Objectives. The objective of this study was to quantify the relative movement between the articular surfaces in the tibiotalar and subtalar joints during normal walking in asymptomatic individuals. Methods. 3D movement data of the ankle joint complex were acquired from 18 subjects using a biplanar fluoroscopic system and 3D-to-2D registration of bone models obtained from CT images. Surface relative velocity vectors (SRVVs) of the articular surfaces of the tibiotalar and subtalar joints were calculated. The relative movement of the articulating surfaces was quantified as the mean relative speed (RS) and synchronization index (SI. ENT. ) of the SRVVs. Results. SI. ENT. and mean RS data showed that the tibiotalar joint exhibited translational movement throughout the stance, with a mean SI. ENT. of 0.54 (. sd. 0.21). The mean RS of the tibiotalar joint during the 0% to 20% post heel-strike phase was 36.0 mm/s (. sd. 14.2), which was higher than for the rest of the stance period. The subtalar joint had a mean SI. ENT. value of 0.43 (. sd. 0.21) during the stance phase and exhibited a greater degree of rotational movement than the tibiotalar joint. The mean relative speeds of the subtalar joint in early (0% to 10%) and late (80% to 90%) stance were 23.9 mm/s (. sd. 11.3) and 25.1 mm/s (. sd 9.5). , respectively, which were significantly higher than the mean RS during mid-stance (10% to 80%). Conclusion. The tibiotalar and subtalar joints exhibited significant translational and rotational movement in the initial stance, whereas only the subtalar joint exhibited significant rotational movement during the late stance. The relative movement on the articular surfaces provided deeper insight into the interactions between articular surfaces, which are unobtainable using the joint coordinate system. Cite this article: C-B. Phan, D-P. Nguyen, K. M. Lee, S. Koo. Relative movement on the articular surfaces of the tibiotalar and subtalar joints during walking. Bone Joint Res 2018;7:501–507. DOI: 10.1302/2046-3758.78.BJR-2018-0014.R1

Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs. A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services. Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing. This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden

To be able to assess the biomechanical and functional effects of ankle injury and disease it is necessary to characterise healthy ankle kinematics. Due to the anatomical complexity of the ankle, it is difficult to accurately measure the Tibiotalar and Subtalar joint angles using traditional marker-based motion capture techniques. Biplane Video X-ray (BVX) is an imaging technique that allows direct measurement of individual bones using high-speed, dynamic X-rays. The objective is to develop an in-vivo protocol for the hindfoot looking at the tibiotalar and subtalar joint during different activities of living. A bespoke raised walkway was manufactured to position the foot and ankle inside the field of view of the BVX system. Three healthy volunteers performed three gait and step-down trials while capturing Biplane Video X-Ray (125Hz, 1.25ms, 80kVp and 160 mA) and underwent MR imaging (Magnetom 3T Prisma, Siemens) which were manually segmented into 3D bone models (Simpleware Scan IP, Synopsis). Bone position and orientation for the Talus, Calcaneus and Tibia were calculated by manual matching of 3D Bone models to X-Rays (DSX Suite, C-Motion, Inc.). Kinematics were calculated using MATLAB (MathWorks, Inc. USA). Pilot results showed that for the subtalar joint there was greater range of motion (ROM) for Inversion and Dorsiflexion angles during stance phase of gait and reduced ROM for Internal Rotation compared with step down. For the tibiotalar joint, Gait had greater inversion and internal rotation ROM and reduced dorsiflexion ROM when compared with step down. The developed protocol successfully calculated the in-vivo kinematics of the tibiotalar and subtalar joints for different dynamic activities of daily living. These pilot results show the different kinematic profiles between two different activities of daily living. Future work will investigate translation kinematics of the two joints to fully characterise healthy kinematics

