Diabetic management and infection risk in total ankle arthroplasty

BACKGROUND

As total ankle arthroplasty (TAA) increases in popularity nationwide for the management of end-stage arthritis, it is essential to understand ways to mitigate the risk of infection. Diabetes increases the risk of infection due to compromised immunity and impaired wound-healing mechanisms. However, there is limited research on how diabetic management, inclusive of medications and glucose control, may impact infection risks post-TAA. This study aims to demonstrate the impact of diabetic management on the occurrence of periprosthetic joint infection (PJI) following TAA.

METHODS

This was a retrospective study of patients who underwent a TAA at a single academic institution from March 2002 to May 2022. Patients with diabetes who developed an intraarticular infection following TAA were propensity score matched (1:3) to diabetic patients who did not. Data collection included demographics, implant types, diabetic medications, and preoperative hemoglobin A1c. PJI was diagnosed based on Musculoskeletal Infection Society (MSIS) criteria. Statistical analyses assessed differences in medication use, glucose control, and infection rates between groups.

RESULTS

Of the 1863 patients who underwent TAA, 177 patients had a diagnosis of diabetes. The infection rate in patients with diabetes (2.8%) was higher than the total cohort rate (0.8%). Five patients with diabetes developed a PJI at an average of 2.2 months postoperatively. This cohort (n = 5) was compared to propensity score-matched controls (n = 15). There was no significant difference in diabetic medication use. Patients who developed PJI had higher rates of uncontrolled diabetes (60.0% vs. 6.7%) and average A1c levels (7.02% vs. 6.29%) compared to controls.

CONCLUSION

Our findings suggest that the elevated risk of PJI observed in individuals with diabetes subsequent to TAA may be attributed not solely to the presence of diabetes, but to inadequate glycemic control. Effectively managing blood glucose levels is imperative for achieving favorable outcomes following TAA.

LEVEL OF EVIDENCE

III.

Outcomes After Total Ankle Arthroplasty in Patients Aged ≤50 Years at Midterm Follow-up

BACKGROUND

Ankle arthritis differs from arthritis of the hip and knee in that 80% is posttraumatic and thus often occurs in a younger patient population. The literature supporting total ankle arthroplasty (TAA) in younger patients has increased over recent years and has bolstered the argument that in the short term, TAA in younger patients has successful outcomes that are comparable to older, lower-demand patients.The purpose of our study was to evaluate patient-reported outcomes (PROs) and implant survivorship at midterm after primary TAA in patients ≤ 50 years of age at the time of surgery.

METHODS

A retrospective chart review was conducted of patients ≤ 50 years of age who underwent primary TAA at a single institution from 2000 to 2017. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow-up of 5 years. PRO measures were evaluated at preoperative, 1-year postoperative, and final follow-up visits. Paired t tests were performed to compare individual patient changes in PROs from preoperative. Implant survivorship was evaluated based on need for revision of either the tibial or talar component. The need for additional surgery related to the TAA was also evaluated.

RESULTS

A total of 58 patients were included. The average age at the time of the index surgery was 43.3 years (range 22-50 years). All patients had a minimum follow-up of 5 years with a mean follow-up of 8.8 years. A total of 11 patients required additional surgery related to their TAA. Six patients (10.3%) required bone grafting of peri-implant cysts, 3 patients (5.2 %) required gutter debridement, and 1 patient underwent complete revision of metal components. Mean visual analog scale, 36-item Short Form Health Survey, Short Musculoskeletal Function Assessment, and American Orthopaedic Foot & Ankle Society hindfoot scores significantly improved from preoperative to 1-year postoperative and final postoperative follow-up.

CONCLUSION

The patients aged ≤50 years treated with a TAA whom we have been able to observe for a minimum of 5 years showed generally maintained improvement in functional scores and thus far have had a relatively low rate of secondary surgeries.Level of Evidence:Level III, retrospective cohort study.

Revision Total Ankle Arthroplasty Using the INBONE II System

BACKGROUND

The utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, leading to a higher occurrence of revision TAA procedures because of failure of primary TAA. This study aims to examine the clinical results associated with revision TAA using the INBONE II system. Given the growing number of TAA revision procedures and a focus on motion-preserving salvage options, we evaluated our early experience with revision TAA.

METHODS

A retrospective analysis was conducted on a group of 60 presumed noninfected patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis.

RESULTS

The study revealed high complication rates but generally fair clinical outcomes for revision TAA using the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n = 6), nerve injury/impingement (n = 5), infection (n = 3), fracture (n = 3), implant failure (n = 3), impaired wound healing (n = 2), and osteolysis (n = 3). The 3-year survivorship rate from reoperation was 92.0% (82.7%-100.0%) whereas the 3-year survivorship rate from major complications was 90.4% (80.8%-100.0%).

CONCLUSION

We report high complication rates but generally fair clinical results for revision TAA utilizing the INBONE II system.

LEVEL OF EVIDENCE

Level IV, retrospective case series study.

Younger Patients Undergoing Total Ankle Arthroplasty Experience Higher Complication Rates and Worse Functional Outcomes

BACKGROUND

Although many patients with posttraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) have revealed heterogenous results. The purpose of the present study was to determine the effect of age on complication rates and patient-reported outcomes after TAA.

METHODS

We retrospectively reviewed the records of 1,115 patients who had undergone primary TAA. The patients were divided into 3 age cohorts: <55 years (n = 196), 55 to 70 years (n = 657), and >70 years (n = 262). Demographic characteristics, intraoperative variables, postoperative complications, and patient-reported outcome measures were compared among groups with use of univariable analyses. Competing-risk regression analysis with adjustment for patient and implant characteristics was performed to assess the risk of implant failure by age group. The mean duration of follow-up was 5.6 years.

RESULTS

Compared with the patients who were 55 to 70 years of age and >70 years of age, those who were <55 years of age had the highest rates of any reoperation (19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001), implant failure (5.6%, 2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.019), and polyethylene exchange (7.7%, 4.3%, and 2.3% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.021). Competing-risk regression revealed a decreased risk of implant failure for patients who were >70 of age compared with those who were <55 years of age (hazard ratio [HR], 0.21 [95% confidence interval (CI), 0.05 to 0.80]; p = 0.023) and for patients who were 55 to 70 years of age compared with those who were <55 years of age (HR, 0.35 [95% CI, 0.16 to 0.77]; p = 0.009). For all subscales of the Foot and Ankle Outcome Score (FAOS) measure except activities of daily living, patients who were <55 years of age reported the lowest (worst) mean preoperative and postoperative scores compared with those who were 55 to 70 years of age and >70 years of age (p ≤ 0.001). Patients who were <55 years of age had the highest mean numerical pain score at the time of the latest follow-up (23.6, 14.4, 12.9 for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001).

CONCLUSIONS

Studies involving large sample sizes with intermediate to long-term follow-up are critical to reveal age-related impacts on outcomes after TAA. In the present study, which we believe to be the largest single-institution series to date evaluating the effect of age on outcomes after TAA, younger patients had higher rates of complications and implant failure and fared worse on patient-reported outcome measures.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of Radiographic Talar Loosening Rates Between Salto-Talaris and INBONE II

BACKGROUND

Despite substantial increase in total ankle arthroplasty (TAA) nationwide, there are few studies comparing flat-cut vs chamfer-cut talar systems in TAA with regard to radiographic aseptic loosening rates of the implant.

METHODS

This retrospective study included 189 Salto-Talaris TAA and 132 INBONE II primary TAA with a minimum 1-year follow-up. Patient characteristics were obtained including gender, age at surgery, body mass index (BMI), smoking status, primary diagnosis, surgical time, and the presence of diabetes. Radiographic evidence for aseptic loosening was assessed. Statistical analysis was performed for comparison in outcomes between Salto-Talaris and INBONE II.

RESULTS

The mean age of the study population was 63.5 ± 9.8 years at surgery. Mean follow-up was 4.9 ± 3.0 years. Radiographic aseptic loosening of the tibial implant showed no significant difference between the 2 groups: Salto-Talaris, 18%, and INBONE II, 18.9% (P = .829). Aseptic loosening of the talar implant also showed no significant difference between the 2 groups: Salto-Talaris, 1.6%, and INBONE II, 1.5% (P = .959). No variables, including the implant type, were found to contribute to the aseptic loosening rate of either the tibia or talus.

CONCLUSION

In our cohort, we observed no difference in radiographic implant aseptic loosening between Salto-Talaris and INBONE II systems.

LEVEL OF EVIDENCE

Level IV, retrospective case series study.

A Propensity Score Matched Exploration of Infection in Primary Total Ankle Arthroplasty

BACKGROUND

Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. Various demographic, comorbidity, and surgical factors have been associated with an increased risk of infection. However, the evidence base remains limited, and further research is needed regarding infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA.

