Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.

Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673602086579.pdf

Epidemiology and outcomes of osteoporotic fractures.

Modern techniques have reduced the frequency of infections that are associated with prosthetic joints, but such infections continue to pose difficult problems in clinical management. Advances in understanding biofilms and the pathogenesis of microbial interactions with the implant have led to more rational approaches to therapy. This review offers guidance in establishing the diagnosis correctly and an algorithm summarizing the appropriate medical and surgical options.

/pdf/prosthetic-joint-infections-qrunwr5dn0.pdf

Prosthetic-Joint Infections

https://zirconia.typepad.com/files/zirconia-as-a-ceramic-biomaterial---piconi---biomaterials-1999.pdf

Zirconia as a ceramic biomaterial

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673607604577.pdf

The operation of the century: total hip replacement

A technique was developed to determine the wear of the acetabular component of a total hip replacement by examination of standardized initial and follow-up radiographs. Three hundred and eighty-five hips were followed for at least 9.5 years after replacement. The least amount and rate of linear wear were associated with use of a femoral head that had a diameter of twenty-eight millimeters (p less than 0.001). The greatest amount and mean rate of linear wear occurred with twenty-two-millimeter components, but these differences were not statistically significant. The greatest volumetric wear and mean rate rate of volumetric wear were seen with thirty-two-millimeter components (p less than 0.001). A wider radiolucent line in acetabular Zone 1 was associated with use of the thirty-two-millimeter head. The amounts of resorption of the proximal part of the femoral neck and of lysis of the proximal part of the femur both correlated positively with the extent of linear and volumetric wear; this suggests an association between the amount of debris from wear and these changes in the femoral neck and proximal part of the femur.

Effect of femoral head size on wear of the polyethylene acetabular component.

At a minimum of one year after operation, we studied 64 patients with 86 total hip arthroplasties (THA) by standard anteroposterior hip and pelvic radiographs and measurement of range of motion and of isometric abduction strength. The femoral offset correlated positively with the range of abduction (p = 0.046). Abduction strength correlated positively with both femoral offset (p = 0.0001) and the length of the abductor lever arm (p = 0.005). Using multiple regression, abduction strength correlated with height (p = 0.017), gender (p = 0.0005), range of flexion (p = 0.047) and the abductor lever arm (p = 0.060). Our findings suggest that greater femoral offset after THA allows both an increased range of abduction and greater abductor strength.

/pdf/effect-of-femoral-offset-on-range-of-motion-and-abductor-1bpbn15kte.pdf

Effect of femoral offset on range of motion and abductor muscle strength after total hip arthroplasty

Twenty-six consecutive patients who had post-traumatic contracture of the elbow were treated by operative release alone or by release and distraction arthroplasty, with or without fascial interposition. The type of operative procedure was determined by whether the factors limiting motion were purely extra-articular (extrinsic) or whether they included intra-articular (intrinsic) elements as well. The mean preoperative arc of total motion was 30 degrees (from 63 to 93 degrees of flexion). At follow-up examination, twenty-two to ninety-four months post-operatively, of twenty-five patients, the mean arc of total motion was 96 degrees (from 30 to 126 degrees). There were eight complications in seven (27 per cent) of the patients. Of these, four (avulsion of the triceps tendon, deep infection, and two ulnar-nerve paresthesias) were managed by subsequent operative treatment. The other four complications included drainage from a pin site, which resolved after removal of the pin: a three by two-centimeter skin slough, which spontaneously epithelialized; aseptic resorption of the distal end of the humerus and proximal end of the ulna, which stopped after immobilization and subsequent bracing of the elbow but resulted in moderate instability; and ulnar-nerve paresthesia, which was not operatively treated and persisted. Twenty-four (96 per cent) of the twenty-five patients who were followed for twenty-two months or more were satisfied with the results of the procedure because of the improved facility in carrying out activities of daily living. No patient had increased pain, but two had moderate instability. It was concluded that the results of distraction arthroplasty can be gratifying, but the technique is demanding and the rate of complications is high.

Post-traumatic contracture of the elbow: operative treatment, including distraction arthroplasty

A review of sixty patients who had undergone ankle fusion for post-traumatic arthritis revealed that thirty-five (58 per cent) had the procedure performed within the first year after injury. A total of forty-eight complications occurred in twenty-nine (48 per cent) of the patients. Frequent complication were infection (23 per cent), non-union (23 per cent), inadequate surgical alignment or early loss of position (15 per cent), malunion (12 per cent), and delayed union (7 per cent). The lateral transfibular approach had the highest incidence of complications, and a two-incision approach using the Charnley compression apparatus was the procedure with the fewest complications. Forty-one patients were followed for an average of 7.5 years after operation. Of these, thirty-four (83 per cent) were satisfied with the procedure. Examination of thirty of the forty-one patients at an average of 7.3 years after surgery revealed virtually no subtalar motion but motion of 13 degrees at Chopart's joint. With shoes, patients had a near-normal gait. The roentgenograms revealed a minimum amount of degenerative arthritis at Chopart's joint, which may worsen with time. Varus or valgus angulation of the hind part of the foot was associated with a greater degree of symptoms in the subtalar area as well as the middle of the foot. The neutral position in varus-valgus angulation as well as dorsiflexion-plantar flexion was the optimum position for both men and women. The results of the procedure did not deteriorate with time.

Complications and long-term results of ankle arthrodeses following trauma.

Findings from biomechanical analyses of gait were used to estimate the optimum position of arthrodesis of the ankle. Nineteen patients who were followed for an average of 10.4 years (range, four to seventeen years) were studied. By including the knee in the analysis as well as studying the effects on gait of different ground conditions, objective data for the weight-bearing extremities in the transverse, sagittal, and coronal planes were generated. Genu recurvatum was shown to be associated with a plantar-flexion position of fusion of the ankle. Laxity of the medial collateral ligament of the knee was noted in twelve patients (63 per cent). Among these patients, in three (16 per cent) the laxity was graded as moderate to severe, possibly due to external rotation of the extremity during gait to avoid rolling over the rigid plantar-flexed ankle. The patterns of gait showed that a valgus position of the arthrodesis is more advantageous and provides more normal gait, particularly on uneven ground. To attain more normal function of the knee and improve performance on rough ground, the optimum position of arthrodesis of the ankle appears to be neutral flexion, slight (zero to 5 degrees) valgus angulation, and approximately 5 to 10 degrees of external rotation. Posterior displacement of the talus under the tibia tends to produce a more normal pattern of gait and decreases the stress at the knee. CLINICAL RELEVANCE: This study has shown the ideal position of fusion of the ankle to be neutral flexion, slight (zero to 5 degrees) valgus angulation of the hind part of the foot, and 5 to 10 degrees of external rotation. This position allows the greatest compensatory motion at the foot and places the least strain on the knee.

B. F. Morrey

Papers

Effect of femoral head size on wear of the polyethylene acetabular component.

Effect of femoral offset on range of motion and abductor muscle strength after total hip arthroplasty

Post-traumatic contracture of the elbow: operative treatment, including distraction arthroplasty

Complications and long-term results of ankle arthrodeses following trauma.

The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle.