Of all joints in the body, the ankle joint is subjected to the highest forces per square centimeter and is injured more commonly. Yet, the incidence of symptomatic ankle arthritis is much lower than that of the knee and hip. Various mechanical, biochemical and anatomic peculiarities of the ankle account for its apparent resilience to the process of aging and trauma. The goal of this article is to help the reader better understand the functional paradoxes that make the ankle joint a unique and fascinating articulation.

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

This research studied a novel form of distillation (high vacuum distillation) as a method for preserving volatile aroma chemicals important to the organoleptic attributes of a four botanical model gin as well as the degradation products generated during the heating required in traditional methods of gin distillation. A 2 (5) factorial experiment was conducted in a partially confounded incomplete block design and analyzed using the PROC MIXED procedure from SAS. A model gin was made of dried juniper berries (Juniperus communis), coriander seed (Coriandrum sativum), angelica root (Angelica archangelica), and dry lemon peel (Citrus limonum). This was distilled on a traditional still utilizing atmospheric pressure and a heating mantel to initiate phase separation as well as a novel still (high vacuum) utilizing high vacuum pressures below 0.1 mmHg and temperatures below -15 degrees C to initiate phase separation. The degradation products (alpha-pinene, alpha-phellandrene, E-caryophyllene, and beta-myrcene) were present at greater levels (approximately 10 times) in the traditional still-made gin as compared to the novel gin.

BACKGROUND:The functional outcomes following ankle arthrodesis are not known. The purpose of the present study was to compare the intermediate-term clinical results for a group of patients in whom an ankle arthrodesis had been performed with use of modern surgical techniques with the findings for a group of healthy gender and age-matched controls on the basis of validated outcome measures and gait analysis. METHODS:Twenty-six patients who had undergone ankle arthrodesis for the treatment of isolated unilateral ankle arthritis were identified and retrospectively assessed clinically and radiographically. The mean age at the time of surgery was fifty-four years, and the mean interval between surgery and assessment was forty-four months. A gender and age-matched control group of twenty-seven individuals was recruited for comparison. All subjects were evaluated with gait analysis, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, the Musculoskeletal Outcomes Data Evaluation and Management Systems (MODEMS) questionnaire, and the Ankle Osteoarthritis Scale (AOS). RESULTS:On preliminary review, twenty of the twenty-six patients were completely satisfied or satisfied with their surgical outcome. All patients but one stated that they would undergo the surgery again. Five patients stated that they did not notice a gait abnormality. Twelve patients wore orthotics, and all believed that the use of the orthotics improved their gait. When the functional outcome scores in the arthrodesis group were compared with those in the control group, specific scores assessing hindfoot pain and satisfaction were similar. However, scores focusing on ankle-hindfoot function and disability revealed significant differences. Gait analysis also identified significant differences between the two groups with regard to cadence and stride length. In addition, there was significantly decreased sagittal, coronal, and transverse range of motion of the hindfoot and midfoot during the stance and swing phases of gait in the arthrodesis group. Radiographic review demonstrated that four of the twenty-six patients had development of moderate to severe arthritis of the subtalar joint. CONCLUSIONS:In the intermediate term following an arthrodesis for the treatment of end-stage ankle arthritis, pain is reliably relieved and there is good patient satisfaction. However, there are substantial differences between patients and the normal population with regard to hindfoot function and gait. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function; however, it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of ipsilateral hindfoot arthritis.

SUMMARY The issues surrounding the crisis in scholarly communication are well known to librarians. However, academic faculty and administrators often do not have a similar understanding of these concerns, or what librarians are doing to deal with them. Developing dialog with campus groups to further their awareness of the current situation is important. During this session, three librarians describe different approaches to proactively engaging university communities in the discussion of current issues and options relating to scholarly communication.

Clinical indications for distal tibial osteotomies are rare and information on fixation techniques is limited. This article reviews a retrospective study of 4 patients who underwent 5 distal tibial open-wedge osteotomies stabilized with a Puddu plate. All osteotomies healed within 3 months with no incidence of malunion, nonunion, or fixation failure and all deformities were adequately corrected. The Puddu plate (Arthrex Inc, Naples, Fla) provides secure fixation for open-wedge distal tibial osteotomies with accurate and reproducible results.

