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Chronic & Degenerative

Ankle osteoarthritis: predominantly post-traumatic, diagnostic approach, and consideration of cartilage regenerative potential.

Overview

Modern medicine lacks a cure for degenerative arthropathies of the foot and ankle [1]. Treatment strategies focus on symptom relief via nonsurgical methods or surgical removal of arthritis through fusion or replacement [1]. Surgical management for end-stage ankle osteoarthritis currently prioritizes ankle arthrodesis and total ankle arthroplasty, though specific indications for choosing arthrodesis over arthroplasty remain a subject of debate [23]. Inherent risks include early implant loosening with ankle arthroplasty and the acceleration of adjacent joint degeneration following ankle arthrodesis [4]. Surgical treatment for end-stage ankle osteoarthritis in patients aged ≥75 years yields satisfactory clinical outcomes comparable to those in younger patients [5].

Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures, including cheilectomy, arthroplasty, and arthrodesis [25]. Selection depends on disease stage and patient factors [25]. Conversely, total meniscectomy for discoid meniscus in children should be avoided whenever possible due to persistent symptoms in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees [6]. Major primary complications occur with bipolar radial head arthroplasty, which also shows a high incidence of radiographic degenerative changes after 8.8 years, despite achieving good clinical results [7].

Chronic Achilles disorders lack a clear consensus definition or uniform classification and treatment scheme [2]. Approximately every 10th patient treated surgically for chronic Achilles tendon overuse injury suffers a postoperative complication that clearly delays recovery [8]. Regarding isolated Weber B ankle fractures, non-surgical approaches may provide comparable functional outcomes and fewer short-term complications than operative approaches, though high bias in existing studies calls for caution in these comparisons [13]. Double semitendinosus anterior cruciate ligament reconstruction efficiently restores satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [3].

Anatomy & Pathophysiology

Modern medicine lacks a cure for degenerative arthropathies of the foot and ankle [1]. Treatment strategies focus on symptom relief via nonsurgical methods or surgical removal of arthritis through fusion or replacement [1]. In the early stages of ankle osteoarthritis, only periarticular osteotomies possess sufficient evidence to recommend treatment for cases with malalignment [26]. Correcting altered biomechanics associated with asymmetric arthritis improves functional outcomes [11]. The majority of patients with ankle osteoarthritis present with average tibiotalar alignment in varus, regardless of the underlying etiology [33]. Key molecular markers of ankle osteoarthritis include aggrecan, BMP-7, and BMP-2 [36].

Surgical Outcomes: Surgical treatment for end-stage ankle osteoarthritis yields satisfactory clinical outcomes in patients aged ≥75 years [5]. Improvements in clinical outcomes for this demographic are comparable to those observed in younger patients [5]. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of ankle osteoarthritis [26]. Intermediate results for second-generation total ankle arthroplasty are promising but require careful interpretation due to the poor history of earlier prostheses and technical difficulties [28]. Ankle function following joint distraction declines over time [30].

Non-Surgical & Adjunctive Therapies: Platelet-rich plasma injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections in patients with ankle osteoarthritis [22]. Subjects with chronic ankle instability demonstrate less variability in muscle activation patterns between test conditions during the transition from double-leg to single-leg stance [21]. Treatment rationale, surgical techniques, and expected imaging appearances of common operative procedures exist for posttraumatic ankle and hindfoot osteoarthritis [16].

Fracture Sequelae & Complications: Ankle fractures are common injuries that may result in tibiotalar instability [24]. These fractures typically have good outcomes when appropriately managed either surgically or nonsurgically [24]. Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [27]. Synostosis is a frequent complication of surgery for a fracture of the ankle [37]. While synostosis theoretically impairs the range of movement of the ankle, it did not affect the outcome of surgery for a fracture of the ankle [37].

Classification

General Management: Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle [1]. Treatment is based on symptom relief through nonsurgical methods or surgical removal of arthritis via fusion or replacement [1].

Chronic Achilles Disorders: There is no clear consensus on what defines a chronic Achilles disorder [2]. Consequently, there is no uniform classification and treatment scheme for chronic Achilles disorders [2]. Evaluation of the condition reveals that no fibrillogenesis, inflammation, or wound healing could be detected in human Achilles tendinopathy [9]. The data supports the notion that tendinopathy is an ongoing degenerative process [9]. Immunohistochemical staining of the fibrocartilaginous components biglycan and aggrecan showed a progressive increase correlated with a further evolved histopathological stage in midportion Achilles tendinopathy [39].

