Review of Management for Nerve Entrapment Issues in the Foot and Ankle

While relatively uncommon, nerves can become entrapped in the lower leg and ankle. A recent updated review article touched upon management of these diagnoses. The author stated that it’s important to establish an accurate diagnosis through which physicians will rely on a thorough physical examination and must additionally possess a thorough understanding of relevant anatomy. Electrodiagnostic testing, including nerve conduction velocity NVC and electromyography EMGs and advanced imaging such as magnetic resonance imaging MRI and ultrasonography can assist with localizing the area of entrapment and contributing factors.

Tarsal tunnel syndrome occurs when the tibial nerve is entrapped and can be further divided into proximal syndrome and distal syndrome. Proximal tarsal tunnel syndrome is the most common and occurs when the tibial nerve is compressed in the tarsal tunnel proper. Patients will typically present with diffuse pain along the inside of the ankle and bottom of the foot. It is often described as burning, shooting, electric, tingling and numbing. After comprehensive physical examination, radiographs and MRI or ultrasonography may be used to identify soft tissue or bony contributions. Electrodiagnostic studies may be used to confirm entrapment but they cannot be used to exclusively rule in or out tarsal tunnel syndrome. Typically non-surgical management is used first including anti-inflammatory medication, activity modifications, physical therapy, and eliminating use of compressive clothing or footwear. Surgical release is only recommended when these conservative measures have failed. Full release of the flexor retinaculum is recommended. It was also found that early diagnosis and intervention provided improved outcome than those who had more chronic symptoms.

Distal tarsal tunnel syndrome is further divided into entrapment of the terminal branches of the tibial nerve, specifically the medial plantar nerve and lateral plantar nerve otherwise known as jogger’s foot and Baxter nerve respectively. Patient’s with jogger’s foot report pain along the medial plantar side of the foot that is induced with exercise. The pain can radiate to the bottom of the first, second and third toes and can also radiate up into the inside of the heel and ankle. It’s important for physical examination to occur including examining shoe wear for sources of external compression such as excessive or rigid arch support. Imaging can further assist with diagnosing causative deformities. Again initial treatment is non-surgical management and if these fail surgical release may be considered. Patient’s with Baxter neuropathy, or compression of the lateral plantar nerve, present with pain along the medial plantar aspect of the heel often similar to distribution of pain from plantar fasciitis. Paresthesias and weakness are not typically reported. If diagnosis is unclear, further diagnostic studies may prove to be beneficial. In this case, surgical intervention is often required.

Soleal sling syndrome occurs with the tibial nerve is entrapped in the calf region by a fibrous sling at the origin of the soleus muscle. Patients may report calf pain and have pain that mimics tarsal tunnel syndrome and may even possess a history of failed tarsal tunnel release. Pain with gentle palpation on the calf approximately 9 cm below the flexion crease of the knee will typically generate pain. Weakness may also be present, specifically the flexor hallucis longus. Electrodiagnostic testing can be difficult to perform secondary to the depth of the nerve at this level. Non-surgical management should include modification of activities and discontinued use of restricted clothing or footwear. Anti-inflammatory and nerve-modulating medications may also proved some benefit. If conservative management fails to provide relief then surgical decompression is recommended.

Morton neuroma occurs when there is entrapment of the interdigital nerve most commonly in the third web space and occasionally in the second web space. Patients will present with burning or electric pain and numbness and tingling in the affected webspace. Women are affected more than men. Symptoms are reproduced with direct pressure on the plantar aspect of the foot between the metatarsal heads upon physical examination. Lidocaine injection can also help confirm diagnosis as patient will receive pain relief. Diagnostic tests are usually reserved for abnormal presentations to confirm the diagnosis. Nonsurgical treatment includes fabrication of custom orthoses, metatarsal pads, accommodative footwear and anti-inflammatory medications and injections. If these treatment modalities fail, surgical management may be warranted. One study reviewed advocated a hybrid intraoperative approach in which the nerve is resected if it is found to be thickened otherwise the authors released only the transverse metatarsal ligament and total relief of symptoms was reported in 96-98 per cent of patients.

Superficial peroneal nerve entrapment occurs when the nerve is compressed or entrapped as it pierces the deep fascia because of thickened fascia tunnel, a fascial defect or soft-tissue mass. Most patients will report pain related to activity in the lower outside leg as well as dysesthesias in the dorsum and lateral aspect of the foot. Chronic exertional compartment syndrome should be considered as differential diagnosis. First line of treatment includes removing external factors that may be causing the compression as well as stabilizing any instability that may be tensioning the nerve. Surgery is rarely required.

Anterior tarsal tunnel syndrome occurs when the deep peroneal nerve is entrapped in the anterior tarsal tunnel. Patient’s with entrapment of the lateral branch will report pain along the dorsal foot. Patients with entrapment of the medial nerve branch will report pain and or numbness to the first web space. After thorough physical evaluation, radiologic evaluation can prove critical in the workup as the most common causes of anterior tarsal tunnel syndrome are trauma and impingement of the nerve by bony growths or osteophytes are the talonavicular joint. Non-operative management focuses on reducing external compression, stabilizing ankle laxity and reducing inflammation. Surgical cases should only be reserved for very site specific difficult cases to reduce the risk of scarring from excessive nerve dissection.

Sural nerve entrapment is rare but can occur anywhere in the leg ankle or foot. Patients may report pain, burning, numbness or aching in the back-outside leg, outside part of the ankle or foot. Treatment is dependent on the accurate identification of causative factors and the location of the entrapment. Swelling and underlying instability should be treated first as should any external factors. The authors recommend that if the cause is post traumatic or postoperative then a three to six month period of observation, desentization and neural gliding should occur prior to proceeding to surgery.

Saphenous nerve entrapment is also very rare. Typically it occurs more proximally and patients will present with pain and paresthesias to the foot and ankle. Surgical treatment should be delayed until nonoperative management have failed to provide relief.

In summary, in treatment of entrapment neuropathies of the lower leg, ankle and foot a comprehensive knowledge of relevant anatomy must be possessed followed by thorough physical examination and appropriate treatment. Patient’s will often respond to nonoperative treatment, however, when this fails to provide relief surgical involvement will be considered.

Clinical Outcomes for Patients with Rheumatoid Arthritis After Undergoing Total Ankle Replacement as Compared to Those with Noninflammatory Arthritis

Rheumatoid arthritis (RA) is an inflammatory condition in which the body’s immune system attacks it’s own tissues, in this case the small joints in your body. The ankle joint is commonly affected and can lead to great disability in RA patients. In the past, patients with RA who suffered from disabling ankle arthritis often underwent ankle fusion. This has led to complications including wound healing difficulties, great stiffness as there is often involvement of other small joint in the same foot and even tibial stress fracture from limited forward translation of the affected limb. Total ankle arthroplasty (replacement) has been pursued as a way to preserve hindfoot motion. A recent study aimed to investigate the intermediate-term clinical outcomes and safety of total ankle replacement in patients with RA and matched a cohort of patients with noninflammatory arthritis who underwent the same procedure.

