3D kinematics of tibiotalar motion in patients with mobile bearing and fixed bearing total ankle arthroplasty: In vivo videofluoroscopic feasibility study

BACKGROUND

As total ankle arthroplasty (TAA) is an increasingly common surgical intervention for patients with end-stage ankle arthritis, there is a need to better understand the dynamic performance of prosthetic implants during activities of daily living. Our purpose was to quantify and compare relative tibiotalar motion during gait in persons with a fixed-bearing (FB) and mobile-bearing (MB) total ankle arthroplasty. We hypothesized a FB prosthesis would have lower tibiotalar range of motion (ROM).

METHODS

Patients at least 12 months postoperative with either a FB (n=5) or MB (n=3) total ankle arthroplasty were tested. We used high-speed biplanar videoradiography to quantify tibiotalar kinematics during self-selected gait. Angular and linear ROM in three axes were compared between the groups.

RESULTS

ROM for dorsiflexion-plantarflexion, internal-external rotation, and inversion-eversion angles in FB subjects averaged 7.47±4.05°, 7.39±3.63°, and 4.51±2.13°, respectively. ROM in MB subjects averaged 6.74±2.04°, 6.28±4.51°, and 5.68±2.81°, respectively. Linear ROM along anteroposterior, mediolateral, and superior-inferior axes in FB subjects averaged 1.47±2.07 mm, 1.13±1.49 mm, and 0.28±0.30 mm, respectively. Linear ROM in MB subjects averaged 0.68±1.44 mm, 0.60±1.41 mm, and 0.20±0.13 mm, respectively. We found no significant difference between the two groups for any of these ROM parameters (p>0.05).

CONCLUSION

Total ankle arthroplasty using either FB or MB design appears to confer similar ankle motion during the gait cycle in this biplanar fluoroscopic model.

LEVEL OF EVIDENCE

Level IV, case series.

Elective Foot and Ankle Procedures in the Patients Greater than 65 Years of Age: Worth the Mobility Gains

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were .05 and .8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P = .041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery.

Republication of "Assessment of Recovery From Geriatric Ankle Fracture Using the Life Space Mobility Assessment (LSA): A Pilot Study"

Background

The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one's own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients.

Methods

Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form-36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance.

Results

20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year (P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA.

Conclusion

The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant.

Level of Evidence

Level II.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair.

PURPOSE

The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time.

RESULTS

There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I² = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I² = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I² = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I² = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I² = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I² = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I² = 15%).

CONCLUSION

Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Donor site morbidity of calcaneal, distal tibial, and proximal tibial cancellous bone autografts in foot and ankle surgery. A systematic review and meta-analysis of 2296 bone grafts

PURPOSE

This study aims to report on the safety and donor site morbidity of the distal lower extremity (calcaneal, proximal, and distal tibial) cancellous bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date.

METHODS

Following the PRISMA guidelines, two independent investigators searched MEDLINE (PubMed), EMBASE, SCOPUS, Google Scholar, and Cochrane databases in December 2020 using the following keywords and their synonyms: ("bone graft", "donor site morbidity", "calcaneal graft", "proximal tibia graft", and "distal tibia graft"). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) chronic pain, (2) fracture, and (3) infection, whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one of the desired outcomes. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded.

RESULTS

After the removal of duplicates, a total of 5981 studies were identified. After screening those records, 85 studies remained for full-text assessment. Out of those, 15 studies qualified for the meta-analysis with a total of 2296 bone grafts. Out of those grafts, 1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%, CI:1.10-2.50%, I² = 66%], 5 fractures [0.32%, CI: 0.10-0.60%,I² = 0%], 20 sural neuritis [1.28%, CI:0.70-1.80%, I² = 0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%, CI: 1.01-3.2%, I² = 34.5%], 1 fracture [0.16%, CI:0.10-0.50%, I² = 0%], and 3 superficial wound infections [0.48%, CI: 0.10-1.01, I² = 0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%, CI: 0.80-2.6%, I² = 0%], and 5 saphenous neuritis [4.5%, CI: 0.70-8.40%, I² = 65%].

