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PubMed2005

[Tibiotalar arthrodesis with the tibial compression nail].

OBJECTIVE: Arthrodesis of the ankle joint in proper position (neutral position in respect to flexion/extension, 5 degrees external rotation, 0-5 degrees of valgus). Pain-free weight bearing of the affected limb. INDICATIONS: Painful osteoarthritis of the ankle joint resistant to conservative approaches even in the presence of poor bone quality of the distal tibia such as after pilon fractures and osteoporosis. Failure of other methods of internal fixation. CONTRAINDICATIONS: Osteitis. Partial necrosis of the talar dome. Medullary canal of tibia not patent. SURGICAL TECHNIQUE: Lateral approach and resection of lateral malleolus. If the joint position is normal, removal of articular cartilage of tibia and talus. If axial correction is necessary, wedge resection of articular surfaces with underlying bone. Opening of proximal tibial medullary canal, insertion of compression nail into tibia and talus. Compression osteosynthesis and cancellous bone grafting. Alternatively, the arthrodesis can be achieved with the dowel technique. RESULTS: Between September 1993 and March 2001, 137 patients (43 women, 94 men, average age 49 years [21-79 years]) were operated. Follow-up of 110 patients after 42 months: successful bony fusion in 99 patients (90%). In six patients (5.5%) the goal of treatment was obtained after revision with recompression of the nail and bone grafting. Nonunion in five patients (4.5%). COMPLICATIONS: one tibial shaft fracture, one hematoma needing evacuation, three superficial infections, and eight deep infections. Three patients developed an osteoarthritis of the subtalar joint. 70 patients (63.6%) reported an improvement, 37 (33.6%) no notable change of symptoms, and three (2.7%) a deterioration.

Adult↗
PubMed2003

The trapezoid form of the trochlea tali.

The wedge-shaped superior surface of the trochlea tali may be seen in a proximal view as a trapezium. The angle of this trapezium was calculated by measuring the length, and the smallest and largest widths of the trochlea, and was found to be 16.04 degrees for the left talus and 12.48 degrees for the right talus, respectively. The difference between these angles is highly significant. Due to biomechanical features of the talocrural joint an increase in the angle of the trochlea tali also intensifies the incongruency of this joint in plantar-flexion. Thus, this incongruency is larger on the left side. With this diminution of the joint-surface contact, increased internal rotation or "wobbling" movements are possible. An explanation for these facts might be found in footedness, similar to handedness. When constructing a prosthesis one has to consider that the trochlea tali cannot be exactly mirrored from one side to the other but may have to be calculated separately for each side. The fact that footedness seems to correlate with the angle of the trochlea tali can be also helpful.

Age Factors↗
PubMed1988

The role of the anterior tibio-fibular ligament in talar rotation: an anatomical study.

An anatomical study of fresh cadaver ankles has been made to examine the role of the anterior tibio-fibular ligament. It was found that when this ligament was divided along with division of the fibula, either above or below the syndesmosis, there was a degree of external rotation of the talus within the ankle mortise. This suggests that the anterior tibio-fibular ligament is one of the main structures of the ankle joint acting against excessive fibular movement and preventing external rotation of the talus within the ankle joint.

Ankle Joint↗
PubMedDate not supplied

Visualization and quantitative analysis of talocrural joint kinematics.

The three dimensional (3D) in vivo kinematic behavior of the ankle joint was evaluated using spiral volumetric CT scanning of a normal adult foot. The CT data were reconstructed and interpolated to create an isotropic 3D data volume. These data were rendered, visualized, segmented into their bony elements, labeled, and exported to disk using Mayo Analyze software. The labeled 3D CT datasets were analyzed to determine relative orientation, translation, and rotation of the tibia-talus, tibia-calcaneus and calcaneus-talus. Using these results, the 3D motion characteristics during normal adult foot flexion/extension were described quantitatively.

Adult↗
PubMed2006

Arthroscopic excision of the talar Stieda's process.