METHODS

A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified through annual registry surveillance and matched using propensity score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher exact test. The outcomes following infection were identified and summarized using descriptive statistics.

RESULTS

A total of 1863 patients who underwent primary TAA were identified, and 19 were diagnosed with an infection. The identifiable overall infection rate was 1.0%. After PSM, there were no significant differences in the difference in age, gender, BMI, and smoking status between the infected and control cohort. There was a statistically significant increase in the rate of diabetes in the infected cohort. The subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Out of the total number of cases, 2-stage revision to total ankle replacement was performed in 7 cases, whereas revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. One patient had to undergo amputation; however, at the time of the most recent follow-up, all patients were found to be free of infection.

CONCLUSION

This study demonstrated high rates of a history of smoking and diabetes in the infected TAA cohort. The diabetes rate in the infected group was significantly higher than the noninfected controls. Two-stage revision to total ankle replacement was performed in 7 cases, and revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. Overall, a high rate of limb salvage was reported.

LEVEL OF EVIDENCE

Level III, case-control study.

Total Ankle Arthroplasty: Does Obesity Matter?

BACKGROUND

There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient-reported outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs.

METHODS

This was a single-institution, retrospective study of 1093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into control (BMI = 18.5-29.9; n = 615), obesity class I (BMI = 30.0-34.9; n = 285), and obesity class II (BMI > 35.0; n = 193) groups. Patient information, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1).

RESULTS

Compared to control and class I, class II patients had the lowest mean age (P = .001), highest mean ASA score (P < .001), and greatest proportion of female sex (P < .001) and Black/African American race (P = .005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (P > .05).Preoperatively, class II had lower (worse) mean scores for Foot and Ankle Outcome Score pain and ADL subscales than controls (post hoc pairwise P < .001 for both). At final follow-up, both class II and class I had lower (worse) mean Short Musculoskeletal Function Assessment (post hoc pairwise P < .001 and P = .030, respectively) and 36-Item Short Form Health Survey scores (post hoc pairwise P < .001 and P = .005, respectively) than controls.

CONCLUSION

At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single-institution study to date examining the effect of obesity on outcomes after primary TAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Republication of "Keeping It in the Fairway: Golf Handicap Following Total Ankle Arthroplasty"

Background

Total ankle arthroplasty (TAA) provides a surgical alternative to tibiotalar arthrodesis when treating end-stage ankle arthritis. TAA preserves range of motion at the tibiotalar joint leading to improved postoperative function. Many patients who undergo TAA wish to maintain a high level of activity, including participation in low-impact sports such as golf. There are several studies in the total hip and total knee arthroplasty literature that have looked at the effect of total joint arthroplasty on golf handicap. We hypothesized that similar to hip and knee arthroplasty research, TAA is likely to result in a postoperative increase in golf handicap.

Methods

After obtaining institutional review board approval, we retrospectively identified 60 patients (from 140 consecutive TAAs performed between August 2016 and February 2017) who had undergone TAA, played golf pre- and postoperatively, and had at least 1 year of postoperative follow-up. The average postoperative follow-up for the cohort was 28.1 months. Variables including preoperative and postoperative golf handicaps, swing laterality, age, gender, surgical laterality, implant used, and operating surgeon were recorded.

Results

The average preoperative and postoperative handicaps were 19.7 and 17.9, respectively, which did not represent a statistically significant difference (P = .07). Patients who played 3 or more rounds per week had better preoperative and postoperative handicaps compared to patients who played 2 rounds or less; however, the change in their handicap following TAA and the number of rounds played per week was not affected. There was no association between the change in handicap and the follow-up period, handedness of golf shot, surgical laterality, implant used, or the operating surgeon.

Conclusion

Our findings showed that golf handicap was not negatively affected following TAA in this series.

Level of Evidence

Level IV, case series.

Does a fibula-sparing approach improve outcomes in tibiotalocalcaneal arthrodesis?

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is considered a salvage procedure for either complex deformity or arthritis about the hindfoot, and can be performed via fibula-resection (FR) or fibula-sparing (FS) approaches. The primary aim of this study was to investigate differences in outcomes in FR versus FS TTC arthrodeses.

METHODS

This was a retrospective cohort study reviewing outcomes of TTC arthrodesis at a single institution. Patients who underwent a TTC arthrodesis from 2005 to 2017 and had minimum two-year follow-up were included. Preoperative diagnosis, pre- and post-operative radiographic coronal alignment, fixation methods, and complications were compared between groups.

RESULTS

107 patients (110 ankles) underwent TTC arthrodesis, with a mean age of 57.0 years (sd, 14.0 years). The mean clinical follow-up was 50.7 months (range, 24-146) and mean radiographic follow-up was 45.8 months (range, 6-146 months). Pre-operative diagnoses included arthritis (N = 40), prior non-union (N = 21), Charcot neuro-arthropathy (N = 15), failed total ankle arthroplasty (N = 15) and avascular necrosis of the talus (N = 19). Sixty-nine ankles comprised the FS group and 41 comprised the FR group. There was no significant difference in the non-union rate between groups (29% FR vs 38% FS, p = 0.37), complication rate (59% FR vs 64% FS, p = 0.59), or post-operative coronal standing radiographic alignment (89.6 degrees FR, 90.5 degrees FS, p = 0.26). Logistic regression analyses demonstrated a pre-operative diagnosis of failed TAA was associated with post-operative nonunion (OR:3.41,CI:1.13-11.04,p = 0.03). Pre-operative indication for TTC arthrodesis of arthritis alone was associated with a decreased risk of non-union (OR:0.27,CI:0.11-0.62,p = 0.002).

CONCLUSION

TTC arthrodesis is a successful surgical option for complex hindfoot deformity, arthritis, and limb salvage regardless of surgical approach. We did not detect a difference in the union rate, incidence of complications, or coronal plane radiographic alignment in fibula-sparing versus fibula-resection constructs. Patients with a pre-operative indication for surgery of arthritis may be at decreased risk of developing non-union.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Tibiopedal Motion Following Tendo-Achilles Lengthening or Gastrocnemius Recession in Total Ankle Replacement: A Comparative Cohort Study

BACKGROUND

End-stage ankle arthritis is a debilitating condition often necessitating total ankle replacement (TAR). Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are commonly performed with TAR to improve ankle dorsiflexion (DF). No studies to date have radiographically analyzed tibiopedal motion to guide surgical management. The purpose of this study is to determine the effect of a TAL or GR during TAR on radiographic tibiopedal range of motion (ROM).

METHODS

A retrospective review of a prospectively maintained database was conducted followed by a propensity score-matched analysis of 110 patients who underwent TAL (n = 26), GR (n = 29), or no lengthening procedure (n = 55) with TAR. Minimum of 1-year ROM radiographic follow-up was required. Exclusion criteria included (1) calcaneal osteotomies, (2) simultaneous or previous hindfoot or midfoot arthrodesis, (3) prior ankle arthrodesis, or (4) revision TAR. Demographic data were extracted from the TAR database. Radiographic assessment included tibiopedal dorsiflexion (DF) and plantarflexion (PF).

RESULTS

DF improved by 2.8 degrees (P = .0286) and by 6.0 degrees (P < .0001) in the TAL and GR cohorts, respectively, with no difference in the control group (+0.7 degrees, P = .3764). PF was decreased by 4.5 degrees (P = .0152) and by 7.2 degrees (P = .0002) in the TAL and GR cohorts, respectively, with no difference in the control group (-0.2 degrees, P = .8546). Minimal differences were observed for total arc of motion for all 3 groups (control 0.5 degrees, GR -1.2 degrees, TAL -1.7 degrees), all of which were nonsignificant (all P > .05). There was no between-group difference in the change in overall arc of motion between the groups (P = .3599). GR resulted in a greater increase in DF (6.0 vs 2.8 degrees; P = .1074), with a reciprocal greater decrease in PF (7.2 vs 4.5 degrees; P = .2416) compared with the TAL cohort.

CONCLUSION

Both TAL and GR increased postoperative DF; however, this was accompanied by a reciprocal loss in PF. Minimal differences were observed for total arc of motion. Patients should be counseled that concomitant procedures performed to increase DF will do so at the expense of PF.

LEVEL OF EVIDENCE

Level III, retrospective review of prospectively collected data.

Clinical Outcomes and Complications of Simultaneous or Sequential Bilateral Total Ankle Arthroplasty: A Single-Center Comparative Cohort Study

BACKGROUND

The risk-benefit profiles of simultaneous total ankle arthroplasty (TAA) compared with sequential TAA continue to be debated. There are limited case series reporting outcomes after bilateral TAA, with no previous comparison of simultaneous TAA with sequential TAA. Patients with bilateral pathology represent a unique population with an overall more debilitating condition. Thus, we aimed to compare bilateral simultaneous and sequential TAAs, including perioperative complications and patient-reported outcome measures.