CONCLUSION

Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with a large sample size are required.

Complications Associated with the Surgical Management of Hallux Rigidus

Hallux rigidus is the most common arthritic pathology of the foot. This review article discusses the pathophysiology and common clinical presentation of hallux rigidus. Furthermore, we discuss multiple classification systems that categorize the arthritic process and guide management. Surgical interventions include cheilectomy, Moberg osteotomy, synthetic cartilage implants, interpositional arthroplasty, and arthrodesis. The common complications are reviewed, and the rates of these complications highlighted. Surgical options for hallux rigidus globally have successful outcomes with low rates of complications when done on appropriate patients.

Telemedicine Foot and Ankle Visits in the COVID-19 Era

Background:

The COVID-19 pandemic created a difficult environment to provide musculoskeletal care to patients with foot and ankle pathology given the limitations placed on in-office visits. Telemedicine offered a unique avenue to reach these patients; however, the efficacy of telemedicine visits in patients with foot and ankle pathology is not well studied. We propose a telemedicine protocol that has allowed us to effectively see and treat patients with foot and ankle pathology.

Methods:

A 12-step standardized telemedicine protocol was created within the Foot and Ankle division that was used for seeing patients through telemedicine. Also included in this is previsit preparation and follow-up recommendations. Press Ganey surveys were retrospectively reviewed to understand patient experience with telemedicine.

Results:

85.2% of patients surveyed responded with scores indicating excellent care. When comparing patients who were seen in-office and through telemedicine, 89.2% and 83.4% responded with scores indicating excellent care, respectively (P = .37).

Conclusion:

Telemedicine offers an effective and convenient way to provide excellent musculoskeletal care to patients affected with foot and ankle pathology. This is the first study that evaluated a comprehensive protocol for telemedicine encounters and can be used to implement telemedicine by others using this approach.

Level of Evidence:

Level V, expert opinion.

Tenosynovial fluid as an indication of early posterior tibial tendon dysfunction in patients with normal tendon appearance

OBJECTIVE

Our primary aim was to quantify the posterior tibial tendon (PTT) sheath fluid volume in individuals with the clinical diagnosis of stage 1 posterior tibial tendon dysfunction (PTTD) and no MRI-detectable intra-substance tendon pathology and compare them with patients with other causes of medial ankle pain, also without MRI-detectable intra-substance PTT pathology and with normal controls. We also wanted to determine if there is a fluid measurement that correlates with the clinical diagnosis of PTTD.

MATERIALS AND METHODS

A total of 326 individuals with medial ankle pain and no intra-substance PTT pathology were studied. Group 1 included 48 patients with a clinical diagnosis of stage 1 PTT dysfunction, group 2 comprised 278 patients with other causes of medial ankle pain, and a third control group consisted of 56 patients without any medial ankle pain. MRI-based geometric measurements included PTT fluid volume, maximum cross-sectional fluid area, and fluid width. Fluid measurements were compared between groups and measurement reliability was tested.

RESULTS

Group 1 showed greater PTT fluid volume, area, and width compared with groups 2 (other causes of medial ankle pain) and 3 (asymptomatic controls) (all p values < 0.001). A 9-mm threshold maximum fluid width was associated with PTTD (sensitivity 84%, specificity 85%). Measurements were reliable (all p values < 0.03) among three observers blinded to the gold standard.

CONCLUSION

Patients with stage 1 PTT dysfunction displayed greater volumes of tendon-sheath fluid than those with other causes of medial ankle pain and compared with asymptomatic controls. A threshold maximum fluid width greater than or equal to 9 mm distinguishes those with PTTD. An association between tendon sheath fluid distension and the clinical diagnosis of stage 1 posterior tibial tendon disease in the setting of no MRI-detectable intra-substance tendon pathology may allow for differentiation of medial ankle pain from other sources and may allow for early intervention aimed at preventing progressive PTTD. The level of evidence was prognostic (level III).

