Search Results
Abstract
Unstable fracture-dislocation of the ankle is a common lower extremity injury. Treatment is challenging when the fracture-dislocation is open and cannot be treated with conventional open reduction and internal fixation (ORIF). Immediate ORIF may not be possible for severe, unstable ankle injuries, such as those with ischemic foot due to a poor blood supply caused by soft tissue injury, or open fracture-dislocation of the ankle with a deltoid ligament rupture. We described a staged treatment for unstable open fracture-dislocation of the ankle with a deltoid ligament rupture. The first stage involves temporary vertical transarticular pinning combined with external fixation. The second stage involves delayed definitive plating with autogenous bone graft for the bone defect of the distal fibula. This staged management is useful in select emergency cases of unstable open fracture-dislocations of the ankle combined with deltoid ligament rupture for which conventional ORIF cannot be performed.
An osteochondroma or exostosis is the most common benign bone tumor, and it is commonly localized in the metaphyses of the long tubular bones. Lesions are rarely localized around the ankle. We present a case series with osteochondroma around the ankle. All of the patients presented with a mass around the ankle. In these three cases, the masses were symptomatic, and in one patient it caused a deformity. Osteochondroma was suspected after physical examination and radiologic evaluation. After preoperative work-up, diagnosis, and exhaustion of conservative care, a plan for surgical excision was presented to each patient. Histopathologic evaluations confirmed the diagnosis of osteochondroma. The patients have been discharged without any complications or symptoms during clinical follow-up.
Static Ankle Joint Equinus
Toward a Standard Definition and Diagnosis
Equinus is characterized by reduced dorsiflexion of the ankle joint, but there is a lack of consensus regarding criteria for definition and diagnosis. This review examines the literature relating to the definition, assessment, diagnosis, prevalence, and complications of equinus. Articles on equinus and assessment of ankle joint range of motion were identified by searching the EMBASE, Medline, PubMed, EBSCOhost, Cinahl, and Cochrane databases and by examining the reference lists of the articles found. There is inconsistency regarding the magnitude of reduction in dorsiflexion required to constitute a diagnosis of equinus and no standard method for assessment; hence, the prevalence of equinus is unknown. Goniometric assessment of ankle joint range of motion was shown to be unreliable, whereas purpose-built tools demonstrated good reliability. Reduced dorsiflexion is associated with alterations in gait, increased forefoot pressure, and ankle injury, the magnitude of reduction in range of motion required to predispose to foot or lower-limb abnormalities is not known. In the absence of definitive data, we propose a two-stage definition of equinus: the first stage would reflect dorsiflexion of less than 10° with minor compensation and a minor increase in forefoot pressure, and the second stage would reflect dorsiflexion of less than 5° with major compensation and a major increase in forefoot pressure. This proposed definition of equinus will assist with standardizing the diagnosis and will provide a basis for future studies of the prevalence, causes, and complications of this condition. (J Am Podiatr Med Assoc 100(3): 195–203, 2010)
Ankle equinus has been proposed to be associated with lower-extremity pathology. Physiologically normal measurements have been quantified in various populations. Forty high-school athletes (16 girls and 24 boys) without a history of ankle injury had ankle dorsiflexion measured with the knee extended and flexed by an experienced evaluator using a goniometer with the subjects supine. The group mean ± SD dorsiflexion for the right ankle was 0.35° ± 2.2° with the knee extended and 4.88° ± 3.23° with the knee flexed. The values for the left ankle were –0.6° ± 2.09° and 4.68° ± 3.33°, respectively. There were no statistically significant differences between limbs using the Student t-test. In girls, values for right and left ankle dorsiflexion were 0.19° ± 2.1° and –0.7° ± 2.3°, respectively, with the knee extended and 4.88° ± 3.59° and 4.88° ± 3.07°, respectively, with the knee flexed. In boys, these values were 0.46° ± 2.3° and –0.5° ± 1.98° with the knee extended and 4.88° ± 3.04° and 4.54° ± 3.55° with the knee flexed. There were no statistically significant differences between boys and girls. Ankle dorsiflexion in asymptomatic adolescent athletes is approximately 0° with the knee extended and just less than 5° with the knee flexed. (J Am Podiatr Med Assoc 93(4): 312-314, 2003)
Reliability of Ankle Goniometric Measurements
A Literature Review
This article reviews the existing range-of-motion measurement literature related to ankle dorsiflexion and plantarflexion to determine whether the reliability of ankle range-of-motion measurements can be defined, how the characteristics of the study population or clinician affect reliability, and the level of responsiveness for these measures. A MEDLINE search was performed through February 2004, and 11 articles met the inclusion criteria established for this review. Ample evidence was found for intrarater reliability for ankle dorsiflexion and plantarflexion range of motion. Although some evidence for interrater reliability of dorsiflexion was found, little evidence for interrater reliability of plantarflexion range of motion was uncovered. On the basis of the current literature, the responsiveness of ankle joint range-of-motion measurements is uncertain and requires further studies using patient populations. (J Am Podiatr Med Assoc 95(6): 564–572, 2005)
Background:
Measurement of weightbearing ankle dorsiflexion (DF) passive range of motion (PROM) has been suggested as a way to estimate ankle kinematics during gait; however, no previous study has demonstrated the relationship between ankle DF during gait and ankle DF PROM with knee extension. We examine the relationship between maximum ankle DF during gait and nonweightbearing and weightbearing ankle DF PROM with knee extension.