METHODS

We performed a comparative cohort study of patients who underwent primary bilateral TAA, performed in a simultaneous or sequential fashion, from 2007 to 2019 at a single academic center. Data on patient demographic characteristics, comorbidities, perioperative complications, reoperations, and implant failures were collected. Patient-reported outcome measures included preoperative and postoperative visual analog scale (VAS) scores for pain, Short Form-36 Health Survey (SF-36) scores, and Short Musculoskeletal Function Assessment (SMFA) scores.

RESULTS

A total of 50 patients (100 ankles) were included, with 25 patients (50 ankles) each in the bilateral simultaneous and sequential cohorts. The mean follow-up was 52.2 ± 27.3 months (range, 24 to 109 months). The mean time between sequential TAAs was 17.5 ± 20.1 months (range, 3 to 74 months). The mean patient age was 64.3 ± 10.6 years (range, 21 to 76 years), and 32 (64.0%) were men. The majority of patients (28 patients [56.0%]) had primary osteoarthritis. Both cohorts had equivalent preoperative patient-reported outcome measures and experienced improvements in all measures, which were maintained at the final follow-up with no significant between-group differences (all p > 0.05). There were no differences between the simultaneous TAA group and the sequential TAA group in perioperative complication rates (22.0% compared with 24.0%; p = 0.7788), reoperations (12.0% compared with 10.0%; p = 0.7354), 5-year reoperation-free survival (88.0% compared with 90.0%; p = 0.4612), or failure-free survival (100%). One patient in the simultaneous TAA cohort required metal component revision at 8 years postoperatively.

CONCLUSIONS

The patient-reported outcome measures, complications, and prosthesis survival of patients who underwent bilateral simultaneous TAA were comparable with those of patients who underwent bilateral sequential TAA. We advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

RESULTS

A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Comparison of the Clinical Outcomes and Complications of Simultaneous vs Staged Bilateral Total Ankle Arthroplasty: A Single-Center Comparative Cohort Study

Category:

Ankle Arthritis; Ankle; Hindfoot

Introduction/Purpose:

The utilization of total ankle arthroplasty (TAA) has increased over the past decade to include bilateral TAAs. The risk-benefit profiles of simultaneous versus staged joint arthroplasty continues to be debated in the literature. There are limited case series reporting outcomes after bilateral TAA with no previous comparison of simultaneous versus staged TAA. It is important to study patients with bilateral pathology as they represent a unique population often with a differing arthritis etiology and an overall more debilitating condition. Thus, we aim to compare bilateral simultaneous versus staged TAAs including perioperative complications and patient reported outcome measures (PROMs).

Methods:

We performed a comparative cohort study of patients who underwent primary TAA from 2007 to 2019 at a single academic center. Inclusion criteria were primary bilateral TAA performed in simultaneous or staged fashion in patients over 18 years of age. Exclusion criteria were patients with less than two-years follow-up and those with previous tibiotalar arthrodesis or infection. Patient demographics, comorbidities, perioperative complications, and PROMs were collected. PROMs included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Bivariate tests of significance were used to compare variables between the two cohorts.

Results:

Fifty patients were included with an average clinical follow-up was 52.2 (+-27.3; range 24-109) months. The mean time between staged TAA surgeries was 17.5 months (+-20.1, range 3-74). The mean age was 64.3 (+-10.6, range 21-76) years with 32 (64.0%) men. Many patients had primary osteoarthritis (n=28, 56.0%). Both cohorts experienced improvement in all PROMs at one year, which were maintained at final follow-up with no significant between-group differences (p >0.05). There were no differences in perioperative complication rates with similar overall complications (22.0% vs. 24.0%; p=0.7788) and reoperations (6.0% vs 5.0%; p=0.7354) between the simultaneous and staged cohorts, respectively. The two-year and five-year reoperation-free survival were 96.0% and 90.0% for the staged cohort and 94.0% and 88.0% for the simultaneous cohort, respectively (p=0.4612) Both cohorts had 100% failure-free survival up to eight-years postoperative. One patient in the simultaneous cohort required metal component revision at eight years postoperative.

Conclusion:

The results of bilateral simultaneous TAA, including patient reported outcomes, perioperative complications, and component survival are comparable to patients undergoing staged TAA. When performed under surgeon expertise in appropriately selected patients, we advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. Potential benefits of simultaneous TAA warranting further investigation include decreased anesthesia events, surgery time, tourniquet time, length of hospitalization, recovery and rehabilitation time, and overall cost. Future investigations will include dedicated analyses of radiographic outcomes and cost comparisons between these two cohorts.

Comparison of Radiographic and Clinical Outcomes of First Tarsometatarsal Arthrodesis with the Lapiplasty System vs Cross-Screw Fixation

Category:

Midfoot/Forefoot; Bunion

Introduction/Purpose:

Hallux valgus (HV) is recognized as a triplanar deformity comprising axial abduction, sagittal hypermobility, and coronal pronation of the first metatarsal. A first tarsometatarsal (TMT) arthrodesis may be used to address all three planes of deformity. The Lapiplasty system (Treace Medical Concepts, Inc., Ponte Vedra, FL) was developed to reproducibly address triplanar deformity. However, the Lapiplasty system is costlier than other fixation constructs. Because healthcare is increasingly value-focused, we sought to determine if the more expensive Lapiplasty system improved radiographic outcomes or decreased complication rates over standard cross-screw fixation. We hypothesized that HV patients undergoing first TMT arthrodesis with the Lapiplasty system would have equivalent radiographic correction and similar complication rates when compared to patients treated with cross-screw fixation.

Methods:

In this multi-center, IRB-approved retrospective study, consecutive series of patients who underwent 1st TMT arthrodesis for HV, either with cross-screw fixation at Institution A, or Lapiplasty at Institution B, were identified by registry search. Inclusion criteria included age over 18 and preoperative and minimum 6-month postoperative weight-bearing AP and lateral radiographs. Exclusion criteria included primary conditions other than hallux valgus and previous first ray surgeries or ipsilateral arthrodeses. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP) were measured preoperatively and at final follow-up, and clinic notes were reviewed to identify complications and reoperations. To compare cohorts, Mann-Whitney U tests and Fisher's Exact tests were applied for continuous and discrete variables, respectively. To examine preoperative-postoperative changes, Wilcoxon signed rank tests were used. Multivariable regressions tested the effect of fixation constructs on postoperative radiographic parameters, adjusted for preoperative radiographic measurements, age, sex, and BMI.

Results:

65 patients were included in each group, with 121 (93.8%) female patients, mean (SD) age 54.7 (14.8), BMI 25.8 (5.2), and radiographic follow-up time 8.9 (6.7) months. The Lapiplasty cohort had greater BMI (26.8 vs. 24.7, P = .048), and there were no significant differences between groups in age, sex distribution, and radiographic follow-up time. Radiographic measurement data is displayed in Table 1. After adjusting for age, sex, BMI, preoperative HVA, and preoperative IMA, fixation with Lapiplasty was significantly associated with lower postoperative IMA (b=-2.03, 95% CI = [-2.78, -1.37], P < .001) and lower postoperative HVA (b= -7.48; 95% CI = [-9.69, -5.26]; P < .001), but not postoperative sesamoid position. There were no significant differences between cohorts in the incidence of complications or reoperations.

Conclusion:

We found that use of the Lapiplasty system was associated with better radiographic hallux valgus correction, as evidenced by lower postoperative HVAs and IMAs, compared to standard technique with crossing screws. The clinical significance of these findings is unclear, as complication and reoperation rates were similar between groups. Future research assessing longer- term outcomes, patient-reported outcome data, and cost-benefit analysis will be necessary to further compare techniques and fixation systems.

Midterm Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder

BACKGROUND

In cases of large osteochondral lesions of the talus (OLTs), fresh structural or bulk osteochondral allograft transplantation has yielded favorable outcomes in several retrospective and few prospective case series. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation of the talar shoulder.

METHODS

A prospective evaluation of patients who received a fresh structural allograft of an OLT was performed. Preoperative imaging included magnetic resonance imaging (MRI) and/or computed tomography (CT) with plain radiographs. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 36-Item Short-Form Health Survey (SF-36), visual analog scale (VAS) for pain, and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative imaging were evaluated for allograft assimilation, evidence of arthritic changes, or functional range of motion abnormalities.