One of the causes of posterior ankle pain is posterior impingement syndrome. When the talar lateral process is long, in which case it is called Stieda's process, it may be impinged between the tibia and calcaneus. We report the case of a 19-year-old patient who complained of posterior ankle pain and was diagnosed with posterior impingement of Stieda's process. He failed to respond to conservative treatment and thus underwent arthroscopic excision. The ankle was approached through standard posterior lateral and trans-Achilles portals. A 4.5-mm diameter 30 degrees arthroscope was used. Soft tissues around the talus were cleared with the help of a motorized shaver; after this, the posterior aspect of the subtalar joint could be visualized. The Stieda's process was seen to impinge between the tibia and the calcaneus in forced plantar flexion. The talar process was removed with a burr until the impingement disappeared. The patient returned to contact sports 8 weeks after surgery. Arthroscopic excision of the lateral process of the talus can be accomplished easily and return to sports is achieved in a relatively short time.

Adult↗
PubMed2005

Radiographic measurement of anterior talar translation in the ankle: determination of the most reliable method.

BACKGROUND: Although most would agree that stress radiography is an important research tool to evaluate the integrity of the ankle ligaments in studies of chronic ankle instability, there is little agreement with regard to the best technique to make these measurements. The primary objective of this study was to establish the most reliable method for measuring anterior displacement of the talus relative to the tibia using stress radiographs of the ankle. This information is necessary to standardize radiographic evaluation of injured ankles and for biomechanical studies of the ankle joint, but has never been investigated. METHODS: This study examined the reliability of four available methods by measuring the intra-observer repeatability and inter-observer reproducibility of three different investigators. Lateral radiographs were obtained while the ankle was supported in the Telos device with the joint unloaded, and then with a 150 N anterior directed load applied to the calcaneus. At two separate time intervals, the radiographs were read by three different observers using four measurement techniques. For each technique, the measurement of the unloaded ankle was subtracted from the loaded ankle to obtain anterior talar translation. FINDINGS: The method that measured the shortest distance between the posterior lip of the distal tibia and the talar dome (designated Method I in the current series) was significantly more reproducible between readers and within readers across repeated measurements than the other methods tested. INTERPRETATION: Based on the findings from this study, it can be concluded that measurement of the distance between the posterior lip of the distal tibia and the talar dome is the method of choice to characterize the position of the talus relative to the tibia in stress radiography. In order to standardize the radiographic evaluation of ankle injuries, this method should be the one employed to measure anterior talar translation.

Ankle Injuries↗
PubMed2006

Talar neck osteotomy for flatfoot reconstruction: a 27-year follow-up study.

The talar neck osteotomy is done at the junction of the head and neck of the talus, frequently in conjunction with desmoplasty and posterior tibial tendon advancement. This is done effectively to correct severe deformities involving the talus. The correction produces a structural realignment of the talar head. Adjunctive procedures are also done when these are deformities involving the posterior column, lateral column, and/or medial column. A 27-year follow-up study is presented containing data from 215 procedures on 117 patients with a minimum of one year follow-up.

Adolescent↗
PubMed2004

Talar neck fractures.

Talus fractures are rare injuries that account for approximately 3% of all foot fractures; talar neck fractures account for almost 50% of all talus fractures. The appropriate diagnosis and treatment of these fractures play an important role in the patient's outcome. Treatment has evolved slowly throughout the years, from closed treatment to open reduction and internal fixation (ORIF). The treatment of type I and type II talar neck fractures is not uniform in the orthopedic community. The option of closed reduction versus ORIF is dependent upon the degree of injury, surgeon experience, and preference.

Fracture Fixation↗
PubMed2006

Determination of in-vivo articular cartilage contact areas of human talocrural joint under weightbearing conditions.