Methods:
Forty physically active individuals (mean ± SD age, 21.63 ± 1.73 years) participated in this study. Ankle DF PROM with knee extension was measured in the nonweightbearing and weightbearing conditions; maximum ankle DF during gait was assessed using a three-dimensional motion analysis system. The relationship between each variable was calculated using the Pearson product moment correlation coefficient, and the difference in ankle DF PROM between the nonweightbearing and weightbearing conditions was analyzed using a paired t test.
Results:
The weightbearing measurement (r = 0.521; P < .001) for ankle DF PROM showed a greater correlation with maximum ankle DF during gait than did the nonweightbearing measurement (r = 0.245; P = .029). Ankle DF PROM was significantly greater in the weightbearing than in the nonweightbearing condition (P < .001) despite a significant correlation between the two measurements (r = 0.402; P < .001).
Conclusions:
These findings indicate that nonweightbearing and weightbearing measurements of ankle DF PROM with knee extension should not be used interchangeably and that weightbearing ankle DF PROM with the knee extended is more appropriate for estimating ankle DF during gait.
The causes of late-onset pain after total ankle replacement (TAR) are various, and include infection, subsidence, polyethylene spacer failure, osteolysis, and wear. There are few reports of late-onset pain caused by gouty attacks after total knee and hip arthroplasty. In addition, no research has reported gouty attacks after total ankle arthroplasty. Therefore, we report a case of a gouty attack after total ankle replacement. A 43-year-old man presented with pain after total ankle arthroplasty performed 5 years previously. We found a white-yellow crystalline deposit within the synovial tissue during ankle arthroscopy, confirmed by histologic examination.
Realignment Arthrodesis of the Rearfoot and Ankle
A Comprehensive Evaluation
Ankle and tibiotalocalcaneal arthrodeses are performed for the treatment of painful, arthritic, unstable, and deformed rearfoot and ankle joints. Surgical complications are not uncommon (~30%); some can be attributed to poor preoperative planning and inadequate intraoperative position. Several authors have attempted to define the optimal position for ankle arthrodesis without objective multiplanar radiographic analysis and consistent reference points. This investigation explored the effects of ankle and tibiotalocalcaneal realignment arthrodeses on static lower-extremity position in 20 patients. The most common preoperative diagnosis was severe degenerative joint disease following ankle fractures and ankle instability. Seven tibiotalocalcaneal arthrodeses and 13 isolated ankle arthrodeses were performed (mean follow-up, 22 months). Average time to radiographic osseous union of the isolated ankle and tibiotalocalcaneal arthrodeses was 11 and 7 weeks, respectively. Medical complications occurred in 2 patients (10%). There were no statistically significant differences between preoperative and postoperative angular relationships. This study objectively quantifies multiplanar foot-to-leg realignment and defines the optimal clinical and radiographic positions for ankle and tibiotalocalcaneal realignment arthrodeses. (J Am Podiatr Med Assoc 95(1): 60–71, 2005)
Pigmented Villonodular Synovitis of the Ankle
Radiologic Characteristics
Background:
Pigmented villonodular synovitis (PVNS) of the ankle is a rare benign proliferative growth of the synovium. Studies of the radiologic characteristics of ankle PVNS are sparse.
Methods:
To characterize the radiologic features of ankle PVNS, five patients with histologically proven ankle PVNS were retrospectively studied. The features of their radiographs, computed tomographic scans, and magnetic resonance images were reviewed, with emphasis on the morphological features, extension, margin, bone involvement, signal intensity, and degree of magnetic resonance enhancement.
Results:
All five lesions were diffuse, affecting the ankle and distal tibiofibular joint; three lesions also involved the subtalar joint. Radiography demonstrated extrinsic bone erosions with marginal sclerosis of the involved joints in all of the patients, but computed tomography identified this much better than did radiography. Magnetic resonance imaging revealed multiple lobulated soft-tissue masses in all of the cases. These soft-tissue masses surrounded the flexor hallux longus tendon and were hypointense on T1-weighted images, with a heterogeneous signal in two cases and homogenous hypointensity in three cases on fat-suppressed T2-weighted images. In one patient who underwent gadolinium-enhanced imaging, the masses showed intense enhancement.
Conclusions:
Magnetic resonance imaging is the best way to reveal ankle PVNS. Magnetic resonance imaging findings of predominant hypointensity on all pulse sequences and standard radiography findings of bone erosion with marginal sclerosis are characteristic. (J Am Podiatr Med Assoc 101(3): 252–258, 2011)
Clinical Assessment of Ankle Joint Dorsiflexion
A Review of Measurement Techniques
Ankle dorsiflexion measurement is important for clinical and research use. With so much evidence on the unreliability of goniometric measurements, a systematic review was performed to investigate various alternative techniques for measuring ankle dorsiflexion in the nonneurologic patient. All of the major databases were queried electronically to identify studies that used any method of ankle dorsiflexion measurement in the nonneurologic subject. Keywords included ankle dorsiflexion NOT cerebral palsy NOT stroke, the latter to exclude neurologic conditions. In 755 studies that used some form of ankle joint dorsiflexion measurement, ten different techniques were identified that included various apparatuses designed specifically for this purpose. Reliability testing of these techniques involved test-retest trials with small student populations as subjects, which returned high intraclass correlation coefficient scores. However, their methodological quality would have benefitted from the use of an actual patient population and comparison with a reference standard. When validating ankle dorsiflexion measurement techniques, actual patient populations should be used, otherwise papers would score poorly on methodological quality assessment. Standardizing patient position, foot posture, amount of moment applied, and reference landmarks will ensure that various trial results can be compared directly. (J Am Podiatr Med Assoc 101(1): 59–69, 2011)