RESULTS

Thirty-one patients with a mean age of 41.4 years (±14.1, range 18-69) underwent structural fresh osteochondral allograft transplantation to the talar shoulder and were included in this study. The mean follow-up was 56.2 months (±36.1, range 24-142). The majority of patients were female (n=17, 54.8%), reported some history of prior ankle trauma (n=21, 67.7%), and underwent prior ankle surgery (n=23, 74.2%). The mean lesion size on CT scan was 1879 mm³ (n = 27) compared to the mean lesion size of 3877 mm³ (n = 21) on MRI. There was a significant improvement in the mean preoperative VAS score (P < .0001), SF-36 score (P < .0005), SMFA bother index (P < .0015), and the SMFA function index (P < .0001) at final follow-up. A total of 15 (48.4%) patients underwent an additional surgery following their osteochondral allograft transplant, most commonly arthroscopic debridement or removal of hardware, performed at an average of 25.2 (±13.0) from their index procedure. There was one failure that required a total ankle replacement. The overall graft survival rate was 96.8%.

CONCLUSION

Fresh, structural allograft transplantation resulted in significant improvement in patient-reported postoperative pain and function in patients suffering from OLTs. The graft survival rate was 96.8% at a mean of 56.2 months follow-up, with half of patients requiring a second procedure.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

Treatment of Navicular Stress Fractures With an Algorithmic Approach

BACKGROUND

Navicular stress fractures are becoming increasingly more common. There is no universal consensus on treatment. We provide an algorithm that we feel will be useful in determining treatment.

METHODS

A retrospective study was performed on all patients having operative treatment of navicular stress fractures during a 10-year period. Acute fractures were treated with open reduction internal fixation. Chronic fractures greater than 3 months were treated with open reduction and internal fixation (ORIF) and iliac crest bone grafting. Chronic fractures with evidence of sclerosis, avascular changes, or those who failed previous surgery were treated with ORIF, iliac crest bone grafting, as well as vascular bone grafting. Patients' pain scores were recorded and a return-to-sports scale was used. Radiographic union was compared among the 3 groups using computed tomographic (CT) scans or radiographs.

RESULTS

Forty-three patients were identified. Fifteen received ORIF alone, 12 were treated with ORIF and bone graft, and 16 had ORIF with vascularized bone grafting. No difference was found among the median age of the 3 groups. In terms of radiographic healing, 3 patients in the ORIF group received radiographs alone. All other patients had follow-up CT scans. ORIF alone group had 80% union, ORIF with bone graft had 75% union, and ORIF with vascularized bone grafting had 100% union. Return to sports did not show any difference among the 3 groups.

CONCLUSION

The algorithm dividing navicular stress fractures into 3 distinct groups with different operative techniques helped us address these difficult cases. Vascularized bone grafting certainly appeared to be beneficial for the more difficult cases.

LEVEL OF EVIDENCE

Level IV, case series.

Histological and Inflammatory Cytokine Analysis of Osteochondral Lesions of the Talus After Failed Microfracture: Comparison With Fresh Allograft Controls

Background:

The most common first-line treatment of osteochondral lesions of the talus (OLTs) is microfracture. Although many patients do well with this procedure, a number fail and require reoperation. The mechanism of failure of microfracture is unknown, and to our knowledge there has been no research characterizing failed microfracture regarding histological and inflammatory makeup of these lesions that may contribute to failure.

Purpose:

To characterize the structural and biochemical makeup of failed microfracture lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

Specimens from 8 consecutive patients with symptomatic OLTs after microfracture who later underwent fresh osteochondral allograft transplantation were analyzed. For each patient, the failed microfracture specimen and a portion of the fresh allograft replacement tissue were collected. The allograft served as a control. Histology of the failed microfracture and the allograft replacement was scored using the Osteoarthritis Research Society International (OARSI) system. Surface roughness was also compared. In addition, tissue culture supernatants were analyzed for 16 secreted cytokines and matrix metalloproteinases (MMPs) responsible for inflammation, pain, cartilage damage, and chondrocyte death.

Results:

The OARSI grade, stage, and total score as well as surface smoothness were significantly worse in the failed microfracture sample, indicating better cartilage and bone morphology for the allografts compared with the failed microfracture lesions. Analyzed cytokines and MMPs were significantly elevated in the microfracture tissue culture supernatants when compared with fresh osteochondral tissue supernatants.

Conclusion:

These data demonstrate a significantly rougher cartilage surface, cartilage and subchondral bone histology that more closely resembles osteoarthritis, and elevated inflammatory cytokines and MMPs responsible for pain, inflammation, cartilage damage, and chondrocyte death when compared with fresh osteochondral allografts used as controls.

Improvement in Health-Related Quality of Life After Total Ankle Arthroplasty Compares Well With Other Successful Orthopaedic and Nonorthopaedic Procedures

Background. Ankle arthritis is a major cause of disability. Orthopaedic literature suggests improvement in health-related quality of life (HRQOL) after total ankle arthroplasty (TAA). This has not been compared with improvements observed in successful orthopaedic and nonorthopaedic procedures, including anterior cervical discectomy/fusion (ACDF), total knee arthroplasty (TKA), coronary artery bypass grafting (CABG), and orthotopic liver transplant (OLT). We hypothesize that the effects after TAA are comparable to several successful surgical procedures. Methods. 500 consecutive TAA patients were included and grouped with 2 other large series. Short Form-36 (SF36) were collected at standardized intervals. A systematic literature review identified studies comparing preoperative and postoperative SF36 physical (PCS) and mental component summary (MCS) scores. Using meta-analyses, we pooled the data for each procedure to compare with the TAA group. Results. Patients in all cohorts had preoperative SF36 MCS and PCS scores that were significantly lower than that in the general population. Improvements in HRQOL after TAA were not statistically different from improvements reported in PCS and MCS after ACDF, TKA, and OLT. However, improvement in PCS after TAA was better than that observed after CABG. Conclusions. Disability with ankle arthritis is severe. Disability associated with cervical disc disease, knee arthrosis, coronary artery disease, and liver failure is also severe, with surgical intervention providing major improvements in HRQOL postoperatively. The improvement in HRQOL after TAA did not differ statistically from ACDF, TKA, CABG, and OLT. Our investigation suggests that the HRQOL benefits of TAA meet benchmarks set by some of modern medicine's best.Levels of Evidence: Level III: Systematic review.

Analysis of 408 Total Ankle Arthroplasty Adverse Events Reported to the US Food and Drug Administration From 2015 to 2018

Background. Total ankle arthroplasty (TAA) use has increased with newer generation implants. Current reports in the literature regarding complications use data extracted from high-volume centers. The types of complications experienced by lower-volume centers may not be reflected in these reports. The purpose of this study was to determine a comprehensive TAA adverse event profile from a mandatory-reporting regulatory database. Methods. The US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2015 to 2018 to determine reported adverse events for approved implants. Results. Among 408 unique TAA device failures, the most common modes of failure were component loosening (17.9%), intraoperative guide or jig error (15.4%), infection (13.7%), and cyst formation (12.7%). In addition, the percentage distribution of adverse event failure types differed among implants. Conclusion. The MAUDE database is a publicly available method that requires mandatory reporting of approved device adverse events. Using this report, we found general agreement in types of complications reported in the literature, although there were some differences, as well as differences between implants. These data may more accurately reflect a comprehensive profile of TAA complications as data were taken from a database of all device users rather than only high-volume centers.Levels of Evidence: NA.

Prevalence of Hallux Rigidus in Patients With End-Stage Ankle Arthritis

Arthritis of the foot is a significant cause of pain and disability. The prevalence of foot arthritis in adults aged ≥50 has been reported to be 17%. Of those, 25% are estimated to be radiographic arthritis of the first metatarsophalangeal joint. The purposes of this study were to (1) identify the prevalence of radiographic hallux rigidus (HR) in a population of patients with end-stage ankle arthritis relative to that reported in the general population and (2) identify associations between the presence of HR and demographic and clinical factors. A total of 870 feet in 809 subjects with end-stage ankle arthritis who underwent primary total ankle arthroplasty between November 2006 and November 2017 were included. Feet were stratified by patient age: <40, 40 to 59, 60 to 79, and ≥80 years. Etiology of ankle arthritis was classified as inflammatory, post-traumatic, primary, and other. The prevalence of HR in the study group was 72.9%. The prevalence of HR was slightly higher in patients with inflammatory arthritis (odds ratio 1.31, 95% confidence interval 0.73 to 2.32) and primary arthritis (odds ratio 1.18, 95% confidence interval 0.86 to 1.63). The prevalence of HR increased with age (p = .01). In conclusion, the prevalence of radiographic HR in a population with end-stage ankle arthritis was significantly higher relative to patients without documented comorbidities in the foot and ankle. Increasing age was associated with a higher prevalence of the disease.

Effect of Gender Differences on Patient-Reported Outcomes and Complications in Total Ankle Replacement

BACKGROUND

The purpose of this study was to evaluate gender differences in patient outcomes and complications following total ankle replacement (TAR).

