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Background: Newer designs and techniques of total ankle arthroplasty (TAA) have challenged the assumption of ankle arthrodesis (AA) as the primary treatment for end-stage ankle arthritis. The objective of this study was to compare physical and mental function, ankle-specific function, pain intensity, and rates of revision surgery and minor complications between these 2 procedures and to explore heterogeneous treatment effects due to age, body mass index (BMI), patient sex, comorbidities, and employment on patients treated by 1 of these 2 methods.Methods: This was a multisite prospective cohort study comparing outcomes of surgical treatment of ankle arthritis. Subjects who presented after nonoperative management had failed received either TAA or AA using standard-of-treatment care and rehabilitation. Outcomes included the Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores, pain, ankle-related adverse events, and treatment success.Results: Five hundred and seventeen participants underwent surgery and completed a baseline assessment. At 24 months, the mean improvement in FAAM activities of daily living (ADL) and SF-36 PCS scores was significantly greater in the TAA group than in the AA group, with a difference between groups of 9 points (95% confidence interval [CI] = 3, 15) and 4 points (95% CI = 1, 7), respectively. The crude incidence risks of revision surgery and complications were greater in the AA group; however, these differences were no longer significant after adjusting for age, sex, BMI, and Functional Comorbidity Index (FCI). The treatment success rate was greater after TAA than after AA for those with an FCI of 4 (80% versus 62%) and not fully employed (81% versus 58%) but similar for those with an FCI score of 2 (81% versus 77%) and full-time employment (79% versus 78%).Conclusions: At 2-year follow-up, both AA and TAA were effective. Improvement in several patient-reported outcomes was greater after TAA than after AA, without a significant difference in the rates of revision surgery and complications.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The rate of total ankle arthroplasty (TAA) is increasing relative to ankle arthrodesis (AA) for patients seeking surgical treatment for end-stage ankle arthritis. Patients and providers would benefit from a more complete understanding of the rate of improvement, the average length of time to achieve maximal function and minimal pain, and whether there is a greater decline in function or an increase in pain over time following TAA compared with AA. The objectives of this study were to compare treatment changes in overall physical and mental function and ankle-specific function, as well as pain intensity at 48 months after TAA or AA in order to determine if the improvements are sustained.Methods: This was a multisite prospective cohort study that included 517 participants (414 TAA and 103 AA) who presented for surgical treatment. Participants were compared 48 months after surgery using the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports subscales (0 to 100 points), the Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores (0 to 100 points), and pain scores (0 to 10 points).Results: Both groups achieved significant improvement in the 2 FAAM measures, the SF-36 PCS score, and all of the pain measures at 48 months after surgey (p < 0.001). Mean improvements from baseline in patients undergoing TAA for the FAAM Activities of Daily Living, FAAM Sports, and SF-36 scores were at least 9 points, 8 points, and 3.5 points, respectively, which were higher than in those undergoing AA. Mean improvements in worst and average pain were at least 0.9 point higher in patients undergoing TAA than in those undergoing AA at 12, 24, and 36 months. These differences were attenuated by 48 months. For both treatments, all improvements from baseline to 24 months had been maintained at 48 months.Conclusions: When both procedures are performed by the same group of surgeons, patients who undergo TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) is becoming a more prevalent treatment for end-stage ankle arthritis. However, the effects of malalignment on TAA remain poorly understood.Questions/purposes: The purpose of this study was to quantify the mechanical effects of coronal plane malalignment of the tibial insert in TAA using cadaveric gait simulation. Specifically, we asked, is there a change in (1) ankle joint congruency, (2) kinematic joint position, (3) kinematic ROM, (4) peak plantar pressure, and (5) center of pressure with varus and valgus malalignment?Methods: A modified TAA was implanted into seven cadaveric foot specimens. Wedges were used to simulate coronal plane malalignment of the tibial insert. The degree of malalignment (tibial insert angle [TIA] and talar component angle [TCA]) was quantified radiographically for neutral and 5°, 10°, and 15° varus and valgus wedges. Dynamic walking at 1/6 of physiological speed was simulated using a robotic gait simulator. A motion capture system was used to measure foot kinematics, and a pressure mat was used to measure plantar pressure. Joint congruency was quantified as the difference between TIA and TCA. Continuous joint position, joint ROM, peak plantar pressure, and center of pressure for varus and valgus malalignment compared with neutral alignment were estimated using linear mixed effects regression. Pairwise comparisons between malalignment conditions and neutral were considered significant if both the omnibus test for the overall association between outcome and malalignment and the individual pairwise comparison (adjusted for multiple comparisons within a given outcome) had p ≤ 0.05.Results: Descriptively, the TIA and TCA were both less pronounced than the wedge angle and component incongruence was seen (R = 0.65; p < 0.001). Varus malalignment of the tibial insert shifted the tibiotalar joint into varus and internally rotated the joint. The tibiotalar joint's ROM slightly increased as the TIA shifted into varus (1.3 ± 0.7° [mean ± SD] [95% confidence interval -0.7 to 3.4]; p = 0.03), and the first metatarsophalangeal joint's ROM decreased as the TIA shifted into varus (-1.9 ± 0.9° [95% CI -5.6 to 1.7]; p = 0.007). In the sagittal plane, the naviculocuneiform joint's ROM slightly decreased as the TIA shifted into varus (-0.9 ± 0.4° [95% CI -2.1 to 0.3]; p = 0.017). Hallux pressure increased as the TIA became more valgus (59 ± 50 kPa [95% CI -88 to 207]; p = 0.006). The peak plantar pressure slightly decreased in the third and fourth metatarsals as the TIA shifted into valgus (-15 ± 17° [95% CI -65 to 37]; p = 0.03 and -8 ± 4° [95% CI -17 to 1]; p = 0.048, respectively). The fifth metatarsal's pressure slightly decreased as the TIA shifted into valgus (-18 ± 12 kPa [95% CI -51 to 15]) or varus (-7 ± 18 kPa [95% CI -58 to 45]; p = 0.002). All comparisons were made to the neutral condition.Conclusions: In this cadaver study, coronal plane malalignment in TAA altered foot kinematics and plantar pressure. In general, varus TAA malalignment led to varus shift and internal rotation of the tibiotalar joint, a slight increase in the tibiotalar ROM, and a slight decrease in the first metatarsophalangeal ROM, while a valgus TAA malalignment was manifested primarily through increased hallux pressure with a slight off-loading of the third and fourth metatarsals.Clinical Relevance: This study may increase our understanding of the biomechanical processes that underlie the unfavorable clinical outcomes (such as, poor patient-reported outcomes or implant loosening) that have been associated with coronal plane malalignment of the tibial component in TAA. [ABSTRACT FROM AUTHOR]