Ankle Osteoarthritis: Inherent risks linked with ankle arthroplasty include early implant loosening [4]. Inherent risks linked with ankle arthrodesis include the acceleration of adjacent joint degeneration [4]. Surgical treatment for end-stage ankle osteoarthritis resulted in satisfactory clinical outcomes in patients aged ≥75 years [5]. Improvements in clinical outcomes for end-stage ankle osteoarthritis in patients aged ≥75 years are comparable to those in younger patients [5].

Knee Pathology: Double semitendinosus anterior cruciate ligament reconstruction stabilises the evolution of degenerative lesions as shown by standing X-ray [3]. Total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible due to persistent symptoms and evidence of osteoarthrosis [6]. Persistent symptoms were found in ten of seventeen knees following total meniscectomy for discoid meniscus in children [6]. Evidence of osteoarthrosis was found in nine of eleven knees following total meniscectomy for discoid meniscus in children [6]. Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scoring system results for knee symptoms [14].

Radial Head Arthroplasty: Major primary complications occur after bipolar radial head arthroplasty [7]. There is a high incidence of radiographic signs of degenerative changes after 8.8 years following bipolar radial head arthroplasty [7].

Other Considerations: Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition [10]. About every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery [8]. Subjects with chronic ankle instability show less variability in muscle activation patterns between test conditions during the transition from double-leg to single-leg stance [21].

Clinical Presentation

Modern medicine lacks a cure for degenerative arthropathies of the foot and ankle [1]. Defining a chronic Achilles disorder remains contentious, with no clear consensus on diagnostic criteria or a uniform classification and treatment scheme [2]. Inherent risks for surgical management include early implant loosening with ankle arthroplasty and the acceleration of adjacent joint degeneration following ankle arthrodesis [4]. While correcting altered biomechanics in asymmetric arthritis improves functional outcomes in ankle arthritis [11], surgical treatment for end-stage ankle osteoarthritis yields satisfactory and comparable clinical outcomes in patients aged ≥75 years relative to younger cohorts [5].

Evaluation of coxa vara in childhood requires a systematic search for family history, trauma, infection, and associated skeletal abnormalities [10]. Juvenile arthritis remains a diagnosis of exclusion necessitating a broad differential diagnosis [19]. In pediatric populations, total meniscectomy for discoid meniscus is associated with persistent symptoms in ten of seventeen knees and osteoarthrosis in nine of eleven knees, warranting avoidance whenever possible [6]. Conversely, double semitendinosus anterior cruciate ligament reconstruction has been shown to stabilise the evolution of degenerative lesions on standing X-ray [3].

Chronic overuse and degenerative conditions present with distinct sensory and functional profiles. Patients with chronic whiplash injury exhibit widespread sensory hypersensitivity to both mechanical and thermal stimuli [32]. In chronic Achilles tendon overuse injury, approximately one in ten patients suffers a postoperative complication delaying recovery [8], and human tendinopathy is characterized by a lack of fibrillogenesis, inflammation, or wound healing, supporting its classification as an ongoing degenerative process [9]. Similarly, major primary complications occur after bipolar radial head arthroplasty, with a high incidence of radiographic degenerative changes observed 8.8 years post-procedure [7].

Demographic variables significantly influence clinical scoring systems for knee symptoms, including advanced age, low family income, and multiple medical conditions [14]. For chronic/overuse elbow disorders, nonsurgical treatment typically permits a safe return to sport, reserving surgical intervention for the few cases with recalcitrant symptoms [15]. Nonsurgical management generally allows patients with leg pain disorders to return to prior activity levels, though prolonged rest is often required [17]. Finally, the history, examination, radiographic appearance, and recovery of a distal tibial physis stress lesion are consistent with a stress lesion secondary to athletic activity [12]. Early recurrence of Dupuytren's disease is most prevalent in individuals with Dupuytren's diathesis [20].

Investigations

Plain radiography: Standing X-rays are utilized to stabilize the evolution of degenerative lesions in anterior cruciate ligament reconstruction [3]. In the context of chronic Achilles disorders, there is no uniform classification or treatment scheme, and no clear consensus defines the condition [2]. For end-stage ankle osteoarthritis, surgical treatment in patients aged ≥75 years yields satisfactory clinical outcomes comparable to younger cohorts [5]. Post-bipolar radial head arthroplasty, a high incidence of radiographic signs of degenerative changes is observed after 8.8 years [7]. Following total meniscectomy for discoid meniscus in children, evidence of osteoarthrosis was found in nine of eleven knees at the latest follow-up [6].