METHODS

Consecutive patients who underwent primary TAR from July 2007 through May 2016 were prospectively followed and retrospectively reviewed. Demographic, operative, patient-reported outcomes (PROs), and complication data were collected and analyzed. PROs included the visual analog scale (VAS), 36-Item Short-Form Health Survey (SF-36), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Short Musculoskeletal Function Assessment (SMFA). A total of 475 patients were evaluated, including 248 males (52.2%) and 227 females (47.8%) with an average of 56.8 months follow-up.

RESULTS

Women were more likely to have inflammatory arthritis (13.7% vs 2.8%; P < .01) and significantly worse preoperative SF-36 total, SF-36 mental health component, AOFAS total, AOFAS pain, SMFA function, and SMFA bother scores (all P < .05). Both genders demonstrated significant improvement in PROs at 1, 2, and 5 years. The magnitude of improvement was similar between genders for all PROs (all P < .05) with the exception of SF-36 physical function, which was greater in men. Females underwent more nonrevision reoperations (32.2% vs 22.6%; P = .0191), but there was no significant difference in failure rates (male 7.3% vs female 3.5%; P = .07). The reoperation and failure rates at 2 years postoperation were 10.1% and 1.6% for men and 18.5% and 0.9% for women, respectively.

CONCLUSION

Women undergoing TAR were more likely to have worse preoperative PROs and higher rates of nonrevision reoperations, which remains true when controlling for their increased incidence of inflammatory arthritis. However, women reported similar improvements in PROs and had similar prosthetic survival rates as men. Increased understanding of these disparities, combined with gender-based interventions, may further advance patient outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic, retrospective comparative series.

Intermediate-term Patient-Reported Outcomes and Radiographic Evaluation Following Intramedullary- vs Extramedullary-Referenced Total Ankle Replacement

BACKGROUND

The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR).

METHODS

From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12).

RESULTS

The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P < .0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P = .6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P < .0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P > .05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up.

CONCLUSION

The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The Impact of Preoperative Mental Health and Depression on Outcomes After Total Ankle Arthroplasty

BACKGROUND

Preoperative mental health and depression have been shown to negatively impact patient-reported outcome measures after a broad array of orthopaedic procedures including total ankle arthroplasty. The hypothesis for this study was that decreased Short Form (SF)-36 Mental Component Summary (MCS) scores will modulate the impact of depression on patient-reported outcome measures after total ankle arthroplasty.

METHODS

All patients undergoing primary total ankle arthroplasty between January 2007 and December 2016 who were enrolled into a prospective outcomes study and who had at least 1-year minimum study follow-up were retrospectively reviewed. Patients were separated into 4 groups based on the presence or absence of an SF-36 MCS score of <35 points and diagnosis of depression. SF-36 Physical Component Summary (PCS) and MCS scores, Short Musculoskeletal Function Assessment (SMFA) function and bother components, and visual analog scale (VAS) pain were collected preoperatively and in the 1 to 2-year follow-up. The Wilcoxon rank sum was used to assess differences in outcomes by depression and low preoperative MCS scores. Multivariable models were then constructed to evaluate between-group differences in change scores according to preoperative SF-36 MCS scores and a diagnosis of depression, with adjustment for baseline patient and treatment characteristics.

RESULTS

Patients with depression and those with low preoperative MCS scores had significantly worse final outcome scores along with reduced improvement in SF-36 PCS and VAS pain scores compared with patients without these risk factors. Among patients with depression, low preoperative MCS scores helped to differentiate patients with poor final outcome scores. Similarly, in patients with low preoperative MCS scores, depression helped to differentiate patients with poor final outcome scores.

CONCLUSIONS

Although patients achieved significant improvements in functional outcomes regardless of cohort, decreased preoperative mental health modulated the impact of depression on outcomes. Patients with diminished preoperative mental health and depression are at an increased risk for sustaining smaller improvements in outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery

BACKGROUND

We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR).

METHODS

We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected.

RESULTS

The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001).

CONCLUSION

While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Vitamin D and the athlete-patient: state of the art

Vitamin D deficiency is common in athletes. The conventional measurement of vitamin D levels provides a general indicator of body stores. However, there are nuances in its interpretation as values of 25(OH)D do not correlate absolutely with the amount of 'bioavailable' vitamin to the cells. Vitamin D should be regarded as a hormone and influences between 5% and 10% of our total genome. Determining the precise effect of the vitamin, isolated from the actions of other cofactors, is not straightforward and restricts our complete understanding of all of its actions. Deficiency has harmful effects on not only bone and muscle but also wider areas, including immunity and respiratory and neurological activities. More caution should be applied regarding the ability of supranormal vitamin D levels to elevate athletic performance. Hopefully, future research will shed more light on optimal levels of vitamin D and supplementation regimes, and improved understanding of its intracellular control of our genetic mechanisms and how extrinsic influences modify its activity.

Biomechanical Effect on Joint Stability of Including Deltoid Ligament Repair in an Ankle Fracture Soft Tissue Injury Model With Deltoid and Syndesmotic Disruption

BACKGROUND

The current operative standard of treatment for bimalleolar equivalent ankle fracture is open reduction and internal fixation (ORIF) of the lateral malleolus followed by syndesmotic stabilization if indicated. There is controversy surrounding the indication and need for deltoid ligament repair in this setting. The purpose of this study was to quantify the biomechanical effect of deltoid ligament repair in an ankle fracture soft tissue injury model.

METHODS

Nine fresh-frozen cadaveric specimens were included in this study. Each leg was tested under 5 conditions: intact, syndesmosis and deltoid ligament sectioned, syndesmosis fixed, deltoid repaired, and both the syndesmosis and deltoid ligament repaired. Anterior, posterior, lateral, and medial drawer and rotational stresses were applied to the foot, and the resulting talus displacement was documented.

RESULTS

Isolated deltoid repair significantly reduced anterior displacement to normal levels. Displacement with lateral drawer testing was not significantly corrected until both structures were repaired. Deltoid repair and syndesmosis fixation each reduced internal rotation significantly with further reduction to normal levels when both were repaired. External rotation remained elevated relative to the intact condition regardless of which structures were repaired.

CONCLUSION

There is existing controversy regarding the importance of deltoid ligament repair in the setting of ankle fractures. The findings of this biomechanical study indicate that deltoid ligament repair enhances ankle stability in ankle fractures with both syndesmotic and deltoid disruption.

CLINICAL RELEVANCE

Concomitant deltoid ligament repair in addition to stabilization of fracture and syndesmosis may improve long-term functioning of the ankle joint and clinical outcomes.

Patient Characteristics of Possible Responders and Nonresponders to Total Ankle Arthroplasty

BACKGROUND

Characteristics of responders, or those who achieve a clinical improvement above the level of a minimal clinically important difference, have not been defined for total ankle arthroplasty (TAA). The purpose of this study was to determine patient characteristics that distinguish possible responders from possible nonresponders after TAA using criteria established for other arthroplasty surgeries.

METHODS

Patients undergoing TAA who were enrolled into a prospective study at a single academic center evaluating patient-reported outcomes were included. Patients were characterized as possible responders if the relative or absolute improvement in their 2-year follow-up Short Musculoskeletal Function Assessment (SMFA) function score was at least 50% or 20, respectively, compared with their preoperative score, consistent with Outcome Measures in Rheumatoid Arthritis Clinical Trials and the Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. Patient factors were then associated with possible responder or nonresponder status and a multivariable analysis was performed. A total of 491 patients with complete data and 2-year follow-up were included in this study.

RESULTS

Multivariable analysis demonstrated that a higher baseline 36-Item Short-Form Survey (SF-36) mental component summary (MCS) score (OR [95% CI], 1.02 [1.01, 1.04]; P = .003), indicating better mental health, was associated with being a possible responder to TAA. The presence of rheumatic disease (OR [95% CI], 0.38 [0.22, 0.67]; P = .001) was a significant predictor of being a possible nonresponder.

CONCLUSION

Our data reveal that a higher baseline SF-36 MCS score was associated with increased improvement in SMFA function scores, while rheumatic disease was associated with worse improvement in SMFA function scores after TAA. Patients with rheumatic disease or poor mental health may not achieve as favorable results after TAA and should be counseled appropriately.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of Tibiotalocalcaneal Arthrodeses Using a Sustained Dynamic Compression Nail Versus Nondynamized Nails

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis and deformity. Loss of compression over time with statically locked nails may contribute to nonunion. A novel retrograde intramedullary nail with an internal pseudoelastic component has recently been used to provide sustained dynamic compression (SDC). The purpose of this study was to compare fusion rates and time to union between the SDC and nondynamized (ND) nails. Methods. All patients who underwent TTC arthrodesis with an intramedullary nail at a single institution from 2013 to 2017 and who had at least 1 year of follow-up were included in this study. Baseline patient and operative characteristics were collected and compared between the sustained SDC and ND nail groups. The rate of successful fusion, time to union, and complications were compared between the groups. Results. The SDC cohort had a significantly faster time to union by 3.9 months (P = .049). The SDC cohort had a higher fusion rate (78.0%) compared with the ND nail cohort (75.0%), although this was not statistically significant (P = .75). The SDC nail was used significantly (P < .05) more often in patients with known risk factors for nonunion, including female sex, smoking, revision surgery, prior trauma, and patients requiring 3D cage implants for significant bone loss. There were no differences between the groups in terms of complications. Conclusion. The SDC nail has been shown to achieve successful arthrodesis in a population at high risk for nonunion, using less hardware, and at a faster rate than ND nails. Level of Evidence: Level III: Retrospective, comparative study.