Background: Ambulatory activity is reduced in patients with ankle arthritis. In this study, we measured step activity over time in 2 treatment groups and secondarily compared step activity with results of patient-reported outcome measures (PROMs).Methods: Patients who were treated with either ankle arthrodesis or ankle arthroplasty wore a step activity monitor preoperatively and at 6, 12, 24, and 36 months postoperatively. Changes from preoperative baseline in total steps per day and per-day metrics of low, medium, and high-activity step counts were measured in both treatment groups. Step activity was compared with each subject's PROM scores as reported on the Musculoskeletal Function Assessment (MFA) and the Short Form-36 (SF-36) physical function and bodily pain subscales.Results: Of the 3 activity levels, combined group high-activity step counts showed the greatest increase (mean of 278 steps [95% confidence interval (CI), 150 to 407 steps], a 46% improvement from preoperatively). At 6 months, the mean high-activity step improvement for the arthroplasty group was 194 steps compared with a mean decline of 44 steps for the arthrodesis group (mean 238-step difference [95% CI, -60 to 536 steps]). By 36 months postoperatively, the greater improvement in high-activity steps for the arthroplasty versus the arthrodesis group was no longer present. There were no significant pairwise differences in improvement based on surgical treatment method at any individual follow-up time point. For a within-patient increase of 1,000 total steps, there was a mean change in the MFA, SF-36 physical function, and SF-36 bodily pain scores of -1.8 (95% CI, -2.4 to -1.2), 3.8 (95% CI, 2.8 to 4.8), and 2.8 (95% CI, 1.8 to 3.9), respectively (p < 0.0001 for all associations). There was no evidence that the association differed by study visit, or by study visit and surgical procedure interaction (p > 0.10).Conclusions: Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. Improvement may occur more quickly following arthroplasty than arthrodesis, but at 3 years, we detected no significant difference between the 2 procedures. Step counts, while associated with PROMs, do not parallel them, and thus may be a useful supplementary measure, particularly in longitudinal studies.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: We analyzed self-reported outcomes in a prospective cohort of patients treated with ankle arthrodesis or total ankle replacement (TAR) during a time of transition from older to newer-generation TAR implants.Methods: We performed a prospective cohort study comparing outcomes in 273 consecutive patients treated for ankle arthritis with arthrodesis or TAR between 2005 and 2011. Adult patients with end-stage ankle arthritis who were able to walk and willing and able to respond to surveys were included in the study. Patients were excluded when they had another lower-limb problem that might affect walking. At baseline and at 6, 12, 24, and 36-month follow-up visits, participants completed a pain score, a Musculoskeletal Function Assessment (MFA), and a Short Form-36 (SF-36) survey.Results: There was significant mean improvement in most outcomes after surgery regardless of procedure. In general, the greatest improvement occurred during the first 6 months of follow-up. Linear mixed-effects regression adjusted for differences at baseline in age, body mass index (BMI), and surgery type showed that at 6 months the scores were improved by a mean (and standard error) of 12.6 ± 0.7 (33%) on the MFA, 22.0 ± 1.4 (56%) on the SF-36 Physical Functioning (PF) scale, 32.4 ± 1.6 (93%) on the SF-36 Bodily Pain (BP) scale, and 4.0 ± 0.2 (63%) on the pain rating scale. The mean improvements in the MFA and SF-36 PF scores over the 3-year follow-up period were significantly better after the TARs than after the arthrodeses, with differences between the 2 groups of 3.6 ± 1.6 (p = 0.023) and 7.5 ± 2.9 (p = 0.0098), respectively. The differences between the 2 groups were slightly greater when only the newer TAR devices were compared with the arthrodeses (MFA = 3.8 ± 1.8 [p = 0.031], SF-36 PF = 8.8 ± 3.3 [p = 0.0074], SF-36 BP = 7.3 ± 3.6 [p = 0.045], and pain score = 0.8 ± 0.4 [p = 0.038]).Conclusions: Patients reported improved comfort and function after both surgical treatments. The average improvement in the MFA and SF-36 PF scores was better after TAR than after arthrodesis, particularly when the TAR had been done with later-generation implants. Younger patients had greater functional improvements than older patients.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Ankle arthritis, like hip and knee arthritis, has a substantial impact on patient function. Understanding the functional limitations of ankle arthritis may help to stratify treatment strategies. Methods: We measured the preoperative demographic characteristics, physical function, and self-assessed function of patients with end-stage ankle arthritis and identified correlations among these metrics. Participants wore a StepWatch 3 Activity Monitor for two weeks and completed the Musculoskeletal Function Assessment and Short Form-36 surveys. Gait kinematics and kinetics were also measured as participants walked at a self-selected pace. Results: Musculoskeletal Function Assessment and Short Form-36 scores revealed reduced perceived function for patients with end-stage ankle arthritis compared with healthy controls. These patients also took fewer total steps per day, took fewer high-intensity steps, and chose to walk at a slower walking speed. Gait analysis revealed reduced ankle motion, peak ankle plantar flexor moment, peak ankle power absorbed, and peak ankle power generated for the affected limb compared with the unaffected limb. High-intensity step count was also correlated with both survey scores, walking speed, step length, peak ankle plantar flexor moment, and peak ankle power generated. Walking speed, step length, and ankle motion were correlated with peak ankle plantar flexor moment and power generated. Conclusions: Generally, patients with end-stage ankle arthritis have reduced physical and perceived function compared with healthy individuals. Additionally, high-intensity step count was a better indicator of physical and perceived function compared with total steps per day for this population. [ABSTRACT FROM AUTHOR]

