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Das mediale Kollateralband, bestehend aus oberflachlichen und tiefen Bandanteilen, in Kombination mit dem Pfannenband ist der primare Stabilisator im Sprunggelenk. Verletzungen dieser Strukturen sind haufiger als bisher angenommen und werden oft ubersehen. In der Folge kann es zu chronischen Schmerzen, Instabilitaten, Ruckfusdeformitaten und Arthrosen kommen. Anamnese und klinische Untersuchung konnen Hinweise auf Verletzungen des medialen Kollateralbands liefern. Die Magnetresonanztomographie (MRT) gilt als Diagnostik der Wahl. Die Arthroskopie des oberen Sprunggelenks kann zusatzlich wertvolle Hinweise bei der Beurteilung der Verletzung bieten. Die Therapie sollte begleitende Verletzungen und Deformitaten einschliesen und reicht von einer Ruhigstellung im Gips uber eine Bandnaht bis hin zur Bandrekonstruktion mithilfe eines freies Sehnentransplantats.

Zusammenfassung Das mediale Kollateralband ist der primare Stabilisator im Sprunggelenk. Verletzungen des medialen Kollateralbandes sind haufiger als bisher angenommen und werden dennoch haufig ubersehen. In der Folge kann es zu chronischen Schmerzen, Instabilitaten und Arthrosen kommen. Eine besondere anatomische Beziehung besteht zum Spring Ligament. Bereits Anamnese und klinische Untersuchung konnen Hinweise auf Verletzungen des medialen Kollateralbandes liefern. Das MRT gilt als Diagnostik der Wahl. Die Therapie richtet sich auch nach den Begleitverletzungen und reicht von Ruhigstellung im Gips uber Bandnaht bis hin zur Bandrekonstruktion mittels freiem Sehnentransplantat.

The purpose of this study was to quantify limitations in sagittal ankle range of motion (ROM) at least two years after lateral column lengthening osteotomy of the calcaneus (LLC) and their implications regarding quality of life.; Fifteen patients with a mean follow-up of 80 ± 27 months after LLC and 15 age-matched healthy persons participated in this study. Ankle joint complex ROM in plantarflexion and dorsiflexion was measured bilaterally using a goniometer and fluoroscopy (patients only). Quality of life was assessed using the short-form health questionnaire (SF36). Differences in ROM parameters (for the tibiotalar and subtalar joint) between sides (affected vs. unaffected) and between groups (patient vs. controls) and the relationship between ROM parameters and quality of life scores were assessed.; ROM of the ankle joint complex on the affected side in patients was smaller than on the contralateral side (goniometer and fluoroscopy) and in healthy persons (goniometer; all P < .05). Among patients, SF36 total and pain scores, respectively, correlated with ROM of the subtalar joint (fluoroscopy; R = 0.379, P = 0.039 and R = 0.537, P = 0.001). Among patients and healthy persons, those with smaller dorsiflexion (goniometer) had lower quality of life scores.; The smaller sagittal ROM of the affected ankle joint complex compared with the contralateral foot and healthy controls was mainly explained by limitations in the tibiotalar joint. Because of its association with quality of life, ROM should be considered in the treatment and rehabilitation planning in patients who are candidates for LLC.

Summary Objective The aim of this study was to document the natural history of development and long-term progression of osteoarthritis (OA) in the feline knee after minimally invasive anterior cruciate ligament (ACL) transection. Design ACL transections of the left knee joint of 14 skeletally mature cats were performed. Radiographic scores, tibiofemoral and patellofemoral joint space and anterior tibial translation were assessed before, immediately and every 3 months after ACL transection (longest follow-up: 93 months). Results After 26 months, all ACL transected knees had developed definite OA. The earliest changes were observed on the tibia plateau starting as early as 2 months after ACL transection, and at 12 months signs of OA were present in more than 80% of cats in the medial and in almost 80% of cats in the lateral compartment. In the first 24 months, medial tibiofemoral joint space decreased by 0.88 mm (95% confidence interval [−0.55;−1.21] mm) and lateral tibiofemoral joint space by 0.55 mm ([−0.26;−0.85] mm). In the same interval, the joint space in the patellofemoral joint increased by 0.98 mm ([0.59; 1.37] mm). Throughout the entire observation period, the anterior tibial translation was on average 5.3 mm greater than in the contralateral knee ([4.5; 6.0]mm). Conclusions Immediate changes in anterior tibial translation during an anterior drawer test clearly showed joint instability that persisted throughout the lifetime of the animals. Degenerative changes were observed on radiographs within 4 months of the injury only in the transected but not the contralateral limb suggesting the role of mechanical instability for the development and progression of knee OA.