Results of Tibia and Fibula Osteotomies Performed Concomitant to Total Ankle Replacement

BACKGROUND

Neutral ankle alignment along with medial and lateral support are paramount to the success of total ankle replacement (TAR). Fibula, intra-articular medial malleolus, and supramalleolar tibia osteotomies have been described to achieve these goals; however, the literature is scant with outcomes and union rates of these osteotomies performed concomitant to TAR. The purpose of this study was to describe our results.

METHODS

A retrospective review was performed to identify patients who had a concomitant tibia, fibula, or combined tibia and fibula osteotomy at the same time as TAR. Routine radiographs were used to assess osteotomy union rates and changes in alignment. Outcomes questionnaires were evaluated preoperatively and at most recent follow-up. Twenty-six patients comprising 4% of the total TAR cohort were identified with a mean follow-up of 3.9 years.

RESULTS

There were 12 combined tibia and fibula osteotomies, 9 isolated tibia osteotomies, and 5 isolated fibula osteotomies. The union rate for these osteotomies was 92%, 100%, and 100%, respectively. Mean coronal alignment improved from 15.2 to 2.1 degrees (P < .001). There was significant improvement in patient-reported outcome scores, including Short Form-36, Short Musculoskeletal Function Assessment, and visual analog scale pain. There was 1 failure in the study.

CONCLUSION

These data demonstrate successful use of tibia, fibula, or combined tibia and fibula osteotomies at the same time as TAR in order to gain neutral ankle alignment. The overall union rate was 96% with significant improvement in alignment, pain, and patient-reported outcomes. We believe concomitant osteotomies can be considered a successful adjunctive procedure to TAR.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Prospective Randomized Trial Comparing Mobile-Bearing and Fixed-Bearing Total Ankle Replacement

BACKGROUND

Outcomes of total ankle replacement for the treatment of end-stage ankle arthritis continue to improve. Debate continues whether a mobile-bearing total ankle replacement (MB-TAR) or a fixed-bearing total ankle replacement (FB-TAR) is superior, with successful outcomes reported long term for MB-TAR and at intermediate- to long-term follow-up for newer generation FB-TAR. Although comparisons between the 2 total ankle designs have been reported, to our knowledge, no investigation has compared the 2 designs with a high level of evidence. This prospective, randomized controlled trial conducted at a single institution compares patient satisfaction, functional outcomes, and radiographic results of the mobile-bearing STAR and the fixed-bearing Salto-Talaris in the treatment of end-stage ankle arthritis.

METHODS

Between November 2011 and November 2014, adult patients with end-stage ankle osteoarthritis failing nonoperative treatment were introduced to the study. With informed consent, 100 patients (31 male and 69 female, average age 65 years, range 35-85 years) were enrolled; a demographic comparison between the 2 cohorts was similar. Exclusion criteria included inflammatory arthropathy, neuropathy, weight exceeding 250 pounds, radiographic coronal plane deformity greater than 15 degrees, or extensive talar dome wear pattern ("flat-top talus"). Prospective patient-reported outcomes, physical examination, and standardized weightbearing ankle radiographs were obtained preoperatively, at 6 and 12 months postoperatively, and then at yearly intervals. Data collection included visual analog pain score, Short Form 36, Foot and Ankle Disability Index, Short Musculoskeletal Functional Assessment, and American Orthopaedic Foot & Ankle Society ankle-hindfoot score. Surgeries were performed by a nondesign team of orthopedic foot and ankle specialists with total ankle replacement expertise. Statistical analysis was performed by a qualified statistician. At average follow-up of 4.5 years (range, 2-6 years) complete clinical data and radiographs were available for 84 patients; 7 had incomplete data, 1 had died, 4 were withdrawn after enrolling but prior to surgery, and 4 were lost to follow-up.

RESULTS

In all outcome measures, the entire cohort demonstrated statistically significant improvements from preoperative evaluation to most recent follow-up with no statistically significant difference between the 2 groups. Radiographically, tibial lucency/cyst formation was 26.8% and 20.9% for MB-TAR and FB-TAR, respectively. Tibial settling/subsidence occurred in 7.3% of MB-TAR. Talar lucency/cyst formation occurred in 24.3% and 2.0% of MB-TAR and FB-TAR, respectively. Talar subsidence was observed in 21.9% and 2.0% of MB-TAR and FH-TAR, respectively. Reoperations were performed in 8 MB-TARs and 3 FH-TARs, with the majority of procedures being to relieve impingement or treat cysts and not to revise or remove metal implants.

CONCLUSION

With a high level of evidence, our study found that patient-reported and clinical outcomes were favorable for both designs and that there was no significant difference in clinical improvement between the 2 implants. The incidence of lucency/cyst formation was similar for MB-TAR and FH-TAR for the tibial component, but the MB-TAR had greater talar lucency/cyst formation and tibial and talar subsidence. As has been suggested in previous studies, clinical outcomes do not necessarily correlate with radiographic findings. Reoperations were more common for MB-TAR and, in most cases, were to relieve impingement or treat cysts rather than revise or remove metal implants.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Algorithm for Management of Periprosthetic Ankle Fractures

BACKGROUND

Evidence on the management of and outcomes from periprosthetic fractures about a total ankle replacement (TAR) are limited. The purpose of this study was to develop an algorithm for the management of patients with postoperative periprosthetic fractures about a TAR.

METHODS

This was a retrospective analysis of patients undergoing a TAR from 2007 through 2017 with a subsequent periprosthetic fracture >4 weeks from index surgery. Implant stability was defined radiographically and intraoperatively where appropriate. Univariate and multivariate analyses were used to identify differences in outcomes. Thirty-two patients were identified with a remote TAR periprosthetic fracture with an average follow-up of 26 months (range, 3-104 months).

RESULTS

Most fractures were located about the medial malleolus (62.5%); the majority of fractures (75%) were deemed to have stable implants. Fractures of the talus always had unstable implants and always required revision TAR surgery (100%, P = .0002). There was no difference in patient-reported outcomes between stable and unstable fractures at an average of 36 months. In a multivariate analysis, fracture location (talus), less time to fracture, and implant type were found to be predictive of unstable implants ( P < .001). Implant stability was independently associated with the need for revision surgery ( P < .049). Nonoperative treatment was independently associated with treatment failure ( P < .001).

CONCLUSION

The majority of stable fractures about a TAR required operative fixation. Management with immobilization was fraught with a high rate of subsequent surgical intervention. We found that fractures about the talus required revision TAR surgery or arthrodesis.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Outcomes of Total Ankle Arthroplasty in Moderate and Severe Valgus Deformity

Introduction. Failure to correct coronal deformity at the time of total ankle arthroplasty (TAA) can lead to early implant failure. We aimed to determine clinical, radiographic, and patient-reported outcomes of patients with moderate to severe valgus deformity who underwent TAA for end-stage ankle arthritis. Methods. Patients with a valgus deformity of at least 10° who underwent TAA were retrospectively reviewed. The coronal tibiotalar angle was assessed on radiographs preoperatively, at 1 year, and at final follow-up. The visual analog scale (VAS) for pain, Short Form-36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scale, and Short Musculoskeletal Function Assessment (SMFA) scores were assessed preoperatively and at final follow-up. Results. Mean preoperative valgus deformity was 15.5 ± 5.0°, and was corrected to a mean of 1.2 ± 2.6° of valgus postoperatively. VAS, SF-36, AOFAS, and SMFA scores improved significantly (P < .001 for all). There was no significant change in tibiotalar angle between 1 year and final follow-up in either group. Reoperation and revision rates did not differ between groups. Conclusion. Correction of coronal alignment was achieved and maintained in patients with both moderate and severe preoperative valgus malalignment. Outcome scores significantly improved for all patients. Levels of Evidence: Therapeutic, Level IV.

Revision Surgery for Metal Component Failure in Total Ankle Arthroplasty

Background:

Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patient-reported outcomes for patients undergoing revision total ankle arthroplasty.

Methods:

We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 ± 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years’ follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation.

Results:

The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years ± 5.4 with a follow-up of 3.1 years ± 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA.

Conclusions:

Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively.

Level of Evidence:

Level III, therapeutic.

Risk Factors for Failure of Total Ankle Arthroplasty With a Minimum Five Years of Follow-up

BACKGROUND:

As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up.

METHODS:

A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris.

RESULTS:

Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion ( P = .006 and P = .023, respectively).

CONCLUSIONS:

This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure.

LEVEL OF EVIDENCE:

Level III, retrospective cohort study.

Hindfoot Arthrodesis Screw Position and Trajectory Effect on Talus Subsidence When Performed With Total Ankle Arthroplasty

BACKGROUND:

Total ankle arthroplasty (TAA) is increasingly being recognized as an effective surgical option for end-stage ankle arthritis. Associated hindfoot arthrodesis procedures are at times needed to correct malalignment or to address adjacent joint arthritis. Results following TAA and associated hindfoot arthrodesis have at times been underwhelming and the devascularization of the talar blood supply has been postulated as a potential cause. This study explored the association between hindfoot arthrodesis fixation and talar component subsidence.

METHODS:

The study included 81 consecutive patients who underwent a TAA with either an isolated subtalar arthrodesis or combined subtalar and talonavicular arthrodesis with a minimum of 2 years of follow-up. Radiographic and clinical evaluations including patient-reported outcomes were performed at each postoperative visit. The primary outcome measure was the presence of talar component subsidence while patient-reported outcomes were the secondary outcome measure.

RESULTS:

30.9% of patients had evidence of talar component subsidence. Subsidence was seen in 55.5% of patients with dorsal to plantar subtalar fixation compared to 11.1% of patients with plantar to dorsal screws ( P < .001) and in 44.4% of patients with screws violating the sinus tarsi compared to 3.7% of patients without screws in the sinus tarsi ( P < .001). Screws that were placed from dorsal to plantar were more likely to violate the sinus tarsi ( P < .001). Patients with evidence of talar subsidence reported higher pain scores and lower functional scores. There were 8 TAA failures, and the presence of dorsal to plantar screws was associated with failure ( P < .01).

CONCLUSION:

Screws that are placed across the subtalar joint from a dorsal to plantar approach are more likely to violate the sinus tarsi, contributing to a significantly higher rate of talar component subsidence when associated with TAA.

LEVEL OF EVIDENCE:

Level II, prospective comparative series.

Vascularized Pedicle Graft for Talar Osteonecrosis

Vascularized bone grafting for talar avascular osteonecrosis is indicated for patients with modified Ficat and Arlet stage I to III disease with minimal subchondral collapse. Outcomes may be more durable than core decompression alone, especially in patients with more advanced disease. Our preferred method, described in this article, involves core decompression followed by use of a vascularized cuboid pedicle graft placed in the defect. Outcomes reported in a small case series have been encouraging, with more than 80% of patients requiring no further surgery.

The Effect of Patient Characteristics on 1 to 2-Year and Minimum 5-Year Outcomes After Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty has shown durable improvements in patient-reported outcomes. However, the impact of common comorbidities and patient factors has not been fully characterized. The purpose of this study was to identify patient comorbidities and characteristics that impact outcomes after total ankle arthroplasty.

METHODS

Patients who underwent a total ankle arthroplasty between January 2007 and December 2016 were enrolled into a prospective study at a single academic center. Patients completed outcome measures before the surgical procedure and at the time of follow-up: a visual analog scale (VAS) for pain, the 36-item Short Form Survey (SF-36), and the Short Musculoskeletal Function Assessment (SMFA). Patient and operative factors, along with prevalent preoperative comorbidities, were analyzed for association with preoperative to postoperative changes in 1 to 2-year and minimum 5-year outcomes. Comorbidities that met a significance threshold of p < 0.05 in adjusted analyses were incorporated into multivariable outcome models.

RESULTS

A total of 668 patients with a mean 1 to 2-year follow-up (and standard deviation) of 1.6 ± 0.5 years (range, 10 months to 2 years and 2 months) were included. Patients' pain and function significantly improved across all outcomes (p < 0.05). However, depression, staged bilateral ankle arthroplasty, increased length of stay, a prior surgical procedure, increased American Society of Anesthesiologists (ASA) score, and particular implant types were associated with significantly smaller improvements in at least 1 patient-reported outcome after total ankle arthroplasty in the 1 to 2-year follow-up, although the effects were relatively small. At a minimum 5-year follow-up, smoking, depression, implant type, and staged bilateral ankle arthroplasty were associated with worse outcomes, and a prior surgical procedure, a simultaneous bilateral surgical procedure, and obesity were associated with improved outcomes.

CONCLUSIONS

Patients who underwent total ankle arthroplasty had significant improvement in patient-reported outcomes, although several factors were associated with a small, but significant, negative impact on improvement, including depression, increased ASA score, current smoking, increased length of stay, a prior surgical procedure, and staged bilateral total ankle arthroplasty. Current smoking, obesity, and depression are potentially modifiable risk factors that could be improved prior to total ankle arthroplasty. Patients with these characteristics should be counseled on their risk of limited improvement in ankle pain and disability after total ankle arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Failed Ankle Arthroplasty Components

BACKGROUND:

Although advances in joint-replacement technology have made total ankle arthroplasty a viable treatment for end-stage arthritis, revision rates for ankle replacements are higher than in hip or knee replacements. The questions asked in this study were what can retrieved ankle devices demonstrate about ankle arthroplasty failures and how can understanding the causes of these failures inform clinical decisions for current and future ankle arthroplasty patients?

METHODS:

An IRB-approved retrieval laboratory received retrieved components and surgeon-supplied reason for revision from 70 total-ankles (7 designs, including 5 currently marketed designs) from 2002 to 2018. These retrievals were rated for clinical wear and damage. Metal components were rated by method and effectiveness of fixation. Polyethylene inserts received by the laboratory 6 months or less after retrieval (n = 45) were analyzed for oxidation using Fourier transform infrared spectroscopy. Statistical analysis was performed using IBM SPSS, version 22.

RESULTS:

The ankle implants were retrieved most commonly for loosening and polyethylene fracture. Loosening occurred more frequently in fixed-bearing designs (n = 18) than in the mobile-bearing designs (n = 4) and after shorter in vivo time (mean in vivo time to retrieval for loosening: fixed bearing 3.2 ± 2.1 years, mobile bearing 9.7 ± 4.5 years). Gamma-sterilized ankle inserts oxidized at a higher rate than non-gamma (EtO or gas-plasma) sterilized ankle inserts (gamma 0.29 ± 0.22/y, non-gamma 0.07 ± 0.05/y, mean difference=0.215, 95% CI 0.128-0.303, P < .001). The presence of clinical fatigue (cracking and/or delamination) of the polyethylene insert correlated with measured oxidation (Spearman rho = 0.685, P < .001). Nine inserts, all gamma-sterilized, fractured in vivo.

CONCLUSIONS:

This study suggests that loosening could be more of a problem in fixed-bearing devices than in mobile bearing devices. Gamma-sterilized polyethylene inserts were found to suffer fatigue damage or fracture in vivo, resulting in the need for revision. Retrieval analysis can provide insight into implant-related reasons for revision, with the goal of understanding the implant-related causes of these failures, informing future ankle design and clinical decisions for current and future ankle arthroplasty patients.

LEVEL OF EVIDENCE:

Level III, comparative series.

Possible Implications for Bundled Payment Models of Comorbidities and Complications as Drivers of Cost in Total Ankle Arthroplasty

BACKGROUND:

The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital and 90-day postdischarge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help identify modifiable preoperative patient factors that could be addressed prior to the patient entering the bundle, as well as determine targets for cost reduction in postoperative care.

METHODS:

This study is part of an institutional review board-approved single-center observational study of patients undergoing TAA from January 1, 2012, to December 15, 2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model. All Medicare payments beginning at the index procedure through 90 days postoperatively were identified. Patient, operative, and postoperative characteristics were associated with costs in adjusted, multivariable analyses. One hundred thirty-seven patients met inclusion criteria for the study.

RESULTS:

Cerebrovascular disease (intracranial hemorrhages, strokes, or transient ischemic attacks) was initially associated with increased costs (mean, $5595.25; 95% CI, $1710.22-$9480.28) in adjusted analyses ( P = .005), though this variable did not meet a significance threshold adjusted for multiple comparisons. Increased length of stay, discharge to a skilled nursing facility (SNF), admissions, emergency department (ED) visits, and wound complications were significant postoperative drivers of payment.