Background: Arthrodesis of the first metatarsophalangeal joint is indicated for severe osteoarthritis or as a revision of failed treatment for hallux valgus. The literature suggests that an optimum fused dorsiflexion angle is between 20 degrees and 25 degrees from the axis of the first metatarsal. The purpose of this study was to investigate the relationship between dorsiflexion angle and plantar pressure in the postoperative gait. We assumed that there is a fused dorsiflexion angle at which pressures are minimized under the hallux and the first metatarsal head.Methods: Six cadaver foot specimens underwent incremental changes in simulated fused metatarsophalangeal joint dorsiflexion angle followed by dynamic gait simulation. A robotic gait simulator performed at 50% of body weight and one-fifteenth of physiologic velocity. In vitro tibial kinematics and tendon forces were based on normative in vivo gait and electromyographic data and were manually tuned to match the in vitro ground reaction force and tendon force behavior. Regression lines were calculated for peak pressure and pressure-time integral under the hallux and the metatarsal head by dorsiflexion angle.Results: Peak pressure and pressure-time integral under the hallux were negatively correlated with dorsiflexion angle (p < 0.004), while peak pressure and pressure-time integral under the metatarsal head were positively correlated with dorsiflexion angle (p < 0.004). The intersection of the regression lines that represented the angle at which peak pressure and pressure-time integral were minimized was 24.7 degrees for peak pressure and 21.3 degrees for pressure-time integral.Conclusions: Our findings support the hypothesis that an angle-pressure relationship exists following arthrodesis of the first metatarsophalangeal joint and that it is inversely related for the hallux and the metatarsal head. Our results encompass the suggested range of 20 degrees to 25 degrees. [ABSTRACT FROM AUTHOR]