MRI: Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities [10]. History, examination results, and radiographic appearance consistent with a stress lesion of the distal tibial physis secondary to athletic activity require specific imaging correlation [12]. In chronic Achilles tendon overuse injury, no fibrillogenesis, inflammation, or wound healing could be detected in human tendinopathy, supporting the notion that the condition is an ongoing degenerative process [9].

Other Considerations: Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle; treatment is based on symptom relief through nonsurgical methods or surgical removal of arthritis via fusion or replacement [1]. Inherent risks linked with each treatment option for ankle arthritis include early implant loosening following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis [4]. Correcting altered biomechanics associated with asymmetric arthritis improves functional outcomes in ankle arthritis [11]. Juvenile arthritis is a diagnosis of exclusion requiring a broad differential diagnosis, though early referral to a pediatric rheumatologist and the use of targeted biologic medications have greatly improved long-term outcomes and reduced the need for surgical intervention [19]. Ankle fractures are common injuries that may result in tibiotalar instability but typically have good outcomes when appropriately managed either surgically or nonsurgically [24]. Posterior ankle impingement syndrome (PAIS) is observed in athletes in many sports, caused mainly by bony impingement, and is often associated with FHL-related pathology [40].

Surgical Outcomes and Complications: Double semitendinosus anterior cruciate ligament reconstruction restores satisfactory stability for most patients [3]. About every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery [8]. Major primary complications occur after bipolar radial head arthroplasty, yet good clinical results were achieved with Judet's bipolar prosthesis despite these complications and the high incidence of radiographic signs of degenerative changes [7]. Total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible due to persistent symptoms [6]. Nonsurgical treatment for chronic/overuse elbow disorders typically allows safe return to sport, with surgical intervention reserved only for the few cases with recalcitrant symptoms [15]. Nonsurgical management for leg pain disorders usually allows patients to return to their earlier activity level, though prolonged rest is often needed [17]. Intermediate results for second-generation total ankle arthroplasty are promising but should be interpreted with care due to the poor history of earlier prostheses and technical difficulties [28]. Treatment rationale and expected imaging appearances of common operative procedures are provided for posttraumatic ankle and hindfoot osteoarthritis [16].

Treatment

Non-Operative

Modern medicine lacks a cure for degenerative arthropathies of the foot and ankle, making treatment focused on symptom relief through nonsurgical methods or surgical removal of arthritis [1]. Nonsurgical management for chronic/overuse elbow disorders typically allows a safe return to sport, while surgical intervention is reserved only for the few cases with recalcitrant symptoms [15]. Similarly, nonsurgical management for leg pain disorders usually allows patients to return to their earlier activity level, though it often requires prolonged rest [17]. For chronic noninsertional Achilles tendinopathy, shock wave therapy is an effective treatment option [34]. In contrast, the long-term benefit of extracorporeal shockwave therapy for patients with insertional Achilles tendinopathy is called into question by findings of inferior outcomes compared to noninsertional cohorts [18]. Platelet-rich plasma injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections in patients with ankle osteoarthritis [22]. Non-surgical approaches for isolated Weber B ankle fractures may provide comparable functional outcomes to surgical approaches, though they may result in fewer short-term complications [13]. However, the presence of high bias and limitations in existing studies regarding non-surgical versus surgical treatment of isolated Weber B ankle fractures calls for caution [13]. Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [27].

Operative

Indications: Surgical treatment for end-stage ankle osteoarthritis is indicated when nonsurgical methods fail, with satisfactory clinical outcomes observed in patients aged ≥75 years [5]. Improvements in clinical outcomes for surgical treatment of end-stage ankle osteoarthritis in patients aged ≥75 years are comparable to those in younger patients [5]. For hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint, treatment selection depends on disease stage and patient factors [25]. In early stages of ankle osteoarthritis with malalignment, only periarticular osteotomies have enough evidence to recommend them [26]. Double semitendinosus anterior cruciate ligament reconstruction is efficient in restoring satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [3]. Total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible due to persistent symptoms and evidence of osteoarthrosis [6]. Evaluation for coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [10].

Surgical Approach / Technique: Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty [23]. Specific indications for ankle arthrodesis versus total ankle arthroplasty are the topic of much debate [23]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis [25]. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of ankle osteoarthritis [26]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [2].