Zusammenfassung: Die Arthrose des oberen Sprunggelenks (OSG) ist häufig mit einer Fehlstellung verbunden, dabei ist die Valgusarthrose seltener als die Varusarthrose. Die Ursachen für eine Valgusarthrose sind eine mediale Bandinstabilität, ein Pes planovalgus und posttraumatische Fehlstellungen z.B. nach Fibulafraktur oder Stauchung des lateralen Tibiaplateaus. Damit eine OSG-Prothese kurz- wie auch langfristig korrekt und schmerzfrei funktionieren kann, muss die Biomechanik entsprechend den Prinzipien der mechanischen Achse, deren Wichtigkeit in der Orthopädie allgemein akzeptiert ist, wiederhergestellt werden. Richtlinien sind dabei (1) ein anteriorer tibiotalarer Winkel von etwa 90° und (2) eine neutrale Rückfußstellung. Diese wird vorzugsweise mit der Rückfußaufnahme nach Saltzman gemessen. Dabei ist zu beachten, dass der normale Rückfuß in einer Neutralstellung bis 1-2° Varusposition und nicht wie bisher angenommen in einer Valgusstellung ist. Je nach Ausmaß und Lokalisation der Valgusdeformität werden in unterschiedlicher Reihenfolge (1) die OSG-Prothese implantiert, (2) supra- und (3) inframalleoläre Korrekturosteotomien/-Arthrodesen, (4) eine mediale Bandplastik, (5) eine Fibulaosteotomie (6) mit eventueller Rekonstruktion der Syndesmose durchgeführt

We present a novel operative technique for ankle joint fusion in a case of severe talar bone loss. Fusion was achieved with a trabecular metal spacer combined with a single anterior, anatomically preshaped, angular, stable plate. Excellent postoperative results with good bone consolidation and preservation of lower leg length were present shown at 1 year of follow-up.

Severe haemophilia with recurrent joint bleeding maycause secondary ankle osteoarthritis [1]. Commonradiographic findings of haemophilic arthropathyinclude subchondral cysts, osteoporosis, enlargedepiphyses, irregular subchondral surface, narrowing ofthe joint space and gross joint deformities [2]. Haemo-philic pseudotumour occurs in approximately 2% ofpatients with severe haemophilia [3].In the current literature, numerous treatmentoptions have been described for various stages ofhaemophilic ankle arthropathy [4,5]. Ankle arthrode-sis has been considered the standard treatment optionin patients with haemophilic end-stage ankle arthropa-thy [6]. In the last two decades, total ankle replace-ment has become a feasible treatment option [7].However, in patients with asymmetric ankle osteoar-thritis and a concomitant deformity, where a substan-tial part of the tibiotalar joint remains preserved,procedures that sacrifice the native joint may not bean ideal treatment option. In patients with posttrau-matic ankle osteoarthritis, promising short- and mid-term results have been reported in those whounderwent supramalleolar realignment surgery [8].However, there is a paucity of literature to addressthe use of supramalleolar realignment surgery inpatients with bleeding disorders. Herein, we describethe successful orthopaedic management of a patientwith severe haemophilia A and Noonan syndrometreated by debridement of cysts, filling with allograftand allomatrix, and bilateral hindfoot osteotomies. Inaddition to describing our experience, we also providea review of the current literature on realignment sur-gery for ankle haemophilic arthropathy.A 29-year-old man with severe haemophilia A(FVIII:C < 1.0) and Noonan syndrome presented toour clinic. His Noonan syndrome [9] was noted to beof autosomal dominant genetic origin, also occurringin three out of six of his siblings. The patient showedcharacteristic signs of Noonan syndrome, includingshort body height (158 cm) with associated dispropor-tionality, a ventricular septum defect with stenosis ofthe pulmonal valve, and unilateral cryptorchism.Details regarding association between Noonan syn-drome and bleeding disorders are described in the cur-rent literature [10].The patient’s haemophilia A was diagnosed whenhe was 2 months old, receiving factor substitutionsince then. He had a history of recurrent intraarticularbleeding in both ankles (in the last 12 months fourand three episodes in the right and left ankle respec-tively). The patient presented in our orthopaedic out-patient clinic with bilateral ankle and hindfoot painwith the right side being more symptomatic. Clinicallyhe had peritalar instability with supramalleolar varusmalalignment of the ankle in combination with infra-malleolar valgus malalignment of the heel (Figs 1aand 2a). His ability to walk was severely limited bypain and malalignment to less than 100 m. Hereported pain as 10/10 on the visual analogue scale.The total range of motion of the right and left anklejoints was 20° and 15° respectively. The AmericanOrthopaedic Foot & Ankle Society (AOFAS) hindfootscore was 65 out of a maximum of 100 points. Radio-graphs demonstrated gross bilateral cysts of the distaltibia with the medial distal tibial angle on the rightand left side being 65.5° and 77.0° respectively. Com-puted tomography revealed extensive cystic lesions,especially on the right side (Figs 1b and 2b). On theright side, a large cyst left a cortical defect of approxi-mately 3 9 4 cm on the medial aspect of the distaltibia, including the whole medial malleolus; only theperiosteum covered this cyst. A thin rim ofsubchondral bone persisted on the medial malleolusand the tibial plafond. Scintigraphy showed metabolic