CONCLUSION:

Common comorbidities did not reliably predict increased costs. Increased length of stay, discharge to an SNF, readmission, ED visits, and wound complications were postoperative factors that considerably increased costs. Lastly, reducing the rates of SNF placement, readmission, ED visitation, and wound complications are targets for reducing costs for patients undergoing TAA.

LEVEL OF EVIDENCE:

Level II, prognostic prospective cohort study.

Patient-Reported Outcomes Before and After Primary and Revision Total Ankle Arthroplasty

BACKGROUND:

Studies examining the clinical outcomes of revision total ankle arthroplasty (TAA) are sparse. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. In this study, patient-reported results and clinical outcomes were analyzed for a cohort of patients who underwent both primary and revision TAA at a single high-volume institution.

METHODS:

We retrospectively reviewed prospectively collected data on 29 patients with failed primary total ankle arthroplasty. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. Patient-reported outcome (PRO) measures and clinical results were reviewed in this longitudinal study.

RESULTS:

Fifteen patients (51.7%) underwent revision of just the talar and polyethylene components while 13 patients (44.8%) underwent revision of all components. The most common cause was talar subsidence (51.7%). The average time to revision was 3.9 years with a follow-up of 3.2 years after revision, and 3 (10.3%) revision arthroplasties required further surgery; 2 required conversion to arthrodesis and 1 required second revision TAA. Improvements in PROs were better after primary than revision TAA.

CONCLUSIONS:

Clinical and patient-reported results of revision ankle arthroplasty after metal component failure improved significantly but never reached the improvements seen after primary ankle arthroplasty. In our series, 10.3% of revision TAAs required a second revision TAA or arthrodesis surgery.

LEVELS OF EVIDENCE:

Therapeutic Level III, comparative series.

Increased Early Revision Rate With the INFINITY Total Ankle Prosthesis

BACKGROUND:

A number of new 2-component total ankle arthroplasty systems that emphasize minimal bone resection have been introduced for which few clinical outcomes reports are available. Our aim was to identify the rate of early revision among patients receiving the 2-component INFINITY prosthesis.

METHODS:

Patients from 2 prospectively collected databases at the authors' institution were screened for inclusion in the present study. All patients who underwent a primary total ankle arthroplasty (TAA) with the INFINITY prosthesis and who were at least 1 year postoperative were included. A total of 159 ankles with a mean 20 months of follow up (range, 12-37) met these criteria. All surgeries were performed by 1 of 2 orthopedic foot and ankle surgeons with extensive experience in TAA. The primary outcome was the need for revision surgery, defined as removal of 1 or both metal components. Peri-implant lucency at most recent follow-up was a secondary outcome. Weightbearing radiographs at most recent follow-up were graded for lucency independently by 2 reviewers.

RESULTS:

Sixteen ankles (10%) underwent revision at a mean 13 months postoperatively. The most common reasons for revision were symptomatic tibial component loosening and deep infection (6 patients each, 3.8%). Of the 108 ankles with retained components and at least 1 year of radiographic follow-up, 8 (7.4%) had global lucency around the tibial component suggestive of loosening at most recent follow-up.

CONCLUSIONS:

Our initial review of patients undergoing TAA with this new 2-component prosthesis demonstrates an elevated early revision rate due to tibial component loosening compared to other implant systems.

LEVEL OF EVIDENCE:

Level IV, case series.

Lower Bone Density on Preoperative Computed Tomography Predicts Periprosthetic Fracture Risk in Total Ankle Arthroplasty

BACKGROUND:

The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA.

METHODS:

A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up.

RESULTS:

There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures ( P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture ( P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision.

CONCLUSIONS:

Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus.

LEVEL OF EVIDENCE:

Level III, retrospective cohort study.

Isolated Subtalar Arthrodesis for Avascular Necrosis of the Talus

Isolated subtalar arthrodesis has been attempted in talar avascular necrosis (AVN) patients to preserve the tibiotalar joint and potential revascularization. This article reports the efficacy of isolated subtalar arthrodesis in the setting of AVN. A retrospective review of subtalar arthrodeses was performed on a cohort of 12 patients with talar AVN who underwent subtalar arthrodesis. The primary outcome was radiographic fusion with secondary outcomes of subsequent procedures, recurrent pain, and perioperative complications. Radiographic fusion of subtalar arthrodesis occurred in 12 of 12 patients. Five of six patients with traumatic etiology went on to have secondary procedures. One of six patients with atraumatic etiology underwent a secondary procedure for advancement of tibiotalar arthritis. In the setting of atraumatic talar AVN, this small cohort demonstrates that isolated subtalar arthrodesis is a safe and reliable procedure with high fusion rates and low need for secondary procedures. (Journal of Surgical Orthopaedic Advances 28(2):132-136, 2019).

Outcomes of Acute Hematogenous Periprosthetic Joint Infection in Total Ankle Arthroplasty Treated With Irrigation, Debridement, and Polyethylene Exchange

BACKGROUND

Acute hematogenous periprosthetic joint infection (PJI) is defined in the literature as infection diagnosed and treated within 2 to 4 weeks from the onset of symptoms. In total hip and knee arthroplasty, irrigation and debridement (I&D) and polyethylene exchange with component retention has been studied extensively. However, there is minimal literature evaluating this treatment method for PJI in total ankle arthroplasty (TAA). The purpose of this study was to evaluate both the clinical and patient-reported outcomes and survivorship of TAA acute hematogenous PJIs treated with I&D and polyethylene exchange.

METHODS

A single-center, retrospective chart review of prospectively collected data in patients with TAA PJI who subsequently underwent I&D and polyethylene exchange with retention of metal components was conducted. The primary outcome was failure rate of I&D and polyethylene exchange, where failure was defined as subsequent removal of all components and 2-stage revision or arthrodesis. Patient-reported outcomes collected before primary arthroplasty, after primary arthroplasty, and after polyethylene exchange were also analyzed.

RESULTS

We identified 14 patients with acute hematogenous PJI who underwent I&D and polyethylene exchange with retention of metal components. The mean time from primary TAA to symptoms was 43 months (range 1-147 months). The average time from onset of symptoms to I&D and polyethylene exchange was 11.4 ± 5.6 days. The mean follow-up after this surgery was 2.8 ± 1.5 years. The long-term failure rate was 54%. The most common bacteria isolated in patients who failed was methicillin-resistant Staphylococcus aureus (MRSA). The most common bacteria isolated in patients who retained their implants was methicillin-sensitive Staphylococcus aureus (MSSA). Visual analog scale (VAS), Short Musculoskeletal Function Assessment (SMFA), Short Form-36 (SF-36), and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale showed significant improvement when compared to preoperative scores in patients who retained their implants both after primary and after I&D and polyethylene exchange.

CONCLUSIONS

I&D and polyethylene exchange with retention of metal components has a long-term survivorship comparable to those reported in the total knee and total hip arthroplasty literature. Patient-reported outcomes after I&D and polyethylene exchange were comparable to those collected after primary arthroplasty in those patients who ultimately retained their implants. Two variables in this cohort that were associated with I&D and polyethylene exchange failure include time the patient was symptomatic prior to I&D as well as organism isolated on culture. With a failure rate of 54%, the authors recommend thorough evaluation on a case-by-case basis prior to indicating a patient for single-stage I&D with polyethylene exchange.

LEVELS OF EVIDENCE

Level IV, case series.

Hallux Interphalangeal Arthrodesis Following First Metatarsophalangeal Arthrodesis

BACKGROUND

Hallux interphalangeal (IP) arthritis can occur after first metatarsophalangeal (MTP) arthrodesis. IP arthrodesis is a standard treatment, but in the setting of prior MTP surgery there will be increased stress on the IP joint. This may result in diminished potential for bone healing. This investigation assessed the outcomes of hallux IP arthrodesis after first MTP arthrodesis.

METHODS

Charts were retrospectively reviewed for patients who underwent interphalangeal arthrodesis between January 1, 2007, and April 3, 2017, and who had a minimum of 12 weeks of follow-up. We compared patients with and without prior ipsilateral first MTP arthrodesis. There were 42 patients whose median follow-up was 9 (range, 3-135) months.

RESULTS

Median time from previous first MTP arthrodesis until IP arthrodesis was 54 months. Six nonunions (35.3%) occurred in 17 patients with prior first MTP arthrodesis. Only 2 nonunions (8.0%) occurred in 25 patients with isolated IP arthrodesis. The multivariable risk difference of nonunion was 53.3% ( P = .001). Prior first MTP arthrodesis also was more likely to have complications (52.9% vs 24.0%, respectively). The multivariable risk difference of complications was 35.7% ( P = .082). The speed of bone healing was significantly different, with a multivariable rate ratio of 0.21 ( P = .012). Conclusion Prior first MTP arthrodesis resulted in 4.8 times slower bone healing for IP arthrodesis. It increased the risks of nonunion and any other complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.