Implant Selection: Inherent risks linked with ankle treatment options include early implant loosening following arthroplasty [4]. Inherent risks linked with ankle treatment options include the acceleration of adjacent joint degeneration associated with arthrodesis [4].

Other Considerations: Superior subjective clinical outcomes together with a lower failure rate were maintained for >1 year in the noninsertional Achilles tendinopathy cohort compared with the insertional cohort following extracorporeal shockwave therapy [18].

Complications

Infection (PJI): No specific infection data is provided in the current evidence base for foot and ankle degenerative arthropathies or other listed procedures.

Aseptic loosening: Early implant loosening is a documented risk associated with arthroplasty [4].

Instability: No specific instability data is provided in the current evidence base.

Periprosthetic fracture: No specific periprosthetic fracture data is provided in the current evidence base.

Thromboembolism: No specific thromboembolism data is provided in the current evidence base.

Patellar / Extensor-mechanism: No specific patellar or extensor-mechanism data is provided in the current evidence base.

Stiffness / Arthrofibrosis: No specific stiffness or arthrofibrosis data is provided in the current evidence base.

Nerve palsy: No specific nerve palsy data is provided in the current evidence base.

Wound complications: Approximately every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery [8].

Polyethylene wear: No specific polyethylene wear data is provided in the current evidence base.

Other Considerations: Modern medicine lacks a cure for degenerative arthropathies of the foot and ankle, necessitating treatment based on symptom relief via nonsurgical methods or surgical removal of arthritis through fusion or replacement [1]. There is no clear consensus defining a chronic Achilles disorder or a uniform classification and treatment scheme [2]. High-quality studies are required to guide treatment in patients of varying demographics, as inherent risks are linked with each option [4]. Adjacent joint degeneration is a specific risk associated with arthrodesis [4]. In pediatric patients, total meniscectomy for a discoid meniscus should be avoided whenever possible due to persistent symptoms and evidence of osteoarthrosis; persistent symptoms were found in ten of seventeen knees, and evidence of osteoarthrosis was found in nine of eleven knees following this procedure [6]. Major primary complications occur with bipolar radial head arthroplasty, which also carries a high incidence of radiographic signs of degenerative changes after 8.8 years [7]. Tendinopathy is characterized as an ongoing degenerative process where no fibrillogenesis, inflammation, or wound healing could be detected [9]. Evaluation of coxa vara in childhood must include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [10]. For isolated Weber B ankle fractures, non-surgical approaches may provide comparable functional outcomes and fewer short-term complications compared to operative approaches, though the presence of high bias and limitations in existing studies calls for caution regarding this comparison [13]. Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scoring systems for total knee arthroplasty results [14]. Regarding extracorporeal shockwave therapy, superior subjective clinical outcomes and a lower failure rate were maintained for >1 year in the noninsertional Achilles tendinopathy cohort compared with the insertional cohort, while the long-term benefit for patients with insertional Achilles tendinopathy is called into question [18]. Early recurrence of Dupuytren's contracture is most common in individuals with Dupuytren's diathesis, for whom the use of full-thickness skin grafts may be helpful [20]. Finally, platelet-rich plasma injection may beneficially improve pain and functional scores for ankle osteoarthritis in a short-term period [29].

Recovery

Light activity (weeks): Evidence regarding specific timelines for light activity is not explicitly quantified in the provided source material; however, general recovery principles indicate that surgical treatment for end-stage ankle osteoarthritis yields satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to younger patients [5]. For chronic Achilles tendon overuse injury, approximately every 10th patient experienced a postoperative complication that clearly delayed recovery [8]. In contrast, non-surgical approaches for isolated Weber B ankle fractures may provide comparable functional outcomes to operative approaches while potentially resulting in fewer short-term complications [13].

Full activity (months): The evolution of degenerative lesions following double semitendinosus anterior cruciate ligament reconstruction is stabilized as shown by standing X-ray, suggesting a trajectory toward functional stability [3]. While total meniscectomy for discoid meniscus in children should be avoided due to persistent symptoms and osteoarthrosis, with evidence of osteoarthrosis found in nine of eleven knees [6], specific timelines for full activity return are not detailed in the current evidence base. Similarly, while Judet's bipolar prosthesis achieved good clinical results despite major primary complications and a high incidence of radiographic degenerative changes after 8.8 years, the specific duration for full activity resumption is not defined [7].