The purpose of this study was to evaluate survival and clinical outcome of the Scandinavian total ankle replacement (STAR) prosthesis after a minimum of ten years up to a maximum of 19 years. Fifty STAR prostheses in 46 patients with end stage ankle osteoarthritis operated between 1996 and 2006 by the same surgeon (MH) were included. Minimal follow-up was ten years (median 14.6 years, 95% confidence interval [CI] 12.9-16.4). Clinical (Kofoed score) and radiological assessments were taken before the operation and at one, ten (+2), and 16 (±3) years after implantation. The primary endpoint was defined as exchange of the whole prosthesis or conversion to arthrodesis (def. 1), exchange of at least one metallic component (def. 2), or exchange of any component including the inlay (due to breakage or wear) (def. 3). Survival was estimated according to Kaplan-Meier. Further reoperations related to STAR were also recorded. The ten year survival rate was (def. 1) 94% (CI 82-98%), (def. 2) 90% (CI, 77-96%), and (def. 3) 78% (CI 64-87%). The 19-year survival rate was (def. 1) 91% (CI 78-97%), (def. 2) 75% (CI 53-88%), and (def. 3) 55% (CI 34-71%). Considering any re-operations related to STAR, 52% (26/50) of prostheses were affected by re-operations. Mean pre-operative Kofoed score was 49, which improved to 84 after one year (n = 50), to 90 after ten years (n = 46), and to 89 after 16 years (n = 28). The survival rate for def. 1 and 2 was high. However, re-operations occurred in 52% of all STAR prosthesis. Retrospective cohort study, evidence Level 4.

Background:Depending on the direction of the subtalar joint, a foot deformity generally tends towards pronation (pes planovalgus) or supination (pes cavovarus). However, the combination of hindfoot varus and flat midfoot/forefoot (pes planovarus) is an exception to this rule. Pes planovarus has so far only been referred to in connection with Müller-Weiss disease and congenital disease. We diagnosed pes planovarus in otherwise healthy patients without these diseases.Methods:Forty patients with 54 symptomatic feet who were treated between August 2012 and July 2016 were included (mean age, 44.1 ± 15.7 years; 15 male/25 female). They were selected from 1064 consecutive cases (3.8%). Inclusion criteria were hindfoot varus and flat midfoot/forefoot. Their symptoms, radiographs, and therapies within the first 3 months were retrospectively analyzed. The position in the hindfoot alignment view (HAV), talometatarsal-1 angle lateral (TMT1lat) and dorsoplantar (TMT1dp), talocalcaneal angle lateral (TCAlat) and dorsoplantar (TCAdp), and calcaneal pitch angle (CPA) were measured on a DICOM/PACS system.Results:The mean radiological results (standard values from the literature in brackets) were as follows: the hindfoot was significantly in varus in the HAV (−6.9 ± 3.6 mm [−1.6 ± 7.2 mm]; P < .001), the TMT1lat was significantly flatter (−6.7 ± 5.8 degrees [8.4 ± 5.9 degrees]; P < .001), the TMT1dp was significantly less in abduction (1.5 ± 7.9 degrees [7.7 ± 8.2 degrees]; P = .005), the TCAdp showed no difference (25.9 ± 7.9 degrees [24.1 ± 5.7 degrees]; P = .118), the TCAlat was significantly larger (47.5 ± 6.1 degrees [43.4 ± 7.1 degrees]; P < .001), and the CPA was significantly flatter (17.6 ± 3.9 degrees [24.5 ± 3.0 degrees]; P < .001). The most frequent symptoms were stress-induced foot pain (n = 33), hallux valgus (n = 20), chronic ankle instability (n = 17), metatarsalgia (n = 15), chronic midfoot pain (n = 13), heel pain (n = 12), and lesser toe deformities (n = 8). Thirty-one feet were treated conservatively and 23 operatively.Conclusion:This study showed the existence of pes planovarus without Müller-Weiss disease or congenital disease. This unusual foot form leads to difficulties if standard treatment strategies are applied, which raises the issue of the correct treatment for such patients.Level of Evidence:Level IV, retrospective case series.

