Effects of Patient-Specific Instrumentation and Ancillary Surgery Performed in Conjunction With Total Ankle Implant Arthroplasty: Postoperative Radiographic Findings

Distal tibial osteophytes are more accurate than medial malleolar anatomy when using patient specific instrumentation in total ankle replacement

Total ankle replacement (TAR) is a treatment for end stage ankle arthritis. Patient specific instrumentation (PSI) has been used and shown to allow for accurate placement and alignment in TAR in the coronal and sagittal plane. PSI systems are available and use different anatomic landmarks for the cutting guides. This is a retrospective matched case control study comparing accuracy in alignment using 2 different PSI systems. The case series uses a medial malleolar landmark (MM Group), and each case patient was matched based on preoperative coronal plane alignment with 2 ankles in the control series using the distal tibial osteophytes as landmarks (DT Group), as this system has been in use and studied more. A total of 48 ankles were studied, 16 in the MM Group and 32 in the DT Group matched by coronal plane alignment. There was a difference in accuracy of postoperative coronal plane alignment, with the MM Group deviated from expected by 1.6° ± 1.3° compared to the DT Group at 1.1° ± 0.6°, p = 0.04. This corresponded to 68.8 % of MM Group ankles being within 2° of expected compared to 93.4 % of DT Group ankles. There was no statistically significant difference in sagittal plane alignment between the groups, p = 0.57. Procedure time was the only other statistically significant difference with the MM Group taking longer than the DT Group, 97.4 min and 80.6 min, respectively, p = 0.04. While both groups show good accuracy, alignment based on the distal tibial osteophytes is more accurate than using the medial malleolus.

Rejection rate, modifications, and turnaround time for patient specific instrumentation plans in total ankle replacement

Patient specific instrumentation (PSI) in total ankle replacement (TAR) has been reported to be accurate and time saving. However, there has been criticism regarding accuracy and an overreliance on the preoperative plan. This is a retrospective review of a single surgeon's PSI plans from 2016-2024. We report rejection rates, modifications, and turnaround time. A total of 101 plans were reviewed and found an overall rejection rate of 17.8 %, with 18 reports rejected. Average turnaround time was 29:07 hours. When comparing the 1st half of the study period to the second half, a statistically significant increase in rejection rate was found, 0 % to 45 %, p < 0.0001. In addition, there was a higher rate of rejection on more complicated stemmed implants or revision implants compared to low profile implants. This report shows there is not a blind trust of the engineer's plan, and with experience with PSI rejection rate increases. Also, the engineer's understanding of complicated cases is addressed with higher rates of rejection in complicated cases. This report refutes charges that surgeons that use PSI for TAR are overly reliant on CT-derived engineer produced plans. Further studies with national data or multiple surgeons should be undertaken to explore this further.

What is the Total Ankle Arthroplasty Experience of Podiatric Foot and Ankle Surgery Fellows? A National Survey

In 2011, the Council of Podiatric Medical Education, the accrediting body of the American Podiatric Medical Association, approved the conversion of all Podiatric Residencies to 3-year surgical programs. In 2012, there were 12 podiatric fellowships recognized by the American College of Foot and Ankle Surgeons. To date, there are 53 programs listed under the college's website. As podiatric fellowships expand, further research is needed to identify advantages and pitfalls of fellowship training. Our primary aim was to obtain current fellow survey data to enhance our understanding of podiatric reconstructive foot and ankle surgery fellowship training programs. In doing so, we decided to use one of the most salient topics in fellowship training- Total Ankle Replacement. Invitation was administered by email and 73.6% of active reconstructive 2023-24 American College of Foot and Ankle Surgeons postgraduate fellows responded. Fellowship total ankle replacement case volume was significantly greater than residency (p = 0.037). Completion of 0-5 total ankle replacement(s) was 30.8%, and greater than 30 in 17.9% of fellows. Fifty nine percent reported feeling "comfortable" or "very comfortable" with total ankle arthroplasty. Patient specific instrumentation was used in a majority of cases (66.7%). Over three fourths (79.8%) of fellows stated they planned on performing TAR as an attending surgeon after their fellowship. Despite its limitations, we hope our survey data can aid graduating and previous fellows and add to the body of knowledge for future TAR educational programs and industry involvement. As podiatric fellowships continue to transform, so too must our research efforts to track progress.

Effect of Preoperative Coronal Plane Alignment on Actual Versus Predicted Alignment Using Patient Specific Instrumentation in Total Ankle Replacement

Alignment in total ankle replacement is important for success and implant survival. Recently there has been the introduction and adoption of patient specific instrumentation for implantation in total ankle replacement. Current literature does not evaluate the effect of preoperative deformity on accuracy of patient specific instrumentation. A retrospective radiographic analysis was performed on 97 consecutive patients receiving total ankle replacement with patient specific instrumentation to assess the accuracy and reproducibility of the instrumentation. Subgroup analysis evaluated the effect of preoperative deformity. All surgeries were performed by fellowship trained foot and ankle surgeons without industry ties to the implants used. Preoperative and postoperative films were compared to plans based on computerized tomography scans to assess how closely the plan would be implemented in patients. Overall postoperative coronal plane alignment was within 2° of predicted in 87.6% (85 patients). Similarly, overall postoperative sagittal plane alignment was within 2° of predicted in 88.7% (86 patients). Tibial implant size was accurately predicted in 81.4% (79 patients), and talus implant size was correct in 75.3% (73 patients). Patients with preoperative varus deformity had a higher difference between predicted and actual postoperative alignment compared to valgus deformity (1.1° compared to 0.3°, p = .02). A higher average procedure time was found in varus patients, and more adjunctive procedures were needed in patients with varus or valgus deformity, but these were not significant, p > .5. Surgeons can expect a high degree of accuracy when using patient specific instrumentation overall, but less accurate in varus deformity.

Additional Procedures at the Time of Total Ankle Replacement Do Not Increase Risk of Short-term Complications: A Matched Cohort Analysis

Background

This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), alone or with concomitant procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes.

Methods

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology (CPT) codes to identify patients who underwent TAA (27702) between 2010 to 2021. Patients were divided into cohorts based on the presence or absence of ancillary procedures. Propensity score matching was employed to account for demographic differences, and statistical analyses were performed to compare short-term complication rates between matched cohorts.

Results

A total of 2225 patients were identified, with 1432 (64.4%) receiving TAA alone and 793 (35.6%) with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times (P < .001) and length of hospital stay (LOS) (P < 0.001). Rates for extended LOS were significantly higher in the ancillary cohort than in the simple cohort (P = .01). No other complications varied significantly between cohorts, including the incidence of any adverse event (AAE). American Society of Anesthesiologists classification of 4 was found to be an independent risk factor for development of AAE (odds ratio [OR] = 1.091, P = .04). Matched subgroup analysis excluding tendon lengthening as a concomitant procedure found that the ancillary cohort still had longer operative time (P < .001) and LOS (P < .05) than patients undergoing simple TAA.

Conclusion

Without significant difference in rates of AAE other than extended LOS, the relative safety of ancillary TAA appears similar to that of TAA alone. Such knowledge can help inform surgical decision-making and assuage safety concerns for patients requiring additional corrective procedures at the time of TAA.

Level of Evidence

Level III, retrospective comparative study.

A Novel Orthoplastic Reconstruction of Relapsed Clubfoot With Total Ankle Arthroplasty

Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient's poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient's ankle issues and appears to be a viable option for clubfoot patients.