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

Purpose. The goal of Total Ankle Arthroplasty (TAA) is to relieve pain and restore healthy function of the intact ankle. Restoring intact ankle kinematics is an important step in restoring normal function to the joint. Previous robotic laxity testing and functional activity simulation showed the intact and implanted motion of the tibia relative to the calcaneus is similar. However there is limited data on the tibiotalar joint in either the intact or implanted state. This current study compares modern anatomically designed TAA to intact tibiotalar motion. Method. A robotic testing system including a 6 DOF load cell (AMTI, Waltham, MA) was used to evaluate a simulated functional activity before and after implantation of a modern anatomically designed TAA (Figure 1). An experienced foot and ankle surgeon performed TAA on five fresh-frozen cadaveric specimens. The specimen tibia and fibula were potted and affixed to the robot arm (KUKA Robotics Inc., Augsburg, Germany) while the calcaneus was secured to a fixed pedestal (Figure 1). Passive reflective motion capture arrays were fixed to the tibia and talus and a portable coordinate measuring machine (Hexagon Metrology Group, Stockholm, Sweden) established the location of the markers relative to anatomical landmarks palpated on the tibia. A four camera motion capture system (The Motion Monitor, Innovative Sports Training, Chicago, IL) recorded the movement of the tibia and talus. The tibia was rotated from 30 degrees plantar flexion to 15 degrees dorsiflexion to simulate motions during the stance phase of gait. At each flexion angle the robot found the orientation which zeroed all forces and torques except compressive force, which was either 44N or 200N. Results. Preliminary data indicates the tibiotalar motion of the TAA is similar to the intact ankle. The pattern and magnitude of tibiotalar translations and rotations are similar between the intact and implanted states for both 44N and 200N compressive loads (Figure 2). The most variation occurs with internal-external rotation. Increased translation especially in the anterior-posterior directions was observed in plantarflexion while the mediolateral translation remained relatively centered moving less than a millimeter. The intact talus with respect to the calcaneus had less than 3 degrees of rotation over the whole arc of ankle flexion (Figure 3). The angular motion of the implanted talus was similar in pattern to the intact talus, however there were offsets in all three angular directions which changed depending on the loading (Figure 3). This indicates that most of the motion that occurs between the intact tibial calcaneal complex occurs in the tibiotalar joint. Conclusion. Although more investigation is required, this study adds to the limited available tibiotalar kinematic data. This current study suggests the anatomical TAA design allows the tibiotalar joint to behave in similar way to the intact tibiotalar joint. Restoring intact kinematics is an important step in restoring normal function to the joint. For figures/tables, please contact authors directly.

Management of ankle arthritis in young patients is challenging. Although ankle arthrodesis gives consistent pain relief, it leads to loss of function and adjacent joint arthritis. Ankle joint distraction (AJD) has been shown to give good outcomes in adults with osteoarthritis or post-traumatic arthritis. The efficacy in children or young adults and those with juvenile idiopathic arthritis is less well evidenced. Clinical notes and radiographs of all patients (n=6) managed with AJD in one tertiary referral centre were retrospectively reviewed. Radiographs were taken pre-surgery, intra-operatively, 1 month following frame removal and at the last follow up, tibiotalar joint space was assessed using ImageJ software. Measurements were taken at the medial, middle and lateral talar dome using frame components as reference. Radiographic data for patients with a good clinical outcome was compared with those who did not. At time of surgery mean age was 16.1 years (12 – 25 years). Mean follow up was 3.4 years (1.5 – 5.9 years). Indications were juvenile idiopathic arthritis (4) post-traumatic (1) and post-infective arthritis (1). Three patients at last follow up had a good clinical outcome. Two patients required revision to arthrodesis (1.3 and 2.4 years following distraction). One patient had spontaneous fusion. One patient required oral antibiotics for pin site infection. Inter-observer reliability was 95%. Mean joint space was 1.17mm (SD = 0.87mm) pre-operatively which increased to 6.72mm (SD = 2.23mm) at the time of distraction and 2.09mm (SD = 1.14mm) at the time of removal. At one-year follow up, mean joint space was 1.96mm (SD = 1.97mm). Outcomes following AJD in this population are variable although significant benefits were demonstrated for 50% of the patients in this series. Radiographic joint space preoperatively did not appear to be associated with need for arthrodesis. Further research in larger groups of young patients is required