Complete recovery / outcome plateau (months): Platelet-rich plasma injection may beneficially improve pain and functional scores for ankle osteoarthritis in a short-term period, though long-term plateau data is not specified [29]. For Achilles tendinopathy, superior subjective clinical outcomes and a lower failure rate were maintained for >1 year in the noninsertional cohort compared with the insertional cohort following extracorporeal shockwave therapy, calling the long-term benefit for insertional cases into question [18]. The data supports the notion that tendinopathy is an ongoing degenerative process where no fibrillogenesis, inflammation, or wound healing could be detected in human cases [9].

Rehabilitation protocol: Modern medicine does not have a cure for degenerative arthropathies of the foot and ankle; treatment is based on symptom relief through nonsurgical methods or surgical removal of arthritis via fusion or replacement [1]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [2]. Correcting altered biomechanics associated with asymmetric arthritis improves functional outcomes in supramalleolar osteotomies for ankle arthritis [11]. The history, examination results, radiographic appearance, and recovery of a patient with a stress fracture of the distal tibial physis are consistent with a stress lesion secondary to athletic activity [12]. Inherent risks linked with ankle arthritis treatment options include early implant loosening following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis [4].

Functional milestones: The Musculoskeletal Function Assessment Questionnaire was more responsive and efficient than the SF-36 in measuring changes in function between baseline and follow-up values [38]. Forty-seven (96 per cent) of forty-nine shoulders had a good clinical result after distal release of the deltoid muscle contracture [41]. In the context of ankle arthritis, the presence of high bias and limitations in existing studies calls for caution regarding non-surgical versus operative treatment of isolated Weber B ankle fractures [13].

Other Considerations: Double semitendinosus anterior cruciate ligament reconstruction is efficient in restoring satisfactory stability for most patients [3]. Major primary complications occur after bipolar radial head arthroplasty, and there is a high incidence of radiographic signs of degenerative changes after 8.8 years following this procedure [7]. Persistent symptoms were found in ten of seventeen knees following total meniscectomy for discoid meniscus in children [6].

Key Evidence

  • [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
  • [L4] The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. (10.1007/s001670050076)
  • [L3] Surgical treatment for end-stage ankle OA resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients. (10.1186/s13018-023-03734-4)
  • [L4] On the basis of our findings of persistent symptoms in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees at the latest follow-up evaluation, we believe that total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible. (10.2106/00004623-199811000-00003)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L4] About every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery. (10.1177/03635465000280012501)
  • [L3] As no fibrillogenesis, inflammation or wound healing could be detected, the data supports the notion that tendinopathy is an ongoing degenerative process. (10.1186/1471-2474-13-53)
  • [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
  • [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. (10.5435/jaaos-d-12-00124)
  • [L4] The history, examination results, radiographic appearance, and recovery of this patient are all consistent with a stress lesion of the distal tibial physis secondary to athletic activity. (10.1177/0363546513485938)
  • [L1] While non-surgical approaches may provide comparable functional outcomes and fewer short-term complications, the presence of high bias and limitations in the existing studies calls for caution. (10.1186/s13018-024-04835-4)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L5] This review article aims to familiarize the reader with treatment rationale, provide a brief review of surgical techniques, and illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis. (10.3390/jcm10245848)
  • [L3] Superior subjective clinical outcomes together with a lower failure rate were maintained for >1 year in the noninsertional Achilles tendinopathy cohort compared with the insertional cohort, calling into question the long-term benefit of ESWT for patients with insertional Achilles tendinopathy. (10.1177/23259671241265330)
  • [L5] Early recurrence of disease is most common in individuals with Dupuytren's diathesis, and the use of full-thickness skin grafts may be helpful in this setting. (10.5435/00124635-199801000-00003)
  • [L3] Subjects with chronic ankle instability show less variability in muscle activation patterns between test conditions. (10.1177/0363546506294470)
  • [L1] For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections. (10.1177/03635465231182438)
  • [L5] Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate. (10.5435/jaaos-d-23-00743)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L5] In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment, while both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease. (10.1530/eor-21-0117)
  • [L3] The non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union. (10.1186/s12891-024-07924-x)
  • [L4] Intermediate results for second-generation total ankle arthroplasty are promising but should be interpreted with care due to the poor history of earlier prostheses and technical difficulties. (10.5435/jaaos-d-25-00638)
  • [L1] PRP may beneficially improve pain and functional scores for ankle OA in a short-term period. (10.1186/s13018-023-03828-z)
  • [L4] Ankle function following joint distraction declines over time. (10.2106/jbjs.n.00901)
  • [L4] The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. (10.1186/1471-2474-11-29)
  • [L3] Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy. (10.1177/0363546507309674)
  • [L3] The study identified different key markers of ankle osteoarthritis, specifically aggrecan, BMP-7, and BMP-2, which offer starting points for new ways in diagnostics and interventional strategies. (10.1155/2014/434802)
  • [L3] Synostosis is a frequent complication of surgery for a fracture of the ankle; although it theoretically impairs the range of movement of the ankle, it did not affect the outcome. (10.1302/0301-620x.97b7.34460)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L3] Immunohistochemical staining of the fibrocartilaginous components biglycan and aggrecan showed a progressive increase, correlated with a further evolved histopathological stage. (10.1007/s00167-012-2203-3)
  • [L4] PAIS is observed in athletes in many sports, is caused mainly by bony impingement, and is often associated with FHL-related pathology. (10.1177/23259671261422259)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)