OBJECTIVE: The knowledge of in-vivo cartilage contact biomechanics is important to the understanding of the pathogenesis of joint diseases such as osteoarthritis. This study investigated the in-vivo contact areas of human talocrural joint under weightbearing conditions that simulated the stance phase of walking using a combined magnetic resonance (MR) and dual-orthogonal fluoroscopic imaging technique. DESIGN: Nine healthy ankles of living subjects were recruited for this study. The in-vivo talocrural joint positions were recorded using the dual-orthogonal fluoroscopic images at three ankle positions that simulated those occurring during the stance phase of walking: heel strike, mid-stance, and toe off. Three-dimensional (3D) models of the talocrural joints were created from MR images and used to reproduce the in-vivo ankle positions recorded on the fluoroscopic images. The talocrural cartilage contact area was defined as the overlap area of the distal tibial and the proximal talar cartilage surfaces. The method was validated using an in-vitro experimental setup to evaluate its accuracy in determination of cartilage contact area. RESULTS: The validation study demonstrated that the articular cartilage contact area of the talocrural joint determined using the imaging technique was approximately 4% lower than that of the experimental measurement. In the nine living ankles, the average cartilage coverage area was 964.9+/-156.1 mm(2) on the distal tibia and 1304.8+/-208.4 mm(2) on the proximal talus. The average talocrural cartilage contact areas were 272.7+/-61.1 mm(2) at heel strike, 416.8+/-51.7 mm(2) at mid-stance, and 335.7+/-64.5 mm(2) at toe off. The contact area at mid-stance was significantly larger than those at heel strike and toe off, while the contact area at toe off was significantly larger than that at heel strike. CONCLUSION: The combined dual fluoroscopic and MR imaging technique was shown to be capable of determining in-vivo talocrural cartilage contact areas. During the simulated stance phase of walking, the contact areas were less than 44% and 31% of the cartilage coverage areas of the distal tibia and the proximal talus, respectively. These data may be useful for understanding in-vivo biomechanical function of the cartilage as well as the etiology of osteoarthritis.

Adult↗
PubMed2003

Ligament fibre recruitment and forces for the anterior drawer test at the human ankle joint.

Although the anterior drawer test at the ankle joint is commonly used in routine clinical practice, very little is known about the sharing of load between the individual passive structures and the joint response at different flexion angles.A mathematical model of the ankle joint was devised to calculate ligament fibre recruitment and load/displacement curves at different flexion angles. Ligaments were modelled as three-dimensional arrays of fibres, and their orientations at different flexion angles were taken from a previously validated four-bar-linkage model in the sagittal plane. A non-linear stress/strain relationship was assumed for ligament fibres and relevant mechanical parameters were taken from two reports in the literature. Talus and calcaneus were assumed to move as a single rigid body. Antero/distal motion of the talus relative to the tibia was analysed. The ankle joint was found to be stiffer at the two extremes of the flexion range, and the highest laxity was found around the neutral position, confirming previous experimental works. With a first dataset, a 20N anterior force produced 4.3, 5.5, and 4.4mm displacement respectively at 20 degrees plantarflexion, at neutral, and at 20 degrees dorsiflexion. At 10 degrees plantarflexion, for a 6mm displacement, 65% of the external force was supported by the anterior talofibular, 11% by the deep anterior tibiotalar and 5.5% by the tibionavicular ligament. Corresponding results from a second dataset were 1.4, 2.4 and 1.8mm at 40N force, and 80%, 0% and 2% for a 3mm displacement. A component of the contact force supported the remainder.

Ankle Joint↗
PubMed2004

[Ankle arthrodesis after failure of a total ankle prosthesis. Eight cases].

UNLABELLED: We report outcome in eight cases of ankle arthrodesis after failure of a total ankle prosthesis. MATERIAL AND METHODS: This series included eight patients, mean age 57 years (range 36-76) who had initially: post-traumatic talocrural joint degeneration (n=4), rheumatoid polyarthritis (n=3), idiopathic talocrural degeneration (n=1). Three patients had a New Jersey (DePuy) cemented prosthesis, four had a Star (Link) uncemented prosthesis and one, whose implantation was performed in another institution, had a spherical cemented prosthesis. The preoperative Kitaoka score was 19.1 (0-32). Seven patients had subtalar joint degeneration; one patient had a subtalar arthrodesis. The tibial component was cemented alone in two patients, the talar piece in three (two with talar fracture). Failure resulted from loosening, talus fracture or deep infection. Bipolar loosening was observed in two patients. Time to revision was 36 months (range 4-108). Arthrodesis was associated with an iliac graft for seven patients: several tricortical grafts (vertical alignment of the corticals) and cancelous grafts for filling. The height of the graft was adjusted to the substance loss. A bone graft could not be used in one patient who had a deep infection. The arthrodesis was fixed with an anterior plate bridging the talocrural space in six patients, with an external fixator in infected patient, with a conventional centromedullary tibial nail transfixing the talocrural joint and planted in the talus and the calcaneus in one. Outcome was assessed with the Kitaoka score. Mean follow-up was 56 Months (range 10-114). RESULTS: The overall Kitaoka score improved to 54/100 (range 42-70) at last follow-up. The arthrodesis provided improvement in all patients although the final outcome was still considered poor in three patients. Radiographic healing was obtained in seven patients at a mean 3.1 months (range 2.5-6). Wound healing was slow in two patients. One patient developed a deep infection early. DISCUSSION: The rate of fusion was 87%. This is in the general range reported in the literature; use of an iliac graft allows preserving joint height but because of the poor bone quality often encountered, residual bone stock may be insufficient to achieve complete fixation with screwing. Plate fixation appears to be a better way of achieving fixation. This provides a rate of fusion comparable with earlier series where external fixation was generally employed. For us, external fixation should be reserved for infected cases. Use of a conventional anterograde nail can be another solution in the event of poor bone quality. The overall result remains relatively modest although all the patients achieved a functional gain with arthrodesis. The results obtained are less satisfactory than after first-intention ankle arthrodesis.