Zusammenfassung Hintergrund Ziel dieser Arbeit war es, die mittelfristigen Ergebnisse der posterioren Ruckfusendoskopie bei Sportlern zu prasentieren. Material und Methoden Insgesamt wurden 17 Patienten mit einem mittleren Alter von 27,9 ± 4,3 Jahren in diese retrospektive Studie eingeschlossen. Die mittlere Nachuntersuchungszeit betrug 5,4 ± 1,3 Jahre. Klinische Ergebnisse wurden untersucht anhand einer visuellen Punkteskala (VAS) sowie eines AOFAS (American Orthopaedic Foot & Ankle Society)-Hindfoot-Score. Auserdem analysierten wir die praoperativen und die postoperativen sportlichen Aktivitaten. Ergebnisse Zu den praoperativen Diagnosen gehorten schmerzhaftes Os trigonum (n = 9), Sehnenentzundung des M. flexor hallucis longus (n = 4), posteriores Ruckfusimpingement (n = 3) und Impingement der Peronealsehnen (n = 1). Das durchschnittliche Schmerzniveau verringerte sich von praoperativ VAS 5,6 ± 1,7 zum 0,6 ± 1,0 postoperativ (p Schlussfolgerungen Die posteriore Ruckfusendoskopie bei Sportlern fuhrt zu einer deutlichen Schmerzlinderung, funktionellen Verbesserung und Wiederaufnahme der sportlichen Aktivitaten. Evidenzebene Level IV

Zusammenfassung Die Tibialis-posterior-Sehnendysfunktion ist eine haufige, graduell ablaufende Uberlastungserkrankung. Durch die Inkompetenz der Tibialis-posterior-Sehne entwickelt sich eine zunehmende Valgusfehlstellung des Ruckfuses mit langfristigem Versagen der statischen medialen Haltestrukturen,Verkippung des Talus in der Malleolengabel und asymmetrischer Valgus-Arthrose des oberen Sprunggelenks (OSG). Die Therapie dieser weit vorangeschrittenen Deformitat verlangt eine genaue praoperative Analyse der biomechanischen und biologischen Faktoren, eine korrekte Stadienzuteilung und stadiengerechte Verfahren. Nur bei Fallen mit mehrheitlich intaktem Knorpeluberzug des OSG und noch verbliebener Flexibilitat der tibiotalaren Deformitat kann das OSG erhalten werden. Bei weiter vorangeschrittener Arthrose kommen die Implantation einer OSG-Prothese in Kombination mit Arthrodesen des Ruckfuses oder eine tibiotalokalkaneare/pantalare Arthrodese in Frage.

Zusammenfassung Die posttraumatische Arthrose ist die haufigste Atiologie der degenerativen Veranderungen des oberen Sprunggelenks. Etwa 50% aller Patienten haben eine Valgus- oder Varusdeformitat des Ruckfuses. Hierbei ist eine Valgusfehlstellung mit ca. 8% seltener als eine Varusfehlstellung mit ca. 55%. Als Ursachen einer valgischen Sprunggelenkarthrose kommen posttraumatische Fehlstellungen in Frage, wie zum Beispiel nach Malleolarfrakturen, Pilon-tibiale-Frakturen oder Syndesmosenverletzungen. Des Weiteren lassen sich Bandverletzungen oder Instabilitaten, hier insbesondere medial, wie auch Pes-planovalgus-Deformitaten als atiologisch bedeutsam nachweisen. Bei Patienten mit fortgeschrittenen degenerativen Veranderungen des oberen Sprunggelenks ist der endoprothetische Ersatz eine vielversprechende Therapieoption. Samtliche begleitenden Deformitaten und Instabilitaten sollten jedoch ausreichend durch zusatzliche Eingriffe korrigiert werden.

Zusammenfassung Die Endoprothetik des oberen Sprunggelenks hat in den letzten Dekaden enorme Fortschritte zu verzeichnen. Mit zunehmendem Einsatz dieser Therapieoption bei Patienten mit fortgeschrittener Arthrose des oberen Sprunggelenks steigt jedoch die Zahl von gescheiterten Endoprothesen. Die haufigste Ursache dafur ist die aseptische Lockerung von einer oder beiden Prothesenkomponenten. Bislang nahm die Sprunggelenkarthrodese als Goldstandard die Spitzenposition unter den therapeutischen Optionen bei gescheiterter Prothesenimplantation ein. In der letzten Zeit findet jedoch die Revisionsarthroplastik zunehmende Anwendung. In Abhangigkeit von ossaren Defekten kann die Revisionsarthroplastik als einzeitiger oder zweizeitiger Eingriff durchgefuhrt werden.

Zusammenfassung Eine asymmetrische Sprunggelenkarthrose kann sich sowohl bei einer Valgus- als auch bei einer Varusfehlstellung entwickeln. Eine pathologisch veranderte Belastung ubertragt sich in das tibiotalare Gelenk und kann dort zu einer medialen (Varus-) oder lateralen (Valgus-) Degeneration fuhren. Ein gelenkerhaltendes Verfahren kann durchgefuhrt werden, wenn weniger als die Halfte des oberen Sprunggelenks degenerativ verandert ist. Bei diesen Patienten ist ein endoprothetischer Ersatz oder eine Arthrodese kaum indiziert. Die kurz- und mittelfristigen Ergebnisse der gelenkerhaltenden Eingriffe sind vielversprechend in Bezug auf funktionelle Ergebnisse und postoperative Schmerzreduktion.

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.