A cohort of fifty patients with RA who underwent a total ankle replacement was identified through the Canadian Orthopaedic Foot and Ankle Society. The database was drawn from four centers across Canada. The control group consisted of fifty age-matched patients with noninflammatory arthritis who underwent the same procedure and were obtained from the same database. Besides age, these groups were matched for follow-up time and type of prosthesis. Clinical outcomes were assessed utilizing the Ankle Osteoarthritis Scale (AOS) and the quality-of-life Short Form-36 (SF-36) Health Survey Standard Version 2.0. Twelve patients with RA and one patient with noninflammatory arthritis had undergone hindfoot joint fusion prior to their replacement. Clinical outcome score analysis of the AOS pain scores demonstrated that the RA group had a higher level of pain preoperatively but improved to a pain level that was equivalent to that of the noninflammatory arthritis group after total ankle replacement. There was no significant interaction effect between treatment and rheumatoid or noninflammatory groups in regards to the AOS disability score. The physical component scores for the SF-36 demonstrated that while the health of both groups improved after total ankle replacement, the noninflammatory arthritis group demonstrated a greater mean change and significantly better physical health at final follow up. The mental component scores of the SF-36 demonstrated modest, but significant, improvements in both RA and noninflammatory arthritis groups. Revision rates were found to be 12 per cent in the RA group and 10 per cent in the noninflammatory arthritis group with a mean time to revision of four years and six and a half years respectively. In this study, one RA patient required removal of the implant secondary to deep infection while another patient suffered a superficial wound complication which required a skin graft. The RA group underwent a greater number of additional procedures to manage associated arthritis throughout the foot at the time of the replacement. While the noninflammatory arthritis group underwent a greater number of additional hindfoot procedures after total ankle arthroplasty to help protect the replacement through correcting hindfoot alignment.

Overall the authors of this study feel that total ankle replacement provides good outcomes for patient with RA in the intermediate term. While the overall pain and disability for these patients was worse preoperatively than the noninflammatory arthritis group, this did not negatively impact the outcomes after total ankle replacement.

Gait Improvements Following Combined Ankle and Subtalar Joint Fusion

In cases of severe bone loss, severe deformity and advanced arthritis affecting both the ankle and subtalar joints, combined arthrodesis (joint fusion) is still indicated. While there is extensive literature regarding the effect on gait with ankle arthrodesis and ankle arthroplasty (joint replacement) there is very little information regarding the objective functional outcomes measured through gait analysis for patients treated with fusion of both the ankle and subtalar joints otherwise known as tibiotalocalcaneal arthrodesis.

A recent study looked to prospectively analyze twenty-one patients who had underwent a tibiotalocalcaneal fusion utilizing a retrograde, intramedullary nail. All patients were able to walk barefoot without use of assistive device and adhered to a gait analysis protocol. The temporospatial measurements included; cadence, step length, walking velocity and total support time. While the kinematic parameters measured sagittal plane motion and total knee and hip motion and the kinetic parameters were ankle power in the sagittal plane and ankle moment as well as hip power. Symmetry of gait pattern was studied by comparing affected and unaffected limbs. This analysis was completed once prior to surgery, while postoperative analysis was performed at a mean follow time of seventeen +/- six months.

This study demonstrated significant improvement postoperatively in cadence, walking speed, step length (of unaffected limb) and total support time. The authors note that the changes in the affected limb may have been attributed to the decrease in pain which would allow for further use of motion of the joints on the unaffected limb or it may be partially attributed to the mechanical stability provided by the arthrodesis. There was significant increase in hip motion postoperatively, which the authors think may represent compensations for loss through sagittal plane motion in the ankle joint. Ankle moment but not ankle power increased postoperatively in the affected limb. Although definitive conclusions could not be drawn from this data, increased hip power may be related to compensatory mechanism due to stiffness in the ankle restricting the ability to “push off” thus the individual would need to pull the extremity forward to advance the limb. Finally, gait symmetry improved significantly following tibiocalcaneal arthrodesis. This symmetry can be clinically useful in correlation with patient perception of their limping affecting both their self-image and overall postsurgical satisfaction.

Acute Achilles Tendon Rupture: A Review of the Current Best Practice Advice

Your opponent friend Bob jumps up to grab a rebound in the twice-a-week pick-up basketball game, then painfully grabs his right lower calf muscle’s tendon. He hobbles off the court with one sore heel cord. Bob has just joined the growing population of middle-agers with an Achilles tendon strain. The likelihood of Achilles tendon tears has grown in recent decades.   A recent review of the research has found strong support that men, like Bob, around thirty to forty years and women between sixty to eighty are struck with this common injury.

This review article aimed to add strength to the current ‘weak’ body of research on the appropriate management of torn Achilles tendons.  They highlighted the growing research on best management this calf injury both with and without surgery. The authors dug into the studies on this topic and followed groups of injured study subjects to learn more about the effects of complications (for example, repeat ruptures or infections) and/or successes. They also assessed how well they returned to their prior daily activities in the weeks and years following the tendon tear.

When a patient is examined in a medical provider’s office for this injury, there are many assessment options. Expensive MRI’s, ultrasound tests, squeezing the calf and feeling for a gap along the tendon are some of the common injury tests. This review found the calf squeeze test, also known as the Thompson test was the most effective way to diagnose a full Achilles tendon tear.  The provider should be on high alert for this injury when the patient older than fifty-five, or obese, or is injured participating in something nonathletic, or all of the above.

The role of physical therapy and best-practice plans to improve the patient’s function were reviewed as well.  These well-researched action plans that do not involve a surgical repair were found to effectively reduce the tendon injury from happening again. Patients that opted to undergo surgical treatments had some earlier improvements in tasks like walking and getting back to work, but more recent studies suggested that the improvements were short-lived or minor.

One common problem associated with this tendon injury is a higher risk of a blood clot in the veins of the lower leg.  This study found no support that a tear in your Achilles tendon made you more at risk than any other injury to your foot or ankle. The most common risk factors for a dangerous clot problem were in patients that did not get up and move after their injury and/or those older than forty.

Treatment Options For Posterior Heel Pain From Repetitive Overuse Injury

Overuse injuries from repetitive ankle plantar flexion stresses can be attributed to Os trigonum syndrome.  The Os trigonum can be the result of fracture of a bony tubercle in the back of the ankle or it can occur when there is an unfused ossicle in childhood. This condition may also be known as posterior ankle impingement.  Ballet dancers and soccer players have an inherent risk of this condition secondary to the amount of time in a forced plantar flexed position. This occurs with push off procedures and while dancing on pointe (dancing performed on the tip of the toes with the ankles in maximal plantar flexion) and demi-pointe (dancing performed on the balls of the feel with the ankle in maximal plantar flexion).