Background. The vascularized fibular bone graft (VFBG) is one of most common grafts used for free flap transfer. There have been no reports in the literature evaluating the functional outcome of the foot and ankle after a VFBG using validated functional outcome measures. In addition, most of the patients in published studies have had contralateral or ipsilateral lower limb pathology. The purpose of this study was to evaluate the functional outcome of the foot and ankle after a VFBG using validated functional outcome measures in patients with no preexisting lower limb pathology. Methods: We conducted a retrospective analysis of our health center database and identified 28 patients who underwent free flap transfer for maxillofacial reconstruction. Patients were contacted by phone and mailed functional questionnaire packages. Functional outcome assessments were obtained through the use of the following validated functional outcome instruments: the Short Form-36 (SF-36), the Functional Foot Index (FFI), and the lower limb component of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). A matched student t-test was used to compare the experimental limb to the appropriate control group. Results: The response rate was 77%. The incidence of wound complications was 23% (five of 22). Two of the five were caused by wound dehiscence, and three were caused by infection. There was an 18% incidence of clawing of the great toe. The SF-36 scores were not significantly different between the VFBG cohort and the control group. There was a statistically significant difference in FFI scores for all three categories: pain (p = 0.01), disability (p = 0.03), and activity limitation (p = 0.01). Nine patients (41%) were dissatisfied with their foot and ankle function at 3.1 years. Conclusions: The VFBG is an ideal source for a free flap. The impact of the procedure on overall patient health is relatively minimal. However, there is a significant deleterious effect on foot and ankle function.

The talus is predisposed to avascular necrosis (AVN), or bone death due to ischemia, owing to its unique structure, characteristic extraosseous arterial sources, and variable intraosseous blood supply. Both traumatic and atraumatic causes have been implicated in talar AVN. The risk of posttraumatic AVN can be predicted using the Hawkins classification system. In addition, the "Hawkins sign" can be used as a radiographic marker that excludes the development of AVN. At radiography, talar AVN typically manifests as an increase in talar dome opacity (sclerosis), followed by deformity and, in severe cases, articular collapse and bone fragmentation. At any stage of this sequence, the radiographic findings can vary depending on differences in the vascular status of the talus and the degree of bone repair. Magnetic resonance imaging is the most sensitive technique for detecting talar AVN and can be used when AVN is strongly suspected clinically despite normal radiographic findings. Computed tomography (CT) also demonstrates typical patterns and can be used to confirm radiographic findings. Coronal CT is required for viewing the articular surface of the talar dome to rule out subtle depression, collapse, and fragmentation. Nevertheless, radiography remains the mainstay of the diagnosis and temporal observation of talar AVN.

The Atlas of Ankle Replacements, pp. 65-87 (2020) No AccessCHAPTER 4: ANKLE ARTHRITIST. R. Daniels and R. H. ThomasT. R. Daniels and R. H. Thomashttps://doi.org/10.1142/9781786346247_0004Cited by:0 PreviousNext AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsRecommend to Library ShareShare onFacebookTwitterLinked InRedditEmail Abstract: The ankle is a complex joint and appears unique when compared to the other major joints of the lower limb. Despite the ankle being subjected to high forces and being commonly injured, symptomatic ankle arthritis is only rarely seen. Unlike the hip and knee, primary arthritis of the ankle is rare. Posttraumatic arthritis accounts for about 70% of cases, with rotational ankle fractures being the most common cause. Arthritis may develop due to changes in contact stresses and alterations in joint mechanics. Several factors have been postulated as to why the ankle may be resistant to the development of arthritis in the absence of trauma. The ankle maintains its mechanical properties even with ageing and this may allow physiological cartilage metabolism to persist for longer. Ankle articular cartilage is uniform and thin but stiff. During weightbearing, the ankle is maximally congruent and stable. These factors may act to equalise stresses throughout the joint. However, anatomical and biomechanical factors cannot fully explain these protective mechanisms and an increasing number of metabolic factors related to ankle cartilage are being recognised. Ankle stiffness may be related to its dense extracellular matrix due to high glycosaminoglycan (GAG) and lower water concentrations. The ankle is metabolically more active than the knee and activity varies with load. Ankle cartilage is able to resist degeneration by producing less of a response to catabolic stimuli such as interleukin and matrix metalloproteinases (MMPs). However, it also appears to have anabolic properties to enable self-repair by increased production of matrix components. FiguresReferencesRelatedDetails The Atlas of Ankle ReplacementsMetrics History PDF download

