Background: A substantial coronal plane deformity is common in the context of end-stage ankle osteoarthritis. Recent literature shows a trend toward extending the indication of total ankle arthroplasty in increasingly severe coronal deformities, showing promising results when correct alignment is achieved. Nevertheless, the results of lateral transfibular total ankle replacement (LTTAR) in valgus has not been extensively studied. We aimed to evaluate if the outcomes of LTTAR in ankles with valgus deformity were similar to those with no major deformity at short-term follow-up. Methods: This retrospective cohort study included 228 LTTARs. Patients were classified into 2 groups according to the preoperative coronal plane tibiotalar angle (TTS): neutral (less than 10 degrees of coronal deformity, 209 patients) and valgus (above 10 degrees of valgus, 19 patients). Clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS), 12-Item Short Form Health Survey 12 (SF-12) regarding its Physical and Mental Component Summary items. The radiographic evaluation considered anteroposterior and lateral ankle radiographs. Complications were also registered and classified as major or minor. The minimum follow-up was 2 years. Results: The average AOFAS, VAS, and SF-12 scores improved significantly postoperatively ( P < .001), without differences between groups. At final radiographic follow-up, the valgus alignment group did not show significant differences with the neutral alignment group regarding TTS, lateral distal tibial angle, or anterior distal tibial angle ( P > .05). Conclusion: LTTAR in cases with valgus deformity achieved and maintained correction at short-term follow-up, as obtained in neutral alignment ankles. Clinical outcomes improved significantly regardless of preoperative valgus deformity. Level of Evidence: Prognostic Level III, retrospective cohort study.
Category: Trauma Introduction/Purpose: Medial and syndesmotic stability evaluation of isolated supination-external rotation fibula fractures (ISER) is critical to determine surgical conduct. However, there is no agreement on the best method to diagnose instability preoperatively. This problem is especially relevant in those with less than 2mm displacement in non-weightbearing radiographs. Different radiographic stress methods have been proposed: external rotation, weightbearing x-rays (WBx), and gravity stress radiographs (GSx). Likewise, the literature describes the use of ultrasound and magnetic resonance imaging (MRI) as complementary studies. To our knowledge, no studies have described the MRI findings in patients with discordant results between GSx and WBx views. Purpose: To analyze the imaging findings in WBx, GSx, and MRI in a consecutive group of patients with ISER with discordant results on stress views. Methods: For two years and prospectively, consecutive patients treated in a Level 1 trauma center were enrolled, performing the following imaging study protocol:- All patients with ISER fractures with a congruent tibiotalar joint on non-weightbearing radiographs underwent a bilateral WBx and GSx.- When there was a discordant result between WBx and GSx, MRI was taken. A retrospective analysis of the patients who had a complete study was carried out, considering the radiological findings and measurements. Measurements on radiographs were performed by six physicians (2 general practitioners, two trauma residents, and two ankle and foot subspecialists). One musculoskeletal radiologist analyzed the MRIs. The following parameters were measured, medial clear space (MCS), superior clear space (SCS), and tibiofibular clear space (TFCS). Inter-observer agreement in radiographs was analyzed using the intra-class correlation coefficient. Differences between groups were evaluated by t-student for independent samples, considering α <=5% significant. Results: Thirty-four patients were recruited. Interobserver agreement was good to excellent on all radiographic measurements. For all the measurements in the WBx, there were no significant differences between the injured and the healthy side. Average of MCS 2.51, SCS 3.07 and TFCS 3.74 mm for the uninjured side; and MCS 2.51, SCS 3.12, and TFCS 3.67 mm for the injured side. In the GSx, significant differences were observed for all measurements between the fractured and the healthy side. Average of MCS 3.55, SCS 3.85, and TFCS 3.89 for the healthy side; and MCS 5.87, SCS 4.25, and TFCS 4.44 for the injured side.100% of GSx and 0% of WBx met instability criteria (more than 2 mm compared to the healthy side). None of the MRIs showed a complete lesion of the deep deltoid ligament nor syndesmal complex. Conclusion: MRI did not demonstrate a complete deltoid nor syndesmal lesion in any patient with ISER fracture with normal WBx and altered GSx. A positive GSx does not correlate with MRI findings in patients with a non-displaced WBx study.
Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement use has increased among patients with end-stage ankle arthritis. Substantial coronal plane deformity is usual in that context. In addition, recent literature shows a trend towards the extension of the indication of total ankle arthroplasty in increasingly severe coronal deformities, showing good results when correct alignment is achieved. Nevertheless, the results of lateral transfibular total ankle replacement (LTTAR) in valgus has not been extensively studied. We aimed to evaluate if the outcomes of LTTAR in ankles with valgus deformity are similar with those with no major deformity. Methods: This retrospective cohort study included 228 LTTAR. Patients were classified into 2 groups according to the preoperative coronal plane tibiotalar angle (TTS): neutral (less than 10° of coronal deformity, 209 patients) and valgus (above 10° of valgus, 19 patients). Clinical evaluation was performed using American Orthopaedic Foot & Ankle Society Score (AOFAS), Visual analogue scale (VAS), short Form 12 Quality of Life (SF-12) regarding its physical (PCS) and mental (MCS) items. Radiographic evaluation considered anteroposterior and lateral ankle radiographs. Surgical times were recorded in all the cases. There were no differences between groups regarding mean age, mean body mass index and follow up. The minimum follow up was 24 months. Results: The average AOFAS, VAS and SF-12 scores improved significantly postoperatively (p-value<0.01), without differences between groups. At final radiographic follow up, the valgus alignment group did not show significant differences with the neutral alignment group regarding TTS, lateral distal tibial angle or anterior distal tibial angle (p-value>0.05). Surgical time was longer in the valgus group (152.84 +- 40.86 mins vs 129.51 +- 52.13), but the difference was not statistically significant. Conclusion: Lateral transfibular total ankle replacement in ankles with valgus deformity achieved and maintained correction of coronal alignment in a short term follow up, as obtained in neutral alignment ankles. Clinical outcomes improved significantly regardless preoperative valgus deformity. Additional surgical time may be needed in order to obtain a good deformity correction in a valgus ankle. This short term analysis shows that LTTAR in a valgus ankle seems to be a safe option in experienced surgeons hands.
Category: Trauma Introduction/Purpose: Chopart fractures and dislocations are one of the most commonly overlooked injuries of the foot. These injuries are still challenging in both diagnosis and treatment and result in a high degree of long-term disability. Recent studies have shown that around 30 to 40% of these injuries are not adequately diagnosed on first consultation, mainly because of their low incidence and high clinical variability/spectrum of injuries. Anatomical reduction of Chopart injuries seems to be the most important prognostic factor of functional outcomes. However, there is still no consensus or clear evidence-based guidelines on the management of these types of injuries. We report the result of our current management protocol and propose a new algorithm of management of Chopart Injuries. Methods: We present a case series of patients with Chopart fractures and fracture-dislocations admitted to a Level 1 Trauma center between March 2015 and April 2020. Demographic data, mechanism of injury, treatment and complications were obtained from clinical records. Classification of injuries according to Zwipp was performed. Standardized surgical management was performed in 1 or 2 stages, according to soft tissue status. Open reduction and internal fixation of associated fractures of the talus, navicular, calcaneus and cuboid was performed. In cases of severe articular comminution or presence of medial and/or lateral instability, transarticular bridge plating was indicated. Postoperative radiological assessment was performed with X-rays and CT scan. Outcomes were determined using the American Orthopaedic Foot & Ankle Society midfoot score (AOFAS), visual analogue scale (VAS), foot and ankle ability measure (FAAM) and the 12-item Short Form Survey (SF-12). Results: Thirty four patients (12 women) were included in this study with a mean age of 37 years. Mechanisms of injury were: motor vehicle accidents (n=12), low energy midfoot torsion (n=12), crushing injuries (n=7), fall from height (n=2) and firearm injury (n=1). Mean follow up was 39 months (ranging from 8 to 71 months). The mean AOFAS score 84.8 (SD 12.9), mean FAAM of 84.4% (SD 15.4) and mean VAS score was 3/10. In terms of quality of life, the SF-12 physical component score was 43.59 (SD 9.3), with a mental component score of 51.98 (SD 12.1). Secondary procedures included: hardware removal (n=23), midfoot fusion (n=3) and skin coverage procedures by plastic surgery (n=5). Conclusion: In this case series, a standardized strategy for the treatment of Chopart injuries including the use of external fixation, ORIF and transarticular plating is presented. Reestablishment of joint alignment of both columns (medial and lateral) is crucial to obtain acceptable functional outcomes. Transarticular fixation is a useful alternative to post-reduction residual instability and bridging of fractures with periarticular comminution. Functional and quality of life results on this series were acceptable and comparable to previous reports at minimum one year follow up. Long-term follow up is needed to further validate the proposed algorithm.
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