This condition is typically asymptomatic until an overuse injury or trauma occurs. Symptoms can include stiffness, chronic pain and swelling behind the ankle. Because pain and stiffness can occur with activities involving plantar flexion, compensations can occur leading to faulty positions which additionally may lead to other ankle conditions such as ankle sprains, tendonitis or tenosynovitis (inflammation of the fluid-filled sheath that surrounds a tendon). Initial conservative management of Os trigonum syndrome includes rest, ice, anti-inflammatory medication and, of course, avoidance of aggravating activities. One study demonstrated 84 per cent of patients received relief from an ultrasound-guided corticosteroid injection.

If a three to six month course of conservative treatment fails, surgical intervention may be appropriate. Resection of the Os trigonum can be performed via three methods; posterior endoscopy, arthroscopy, or an open procedure.  Most studies report outcomes that posterior endoscopy and arthroscopy can allow for faster return to sport but these techniques tend to be more complex and demanding. The author of this review article argues that a careful open approach may produce long term results that are equal to that of arthroscopic and endoscopy techniques while possibly being safer.  Overall, surgical outcomes show that all three techniques provide improved function and high rate of return to sport.

How effective are dynamic compression therapies at reducing ankle edema compared to the standard treatment of elevation and ice?

It is widely accepted in trauma care that a fractured ankle will usually require surgical stabilization, as bearing weight and walking on the broken bone(s) is imperative to functional progress. Controlling the swelling or edema that comes secondary to the injury is an important consideration in expediting the surgical intervention and subsequent rehabilitation. Excessive edema can complicate the surgery and healing, as well as increase the risk of wound complications and infection following the surgery.

Manuela Rohner-Spengler, a clinical Physical Therapist and a team of MD/PhDs from the Departments of Rheumatology and Physiotherapy and Trauma Surgery at the Lucerne Cantonal Hospital in Switzerland took interest the optimal pre-operative swelling management techniques to yield the best post-operative outcomes. In an age of improving medical care with more sophisticated equipment, Ms. Rohner-Spengler and her team wanted to know how effective are new dynamic compression therapies like intermittent impulse compression devices, at reducing ankle edema compared to the standard treatment of elevation and ice.

This study followed rigorous design methods using randomized, controlled, single-blinded clinical trials with repeated-measures on each subject. The 58 subjects all had a similar traumatic injury of fracturing one of their ankles. They were randomly assigned into one of three groups; the standard cold pack and elevation (control) group, the compression bandage group (Ace wrapping), or the impulse compression (a pneumatic compression sock) group. The resulting measures from the various treatment groups were analyzed with intention-to-treat principles, meaning all resulting measures were based on the initial treatment grouping assignment and not on the treatments the subjects eventually received.

Each subject had their ankle girth measured with a flexible tape measure using the figure-of-eight method for five consecutive days before and after the surgery, then again at six weeks post-op. Other measurements tracked through the study were degrees of ankle mobility, pain levels, number of days in hospital, Physical Therapy treatment sessions, amounts of medication required, wound-healing measures and functional outcome data using the Foot and Ankle Ability Measure.

This study found significant differences in edema reduction both pre-operatively and post-operatively between the compression bandage group and the ice and elevate (control) group. The pneumatic compression sock group did not make significant reductions in ankle edema. For example, after two days of pre-operative intervention, the median edema reduction was -23 per cent, -5 per cent, and 0 per cent for the compression bandage, control group, and pneumatic compression group respectively. Another interesting difference noted was improved ankle range of motion following the surgery in the control group over the compression bandage and pneumatic ‘impulse’ squeezer sock.

Shortcomings of this study were the impulse compression device had to be used as a ‘stand-alone treatment’ and thus other secondary typical pre or post-operative edema reduction measures like elevation, cold pack application and compression wraps were not used. The study design also could only use single-blind methodology, which reduces its strength and validity, but it is nearly impossible to blind the subject pool as to what type of treatment they were receiving. Do I have a cold pack on my ankle or is that one of those nifty pneumatic ‘impulse’ squeezer socks?

The take-away findings for patients that have an acute ankle trauma are multilayer compression wrapping can be very effective at reducing swelling before and after surgery. Using combinations of cold packs, elevation and compression therapy can thus be inferred to be helpful for reducing pain, improving ankle range of motion and mitigating edema. Implementing compression wraps with stabilization splints/boots in the emergency room, as well as post-operatively could also lead to a more efficient, less painful healing time.

Common Causes and Treatment of Heel Pain

Heel pain is a common ailment that is frequently misdiagnosed because of a lot going on in a small space. A review article recently looked at the most common diagnoses and their causes. Authors challenge that a thorough exam should result in a correct diagnosis, which usually can be treated conservatively with over the counter anti-inflammatory medication (NSAIDs), rest, shoe modification, or physical therapy. Corticosteroid injections should be used with caution because of the multiple side effects and brief relief of symptoms. Surgery should only be considered when all other options have been completely explored.

Plantar fasciitis (PF) is the most frequently diagnosed cause of heel pain. The plantar fascia is a stiff piece of tissue that originates at the inner heel and is responsible for helping with maintaining an arch during push off while walking or running. PF is a slow degeneration of this tissue and is often caused by micro-trauma or strain. The telltale symptom is the dreaded first step in the morning that is painfully sharp but does not radiate. Pulling the big toe up or pushing on the PF itself recreates this pain. Effective treatment includes physical therapy, rest, stretches, store bought orthothoses, ice, NSAIDs, and weight loss.  Evidence is mixed on long-term outcomes for night splints, prescription orthoses and the use of walking boots. Corticosteroid injections improve pain initially but can increase risk of PF rupture, along with facial flushing, skin and fat pad shrinking, or increase in pain following the injection.

“Heel pad atrophy” occurs when the fat pad under your heel bone, usually responsible for shock absorbance begins to break down. Pain is deep and localized in the center of the heel and is often mistaken for PF. Treatment should include NSAIDs, padded shoes, silicone heel cups, and low impact activities.  Corticosteroid injections should not be performed as this can shrink the fat pad further and surgery should be avoided as there are no existing techniques that effectively address this problem.

The Baxter nerve travels down the inner side of the heel and can be squished, or entrapped,  between a foot muscle or at the level of the heel bone. Burning pain is felt on the inside of the heel bone, or calcaneus, toward the arch in the foot. About half of patients with Baxter nerve entrapment usually also have PF. Conservative treatment includes physical therapy, rest, NSAIDs, and orthotics for proper heel alignment. Surgery is only considered if conservative measures have not worked and symptoms have lasted greater than three months. The most common surgical technique is to cut the fibrous tissue of the main foot muscle that is crushing the nerve, the abductor hallicus. Other surgical techniques include removing bone spurs and cutting other muscle fascia involved.