Background: There is considerable debate regarding the appropriate treatment of the extruded talus regardless of the presence of a fracture. The purpose of this study was to report the clinical results, complications, and functional outcome following reimplantation of the traumatically extruded talus.Methods: A database of 119 patients with an open injury of the talus occurring between 1995 and 2003 at a level-I trauma center was reviewed to identify patients with a complete talar extrusion. Demographic, imaging, and treatment data were obtained from a review of the medical records. Follow-up was undertaken during clinic visits or by telephone. Preoperative and follow-up radiographs were reviewed to identify posttraumatic arthritis, osteonecrosis, or talar collapse, and the Musculoskeletal Functional Assessment was used to assess functional outcome.Results: Twenty-seven patients were identified. A minimum follow-up of one year (average, forty-two months) was obtained for nineteen patients. Infection and the need for a secondary surgical procedure were the primary determinants of clinical outcome. Two of the nineteen patients had documented infections: one had developed at two weeks and one, after a calcaneal osteotomy at nineteen months. Twelve patients had no subsequent surgery, and seven had subsequent procedures (range, one to four procedures). No patient underwent a delayed amputation. The average Musculoskeletal Functional Assessment score at the time of follow-up was 29.8 (range, 5 to 59). With the numbers studied, no association was found between functional outcome and the following variables: ipsilateral lower-extremity injury, associated talar fracture, secondary procedures, osteonecrosis, or age.Conclusions: While functional outcome is difficult to assess, salvage of the extruded talus appears to be a relatively safe operation, with a minimal risk of infection, which allows maximal flexibility in aftercare by preserving the most normal ankle anatomy possible. [ABSTRACT FROM AUTHOR]

Background: Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role.Methods: We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out.Results: In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively).Conclusions: Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies. [ABSTRACT FROM AUTHOR]

Background: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. Methods: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. Results: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. Conclusions: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications. [ABSTRACT FROM AUTHOR]

Background: Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. Methods: We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. Results: Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-Ill fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. Conclusions: Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications. [ABSTRACT FROM AUTHOR]

Background: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment.Methods: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed.Results: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores.Conclusions: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications. [ABSTRACT FROM AUTHOR]

Background: Patients with symptomatic flatfoot deformity often present with pain in the lateral part of the hindfoot. The cause of this pain has not been clearly established. Impingement between the talus and the calcaneus or between the calcaneus and the fibula has been suggested as a cause but has not been documented.Methods: We examined the computed tomographic scans, performed with simulated weight-bearing, of nineteen adult patients with symptomatic flatfoot to determine the potential causes of pain in the lateral aspect of the foot. The scans were performed with use of a custom loading frame designed to simulate weight-bearing with the foot in a neutral position while a 75-N axial compressive load was applied. Four examiners independently examined the coronal images as well as sagittal plane reconstructions for direct (bone-on-bone contact) and indirect (subchondral sclerosis or cysts) evidence of (1) extra-articular contact between the talus and the calcaneus in the sinus tarsi and (2) contact between the calcaneus and the fibula. The data were compared with those from five scans of normal feet in neutral alignment.Results: Overall, the prevalence of sinus tarsi impingement was 92% and the prevalence of calcaneofibular impingement was 66% in the flatfoot group versus 0% and 5%, respectively, in the control group. The study patients who had calcaneofibular impingement also had sinus tarsi impingement. There was substantial agreement among the examiners as to whether impingement was present.Conclusions: There appear to be two frequently occurring extra-articular sources of bone impingement in the lateral aspect of the hindfoot in adults with symptomatic severe flatfoot deformity. The impingement in the lateral aspect of the hindfoot may first occur within the sinus tarsi and then involve the calcaneofibular region. Cyst formation and/or sclerosis in this region that is visible on plain radiographs or on computed tomographic scans performed without weight-bearing should create suspicion of impingement. [ABSTRACT FROM AUTHOR]