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Abstract. Skeletal kinematics are traditionally measured by motion analysis methods such as optical motion capture (OMC). While easy to carry out and clinically relevant for certain applications, it is not suitable for analysing the ankle joint due to its anatomical complexity. A greater understanding of the function of healthy ankle joints could lead to an improvement in the success of ankle-replacement surgeries. Biplane video X-ray (BVX) is a technique that allows direct measurement of individual bones using highspeed, dynamic X-Rays. Objective. To develop a protocol to quantify in-vivo foot and ankle kinematics using a bespoke High-speed Dynamic Biplane X-ray system combined with OMC. Methods. Two healthy volunteers performed five level walks and step-down trials while simultaneous capturing BVX and synchronised OMC. participants undertook MR imaging (Magnetom 3T Prisma, Siemens) which was manually segmented into 3D bone models (Simpleware Scan IP, Synopsis). Bone position and orientation for the Talus, Tibia and Calcaneus were calculated by manual matching of 3D Bone models to X-Rays (DSX Suite, C-Motion, Inc.). OMC markers were tracked (QTM, Qualisys) and processed using Visual 3D (C-motion, Inc.). Results. Initial results for level walking showed that OMC overestimated the rotational range of motion (ROM) in all three planes for the tibiotalar joint compared with BVX (Sagittal: OMC 30°/BVX 20°, Frontal: OMC 16°/BVX 15° and Transverse: OMC 20°/BVX 17°). For the subtalar joint, OMC (22°) over-estimated sagittal ROM compared with BVX (14°) and underestimated the ROM in the other planes (Frontal: OMC 8°/BVX 15° and Transverse: OMC 18°/BVX 20°). Conclusions. The results highlight the discrepancy between OMC and BVX methods. However, the BVX results are consistent with previous literature. The protocol developed here will form the foundation of future patient-based studies to investigate in-vivo ankle kinematics. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Purpose: Tibiotalar arthrodesis is a classical procedure for the treatment of painful deformation-destruction of the tibiotalar joint. The purpose of this retrospective study was to determine prognostic factors and tolerance to tibiotalar arthrodesis observed in 68 procedures performed with two different techniques (47 surgical fusions (Group 1), and 21 arthroscopic fusions (Group 2)). Material and methods: Between 1985 and 1999, 68 patients, mean age 51 years (22–88) underwent 55 arthrodesis procedures (47 post-traumatic, 2 paralytic, 6 rheumatoid polyarthritis, 4 sequelae of septic arthritis). All patients had major functional impairment. The tibiotalar joint was stiff in all cases and mean motion was 20 ± 15°. The subtalar facet was nearly normal in 33 cases, altered in six and had already fused in nine. The mediotarsal facet was altered in 12 cases, six had already had a double arthrodesis, and was normal in 50. On the preoperative Méary view, there was a normal axis in 13 patients, valgus in 28 and varus in 24. According to the Duquennoy radiographic criteria, there was subtalar involvement in 32 cases and mediotarsal involvement in 19. Tibiotalar arthrodeses procedures were performed arthroscopically after 1993 for cases with little axial deformation. Open surgery was used for all other cases (43 Méary technique). A plaster cast was used in all cases. All patients were reviewed using the Duguennoy score and two radiographic views: lateral weight-bearing view for the sagittal plane position (tibiopedious angle) and the Méary view for the frontal plane. Results: At a mean follow-up of four years, fusion rate was 82% (group 1 83%, group 2 81%). Mean delay to fusion was 3.2 ± 1 month irrespective of the causal disease or surgical technique. Functional outcome was very good in 28%, good in 34.5%, fair in 34.5% and poor in 3% and did not depend on the surgical technique. The subtalar was painful with zero motion in 18 cases (26.5%), generally associated with residual equine. The mediotarsal was stiff in 17 cases and very painful in four. In the frontal plane, 16 ankles were correctly axed, 27 were in valgus (mean 5.6°) and 20 in varus (mean 7.6°) with no difference between the two groups. In the sagittal plane, four ankles were in talus, nine in neutral position, and 49 had a residual equine, including 32 > 5°. In most cases, fair or poor outcome was related to subtalar pain. More than 50% of the patients with equine fusion greater than 5° had subtalar pain. Conclusion: For the same deformity, arthroscopic arthrodesis can shorten hospital stay and improve the rate and degree of trophic disorders. Arthroscopic tibiotalar arthrodesis is an elegant technique that we use for centred ankles or for patients with risk factors, particularly skin conditions. The rate of fusion with the arthroscopic approach is not however better than with open surgery. Precise clinical and radiological assessment of the subtalar facet as well as the position of the fusion in the sagittal plane at 90° without equine deviation are important prognostic factors observed in this series