Calcaneal stress fractures, or tiny breaks in the heel bone, are often caused by a sudden increase in intensity of exercise. Pain is felt on the inside of the heel about one to two centimeters up from the pad of the foot and is a deep ache that increases with bearing weight but can become bad enough to feel even at rest. Stress fractures show up on an x-ray about two to eight weeks following injury. Treatment includes rest and wearing a walking boot or cast for four to eight weeks.

Tarsal tunnel syndrome happens when the tibial nerve, which normally travels through a tunnel created by fibrous tissue and the heel (calcaneal) bone, becomes trapped.  This most commonly affects people with flat feet. The pain is not well pinpointed but is often behind the inside ankle bone and is tingling or burning and can radiate to the foot. Conservative treatment includes NSAIDs, immobilization, or custom orthoses. Surgery is an option when conservative treatment fails and involves careful release (cutting) of the fibrous tissue making up the roof of the tunnel. Good outcomes for surgical intervention, however, are around 50 per cent.

Results of MOBILITY Ankle Replacement

Total ankle surgery is becoming a valid alternative to an ankle fusion for people with severe ankle arthritis. Changes have been made in the implant designs in the past several years, which are showing encouraging results. The benefit for replacement over fusion is preservation of some ankle mobility and thus improved ankle function for all kinds of life activities. This study looks at clinical outcomes as well as patient reported outcomes following ankle replacement with the MOBILITY Total Ankle System. These outcomes were measured with several questionnaires pre and post operatively. There was a clinical outcome measure called the American Orthopaedic Foot and Ankle Society score (AOFAS) and a patient reported, quality of life survey called the 36-item Short-Form Health Survey. They also collected overall patient satisfaction, height, weight, age and details of other medical conditions.

There were 106 participants in this study with a mean age of 61.9 ranging from thirty-three to eighty-nine years. In this group there were fifty-six with a preoperative diagnosis of osteoarthritis, twenty-eight with posttraumatic arthritis, and twenty-two with rheumatoid arthritis. The group of patients with posttraumatic arthritis was significantly younger at 54.8 compared to the other two groups.

The results indicate that there was not much difference between the groups for most of scores at both the one and two year follow-ups, and that all groups showed improvement in the outcome scores. The AOFAS score increased by an average of fifty-three points, which is comparable to some other similar studies, indicating consistency in this score improvement. The Short-Form Health Survey was used to get a feel for the patients’ perception of their general health and improvement related to their ankle replacement surgery. The results here also showed improvement from pre to post surgery. The rheumatoid arthritis group did have slightly lower scores in this questionnaire, indicating possibly the impact of this disease process on overall quality of life.

There were a few complications as a result of the MOBILITY ankle replacement surgery in this study. The most common was a medial malleolar fracture at six patients. Other less common complications included persistent medial ankle pain, infection and distal tibial fracture. There was one revision, however this was following a trauma. In all groups only one patient had a fusion following the total ankle procedure. Two patients had unresolved medial ankle pain and were later diagnosed with medial impingement, and following surgery this pain was resolved.

Total Ankle Replacements Offer a Good Solution to Ankle Arthritis

Ankle arthritis is ranked as debilitating as end-stage kidney disease. It often strikes at an earlier age than other arthritic joints, frequently due to after-effects of trauma, and is extremely painful.  Previously arthrodesis, or ankle joint fusion, was the primary treatment to help stop the pain. But ankle fusion was not a great long-term answer because it additionally caused further joint break down and significantly limited function, such as walking, because the ankle bones no longer moved.  Unlike ankle joint fusion, ankle joint replacement allows for a more natural walking pattern and thus allows for people to do more following replacement.

Thanks to technological advances, there are now two types of total ankle joint options, a mobile joint and a fixed joint. The mobile implant has a ball-bearing type function that allows for improved ankle motion and increased walking speeds.  The hardware shows promising survival rates up to 10 years.  The fixed joint replacement allows for lesser movement from side to side than the mobile implants.  There is less research surrounding this type of joint replacement but the replacements are associated with improved function and a return at the 2-year mark to “moderate exertional activities.”

Ninety patients with end-stage ankle arthritis participated in a recent study, comparing these two implant types.  Authors collected gait analysis, performed a physical exam, x-rays, and functional tests prior to surgery, and at both one and two years following surgery. Participants also filled out several questionnaires self-assessing their function and satisfaction with their surgical outcomes throughout this time period.  Forty-nine participants received the mobile bearing implant and forty-one receive the fixed-bearing implant.  Results found both of the implants to either maintain or improve function.  The fixed-bearing implants had better walking qualities than the mobile implant group, however the mobile implant group reported better improvements in pain. Authors concluded that the implants can be rated as equal when choosing ankle joint replacement type and prove a better option than ankle fusion.

Percutaneous Drilling for Osteonecrosis of the Ankle

Osteonecrosis is a degenerative joint condition caused by decreased blood flow to a bone to the point that the bone begins to break down. A potentially life altering condition, osteonecrosis most commonly affects the femoral head, knee, shoulder and ankle. Risk of developing osteonecrosis has been associated with increased corticosteroid use, alcohol abuse, sickle cell disease, human immunodeficiency virus, and other immunosuppressive diseases.

The most common site for an osteonecrotic lesion in the ankle is in the talus or distal tibia, with a high prevalence in younger patients. Osteonecrosis can be stratified into four Stages according to the Ficat and Arlet classification system:

Stage 1: no apparent evidence of the disease on radiographs, however changes can be seen on MRI
Stage 2: cystic and/or osteosclerotic lesions on radiograph with a normal contour of the talus AND no evidence of subchondral fractures
Stage 3: crescent sign or sunchondral collapse
Stage 4: end stage disease with a narrowing of the joint space and secondary changes in the distal tibia

The treatment options can be non-joint preserving procedures, such as arthrodesis, talectomy, and arthroplasty, or joint preserving techniques, such as core decompression or bone grafting, which are typically preferred for younger populations. One variation of core decompression, described as percutaneous drilling, has been the subject of recent attention as it has been successful in treating osteonecrosis in the femoral head, knee, shoulder, and ankle.

Researchers recently looked at a total of 101 subjects, eighty-one of which had no previous surgical procedure and twenty of which had unsuccessful prior ankle core decompression. All patients underwent 12 weeks of nonoperative management, including analgesics, partial weight bearing exercise, bone stimulators and orthosis, but continued to have pain and thus elected to undergo percutaneous drilling as an outpatient procedure. This technique differs slightly from other core decompression techniques in that it uses smaller drill bits and is thus less invasive and removes less bone.

