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End-stage an kle arthritis is operatively treated with numerous designs of total an kle replacement and different techniques for an kle fusion. For superior comparison of these procedures, outcome research requires a classification system to stratify patients appropriately. A postoperative 4-type classification system was designed by 6 fellowship-trained foot and an kle surgeons. Four surgeons reviewed blinded patient profiles and radiographs on 2 occasions to determine the interobserver and intraobserver reliability of the classification. Excellent interobserver reliability (κ = .89) and intraobserver reproducibility (κ = .87) were demonstrated for the postoperative classification system. In conclusion, the postoperative Canadian Orthopaedic Foot and Ankle Society (COFAS) end-stage an kle arthritis classification system appears to be a valid tool to evaluate the outcome of patients operated for end-stage an kle arthritis.

Flexor and extensor muscle-tendon unit activity at the elbow during the golf swing was recorded from subjects with and without medial epicondylitis. There was no sig nificant difference in total swing time between symp tomatic (1.23 ± 0.15 sec) and asymptomatic (1.15 ± 0.13 sec) subjects nor between golfers with low (1 to 6 handicap, N = 8) and high (11 to 19 handicap, N = 8) scoring abilities. Symptomatic and asymptomatic sub jects displayed similar electromyographic profiles for flexor and extensor muscles of the forearm. Electro myographic activity of the common extensor muscles was persistent throughout the four swing phases, rang ing from 33.59% of maximum voluntary contraction at address to 58.77% at contact. Common flexor muscles produced a consistent burst of electromyographic ac tivity during contact phase (flexor burst, 90.77% of maxi mum voluntary contraction). Symptomatic subjects' mean flexor muscle electromyographic activity was sig nificantly greater than that of asymptomatic subjects in both address and swing phases. When forearm brace and oversized grips were imposed on symptomatic sub jects, there was no significant difference in mean elec tromyographic magnitude or muscle activation pattern during the golf swing. Thus, the method of sympto matic relief of the intervention strategies tested is still in question.

Purpose The purpose was to review the literature on the outcomes of elbow arthroscopy and to make evidence-based recommendations for or against elbow arthroscopy for the treatment of various conditions. Our hypothesis was that the evidence would support the use of elbow arthroscopy in the management of common elbow conditions. Methods A literature search was performed by use of the PubMed database in October 2010. All therapeutic studies investigating the results of treatment with elbow arthroscopy were analyzed for outcomes and complications. The literature specific to common elbow arthroscopy indications was summarized and was assigned a grade of recommendation based on the available evidence. Results There is fair-quality evidence for elbow arthroscopy in the treatment of rheumatoid arthritis of the elbow and lateral epicondylitis (grade B recommendation). There is poor-quality evidence for, rather than against, the arthroscopic treatment of degenerative arthritis, osteochondritis dissecans, radial head resection, loose bodies, post-traumatic arthrofibrosis, posteromedial impingement, excision of a plica, and fractures of the capitellum, coronoid process, and radial head (grade C f recommendation). There is insufficient evidence to give a recommendation for or against the arthroscopic treatment of posterolateral rotatory instability and septic arthritis (grade I recommendation). Conclusions The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. The quality of the evidence, however, is generally fair to poor. Level of Evidence Level IV, systematic review of Level II-IV studies.

Purpose The purpose of this systematic review is to provide a comprehensive analysis of the Level of Evidence and the Grade of Recommendation for hip arthroscopy. Methods A literature review was performed (in June 2010) using the PubMed and Cochrane databases. Studies that focused on the efficacy of hip arthroscopy for all therapeutic indications were reviewed to determine their Level of Evidence. The studies were grouped based on indication, and the literature supporting each indication was analyzed and assigned a Grade of Recommendation. A subscale proposed by us was used to further describe the evidence base for indications receiving a Grade of Recommendation indicating poor-quality evidence. Results Fair evidence (grade B) exists to support the surgical technique of hip arthroscopy for the treatment of femoroacetabular impingement. Poor-quality evidence (grade C f ) exists to support a recommendation for the use of hip arthroscopy in the treatment of acetabular labral tears, extra-articular lesions, septic arthritis, and loose bodies. There is poor-quality conflicting evidence (C c ) regarding the use of hip arthroscopy for the treatment of mild to moderate osteoarthritis of the hip. Conclusions Although fair evidence (grade B) exists to support the use of hip arthroscopy for the treatment of femoroacetabular impingement, a majority of recognized indications for this surgical technique currently lack adequate evidence-based support in the literature (grade C or grade I). Higher-quality trials (Level I and Level II) are needed to provide support for the increasing application of this surgical technique. We also applied a new subscale to the grades of recommendation for summaries or reviews of orthopaedic surgical studies proposed by Wright et al. to provide a description of the direction in which outcomes are trending in Level IV studies. Level of Evidence Level IV, systematic review.