Traditional screw fixation of the syndesmosis can be prone to malreduction. Suture button fixation however, has recently shown potential in securing the fibula back into the incisura even with intentional malreduction. Yet, if there is sufficient motion to aid reduction, the question arises of whether or not this construct is stable enough to maintain reduction under loaded conditions. To date, there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress CT model. Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator frame that allows for the application of sustained torsional (5 Nm), axial (500 N) and combined torsional/axial (5Nm/500N) loads. Baseline CT scans of the intact ankle under unloaded and loaded conditions were obtaining. The syndesmosis and the deltoid ligament complex were then sectioned. The limbs were then randomised to receive a suture button construct tightened at 4 kg force (loose), 8 kg (standard), or 12 kg (maximal) of tension and CT scans under loaded and unloaded conditions were again obtained. Eight previously described measurements were taken from axial slices 10 mm above the tibiotalar joint to assess the joint morphology under the intact and repair states, and the three loading conditions: a measure of posterolateral translation (a, b), medial/lateral translation (c, g), a measure of anterior-posterior translation (f), a ratio of anterior-posterior translation (d/e), an angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula, and an angle (Angle 2) created between the medial surfaces of two malleoli. These measurements have all been previously described. Each measurement was taken at baseline and compared with the three loading scenarios. A repeated measures ANOVA with a Bonferroni correction for multiple comparisons was used to test for significance. Significant lateral (g, maximum 5.26 mm), posterior (f, maximum 6.42 mm), and external rotation (angle 2, maximum 11.71°) was noted with the 4 kg repair when compared to the intact, loaded state. Significant posterior translation was also seen with the both the 8 kg and 12 kg repairs, however the incidence and magnitude was less than with the 4 kg repair. Significant overcompression (g, 1.69 mm) was noted with the 12 kg repair. Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. If inserted too loosely, these constructs allow for supraphysiologic motion which may have negative implications on ligament healing. These constructs also demonstrate overcompression of the syndesmosis when inserted at maximal tension however the clinical effect of this remains to be determined

Tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is a common salvage procedure for a range of indications. Previous work has suggested subtalar joint preparation is unnecessary to achieve satisfactory results. We examine the incidence of symptomatic subtalar nonunion following tibiotalocalcaneal fusion in a series of patients, all of whom had full preparation of the subtalar joint, and consider the possible contributing factors. We performed a retrospective review of all patients who underwent TTC arthrodesis from 2004–2010. All fusions were performed by the same surgeon with full preparation of both tibiotalar and subtalar joints. 61 TTC arthrodeses were performed in 55 patients (mean age = 59 years) using an intramedullary retrograde nail. Mean follow-up was 18 months (6–48 months). Fifty-six ankles (92%) achieved satisfactory union. Five patients (8%) had symptomatic non-union: 4 patients of the subtalar joint - with 3 patients undergoing revision subtalar arthrodesis and 1 patient of the tibiotalar joint. Nine patients required removal of the calcaneal screw (16%) – all had evidence of isolated subtalar nonunion prior to metalwork failure. Eight of these patients achieved asymptomatic union following screw removal. Subtalar nonunion following TTC fusion has resulted in recent changes to nail design to increase stability across the subtalar joint. Our results demonstrate a favourable overall nonunion rate with isolated subtalar nonunion making up the majority of cases. We also observed a significant rate of distal screw loosening, also associated with subtalar nonunion prior to screw removal, the significance of which merits further investigation