Botulinum toxin type A (BTX-A) is a frequently used treatment modality for a variety of neuromuscular disorders. It acts by preventing acetylcholine release at the motor nerve endings, inducing muscle paralysis. Although considered safe, studies suggest that BTX-A injections create adverse effects on target and non-target muscles. We speculate that these adverse effects are reduced by direct electrical stimulation (ES) exercising of muscles. The aims were to determine the effects of ES exercise on strength, mass, and contractile material in BTX-A injected muscles, and to investigate if BTX-A injections affect non-target muscles. Seventeen New Zealand White (NZW) rabbits were divided into three groups: (1) Control group received saline injections; (2) BTX-A group received monthly BTX-A (3.5 U/kg) injections into the quadriceps for six months and (3) BTX-A+ES group received monthly BTX-A injections and ES exercise three times a week for six months. Outcome measures included knee extensor torque, muscle mass, and contractile material percentage area in injected and contralateral, non-injected quadriceps. Glycogen depletion and direct muscle stimulation were used to assess possible muscle inhibition in non-injected quadriceps. ES exercise partially prevented muscle weakness, atrophy, and contractile material loss in injected muscles, and mostly prevented muscle degeneration in contralateral, non-injected muscles. Non-injected muscles of BTX-A+ES group showed higher force with direct muscle compared to nerve stimulation, and retained glycogen following the depletion protocol, suggesting that BTX-A inhibited activation in non-target muscles. We conclude that ES exercise provides some protection from degeneration to target and non-target muscles during BTX-A treatments.

The resection of os trigonum or posterior talar process as treatment for posterior ankle impingement is an established operation. However, the authors encountered several painful stress reactions in the posterior subtalar joint during follow-up resulting in persisting incapacity to do sports. From March 2011 to July 2015, 29 patients with 30 feet were operated (22 endoscopic, 8 open resections). Average follow-up time was 43 ± 13 months. Complications were grouped into “none”, “temporary disadvantage” and “permanent damage”. The following radiographic parameters were measured: (1) length of posterior talar process or os trigonum, (2) length of the uncovered calcaneal joint surface after resection, (3) amount of resection. The rate of permanent damage was 13.3% (4 of 30 feet), and all four of these patients developed a painful stress reaction in the posterior subtalar joint. One temporary disadvantage (persistent pain for three months) was found. All patients with major complications showed retrospectively what we call the “risk configuration” —the radius of the talus ending within the subtalar joint. The length of the uncovered calcaneal joint surface was therefore significantly larger (6.4 mm ± 3.33) in feet with permanent damage than in feet without (1.06 mm ± 2.15, P

Nowadays there is an increase in the number of people, including middle and elderly ages, who are interested in sport games. This is especially those who expect to maintain their active life. However a concern is whether aging inherently causes structural capacity and functional alteration in the human body. One assumption is aging probably make sport seniors more prone to certain types of injuries. Understanding the anatomical and functional change among seniors can make treatment and prevention of injury more effective.

Background Patellofemoral joint pain is a common knee disorder, but its underlying causes remain unknown. One proposed mechanism is an imbalance in force in the knee extensor muscles. Specifically, the vastus medialis and vastus lateralis are thought to play a crucial role in proper patellar tracking, and weakness in vastus medialis is thought to lead to a lateral shift in the patella causing increased contact pressures and pain. The purpose of this study was to create an animal model of vastus medialis weakness and to test the effect of this weakness on patellofemoral contact pressures. Methods Experiments were performed using New Zealand white rabbits (mass 4.9–7.7 kg, n = 12). Loading of the patellofemoral joint was produced by femoral nerve stimulation of the knee extensor muscles. Knee extensor imbalance was produced by vastus medialis ablation. Fuji pressure sensitive film was used to record contact area, shape and pressures for maximal and sub-maximal, matched-force contractions at knee angles of 30°, 60°, and 90°. Findings Patellofemoral peak pressures, average pressures, contact areas and contact shapes were the same across all loading conditions for matched-force contractions before and after elimination of vastus medialis. Interpretation We conclude that vastus medialis weakness does not cause changes in patellofemoral contact pressures. Since the muscular and knee joint geometry in rabbits and humans is similar, we question the idea of vastus medialis weakness as a cause of patellar mal-tracking and patellofemoral joint pain.

Cartilage loading is associated with the onset and progression of osteoarthritis and cell death may play an important role in these processes. Although much is known about cell death in joint impact loading, there is no information on joints loaded by muscular contractions. The aim of this study was to evaluate the influence of muscle generated eccentric and concentric submaximal joint loading on chondrocyte viability. We hypothesised that eccentric muscle activation leads to increased cell death rates compared to concentric loading and to controls.16 rabbits received either 50 min of uni-lateral, cyclic eccentric (n=8) or concentric (n=8) knee loading. Muscle activation for these dynamic conditions was equivalent to an activation level that produced 20% of maximum isometric force. Contralateral joints served as unloaded controls. Cell viability was assessed using confocal microscopy.Eccentric contractions produced greater knee loading than concentric contractions. Sub-maximal contractions caused a significant increase in cell death in the loaded knees compared to the unloaded controls, and eccentric loading caused significantly more cell death than concentric loading.Cyclic sub-maximal muscle loading of the knee caused increased chondrocyte death in rabbits. These findings suggest that low levels of joint loading for prolonged periods, as occurs in endurance exercise or physical labour, may cause chondrocyte death, thereby predisposing joints to degeneration.