Background: Soft-tissue coverage and vascularity likely play a vital role in the genesis of wound complications and infections during open Achilles tendon repair. Planning an appropriate surgical approach might decrease the prevalence of these complications. Methods: Five adult cadavers underwent whole-body arterial perfusion with a mixture of lead oxide, gelatin, and water. The skin of the foot and ankle was dissected, and the vascular supply was evaluated with angiography. All angiograms were analyzed with use of statistical software. Results: We constantly identified three vascular zones: (1) the medial vascular zone, which had the richest blood supply; (2) the lateral vascular zone, in which the density of vascularity was good and much better than that in the posterior zone; and (3) the posterior vascular zone, which showed the poorest blood supply. Conclusions: The richest vascular zones of the skin covering the Achilles tendon are located toward the medial and lateral aspects of the Achilles tendon. On the basis of the present study, we recommend using a medial or lateral incision in the integument covering the tendon, as the posterior incision will be located in a less vascular zone. Clinical Relevance: The present study should help the surgeon to plan the surgical approach to the Achilles tendon by designing skin incisions in a more vascular zone.

Patients with end-stage ankle arthritis have a significantly compromised health-related quality of life. Nonsurgical treatments for end-stage ankle arthritis should be considered prior to surgery. Currently, the most accepted surgical treatment is ankle arthrodesis. The shortcomings of ankle arthrodesis, such as increased rates of ipsilateral periarticular arthritis and the possible long-term need for amputation, have cast doubt on the success of this treatment for end-stage ankle arthritis. Newer second and third generation total ankle arthroplasty prostheses have shown positive short- and medium-term results. An examination of the available literature provides good evidence to support ankle arthrodesis and total ankle arthroplasty for treating patients with end-stage ankle arthritis. Other treatment options, including ankle osteotomies, ankle osteochondral allograft transplantation, and distraction arthroplasty, require further study by surgeons with advanced training in these procedures.

Background:Total ankle arthroplasty (TAA) has become a viable treatment for end-stage ankle arthrosis. Current literature on survival rates and complications of TAA consist of mostly retrospective Level IV papers that do not provide a system for classifying complications. The aim of the current review is to provide a summary of TAA implant survival and complication rates from current literature on outcomes of second or third generation ankle prostheses and subsequently propose a classification system.Methods:A literature review was used to identify articles reporting complications and failures of TAA ankle prostheses. Inclusion criteria included studies with at least 25 cases and a minimum of 24 months followup.Results:Twenty studies met the inclusion criteria. The percentage of failed TAA reported for the short- and intermediate-term followup in this review ranged from 1.3 to 32.3 % with an overall mean of 12.4 % failure at 64 months. Nine main complications of TAA were identified.Conclusion:Deep infection, aseptic loosening and implant failure should be considered “high-grade” complications since they will result in failure greater than 50% of the time. Technical error, subsidence and postoperative bone fracture should be considered “medium-grade”, while intra-op bone fractures and wound healing problems should be considered “low-grade”. We believe this review provides the groundwork for uniform complication reporting in TAA and allows the development of a classification system that will provide prognostic information that may serve to guide postoperative care of patients receiving TAA. Level of Evidence: III, Systematic Review of Level III and IV Studies

Purpose The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence available to support the surgical technique of ankle arthroscopy for the current generally accepted indications and assign a grade of recommendation for each of them. Methods A comprehensive review of the literature was performed (in August 2008) by use of the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of different ankle arthroscopic treatment techniques. All articles were reviewed and assigned a classification (I-IV) of Level of Evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for ankle arthroscopy. Results There exists fair evidence-based literature (grade B) to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence (grade C). Treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended (grade C against). Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the management of synovitis and fractures (grade I). Conclusions There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed. Level of Evidence Level IV, systematic review.

The aims of our study were to: (1) determine if there are differences in the material properties of tendon obtained from implanted tibialis anterior, achilles, bone-patella- bone and tibialis posterior allografts; (2) determine the variability in material properties between the implanted specimens. A total of 60 specimens were collected from fresh frozen allografts implanted at ACL reconstruction. Specimens collected included 15 tibialis anterior, 15 tibialis posterior, 15 achilles and 15 bone-patella-bone tendons. Each specimen was mounted in a custom made cryogrip. The mounted specimens were loaded onto a MTS Testline servo-hydraulic testing machine in a uni-axial tensile test configuration. Specimens were subjected to a strain rate of 5% per second until the ultimate tensile stress (UTS), failure strain and high strain modulus was calculated for each specimen after being normalized for specimen dimensions. Individual material properties were tested using one way analysis of variance (ANOVA) and post hoc Tukey’s B test with a P value of