Aim: The difficulty in accurately assessing coronal alignment of a total knee prosthesis (TKR) is widely accepted in the literature yet standard practice in the UK is to obtain AP and lateral knee views only; we compared standard AP knee films with long leg views of TKR in order to determine the most optimal way of assessment of the prosthetic knee alignment. Methods: We included all patients who underwent TKR between January and September 2005 at Kings College Hospital under the care of one orthopaedic consultant. We excluded 11 patients with revision surgery, augmented prosthesis, high tibial osteotomies or severe tibiotalar joint arthritis. We included 50 sets of radiographs from 48 patients (17 men and 31 women). The prostheses used were PFC (40) and Scorpio (10) and six of them were navigated and 44 were standard TKR. We compared the difference between the angle of the tibial component with the mechanical axis of the tibia in the long leg image and the angle of the prosthesis with the midline of the visualised tibia in a standard antero-posterior knee view. Statistical analysis was carried out using the student t-test. Results: The mean difference between the two views was 5.34o (range 1.9o – 12o) (p< 0.001). We did not find any difference between the Scorpio and PFC knees or between navigated and non navigated prostheses. Conclusion:We concluded that the long leg views compared with the standard antero-posterior knee views provide more accurate information on the position and alignment of the tibial component of a TKR

Numerous techniques are used for the fusion of failed TAR. We wish to report our results of the revision of failed TAR to fusion. Between July 2005 and February 2011 the senior author had performed 20 arthrodeses in 19 patients (13 male and 6 female) who had failed total ankle arthroplasty (TAR). Their mean age was 63.5 years. All of them had the AES total ankle replacement. (Biomet UK). The mean period from the original TAR to fusion was 51 months (6 to72). The indication for revision of TAR to fusion was septic loosening in 4 patients and osteolysis and or aseptic loosening in 16 cases. Three types of fusion techniques were used. The mean follow-up was 15 months. All 3 tibiotalar arthrodeses with screws alone fused successfully. Of the 13 patients where the fusion was augmented with an Ilizarov frame, 4 were done for septic loosening. There were 2 non unions of which one was stable without pain and the other required a further revision fusion with a frame and subsequently fused. Of the 9 patients who had a fusion with a frame for osteolysis and or aseptic loosening, there was one non union which was revised to a tibiotalocalacaneal fusion with a hind foot nail. The nail fractured at the level of the posterior oblique screw hole. The patient subsequently developed a relatively pain free non-union of the tibiotalar joint and not required further surgical intervention. The remaining 8 ankles fused at a mean of 5 months. The average time of frame removal was 17 weeks. There was four pin-site infection all of which settled with oral antibiotics. 5 patients had tibiotalocalacaneal fusion with a hind foot nail. The indication for the hind foot nail was significant osteolysis and loss of talar bone stock. The average shortening as a result of the fusion for the failed TAR was 1.5cms. Our results were comparable to the previous reports of arthrodesis for failed total ankle replacement. We recommend the use of tibiotalocalcaneal fusion with a hind foot nail in the presence of severe osteolysis or accompanying subtalar arthritis. In the presence of good bone stock an ankle fusion supplemented with a circular frame gives a good predictable outcome

Purpose: We evaluated the role of the Distal Tibial Line (DTL by Saltzman et al, 2005) in measuring the pre-operative and postoperative position of the talus on ‘lateral’ radiographs following a Total Ankle Replacement (TAR). Currently there is no validated measure of anteroposterior (AP) alignment of a TAR. Arthritis in the ankle causes considerable malalignment in the anteroposterior plane. The DTL is not affected by the destruction of the tibiotalar joint and is independent of slight variations in the positioning of the foot and radiological magnification. Method: DTL divides the talus into two sections and the proportionate length of the posterior segment is presented as a ratio. The size of the posterior segment and ratio decreases with anterior subluxation. Radiographs of 200 cases of TAR were reviewed. The anterior and posterior outlines of the talus could not be seen in all cases (e.g. preoperative talonavicular fusion). As a result 49 cases of inflammatory arthritis (49 of 119) and 6 of osteoarthritis (6 of 81) could not be assessed. Results: The osteoarthritic ankle (OA) in particular showed a tendency for anterior subluxation. The average ratio in OA cases increased from ‘34.8′ before surgery to ‘40.4’ after surgery, confirming a trend for this subluxation to reduce with a TAR. There was a lesser tendency for subluxation in the inflammatory group of patients although the body of the talus itself was more deformed. The average preoperative value was ‘36.1’ and the post operative value was ‘38.9’. Conclusion: We found the Distal Tibial line to be a reproducible parameter for measurement of AP alignment in TAR in the vast majority of OA cases. The change of anteroposterior alignment post surgery appears to be due to the restoration of soft tissue balance