Background Posttraumatic joint contracture is a common complication of intraarticular injuries and an associated traumatic hemarthrosis could be of importance for its development. The purpose of this investigation was to determine whether the source of the hemarthrosis (peripheral blood vs. bleeding from the bone marrow) affects the amount of contracture and its reversibility and biomechanical properties. Methods 46 New Zealand White rabbits were divided in 6 groups and 33 underwent 8 weeks immobilization with either hemarthrosis from bone marrow or peripheral blood. 16 rabbits underwent remobilization for another 8 weeks. 7 animals had only hemarthrosis (bone marrow) for 8 weeks, while 6 were used as controls. Analysis included mean contracture angle and biomechanical variables. Findings The immobilized animals had an increased contracture angle, the knee angle vs. force curve had a greater hysteresis and showed higher initial stiffness. There was no difference in biomechanical properties of the knee between the different types of hemarthroses. After 8 weeks remobilization most biomechanical properties were not different from control. Interpretation The origin of hemarthrosis, and therewith the presence of marrow-derived factors and pluripotential cells from bone marrow, does not seem to affect the severity of joint contractures nor their reversibility.

Background: Patients and health care professionals alike are often surprised by the course of pain after total ankle arthroplasty (TAA). The current study aimed to determine the baseline patterns of postoperative symptoms during the first year following uncomplicated TAA. Materials and Methods: In a prospective observational study 28 patients with unilateral posttraumatic osteoarthritis were tested for pain with a visual analogue scale, swelling (min grade, 0; max grade, 4), ankle range of motion, and AOFAS ankle score. Assessments were performed preoperatively and 6 weeks, 3, 6, 9, and 12 months after TAA. Results: At 6 weeks all variables had improved significantly. However, at 3 months a relapse with deterioration of mean variables was found. These improved asymptotically during assessments at 6, 9, and 12 months. Conclusion: Our data suggest patients undergoing uncomplicated TAA have to overpass what we believe is an adaptive inflammatory phase with increased periarticular pain and swelling about 3 months after surgery. This distinctive course may influence patient education and increase confidence of healthcare professionals involved in the rehabilitation of TAA patients. Level of Evidence: II, Prospective Observational Study

Recently the relevance of femoroacetabular impingement as a cause of hip and groin pain in sportsmen has been recognized. The entity often poses diagnostic and therapeutic problems to the sports physician. The patients go through an odyssey of different diagnostic and therapeutic modalities before the correct diagnosis is made and an adequate therapy is implemented. Not seldom, patients get even operated at another site which is thought to cause the problems. The present review analyzes the current literature concerning diagnostic standards and therapy of femoroacetabular impingement focussing on their relevance for sports medicine. It is aimed to help the sports physician to recognise this entity as a cause for groin and hip pain in the athlete and realise its importance for the short term performance of the athlete and its long term significance in terms of development of early hip osteoarthrosis.

Category: Ankle Arthritis Introduction/Purpose: The purpose of this study was to evaluate survival and clinical outcome of the Scandinavian total ankle replacement (STAR) prosthesis after a minimum of ten years up to a maximum of 19 years. Methods: Fifty STAR prostheses in 46 patients with end stage ankle osteoarthritis operated between 1996 and 2006 by the same surgeon (MH) were included. Minimal follow-up was ten years (median 14.6 years, 95% confidence interval [CI] 12.9-16.4). Clinical (Kofoed score) and radiological assessments were taken before the operation and at one, ten (+2), and 16 (±3) years after implantation. The primary endpoint was defined as exchange of the whole prosthesis or conversion to arthrodesis (def. 1), exchange of at least one metallic component (def. 2), or exchange of any component including the inlay (due to breakage or wear) (def. 3). Survival was estimated according to Kaplan-Meier. Further reoperations related to STAR were also recorded. Results: The ten year survival rate was (def. 1) 94% (CI 82- 98%), (def. 2) 90% (CI, 77-96%), and (def. 3) 78% (CI 64-87%). The 19-year survival rate was (def. 1) 91% (CI 78-97%), (def. 2) 75% (CI 53-88%), and (def. 3) 55% (CI 34-71%). Considering any re-operations related to STAR, 52% (26/50) of prostheses were affected by re-operations. Mean pre-operative Kofoed score was 49, which improved to 84 after one year (n = 50), to 90 after ten years (n = 46), and to 89 after 16 years (n = 28). Conclusion: The survival rate for def. 1 and 2 was high. However, re-operations occurred in 52% of all STAR prosthesis.