Post-operatively, the patients followed the same protocols beginning with partial weight bearing for four weeks, full weight bearing thereafter, and no high impact activities for ten months. At the most recent follow up of these patients, there were significant improvements in the patient reported outcome measures and pain scores and 83 per cent of the ankles demonstrated no further progression of osteonecrotic lesions. Seventeen of the ankles had progressed to a more advanced stage, four of which were at joint collapse, however the presence of sickle cell disease and HIV was associated with this progression.

Ankle Syndesmotic Injuries

Ankle syndesmotic injuries are involved in 5-10 per cent of all ankle sprains and 23 per cent of ankle fractures. Despite this prevalence, there is a lot of debate regarding proper diagnosis and treatment of this complex injury.

The complexity of the injury to the syndesmosis lies in the anatomy. The convex distal fibula and concave distal, lateral tibia form a syndesmotic articulation and require specific congruency and mobility to accommodate the underlying talus. The fibula must be able to rotate, translate and migrate to allow for normal ankle movement. The syndesmotic articulation must also be stable, and thus comprises four distinct ligaments. The anterior inferior tibiofobular ligament and the deep posterior inferior tibiofibular ligament contribute the most to ankle stability, combining to provide 68 per cent of the stability to the joint.

Ankle sprains that involve a combination of hyperdorsiflexion and external rotation at the ankle are the most common that result in syndesmotic injury. The injury can involve only damage to the ligaments or combine ligamentous damage with fracture. Isolated syndesmotic injuries are often referred to as high ankle sprains and result in pain and ankle instability. Physical examination can be conducted at three to five days after injury with the patient adhering to rest, ice, compression and elevation (RICE) during this time.

Common evaluation stress tests including the squeeze test, the external rotation stress test or cross leg test are considered positive if pain decreases with compression. Physical examination can be conducted
at three to five days after injury with the patient adhering to rest, ice, compression and elevation (RICE) during this time. Radiographic, CT, and/or MRI can be further used to confirm syndesmotic injury including fracture as deemed necessary. The three common syndesmotic fracture injuries include Weber Type C fracture (pronation-external rotation), Weber Type B (supination- external rotation) and Maisonneuve fracture (involving proximal fibular fracture). A malleolar fracture can also result in syndesmotic injury, but this is much more difficult to diagnose unless done intraoperatively with the hook test or external rotation test under flouroscopy.

Traditionally all syndesmotic fractures are treated operatively with screw fixation being the gold-standard. Syndesmotic reduction becomes an important factor with all fixation procedures as malreduction is common and results in significantly worse functional outcomes. Malreduction typically takes place when the fibula is fixed in the wrong position. Malreduction rates decrease from 50 per cent to 15 per cent with direct visualization of the tibiofibular joint. If direct visualization is not possible with the surgical technique, intraoperative 3D imaging show promise in reducing malreduction rates as well.

A second factor of concern with fixation is the elimination of normal movement between the fibula and tibia that is essential for ankle mobility. Suture button fixation is a new technique that may eliminate the latter concern as it is not a rigid fixation like the screws. A recent systematic review showed that suture button fixation resulted in similar healing time to screw fixation, but the patients reported an earlier return to work and less frequent need for implant removal. Restoring normal biomechanics to the ankle joint whether by use of suture button fixation or removal of screw fixation after healing can lead to improved syndesmotic reduction and improved functional outcomes.

Are you at risk for osteonecrosis or arthritis following a talar neck fracture?

In the past twenty years surgical advances have improved for the treatment of talar neck fractures, however there is still a risk of developing osteonecrosis of the talar body and/or posttraumatic arthritis.

The purpose of this study was to see if there is predictive value in the Hawkins Classifications of talar neck fractures for the long term outcomes in respect to osteonecrosis or arthritis. The researchers were also trying to improve on the classification system to better predict outcomes.

Traditionally the system used to describe talar neck fractures is the Hawkins Classification which is divided into the following categories: type I is a non displaced fracture; type II a displaced subtalar joint; and type III, a dislocated tibiotalar joint. The authors proposed further dividing the type II classification into IIA, subluxated subtalar joint and IIB, dislocated subtalar joint to better describe the amount of trauma and possible injury to the blood supply of the talus.

The study then retrospectively followed eighty patients with eighty-one fractures of the talus between 2001 and 2011. They were equally divided between men and women and the age range was from seventeen to seventy-two. A few patients did not return for their follow ups so the remaining sixty-three patients (sixty-four fractures) were followed for a mean of about one and a half years.

Osteonecrosis of the talar body occurred in twenty-five percent of the subjects and the mean time to appearance in radiographs was just under seven months. Forty-four percent of these cases had complete recovery of the vascular system in the talus without talar dome collapse. Within the classification system no patients with type I or type IIA developed osteonecrosis. Twenty-five percent of patients with type IIB classification developed osteonecrosis and forty-one percent of patients with type III classification developed osteonecrosis. These findings do suggest that a fracture with a subluxation or dislocation will increase the risk of developing osteonecrosis. This fits with their hypothesis that more trauma at the talar dome will have a the potential for increased disruption to the blood supply of the talus and subsequently increase likelihood of ostenecrosis. Interestingly no other factors such as age, medical comorbidites, or tobacco use were found to effect the development of osteonecrosis.

In addition to studying the risk of developing osteonecrosis this study also looked at the occurrence of posttraumatic arthritis. At the time of the most recent follow up, fifty-four percent of the patients had radiographic evidence of arthritis. This outcome was more likely with the type III injury, and in the presence of a talar body fracture eighty-three percent of cases developed arthritis. A fracture of the calcaneus or the tibial plafond also greatly increased the risk of developing arthritis to seventy-five percent.

The results of this study suggest that there is a higher likely hood of developing osteonecrosis if there is a type IIB or type III injury, however almost half of these patients had spontaneous revascularization of the talus (return to normal radiographs). This study also confirms that the most common complication following talar neck fracture is posttraumatic arthritis. The authors also suggest that this is the most common reason for secondary procedures such as removal of hardware, arthroplasty and arthrodesis. There is also the possibility that more of these cases will develop radiographic evidence of arthritis over time.

Comparison of Two Surgical Techniques to Remove Os Trigonum in Ankle

Some people are born with an extra little bone in the ankle called the os trigonum. Studies show that up to 50 per cent of all people have this anatomic anomaly. Without an X-ray or other imaging study, they might never know about it. It doesn’t cause any problems until and unless the person is involved in activities that require full and repeated foot and ankle plantarflexion (toe pointed downward). Ballet dancers and soccer players fall into this category most often.