Background: Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. Methods: This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). Results: With the knee fully extended, the average maximal ankle dorsiflexion was 4.5° in the patient group and 13.1° in the control group (p < 0.001). With the knee flexed 90°, the average was 17.9° in the patient group and 22.3° in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of ≤5° during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of ≤10°, it... [ABSTRACT FROM AUTHOR]

Presents letters to the editor of 'The Journal of Bone & Joint Surgery' concerning articles published in the periodical. Role of team physician; Treatment of multiple closed fractures; Post-operative pain in animals used in research.

Background: Malaligned ankle arthroplasty components have been associated with increased postoperative pain and reduced ankle range of motion. With this study, we aimed to quantify how anterior and posterior malalignment of the talar component affects foot bone kinematics and plantar pressures in a dynamic, cadaveric gait simulation.Methods: Ten cadaveric foot specimens received a modified ankle prosthesis. Proper alignment was defined as the prosthesis being neutral to a plantigrade foot, where varus/valgus and internal/external rotation were determined using the tibial alignment guide from the prosthesis manufacturer. Axially loaded lateral radiographs were made to measure the tibiotalar ratio (TTR) preoperatively and postoperatively. Specimens were prepared for gait simulation and mounted into the robotic gait simulator. Foot bone kinematics and plantar pressures were measured for each alignment condition.Results: Posterior malalignment of the talar component decreased mean sagittal-plane range of motion (p ≤ 0.0005) in the tibiotalar joint (by up to 3.9°) and in the first metatarsophalangeal joint (by up to 7.7°) and increased sagittal-plane range of motion (p ≤ 0.0005) in the calcaneocuboid joint (by up to 2.0°). Posterior malalignment increased mean transverse-plane range of motion (p ≤ 0.0005 and p = 0.012) in the tibiotalar joint (by up to 2.3°) and in the calcaneocuboid joint (by 2.3°). Posterior malalignment decreased mean peak plantar pressures (p = 0.001 and p = 0.013) under the hallux and the first metatarsal (by up to 82.1 and 110.1 kPa, respectively) and increased (p = 0.012 and p = 0.0006) peak plantar pressures under the third metatarsal and the hindfoot (by 23.0 and 47.8 kPa, respectively). Anterior malalignment decreased (p = 0.0006) mean hindfoot peak plantar pressure (by 127.7 kPa). Anterior and posterior malalignments shifted center of pressure laterally during early and late stance. The TTR weakly to moderately correlated with range-of-motion changes in the tibiotalar, calcaneocuboid, and first metatarsophalangeal joints (r ≤ 0.39) and weakly correlated with plantar pressure changes under the hindfoot, the first metatarsal, and the hallux (r ≤ 0.15).Conclusions: Anterior and posterior malalignments of the talar component altered foot bone kinematics and plantar pressures. Mild malalignments produced fewer significant differences than moderate and extreme malalignments. A greater number of significant differences were found for posterior malalignments than for anterior. The TTR weakly to moderately correlated with changes in range of motion and plantar pressures.Clinical Relevance: The observed changes in range of motion and plantar pressures may explain why malaligned ankle arthroplasties are associated with unfavorable clinical outcomes and poor prosthesis longevity. Posterior malalignments may produce worse clinical outcomes than anterior malalignments. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses a surgical treatment to Achilles rupture and the impact of late presentation of Achilles rupture.

An introduction is presented which discusses several reports with in the issue and topics including the "Bone biopsy" and "Pathological and culture findings".