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 Tonnis grade III, is not an indication for arthroscopic FAI correction. Level of Evidence Level IV, therapeutic case series.

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. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Introduction: The purpose of this study was to evaluate the impact of computed tomography scanning on the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classifications in the assessment of tibial plateau fractures. Methods: Four independent observers classified 45 consecutive fractures of the tibial plateau according to the criteria of the OTA/AO system, the Schatzker classification, and the Hohl classification. Two sessions of readings were compared; first, the use of plain anterior-posterior and lateral X-rays alone was evaluated, then 4 weeks later the combination of plain X-rays and two-dimensional computed tomography scans were evaluated. The readings were repeated 8 weeks later to evaluate intra-observer reliability. Results: The three classification systems showed ''moderate'' inter-observer reliability and ''good'' and ''moderate'' intra-observer reliability when classified solely on the basis of plain radiographs. After the addition of computed tomography scans inter-observer reliability significantly improved to ''good'' in all classifications. Likewise, intra-observer reliability improved to ''good'' in all classifications after the addition of CT-scans. Statistical analysis showed no significant difference regarding inter- and intra- observer agreement between the three classifications. Conclusions: Computed tomography scanning improved the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classification. Overall, all three classification systems showed ''good'' inter- and intra-observer reproducibility when classified with CT-scans.

The purpose of this study was to evaluate the distribution rate of etiologies leading to ankle arthritis and to quantify and compare the important clinical and radiologic variables among these etiologic groups. We evaluated data from 390 patients (406 ankles) who consulted our center because of painful end-stage ankle osteoarthritis (OA) by using medical history, physical examination, and radiography. Posttraumatic ankle OA was seen in 78% of the cases (n = 318), secondary arthritis in 13% (n = 52), and primary OA in 9% (n = 36). The average American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 38 points (range, 0–74 points), range of motion was 22° (range, 0°−65°), and visual analog scale for pain was 6.8 (range, 2–10). Patients with posttraumatic end-stage ankle OA were younger than patients with primary OA. The average tibiotalar alignment was 88° (range, 51°–116°) and did not differ between the etiologic groups. Our study showed trauma is the main cause of ankle OA and primary OA is rare. In the majority of patients with ankle OA the average tibiotalar alignment is varus regardless of the underlying etiology. Level of Evidence: Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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° or a reduction of the alpha angle of more than 20° 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° (range, 57° to 110°) to 54.2° (range, 40° to 84°). 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.

Zusammenfassung Die Arthroskopie des oberen Sprunggelenks (OSG) stellt heute eine wichtige operative Intervention im Spektrum des Fus- und Sportorthopaden dar. Sie erlaubt die genaue und dynamische In-vivo-Diagnose von artikularen Pathologien, wie beispielsweise chronischer Bandinstabilitat und osteochondralen Lasionen. Daneben gibt es eine bestandig wachsende Bandbreite an direkten arthroskopischen Behandlungsmethoden, wo Patienten von der geringen Invasivitat der Arthroskopie profitieren konnen. Die Arthroskopie des unteren Sprunggelenks (USG) wird deutlich seltener angewendet, ist jedoch in der Hand eines erfahrenen Operateurs ebenfalls eine gute diagnostische und therapeutische Option fur ausgewahlte Pathologien.

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.

Zusammenfassung: Dieser Artikel soll das spezifische Design der HINTEGRA®-Sprunggelenkprothese darstellen und die kurz- und mittelfristigen Ergebnisse klinisch und radiologisch aufarbeiten sowie hinsichtlich der Lernkurve und Revisionsoperationen kritisch analysieren. Von 278 zwischen Mai 2000 und August 2004 operierten Fällen konnten 271Sprunggelenke [261Patienten, 133Männer, 128Frauen; Alter 58,4 (25-90) Jahre] nach 36,1 (12-64) Monaten klinisch und radiologisch nachkontrolliert werden. Die Operationsindikation war in 206Fällen (76,0%) eine posttraumatische Osteoarthrose, in 34Fällen (12,5%) eine Arthritis im Rahmen einer systemischen Erkrankung und in 31Fällen (11,5%) eine primäre Arthrose. Neben 4 perioperativen und 19 frühpostoperativen Komplikationen kam es in 40Fällen (14,8%) zu einer Spätkomplikation; davon waren 22Komplikationen (8,2%) nicht implantatbezogen und 18Komplikationen (6,6%) implantatbezogen. In 39Fällen (14,4%) war eine Revisionsoperation erforderlich, davon in 5Fällen (1,8%) eine Konversion in eine OSG-Arthrodese. Sämtliche 34Fälle zeigten nach der erfolgreichen Revision bezüglich Verlauf und Ergebnis keine Unterschiede zu den komplikationsfreien 231Fällen. Der AOFAS-Hindfoot-Score verbesserte sich von präoperativ 40,3 (14-61) auf 85,0 (44-100) Punkte. Radiologisch zeigten sich alle verbleibenden 266 Tibiakomponenten stabil. 12 Taluskomponenten (4,4%) waren zu weit posterior implantiert und lagen nicht ideal auf dem posterioren Talus auf. Die Konzepte der minimalen Knochenresektion, möglichst großer Knochenabstützung, optimalen ligamentären Balance und minimalen Stressbelastungen in und um die Prothese zeigte sich hinsichtlich Verankerung im tibialen und talaren Knochen sowohl bei der primären Arthroplastik wie auch bei Revisionen erfolgreich. Die Lernkurve war kurz und steil, und die Mehrzahl der 18 implantatbezogenen Revisionen traten in den ersten Fällen auf. Trotz dem hohen Anteil von posttraumatischen Arthrosen mit häufigen Weichteilschäden waren die Ergebnisse ermutigend und lagen im Bereiche von anderen Erfahrungsberichten. Dies nährt die Hypothese, dass in der Arthroplastik des oberen Sprunggelenks (OSG) anatomische Oberflächen und exakte Positionierung der Komponenten für den Erfolg entscheidend sind