When the foot and ankle are plantarflexed, the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone). Ankle pain can develop that is so severe, the athlete must stop all activities and motions that aggravate the problem. Running and jumping are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. In the past, surgeons used an open incision technique to cut the bone out but problems developed. Permanent nerve damage occurred in some patients and the large, visible scar was a problem for professional dancers.

As smaller surgical instruments became available and more precise surgical techniques were developed, it became possible for this procedure to be done using an arthroscope. Then in 2000, a new technique called posterior endoscopy was introduced. Since that time, a group of surgeons from the College of Medicine at the Catholic University of Korea have been using both the arthroscopic and endoscopic techniques to excise (take out or remove) the os trigonum.

In this study, they report the results comparing these two surgical techniques. It is the first study published making direct comparisons. Their goal was to “clarify the efficacy and safety of each surgical procedure.” Patients between the ages of 17 and 55 who had this surgery (os trigonum excision) were followed for three years. Results were measured using a variety of outcomes including pain, motion, function, length of time in surgery, time to return to sports participation, and patient satisfaction.

Patients in both groups improved significantly and were pleased with the results. Both techniques were considered “safe and effective.” Certainly, the length of time for the surgery and recovery were much shorter when compared with the open incision technique.

The differences really lie with the surgical technique and level of surgeon expertise. Large os trigonums are more difficult to remove using the arthroscopic approach. There is very little room inside the subtalar joint where the scope enters. It’s also difficult to see inside this area. Using the endoscopic approach from the back side of the ankle requires cutting the flexor hallucis longus tendon but gives the surgeon more room to work in and greater visibility.

The authors advise surgeons to consider using the endoscopic technique for patients with large-sized os bones (more than 135 mm²) or in cases that are more demanding. Open surgery may be needed if arthroscopic and/or endoscopic techniques are not successful in eliminating the problem. As this study showed, all patients benefitted from either method (arthroscopic or endoscopic). Everyone returned to their previous level of sports participation. Even the ballet dancers were able to dance up on pointe with full motion and without pain.

Best Surgical Management of Chronic Achilles Tendon Ruptures

Whether you are a young adult or in the older adult category (50 years old or older), active in sports or a nonathlete, rupture of the Achilles tendon is possible. A simple event like running to catch a bus, stumbling on the floor, or playing with children can lead to this type of injury in the nonathletic adult. For athletes, any sport or activity that involves running and/or jumping (e.g., jogging, soccer, dancing, biking) can result in the same problem.

It is estimated that one-fourth of all acute Achilles tendon ruptures are missed resulting in a delayed diagnosis. Eventually, the acute problem becomes a chronic one that can no longer be repaired (by sewing the two ends of the tendon back together). Instead, tendon reconstruction is required.

The torn end of a tendon is referred to as a “stump.” In chronic ruptures, the ruptured end of the tendon pulls away or “retracts” from the bone. There is a large gap between the end of the torn tendon and the place where it is supposed to attach to the bone. By now, the ruptured tendon stump is thin and atrophied. It can no longer be pulled back up and reattached. That’s when reconstruction surgery becomes the necessary treatment approach. But which surgical technique (there are several) works the best remains unknown.

In this study, surgeons at a single-center reviewed the results of their 28 patients. The patients ranged in age from 28 years old up to 66 years old. Two-thirds of the group were men and the remaining one-third were women.

Each patient was treated for chronic closed rupture of the Achilles tendon. The surgeons chose to use a tendon graft from the hamstring muscle (the semitendinosus portion of the hamstrings). Details of the operative technique are provided using written description, photos taken during the procedure, and drawings showing the final reconstruction. The postoperative rehabilitation program was also described.

Patients in the case series were followed for two to three years. The mid-term results were reported based on improvement of overall function and rate of complications. Calf circumference and strength were also measured and compared from before surgery to after surgery. Outcomes of surgical management are summarized in a table. Twenty of the 28 patients had no pain after surgery. The remaining eight people had mild to moderate pain; no one reported severe pain.

Daily activities were resumed by all but two patients. Some patients reported limited recreational activity. Only two people were bothered by shoes (usually the more fashionable, less supportive type of footwear). And in the end, 22 of the 28 patients were satisfied with the results. No one was dissatisfied; a few were happy with the results but had a few reservations.

In terms of post-operative problems, there were no infections, nerve injuries, reruptures, or blood clots to complicate matters. There was significant overall improvement of symptoms and function. But the authors also reported that calf circumference of the affected side did not fully return and ankle plantarflexion strength (pointing toe downward or rising up on toes) did not recover fully either. It should be noted that the loss of full strength did not affect patients’ ability to walk normally, rise up on toes, or return to work and recreational activities.

In summary, the best approach to the surgical management of chronic Achilles tendon ruptures remains unknown. This study added some perspective on the subject by showing that using hamstring tendon grafts results in good clinical outcomes. The hamstring tendon is long enough to bridge the wide Achilles tendon gap. It is easy to harvest with quick recovery for the patient. The knee does not suffer significant loss of function in terms of strength and power. And the semitendinosus can grow back in time. The entire procedure can be done with minimally invasive techniques and few (if any) complications.

High Patient Satisfaction with Ankle Replacement Despite Poor Results

In Switzerland, orthopedic surgeons have been working for years to develop and perfect a total ankle replacement. In this article, long-term results of the Scandinavian Total Ankle Replacement (STAR) are reported. This is the second report from a group of patients who received the implant 10 to 15 years ago.

The first reported results for these 72 patients came after the initial two to four years. At that time, the short-term survivorship of the implant was very high. But over time, there were more and more implants that developed problems. The need for a second (revision) surgery increased after 10 years and continued to increase as time went by.

The main reason for implant failure was loosening. Degenerative changes where the implant and bone connected (called the prosthesis-implant interface) was observed. The cause of this degenerative process may be the coating used on some of the component parts of the implant. A single layer of hydroxyapatite was used. Hydroxyapatite can be found in teeth and bones and is commonly used as a coating to promote bone ingrowth into prosthetic implants. It seems the body tends to resorb the coating so that over time, it weakens and then comes off the implant.

Other problems observed in these patients included the formation of bone within the surrounding soft tissues (a condition known as heterotopic ossification), bone cysts, residual pain, and loss of motion.

Three-fourths of the patients in this later follow-up complained of ongoing pain and ankle motion was limited to about 24 degrees (less than one-third of normal). But despite these low functional outcomes, patient satisfaction remained high (reported as “satisfied” or “very satisfied”). The authors did not speculate as to why this may occur. They noted that the same level of patient satisfaction has been reported in other studies where function was progressively worse over time.

Most of the patients needed the ankle replacement because of severe end-stage osteoarthritis from a previous traumatic injury. A few patients had primary osteoarthritis, rheumatoid arthritis, or in one case, hemophilia (bleeding disorder). The diagnosis did not seem to be linked with implant failure. Instead, younger age at the time of the surgery was the biggest risk factor. This is not surprising since younger people tend to be more active and survive longer with the implant in place.