Objective. To compare the functional, radiographic, and pedobarographic results of different reconstructive methods for severe rheumatoid forefoot deformities.Methods. A total of 138 feet in 79 patients with RA forefoot reconstructions between 19 78 and. 1997 were reviewed through a detailed questionnaire, clinical examination, standardized radiographs, and pedobarographic analysis. Five subgroups based on procedure to the 1st ray were identified, then divided into 2 functional categories: Group 1: stable It ray by means of arthrodesis or no surgery; and Group 2: a resection procedure to 1st metatarsophalangeal (MTP) joint.Results. Sixty-one patients (106 feet) attended clinical review; 18 returned the questionnaire. There were 65 women and 14 men, with a mean age of 59 years (range 24-80): with 52 feet in Group 1 and 86 feet in Group 2. Mean age at surgery for both groups was 52 years (range 23-79). Mean age at the time of review was 55 years (Group 1) and 60.5 years (Group 2). Length of followup was significantly different: Group 1 averaged 36 months; Group 2, 102 months (p < 0.001). At:review, no significant difference was noted in SF-36, comorbidities, WOMAC, or Foot Function Index. The disability score as defined by the American Rheumatological Society was. significantly different: Group 1, 2.1 +/- 0.5; and Group 2, 2.4 +/- 0.6 (p = 0.006). Group 1 did significantly better in terms of walking distance, satisfaction with postoperative appearance of foot, relief of plantar pain, less plantar calluses, and higher AOFAS HMIP and LMIP scores. Postoperative, complications occurred in 16 feet (11%); 15 feet required reoperation (10.6%). Major resection of the 1st MTP joint was associated with a significant increase in the 1st and 2nd intermetatarsal angle on radiographic review. The pattern of pressure distribution on the plantar aspect was similar regardless of the surgical procedure. The maximum contact area, maximum peak pressure, and maximum pressure time integral were located under the region of the 1st metatarsal, with a progressive decrease in values under the more lateral rays and under the lesser toes. Significantly higher pressures were seen under the 1st, 2nd, and 3rd metatarsal regions in Group 2 (1st MTP joint resection). Toe function was absent or minimal in the majority of Group 1Conclusion. Forefoot arthroplasty by means of a resection or stabilization provides significant pain relief. Maintenance of a stable. 1st MTP joint and resection of the lesser metatarsal heads with K-wire stabilization will result in a more cosmetic forefoot, more even distribution of forefoot pressures, and more satisfied patients.

For a 29-year-old man with a three-week-old Hawkins Type IV talar neck fracture, intra-operative reduction and fixation were not possible due to soft tissue contractures and severe comminution. A primary talonavicular and subtalar arthrodesis with the use of iliac crest bone graft was performed. Postoperative follow-up at 16 months demonstrated solid fusions, no avascular necrosis of the talus and a functional range of motion at the ankle. He was not capable of returning to his job of roof maintenance.

Surgical management of hallux rigidus remains controversial. Arthrodesis is considered the gold standard. However, many patients are reluctant to undergo fusion. This paper reviews two commonly used procedures that are reasonable alternatives. A retrospective review of 19 patients (24 feet) with grade 2 osteoarthritis and 11 patients (11 feet) with grade 3 osteoarthritis was performed. The patients with grade 2 osteoarthritis were managed with a cheilectomy and the patients with grade 3 osteoarthritis with an interpositional arthroplasty. All patients were individually assessed with a subjective questionnaire, physical exam, AOFAS hallux scale, SF-36 and pedobarographic analysis. Cheilectomy patients (51.9 years) were younger than interpositional arthroplasty (59 years). Follow up between the interpositional arthroplasties (2.0 years) and cheilectomies (2.1 years) were comparable. Postoperative motion, visual analogue pain scale and SF-36 scores were comparable between groups. Cheilectomies had a higher mean AOFAS score (77.3) than interpositional arthroplasties (71.6). Weakness of the great toe was reported in 72.7% of interpositional arthroplasty patients compared to only 16.7% of patients with a cheilectomy. Patient satisfaction was 87.5% in cheilectomies and 72.7% in interpositional arthroplasties. Pedobarographic analysis demonstrated a decreased load under the great toe with increased weight transfer to the lesser metatarsal heads in all patients. The weight transfer to the lesser metatarsal heads was greatest in patients with interpositional arthroplasty. Management of moderate hallux rigidus with a cheilectomy and phalangeal osteotomy is a reliable method of relieving pain and improving function. Management of severe osteoarthritis of the joint with an interpositional arthroplasty should be considered a salvage procedure with less reliable results.

Congenital clubfoot, one of the most common musculoskeletal anomalies, varies considerably in severity and its response to treatment. The aetiology, pathogenesis and treatment have been subjects of wide debate since antiquity. Even today, there is little consensus on how the deformity is best treated and the literature devoted to clubfoot is voluminous and confusing. A comprehensive review article could take up an entire issue of this journal yet provide little insight into practical aspects of management. We have therefore decided to provide a brief overview of the subject and to emphasize two areas of current major interest; the aetiology and late management of the deformity in the adolescent and young adult. The aetiology is important because a true understanding of the precise nature of the deformity will ultimately be essential in determining the preferred method and timing of early correction. Historically, less emphasis has been placed on how best to manage impairment of function at skeletal maturity secondary to residual deformity and the sequelae of treatment in early childhood. A review article by Ponseti 1 describes the early management in detail from a traditional and conservative point of view.

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.

Tarsal tunnel syndrome is an uncommon clinical entity. This article will review the published reports on tarsal tunnel syndrome with respect to its anatomy, cause, pathophysiology, clinical presentation, diagnosis, treatment, and results of treatment in an attempt to improve understanding of this problem.