Background: End-stage ankle arthrosis is one of the leading causes of chronic disability in North America. Information on this condition is limited. The amount of pain and the reduction in health-related quality of life and function have not been quantified with use of universal outcome measures. The purpose of the present study was to compare the extent of pain, loss of function, and health-related quality of life in two cohorts of patients waiting for the surgical treatment of end-stage ankle or hip arthrosis. Methods: One hundred and thirty patients with end-stage ankle arthrosis who were awaiting total ankle arthroplasty or ankle arthrodesis were recruited through a Canadian Orthopaedic Foot and Ankle Society multicenter study. All patients prospectively completed the Short Form-36 (SF-36) generic outcome instrument. This cohort was compared with a similar cohort of 130 patients with end-stage hip arthrosis, randomly selected from an existing prospective joint replacement database, who had completed an SF-36 questionnaire prospectively from 2000 to 2005. Results: In both groups, the scores for all SF-36 subscales were approximately two standard deviations below normal population scores. Patients with ankle arthrosis had significantly worse mental component summary scores (p < 0.05), role-physical scores (p < 0.05), and general health scores (p < 0.05). Patients with hip arthrosis reported significantly lower physical function scores (p < 0.05), although the SF-36 physical component summary score was not significantly different between the two groups. The SF-36 physical component summary, bodily pain, vitality, role-emotional, social functioning, and mental health subscale scores were equally affected in both cohorts. Conclusions: The mental and physical disability associated with end-stage ankle arthrosis is at least as severe as that associated with end-stage hip arthrosis. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

The purpose of this study was to design an animal model that induces histological changes in Achilles tendons consistent with those cited in the literature for human Achilles tendon disease. Sprague-Dawley rats were subjected to 10° uphill treadmill running on a custom-designed rodent treadmill and at a speed of 17 meters per minute for 1 h, five times per week, over a 12-week treatment period. Subsequent histological analysis revealed alterations in the rat Achilles tendon that were generally consistent with those described in the literature for diseased human tendon tissues. These features include: decreased collagen fiber organization, more intense collagen staining, and increased cell nuclei numbers. Interestingly, though, immunohistochemical cell typing suggests that the observed increased cellularity does not include a significant inflammatory component but is secondary to increased numbers of endothelial cells (i.e., vascularization) and fibroblasts. These histological features likely represent a biological repair/remodeling response resulting from overuse running. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:840–846, 2008

Introduction Ankle arthrodesis remains the gold standard treatment for isolated ankle arthritis. Despite improved techniques a 10% nonunion rate, 9% re-operation rate, 5% below knee amputation rate post ankle arthrodesis are reported. Arthroscopic ankle arthrodesis has been recommended by some as a solution to the relatively high rate of complications associated with the open technique. However, to date no other prospective comparative study has been reported to compare the two fusion techniques. Methods Prospective patient data was gathered from consenting patients at baseline, 6 months, one year and two years from two centers, one performing open ankle arthrodesis and one performing arthroscopic arthrodesis. The primary outcome Measures was the Ankle Osteoarthritis Score (AOS). Secondary outcome measures included tourniquet time, length of stay (LOS), non-union rate, and complication rates. A power analysis indicated that 30 patients were required in each group. There were 31 ankles in the open arthrodesis group and 30 ankles in the arthroscopic arthrodesis group. The groups were comparable for age (mean 59.2 vs. 56.0) and BMI (mean 27.9 vs. 29.4). Results The AOS score improved in the open group from 56.8 preoperatively to 33.5 at one year (p Conclusion This was a prospective comparative study of two very similar groups of isolated ankle arthritis using an arthroscopic and open technique of ankle fusion. Both groups showed a significant improvement in symptoms from baseline with a greater change in AOS score and shorter hospital stay in the arthroscopic group.

SUMMARY: Shaken cultures of Streptomyces venezuelae ISP5230 in minimal medium with galactose and ammonium sulphate as carbon and nitrogen sources, respectively, showed extensive sporulation after 72 h incubation at 37 °C. The spores formed in these cultures resembled aerial spores in their characteristics. The ability of the spores to withstand lysozyme treatment was used to monitor the progress of sporulation in cultures and to determine the physiological requirements for sporulation. In media containing ammonium sulphate as the nitrogen source, galactose was the best of six carbon sources tested. With galactose S. venezuelae ISP5230 sporulated when supplied with any of several nitrogen sources; however, an excess of nitrogen source was inhibitory. In cultures containing galactose and ammonium sulphate, sporulation was suppressed by a peptone supplement. The onset of sporulation was accompanied by a drop in intracellular GTP content. When decoyinine, an inhibitor of GMP synthase, was added to a medium containing starch and ammonium sulphate, a slight increase in sporulation was seen after 2 d. The suppression of sporulation by peptone in liquid or agar cultures was not reversed by addition of decoyinine. A hypersporulating mutant of S. venezuelae ISP5230 was altered in its ability to assimilate sugars. In cultures containing glucose the mutant sporulated more profusely than did the wild-type and did not acidify the medium to the same extent. However, the suppressive effect of glucose on sporulation was not merely a secondary result of acid accumulation.