One other risk factor for implant failure identified in other studies is malalignment. Implants that are not anatomically correct can cause increased contact pressures. The result is a wearing away of the polyethylene (plastic) insert and eventual fracture of the insert. There were no cases of this type of problem in the patients in this study.

The authors concluded that the long-term results of the Scandinavian Total Ankle Replacement (STAR) are not nearly as good as the short-term results. They suggest the single-coating of hydroxyapatite may be the cause and should be investigated further. For those patients who did not need revision surgery (i.e., they kept the original implant), results were reported as “generally good.”

Management of Ankle Fractures in Children

Ankle sprains are fairly common in adults but trauma to the ankle in children is more likely to cause a bone fracture than a sprain. These are challenging injuries because the growing child may still have an open physis (growth plate) that could be disrupted. The result can be deformity, a leg length difference, impingement, and overload of one side of the ankle.

In this article, pediatric orthopedic surgeons from the Cleveland Clinic in Ohio review types of physeal ankle fractures and their treatment. The Salter-Harris Classification system is used to determine type of fracture, amount of displacement, amount of growth left, and the best way to manage the problem.

Although the two main goals of treatment are to maintain optimum function and limit risk of physeal (growth plate) damage, the authors say that evidence is lacking as to the best way to accomplish these goals. Studies comparing treatment methods for each type of fracture with long-term outcomes are needed.

Until such results are available, the surgeon must rely on the patient’s history, the physical examination, results of imaging studies, and classification of the fracture to create a plan of care. Besides damage to the growth plate, trauma to the surrounding soft tissues must be assessed as well. Ligamentous damage can create an unstable ankle. But usually, the ligaments are stronger than the weak, growing physis. So in the growing child, physeal injury is more common than ligamentous damage.

The surgeon will look for any damage to the blood vessels, nerves, tendons, and muscles, and also rule out the presence of other bone fractures in the foot. A large amount of swelling may mean a delay in surgical correction or cast immobilization. The risk of infection and difficulties with wound healing are too great to intervene with early surgery. MRI and/or CT scans may provide details about the bone and soft tissue injuries that will help the surgeon plan the most appropriate surgery.

When using the Salter-Harris classification system, there are five major types of ankle fractures (I through V). Each number signifies the severity of the injury and the amount of growth plate involvement. The classification numbers also give an idea of the risk of growth arrest (e.g., low risk with Type I fractures, high risk with Type V). Fortunately, Type V fractures are rare.

The authors provided drawings and X-rays to show each of the Salter-Harris types of pediatric ankle fractures. They also included a second classification scheme (the Dias-Tachdijian classification system) to compare with the Salter-Harris method. There are detailed descriptions of each type of fracture and the recommended treatment for each one.

Three additional descriptors of pediatric ankle fractures are also discussed. These include transitional, Tillaux, and triplane fractures. Transitional fractures refer to the time period during which the growth plate starts to close (usually the last 18 months of growth). For girls, the physis closes and growth is completed by age 14. For boys, growth is usually finished by the time they are 16 years old.

Tillaux fractures go through the growth areas right into the joint itself. Treatment varies depending on whether or not the fracture is displaced (separated). Displaced fractures require surgery and long-term results are reportedly good. Later, there can be early degenerative (arthritic) changes.

And finally, triplane fractures are actually a subgroup of Salter-Harris type IV fractures. As the name suggests, triplane tells us the fracture goes through all three layers of bone and growth tissue (metaphysis, physis, epiphysis). The mechanism of injury is a shearing force. There can be a wide range in the amount of displacement. Treatment often requires screw fixation to create a stable union.

The main concern of this article is growth disturbance after ankle fractures that cause injury to the physis (growth plate). Growth arrest or early closure of the growth plates can cause deformities and leg length differences. The authors advise careful examination and evaluation in order to make an accurate diagnosis. Close follow-up after treatment for at least two years is essential. This is especially true for children who still have quite a bit of growth left at the time of the injury.

Children who are closer to the time of their full skeletal maturity do not need such close follow-up or further intervention. Children who develop bridges of bone across the growth plate before full growth is acquired may need surgery to remove the abnormal bone.

Causes of Ankle Fracture After Ankle Replacement

It doesn’t happen very often but ankle fracture after a total ankle replacement (TAR) is possible. Every effort is being made to reduce the number of these cases. In fact, in this study of over 500 patients, surgeons note that their own work has improved over time. In the first 100 cases, the rate of intraoperative fractures (those that occurred during the surgery) went from three out of every four patients down to one of every three. By the end of the study, only two per cent of the last 100 patients experienced an intraoperative periprosthetic (around the implant) fracture.

What made the difference? There were several possible factors contributing to the improved results. Surgeons gained experience over time. Operative techniques improved as did surgical instruments. And even the implant designs improved over time. Some patients still developed post-operative fractures but these were from stress (overload) and trauma (injury).

The authors expect that as results following total ankle replacement continue to improve, more and more surgeons will choose ankle replacement over ankle fusion (called arthrodesis). Preserving motion and function (especially in younger, active patients) is the number one reason for this choice. And along with the increasing number of candidates for total ankle replacement may come an increasing number of periprosthetic ankle fractures (both intraoperative and postoperative).

Because of this expectation, there is a need for a classification system that will assist surgeons in making decisions about what to do after such a fracture occurs. The authors of this study offer their proposed classification system. This classification model is centered around three key factors: 1) cause of the fracture, 2) location of the fracture, and 3) stability of the implant (also known as the prosthesis).

Using their patient base of 503 people, they divided the classification of periprosthetic ankle fractures based on cause into three categories: Type 1 – intraoperative fracture, Type 2 – postoperative traumatic fracture, and Type 3 – postoperative stress fracture. The classification model divides fracture location into four groups (A, B, C, and D) based on whether the fracture occurred in the medial malleolus, lateral malleolus, tibia, or talus.

And the last classification variable (implant stability) has two possibilities: stable or unstable. A stable implant is not loose and the fracture does not affect the implant. An unstable implant has signs of loosening with loss of bone around the implant. Each of these three classification parameters (location, type, implant stability) helps determine and guide treatment.

For example, a nondisplaced fracture (the bones have not separated at the fracture site) with no sign of implant loosening can be managed nonoperatively (without surgery). But when there is fracture displacement, implant shifting or loosening, or malpositioning of the implant, then it becomes necessary to perform corrective surgery. And each one of those problems calls for a different surgical approach ranging from bone graft to joint fusion.