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.

Osteochondral lesions of the talus are often located posteromedially requiring open surgery to facilitate solid and complete osteochondral reconstruction. The aim of the study was to identify the optimal anatomical site for medial malleolar osteotomy based on the criteria of minimal cartilage damage (Study I) and to report on the morbidity in patients receiving osteotomy performed at the previously identified site (Study II). For Study I, cartilage coverage of the tibiofibular ankle joint facet was measured in 40 cadaveric ankles (20 cadaver specimens). In Study II, we assessed clinical (VAS pain score, AOFAS score, range of motion) and radiological outcome measures (SPECT-CT) in 17 patients (mean age, 36.8 ± 10.8 years) undergoing medial malleolar osteotomy. The medial edge in the transition zone of the tibial plafond to the medial malleolus showed less than 75 % of cartilage coverage in 62.5 % of cadavers (Study I). Surgery resulted in lower pain levels (2.4 ± 2.6 compared with 6.3 ± 1.8 points; p

Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.

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.

Patients with varus or valgus hindfoot deformities usually present with asymmetric ankle osteoarthritis. In-vitro biomechanical studies have shown that varus or valgus hindfoot deformity may lead to altered load distribution in the tibiotalar joint which may result in medial (varus) or lateral (valgus) tibiotalar joint degeneration in the short or medium term. The treatment of asymmetric ankle osteoarthritis remains challenging, because more than half of the tibiotalar joint surface is usually preserved. Therefore, joint-sacrificing procedures like total ankle replacement or ankle arthrodesis may not be the most appropriate treatment options. The short- and midterm results following realignment surgery, are very promising with substantial pain relief and functional improvement observed post-operatively. In this review article we describe the indications, surgical techniques, and results from of realignment surgery of the ankle joint in the current literature.

Onabotulinum toxin A (BTX-A) is a frequently used treatment modality to relax spastic muscles by preventing acetylcholine release at the motor nerve endings. Although considered safe, previous studies have shown that BTX-A injections cause muscle atrophy and deterioration in target and non-target muscles. Ideally, muscles should fully recover following BTX-A treatments, so that muscle strength and performance are not affected in the long-term. However, systematic, long-term data on the recovery of muscles exposed to BTX-A treatments are not available, thus practice guidelines on the frequency and duration of BTX-A injections, and associated recovery protocols, are based on clinical experience with little evidence-based information. Therefore, the purpose of this study was to investigate muscle recovery following a six months, monthly BTX-A injection (3.5 U/kg) protocol. Twenty seven skeletally mature NZW rabbits were divided into 5 groups: Control (n=5), zero month recovery - BTX-A+0M (n=5), one month recovery - BTX-A+1M (n=5), three months recovery - BTX-A+3M (n=5), and six months recovery - BTX-A+6M (n=7). Knee extensor strength, muscle mass and percent contractile material in injected and contralateral non-injected muscles was measured at each point of recovery. Strength and muscle mass were partially and completely recovered in injected and contralateral non-injected muscles for BTX-A+6M group animals, respectively. The percent of contractile material partially recovered in the injected, but did not recover in the contralateral non-injected muscles. We conclude from these results that neither target nor non-target muscles fully recover within six months of a BTX-A treatment protocol and that clinical studies on muscle recovery should be pursued.

Primary osteoarthritis of the ankle is rare. Post-traumatic conditions play a significant role. The following article describes operative and non-operative methods of treatment for ankle osteoarthritis including rationale for decision-making. Joint-preserving surgery in valgus ankles and varus ankles is presented. Ankle replacement and ankle fusion are discussed as non-joint-preserving treatment options.

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.