female who was referred to us with an unexplained clicking and locking phenomenon of the right ankle. The magnetic resonance imaging findings suggested a longitudinal tear of the peroneus brevis tendon. During tendoscopy, not only was a Raikin type B intrasheath tendon subluxation visible, but also a peroneus quartus muscle. The peroneus brevis tear was tubularized and the peroneus quartus muscle resected, which resolved the patients complaints.