Activities of Daily Living↗
PubMedDate not supplied

Talar fracture/dislocation in the adolescent patient.

The authors report an 18-year-old patient who sustained a two-part injury involving his right ankle. The result of this traumatic episode was a fracture/dislocation of the talus. An interesting aspect of this injury is that the body of the talus dislocated laterally, distal to the fibular malleolus. Closed reduction was attempted and subsequent open reduction with internal fixation was performed. The patient was followed for 9 months, during which time a series of radiographs was taken. Nine months postoperatively, Hawkins sign was negative indicative of avascular necrosis. In review of the literature, no fractures with lateral dislocations of this nature were found.

Adolescent↗
PubMedDate not supplied

Rectus abdominis muscle graft post-talectomy: a new approach.

This case represents an option a surgeon has when confronted with an extraordinary dilemma. A 43-year-old male presented to the emergency room with a septic ankle joint along with a fracture through the body of the talus. The surgeons incised and drained the ankle joint and performed a talectomy after finding intraoperatively that the soft, fractured, deformed talus was severely osteomyelitic. After weeks of intravenous antibiotics, a more definitive procedure was needed. After consulting different specialties for their opinion, a procedure was decided upon. The rectus abdominis muscle was hosted with its vascular supply intact and relocated into the ankle joint. The artery to this muscle was anastamosed to the anterior tibial artery. This, acts as both a spacer and a joint between the calcaneus and the tibia. After a few operations and months of physical therapy, this patient walks without a limp, free of pain or any gait-supporting device. There has not been any mention of this type of procedure in any of the literature to date.

Adult↗
PubMed2000

[A typical snowboarding injury--fracture of the processus lateralis tali].

Before the development of the snowboard sport, the fracture of the lateral process of the talus was a very rare injury. Since the increasing popularity of snowboarding, starting in Europe at about 1980, these fractures occurred more frequently. The largest epidemiological serie from Kirkpatrick in 1998 reports an incidence of 2.3% of all snowboarding injuries representing 15% of all snowboarding ankle injuries [1]. The common mechanism for fracture is dorsiflexion of the ankle and inversion of the hindfoot. Early diagnosis is emphasized in all series reviewed in the literature to prevent long-term complications [4]. Because routine radiographs failed to determine either the size or comminution of the fractured process, CT imaging was used to accurately assess the size, displacement, and comminution of the fractured process. CT scans also showed the extent of subtalar joint involvement, any associated tendon pathology, or additional fractures [5]. Many of these fractures are not visible on plain radiographs and require computed tomography imaging to be diagnosed. Diagnosis of this fracture pattern is paramount; the physician should be very suspicious of anterolateral ankle pain in the snowboarder, where subtle fractures that may require surgical intervention can be confused with anterior talofibular ligament sprains [1]. Most authors agree, that nondisplaced fractures are best treated with cast immobilization and that displaced fractures require a surgical treatment: Single large displaced fragments are reduced and internally fixed, small displaced or comminuted fragments may need surgical excision. After two to three days bedrest with elevated leg, ambulation is started under partial weight bearing of 10-15 kg for 6 weeks. Physicians caring for snowboarders should look specifically for fracture of the lateral process of the talus in a snowboarder with a lateral ankle or foot injury [3]. This fracture can mimic a lateral ankle sprain, yet the fracture is easily missed on plain radiographs of the ankle. Because displaced or comminuted fractures can cause long-term disability, primary care physicians and specialists alike need to be aware of the association of this fracture with snowboarding [3].