See Also

References

[1] Chapter 43 Degenerative Conditions and Osteonecrosis of the Foot and Ankle. 2020.

[2] Surgical Treatment for Chronic Disease and Disorders of the Achilles Tendon. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200901000-00002

[3] Double semitendinosus anterior cruciate ligament reconstruction: 10‐year results. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050076

[4] Ankle Arthritis You Can’t Always Replace It. n.d..

[5] Clinical outcomes of surgical treatment for end-stage ankle osteoarthritis in patients aged ≥ 75 years: a multicenter, retrospective study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03734-4

[6] Discoid Lateral Meniscus in Children. Long-Term Follow-up After Total Meniscectomy. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199811000-00003

[7] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[8] Chronic Achilles Tendon Overuse Injury: Complications after Surgical Treatment. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280012501

[9] Local biochemical and morphological differences in human Achilles tendinopathy: a case control study. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-53

[10] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[11] Supramalleolar Osteotomies for the Treatment of Ankle Arthritis. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-12-00124

[12] Stress Fracture of the Distal Tibial Physis in an Adolescent Recreational Dancer. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513485938

[13] Comparison of operatively and nonoperatively treated isolated Weber B ankle fractures: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04835-4

[14] Demographic Biases of Scoring Instruments for the Results of Total Knee Arthroplasty. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00009

[15] Chapter 8 Chronic/Overuse Elbow Disorders. 2019.

[16] Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10245848

[17] Chapter 22 Leg Pain Disorders. 2019.

[18] Outcomes After Extracorporeal Shockwave Therapy for Chronic Noninsertional Achilles Tendinopathy Compared With Chronic Insertional Achilles Tendinopathy: A Retrospective Review. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241265330

[19] Chapter 19 Arthritis. 2020.

[20] Dupuytren’s Contracture. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199801000-00003

[21] Relationship of Chronic Ankle Instability to Muscle Activation Patterns during the Transition from Double-Leg to Single-Leg Stance. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506294470

[22] Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231182438

[23] Ankle Osteoarthritis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00743

[24] Chapter 43 Ankle Fractures. 2021.

[25] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[26] Ankle osteoarthritis: comprehensive review and treatment algorithm proposal. EFORT Open Reviews. 2022. DOI: 10.1530/eor-21-0117

[27] Non-surgical treatment of lateral malleolar fractures is safe: long-term follow-up of a comprehensive treatment algorithm. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07924-x

[28] Clinical Outcomes and Safety Profile for Total Ankle Arthroplasty and Ankle Arthrodesis for Symptomatic Ankle Arthritis: A Systematic Review. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00638

[29] Platelet-rich plasma injection for the treatment of ankle osteoarthritis: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03828-z

[30] Intermediate-Term Follow-up After Ankle Distraction for Treatment of End-Stage Osteoarthritis. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.00901

[32] Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: An exploratory study in chronic whiplash patients. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-29

[33] Etiology_of_Ankle_Osteoarthritis_00003086-200907000-00022. 2009.

[34] High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507309674

[36] Biochemical Characterization of Early Osteoarthritis in the Ankle. The Scientific World Journal. 2014. DOI: 10.1155/2014/434802

[37] Incidence and clinical relevance of tibiofibular synostosis in fractures of the ankle which have been treated surgically. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b7.34460

[38] Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199709000-00006

[39] Arguments for an increasing differentiation towards fibrocartilaginous components in midportion Achilles tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2203-3

[40] Postoperative Results of Posterior Ankle Impingement Syndrome in Athletes and Its Clinical Features. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261422259

[41] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

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