Background: Osteoarthritis is the most common joint disease and the leading cause of chronic disability in the U.S. However, symptomatic osteoarthritis at the ankle occurs nine times less frequently than at the knee and hip, even though the ankle experiences greater pressure and is the most commonly injured joint in the human body. This study sought to quantify the shape and coverage of the talar and tibial articular surfaces by comparing the three-dimensional morphology of the ankle in patients with ankle osteoarthritis and in those without arthritis, including a subset of different foot shapes. Methods: We created three-dimensional models of the joint surfaces of ankles with and without arthritis. We fit cylinders to the joint surfaces, and measured the radius of the tibial and talar articular surfaces, the tibial coverage angle of the talus, and the degree of joint skew. We hypothesized that these measurements would be different between those with and without ankle osteoarthritis and among foot types. We evaluated a total of 108 limbs. Results: The mean tibial and talar radii were significantly higher and the mean coverage angle was significantly lower in feet with ankle osteoarthritis than in all other foot categories. The mean coronal skew in limbs with ankle osteoarthritis was significantly higher than in the neutral and flatfoot groups. The high arched feet had several significantly different skew angles from other foot types. No significant differences in joint morphology measures between neutrally aligned feet and flatfeet were found. Conclusions: Ankles with osteoarthritis had larger tibial and talar radii, a smaller coverage angle, and larger skew angles than ankles without osteoarthritis. Together, these findings suggest a flatter ankle joint with less stability, depth, and containment and reduced articular constraint and support. Clinical Relevance: These findings offer an objective standard that supports the principle that ankle osteoarthritis pathology is related to loss of ankle joint containment. [ABSTRACT FROM AUTHOR]

Objectives: Open wounds occur with calcaneus fracture from direct application of force and from tearing along the medial side of the fracture as the tuberosity displaces laterally. Secondary soft tissue injury can also occur from pressure of the displaced fracture fragments. Tongue-type fractures of the calcaneus lead to variable amounts of displacement of the posterior tuberosity. This displacement may threaten the posterior soft tissue envelope. Because many calcaneus fractures are splinted initially and immobilized for several weeks until swelling resolves, failure to acutely recognize the potential for posterior skin breakdown may lead to severe soft tissue morbidity. The purpose of this study was to determine the incidence of posterior skin involvement in tongue-type calcaneus fractures and to determine the patient and fracture characteristics that lead to high-risk situations., Setting: University level I trauma center., Patients/participants: All tongue-type calcaneus fractures treated at 1 institution between 2002 and 2007 were identified from a trauma registry. Of 954 patients with calcaneal fractures, 139 tongue-type calcaneus fractures in 127 patients formed the study group., Intervention: Patient demographics, comorbidities, injury mechanism, fracture displacement, and time to presentation were evaluated. Those injuries that were associated with posterior, secondary soft tissue breakdown were identified and compared to those without breakdown., Main Outcome Measurements: Univariate analysis and stepwise multinomial logistic regressions were used to identify significant predictors of posterior soft tissue compromise., Results: Twenty-nine fractures (21%) had some degree of posterior skin compromise at presentation, including 12 with threatened skin, 10 with partial thickness breakdown, and 7 with full thickness breakdown. Six soft tissue coverage procedures and one amputation resulted. Patients with posterior skin compromise were less likely to have a fall mechanism (P = 0.001), had significantly greater fracture displacement (P = 0.007), were more likely to smoke (P = 0.039), and were more frequently referred on a delayed basis (P = 0.007). Those with threatened posterior skin who were treated emergently with percutaneous reduction did not progress to soft tissue compromise., Conclusion: A high incidence (21%) of posterior skin compromise occurs in tongue-type calcaneus fractures. These should be treated with immediate reduction, plantarflexion splinting, and close monitoring. Although mechanism, displacement, and time to presentation were significantly correlated with posterior skin involvement, the surgeon should be aware of this potential complicating factor in all tongue-type fractures.

Severe joint depression-type calcaneal fractures cause dramatic distortion of hindfoot anatomy, including gross shortening of the heel and lateral translation of the tuberosity. This displacement may alter the mechanics of the foot, interfere with tendon function, or put the medial soft tissues under tension. The displacement is typically corrected by open reduction. However, surgical intervention may be delayed because of soft tissue involvement, higher priority musculoskeletal injuries, or the presence of life-threatening injury. When treatment has been delayed, it may be difficult to restore the height and length of the calcaneus. Application of an external fixator is one option to allow for early indirect fracture reduction of the hindfoot and initial soft tissue healing. However, a percutaneous screw reduction technique reduces the risk of pin tract infection with the external fixateur and allows the soft tissue to regenerate. Bony reduction is gained with the help of a push screw, which allows controlled and gradual reconstitution of the length and height (Böhler's angle) of the hindfoot. This technique, though, is only recommended as a temporary salvage procedure in situations in which a delayed primary subtalar fusion is the only treatment of choice in a severely comminuted high-energy calcaneal fracture.