Numerous techniques have been described for ankle arthrodesis. Arthroscopic arthrodesis with internal fixation has evolved to reduce the complications associated with open arthrodesis. We present our technique of arthroscopic ankle fusion using two medial cannulated screws with specially designed dished washers. The tibiotalar joint is debrided arthroscopically and internal fixation is achieved with two medial cannulated screws with designed dished washers. Seven ankle arthrodeses were performed on six patients; one underwent bilateral arthrodesis. All the patients suffered from OA (four post traumatic) and were aged between 53–61 (mean 55.4). There were four males and two females. The follow up ranged from 8–18 months (mean 10). All the patients achieved ankle fusion. Time for fusion ranged from 6 to 18 weeks, five fused within 12 weeks. Pre operative pain scores improved from 6–10 out of 10 (mean 7.2) to 1–3 out of 10 (mean 1.4) post-operative. Post-operative AAFOS ankle hind foot score ranged from 74–89 out of 100 (mean 81.8). One patient required further operations for adjustment of fixation and one suffered a stress fracture at the level of the proximal screw. This method of arthroscopic ankle fusion provides an effective alternative to open arthrodesis for selected patients with OA achieving good initial results

Introduction: The long term results of Total Ankle Arthroplasty still remain largely unsatisfactory and Ankle Arthrodesis remains the gold standard treatment for severe degenerative ankle joint disease resulting from trauma and other causes. We describe the method and results of ankle fusion performed with a single anterior midline incision using the standard AO T-Plate. Material and Methods: 18 patients underwent fusion of the tibiotalar joint with this technique over the past 6 years with a follow up range of 10 months to 5 years (mean-19 months). Though the commonest indication was post-traumatic degenerative joint disease (this included 6 patients who had previous internal fixation), other causes included primary osteoarthritis, rheumatoid arthritis, neuropathic joint (Charcot’s) and failed arthrodesis with other methods. The mean age was 65.5 yrs (range 37–91). The patients were assessed clinically and radiologically. Results: There was radiological union in all 18 patients. Excellent clinical results were finally achieved in 16 (89%). Complications included persistent pain(1), delayed union(2), infection(2, including one deep) and 2 underwent removal of plate with good final result. Discussion: This technique is a modification of that described previously by Rowan and Davey. In our practice the plate is contoured to the surface of talus and distal screws are directed more vertically towards the sustenaculum talus. We found it helpful to obtain more compression of adjacent surfaces. Conclusion: With the use of an anterior T-plate not only a better stability in biomechanical terms is achieved, better soft tissue cover of the metalwork help in overall patient satisfaction. Though we have performed ankle arthrodesis with different methods with satisfactory results, with this particular technique we have achieved excellent results and radiological union in all patients

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

Purpose. Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity. Method. Thirty-six ankles with greater than 10 degrees of varus alignment were compared to thirty-six ankles which were matched for implant type, age, gender, and year of surgery. Patients completed preoperative and yearly postoperative functional outcome scores including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, the Ankle Osteoarthritis Scale (AOS) and the Short Form-36 Standard Version 2.0 Health Survey. Weightbearing preoperative and postoperative radiographs were obtained and reviewed by four examiners (AC, AQ, TD, TT) and measurements were taken of the degree of coronal plane deformity. Results. After a mean follow-up of 27 months (9–54), the varus ankles improved significantly on the AOFAS (P<0.0001), AOS-Pain Score (P<0.0001), AOS-Disability Score (P<0.0001), and SF-36 Physical Component Score (P<0.0001). There was no improvement in SF-36-Mental Component Score. (P=0.722). There was no statistically significant differences between the two groups when comparing AOFAS (P=0.155), AOS-Pain Score (P=0.854), AOSDisability Score (P=0.593), SF-36-Physical Component Score (P=0.433), SF-36 Mental Component Score (P=0.633). Sixteen of Thirty-Six ankles in the varus group needed a secondary procedure (implant failure, infection, malalignment) which was approaching significance in comparison to eight ankles in the neutral group. (P = 0.079). Secondary procedures in the varus group included: tendon transfers, calcaneal / metatarsal / malleolar ostoetomies and ligament reconstructions. Radiographically, the pre-operative coronal plane varus tibiotalar deformity averaged 19.4 6.4 and postoperatively 1.44 2.6 (P< 0.0001). There was no statistical difference in post operative tibiotalar alignment between the varus and neutral groups (P<0.05). Conclusion. The clinical outcome of TAR performed in ankles with pre-operative varus alignment >10 degrees is comparable with that of neutrally aligned ankles. The increased number of secondary procedures in the varus group was attributed to the complexity of the deformity and the steep learning curve. Outcomes as measured radiographically and through validate scores were similar to patients without deformity suggesting that varus coronal plane deformity of the talus is not a contraindication to total ankle replacement