In summary, the authors of this study used the results of their 503 patients to design a decision-making classification model to aid and assist management of periprosthetic fractures. The fractures may occur during or after surgery. They may develop as a result of improper implant size or position, mechanical overload of the implant, or weakening of the bone from the surgery. This classification model is practical and easy to apply. How effective it is (i.e., how good are the outcomes of each decision based on this method) remains to be determined in future studies.

Does Hyaluronic Acid Really Help Painful Ankle Arthritis?

There is evidence to support the use of hyaluronic acid injections into the ankle joint to reduce the painful symptoms of osteoarthritis (OA). These are the results of a review of the literature performed by researchers from several universities and hospitals in Taiwan. They searched electronic databases on this topic and found nine acceptable studies over a period of 17 years. The total number of patients from the combining of the studies was 354.

Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic.

The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

Hyaluronic acid (HA) injected into a joint has some additional benefits. The HA replaces unhealthy synovial fluid, reduces inflammation of the synovium (lubricating fluid inside the joint), and therefore has an analgesic (pain relieving) effect. It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal joint motion.

With all these potential benefits, a study (like this one) to determine the true effectiveness of this treatment is important. All studies included were human clinical trials using hyaluronic acid injections into the ankle joint. Only studies of patients with painful osteoarthritis lasting more than six months were allowed. Pain was the primary outcome of interest.

After carefully analyzing the combined results from these nine studies, the authors made the following observations and recommendations:

  • Significant pain reduction is possible using intra-articular hyaluronic acid injections for the treatment of ankle osteoarthritis.
  • There may be some minor, temporary adverse effects (e.g., increased ankle swelling, local itching at the injection site, lymph node enlargement in the groin area); 15 per cent of the patients in the studies included reported these kinds of after effects.
  • Increased pain relief was noted with more injections but not with more volume per dose. The ankle joint is fairly small and cannot accommodate large injection volumes. Too much fluid pushed into the joint can cause swelling and more pain instead of less.
  • Further studies are needed to identify appropriate and optimal dosing of injections.
  • The injection itself accounted for 87 per cent of the improvement in symptoms; this suggests that it isn’t the hyaluronic acid as much as it is the placebo effect of the injection procedure on pain. This phenomenon bears further study as well.

    A simple summary of this systematic review would say: hyaluronic acid injections for the treatment of painful ankle osteoarthritis may be most effective when given in the right dosage (volume and number of injections). Optimal values for dosage remain undetermined except to say that lower volume and higher number of injections seem to have the best results so far.

  • Microfracture for the Ankle: Taking a Step Back to Look at Results

    Many people who sprain (or even break) their ankle end up with an additional injury known as an osteochondral lesion of the talus (OLT). Osteochondral refers to the layer of cartilage over the bone. The talus is one of the ankle bones between the heel and the lower leg bone. This type of defect in the bone can result in deep ankle pain, a clicking or locking sensation of the joint, and loss of motion and function.

    Treatment is often with a technique known as microfracture. Tiny holes are drilled around the lesion through the bone to the bone marrow. Breaching the bone in this way releases stem cells from inside the bone to improve blood circulation to the area. The stem cells form fibrocartilage and fill in the hole. Defects (holes) that measure less than one-half inch (15 millimeters) can be treated this way.

    The hope for this treatment is that the new fibrous cartilage will act as a shock absorber and protect the bone underneath. But no one really knows if the fibrocartilage that forms can hold up under constant load through the ankle — especially in athletes or active adults.

    In fact, there have been a few studies that suggest the fibrocartilage starts to break down over time. Patients who once experienced pain relief and improved function suddenly find themselves back where they started from. This study was done to help compile long-term data and see if studies on this topic are consistent enough to pool the information together. Such a review is referred to as a systematic review and helps give a better picture of what happens down the road.

    The authors searched all the studies on osteochondral talus lesions (OTL) where microfracture was used as the main treatment. Over a period of 45 years (from 1966 to 2011), they found a total of 24 studies that could be included. But the data collected in these studies was NOT consistent enough to combine together for a big picture analysis.

    Most of the studies included complete demographic information about the patients (e.g., age, sex, body size, duration of symptoms, type of injury). But clinical information (e.g., size of lesion, location of defect, presence of other injuries, rehabilitation protocol) was limited. And imaging data (e.g., results from X-rays, MRIs, CT scans) was very poorly reported (only present in about one-third of the studies).

    Patient-reported outcomes (e.g., pain, function, activity, satisfaction) is an important part of any patient-centered study. And although 87 per cent of the studies included this information, they all used different assessment tools to judge results. Without a consistent scoring system, these results cannot be compared.

    When studies are small and don’t routinely report the same information, it can be difficult to combine them together to create a systematic review. The authors suggest a set of guidelines is needed to aid researchers in collecting and then reporting information from their studies. In this way, data collected is standardized and can be organized and used to assess short- medium- and long-term results. Patients benefit by receiving the best treatment based on evidence that it works and has long-lasting effects.

    Comparing Ankle Fusion Techniques

    When ankle pain from osteoarthritis is severe, function is low, and conservative care isn’t helping, surgeons turn to a fusion procedure known as an arthrodesis. There are two ways to do this surgery: open ankle and arthroscopic. As the names suggest, open ankle involves large incisions. Arthroscopy can be done with tiny incisions or just puncture holes where the scope is inserted into the joint.

    Naturally, the question arises: which technique works better? Which one is preferred when measured by improvement in pain levels, function, and costs (hospital stay)? To find out, surgeons from Canada carried out a comparative case series.

    They treated 30 adults (men and women) with ankle osteoarthritis using the arthroscopic arthrodesis and compared the results to 30 adults (similar in age, sex, weight, and diagnosis) treated for the same problem using an open approach. Everyone was re-evaluated at one and two years after the procedure.

    A special self-reported survey designed to measure disability and pain from ankle osteoarthritis was used as the main outcome measure. This tool is known as the Ankle Osteoarthritis Scale or AOS.

    They found that all the patients in both groups improved significantly both at the end of one year and at the end of the second year of follow-up. But the arthroscopic group did show even greater improvement (statistically better) compared with the open incision group. And the arthroscopic group was in the hospital on average 1.2 fewer days.

    There was no difference between the groups in terms of length of time (number of minutes) to do the surgery or quality of alignment of the bones (as viewed on X-ray). The number and type of complications (e.g., nonunion of the bone, delayed wound healing, painful hardware that had to be removed) were also the same between the two groups.

    The authors concluded that surgical treatment for end-stage osteoarthritis of the ankle can be safely done arthroscopically. Compared with open incision procedures, arthroscopic arthrodesis provides better overall results faster and without an increase in postoperative problems or complications.

    Previous studies reported difficulty correcting a particular ankle deformity (coronal plane deformity) using arthroscopic techniques. But these surgeons say it’s just a matter of repositioning the talus bone in the ankle to restore normal alignment and that can be done arthroscopically.