Athletic Injuries↗
PubMedDate not supplied

Talectomy in the treatment of the myelomeningocele patient.

This paper is an analysis of a series of 11 pediatric myelomeningocele patients in whom 20 talectomies were performed for correction of rigid equinovarus of paralytic vertical talus deformities. In most of the patients talectomy achieved a satisfactory correction of the foot deformity with maintenance of the correction for up to 5 years of follow-up in this study. Failure of the procedure related to two factors: (1) severe external rotational contracture of the hips in patients with high spinal lesions; (2) incomplete removal of the talus because of extensive scarring and fibrosis due to prior infection or surgery. Correction of the external rotational deformity of the hip or a derotational supramalleolar osteotomy of the tibia can prevent the first cause of failure. An intra-operative X-ray of the foot can prevent the latter.

Arthrogryposis↗
PubMedDate not supplied

Talo-calcaneal relationship in clubfoot.

Talo-calcaneal angles were measured on anteroposterior, stress dorsiflexion, and plantarflexion lateral radiographs of 75 normal feet and 145 clubfeet. The talus and calcaneum from 15 normal fetal limbs were dissected without disturbing the subtalar capsule. Anteroposterior and lateral radiographs of these specimens were also obtained. The long axes of the ossific nuclei and the long axes of the cartilaginous anlagen of the bones were marked, and the talo-calcaneal angles were measured. The talo-calcaneal angles were lower in clubfeet than in normal feet, but there was considerable overlap in the ranges of normal and clubfeet for all the angles measured. The lateral talo-calcaneal angles in normal feet were higher in dorsiflexion than in plantarflexion, whereas the converse was true in clubfeet. The talo-calcaneal angles measured from the axes of the ossific nuclei of the fetal specimens were higher than those measured from the axes of the cartilaginous anlagen. Using logistic regression analysis, a mathematical model was made to predict the probability of correction of clubfeet. A lateral talo-calcaneal angle difference (between the stress dorsiflexion and plantarflexion angles) of 20 degrees suggests that there is a 93% probability that the hindfoot deformity of clubfoot has been adequately corrected. A talo-calcaneal angle of 30 degrees or a talo-calcaneal index of 40 degrees does not ensure correction of clubfoot. A decrease of the talo-calcaneal angle by up to 10 degrees occurs as the child grows because of the alteration of the shape of the ossific nucleus of the talus that occurs normally with growth.

Cadaver↗
PubMed1994

Intraarticular contact stresses with simulated ankle malunions.

Peak contact stresses were evaluated in a human cadaver ankle model of ankle fracture malunion. In one set of experiments, changes in peak contact stresses were evaluated for ankles loaded with lateral displacements of the talus and fibula of 1, 2, 3, and 4 mm. In a second set of experiments, peak contact stresses were evaluated after removal of posterior malleolar fragments. Peak contact stresses were concentrated over the anterior medial talar dome in normal specimens, and in specimens with stimulated malunions. There were relatively low stresses beneath the medial malleolus. Peak stresses for ankles without talar displacements ranged from 1.9 MPa to 12.4 MPa (eliminating one disparate specimen). There was no increase in peak stresses with lateral displacements of the talus or with removal of posterior malleolar fragments. The fact that peak stresses with simulated ankle malunions were not elevated suggests that factors other than the magnitude of normal contact stresses are of greater importance in the pathogenesis of posttraumatic arthritis.

Ankle Injuries↗
PubMedDate not supplied

Medial malleolar osteotomy for exposure of complex talar body fractures.

Traditional surgical approaches to the talus often fail to afford adequate exposure of the talar body, especially in the case of complex talar body fractures. Preservation of the remaining blood supply to the talus is a main concern during operative repair and can be difficult to accomplish when multiple approaches and forceful manipulations are required to gain satisfactory exposure. A medial malleolar osteotomy was used to gain access to the talar body in situations in which the traditional approaches did not provide adequate exposure. We describe our technique in a small series of patients.

Adult↗