Purpose of the study: The purpose of this study was to assess radiological outcome of double (femoral and tibial) osteotomy for severe genu varum. Between August 2001 and November 2004, eleven double osteotomies were performed amoung a series of 157 knee osteotomies (7%). Material and methods: The series included four women and seven men, mean age 48.5 years (range 20–62 years). The right knee was involved in seven. One femal patient presented a particularly serious deformity but without oseoarthritic degeneration of the knee joint. The ten other patients all presented overtly degenerative knees. According to the Ahlback modified classification there were six grade III knees, three grade IV and one grade V. Mean preoperative radiological varus was 167.5±2.1° (ange 164–170°°. Orthopilot® was used in all cases. The first step was to insert percutaneously rigid bodies, one into the distal femur and the other into the proximal tibia. Kinematic acquisitions of the hip, the knee and the tibiotalar joint yielded the HKA for the lower limb. The second step was to perform the closed wedge lateral femoral osteotomy (5–6°) which was stabilized with an AO T-plate. The final step was to perform an open-wedge medial tibial osteotomy. After checking the desired alignment (182±2°) on the monitor, the osteotomy was fixed with Biosorb® and plated with an AO LCP. Results: There were no complications. The mean intraopeartive HKA was 168.1±2.21° (range 164–170°), identical with the preoperative findings. After osteotomy, the mean angle provided by the computer system was 182.7±1.1° (range 182–184°). Three months after surgery, the mean alignment on the standing x-ray was 180.8±1.6° (range 177–182°). The preoperative objective was achieved for all knees but one (91% success). There were no x-rays with an oblique joint space. Conclusion: Computer-assisted double osteotomy for major genu varum is a reliable accurate and reproducible technique. Use of a navigation simplifies a generally difficult procedure known to require much surgical skill to achieve the preoperative goal. This technique can be considered as an important development since it can help avoid an oblique joint space which can give rise to further problems and the need for a subsequent prosthesis

Clubfoot (CF) is a congenital deformity of the foot with a multi-factorial etiology. The question of the best therapy is still open. The aim of our study was to compare the formerly used limited posteromedial release (PMR) with the recent extensive complete subtalar release (CSR). From 1989 to 1997, 473 children were treated surgically. Our cohort contained 101 patients (129 affected feet) with CF confirmed by radiographs and physical findings. Forty-eight patients (59 feet) were operated with PMR, and 53 (70 feet) with the method of CSR after McKay. Both groups were comparable to Dimeglio’s classification concerning this type of deformity. All feet were operated on primarily with either no preceding therapy or with some conservative therapy. Average age at the time of surgery was 9.3 months. The radiographic parameters (Kite’s angle, lateral TC angle, TC index, T-I.MTT angle, lateral tibiotalar angle) were evaluated according to Simons. The physical parameters (heel position, forefoot adduction, range of motion in the tibiotalar joint, range of motion in the subtalar joint, the process of taking off, the general shape of the foot, assessment of wearing shoes, and plantogram) were also evaluated. Assessment of the radiographs and the physical parameters showed substantially better results in the group with complete subtalar release. A three-grade evaluation was used for assessment of the combined physical and radiographic assessment: good, fair, and poor. In the group with PMR, 54% were classified as good, 31% as fair and 15% as poor. In the CSR group, good results were achieved in 72%, fair in 17%, and poor in 11%. The lower occurrence of re-operation in the group with subtalar release was apparent. With suitable timing, excellent results can be achieved with this operation. We conclude that extensive complete subtalar release is one of the best methods to correct this type of clubfoot. Subtalar release as described by McKay produces significantly better long-term statistical results than posteromedial release, in both clinical evaluation and radiograph assessment