Impact of Vancomycin Treatment on Human Mesenchymal Stromal Cells During Osteogenic Differentiation

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Vancomycin is often delivered locally for surgical site infection prophylaxis. Recent reports of possible osteotoxicity have led to uncertainty concerning vancomycin’s safety in the setting of arthrodesis and bone healing. Bone formation during arthrodesis takes place as recruited human mesenchymal stromal cells (hMSCs) proliferate and differentiate into mature osteoblasts. The purpose of this research was to determine the impact of vancomycin treatment on hMSCs during osteogenic differentiation.

Methods:

Human MSCs were cultured in MSC growth media to an appropriate confluence. Cells were cultured for 24 hours to facilitate adherence, after which the media was aspirated and replaced with osteogenic differentiation media (Lonza, Switzerland). Osteogenic differentiation media was supplemented with vancomycin powder to yield solutions with concentrations of 0, 50, 500 & 5000 µg/mL. Fresh vancomycin powder was added with every media change. MSCs viability and proliferation were assessed via live/dead staining with 1 µM calcein-AM and 0.5 µM ethidium homodimer-1 (EthD-1) after 1, 3, and 7 days of differentiation and vancomycin treatment. Mineralization of differentiated cells was assessed via staining with 40 mM alizarin red (ARS; pH 4.1) after 21 days. Semi-quantification of the degree of mineralization was performed by measuring absorbance values at 405 nm using a microplate reader. Microscopy was used for qualitative evaluation.

Results:

Cell viability decreased with increasing vancomycin concentrations. Impairment of hMSC proliferation was also observed with increasing concentrations of vancomycin. MSCs treated with 5000 µg/mL vancomycin demonstrated significantly less cell growth compared to all other treatment groups (P=0.0001). Absorbance measurements from each well stained with alizarin red was used for semi-quantification of the degree of mineralization. As vancomycin concentrations were increased, absorbance levels decreased (Figure). This reduction in mineralization was also demonstrated qualitatively; with alizarin red less apparent in the wells with increasing vancomycin concentrations (Figure).

Conclusion:

Local vancomycin is utilized for prevention of infection, often in procedures that necessitate the formation of new bone. Bone healing requires migration, proliferation and differentiation of hMSCs. This work demonstrates impaired viability and function of hMSCs following vancomycin as well as decreased osteoblastic mineralization. Future work will require in vivo studies aimed at determining relative nonunion rates in the setting of vancomycin prophylaxis. Still, the results of this study suggest that vancomycin may be toxic to hMSCs and caution should be exercised by providers when considering vancomycin in foot and ankle patients requiring bony healing following fracture or arthrodesis.

Comorbidities associated with poor outcomes following operative hammertoe correction in a geriatric population

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are one of the most common lesser foot deformities and are extremely prevalent in the geriatric population. When nonoperative treatment fails, surgical correction can improve functional status and pain. While complications following these surgeries are rare, older patients with comorbid conditions are often considered worse operative candidates due to an increased risk of adverse outcomes. The aim of this study is to determine if specific comorbidities or perioperative variables are associated with increased complications or unsuccessful outcomes following operative hammertoe correction in geriatric patients.

Methods:

Prospectively collected data was reviewed on 31 consecutive patients aged 60 or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, perioperative variables, and postoperative complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component Score (SF-36 PCS) with a minimum of six-month follow-up. Data was examined using Fisher’s method and multivariable analysis.

Results:

29.0% (9/31) of patients had a history of smoking, 61.2% (19/31) were on anticoagulant therapy, 19.4% (6/31) had osteoporosis, 16.1% (5/31) had rheumatoid arthritis, and 9.7% (3/31) had diabetes mellitus. The mean tourniquet and operative times were 65.7 (SE=6.2) and 95.4 (SE=7.4) minutes, respectively. Postoperative complications occurred in 12.9% (4/31) of patients with the most prevalent being wound infections that were treated with antibiotics in 9.7% (3/31). Impaired wound healing, joint nonunion, and the need for revision surgery each occurred in 3.2% (1/31) of patients. Mean 6-month improvement in VAS was 2.1 (SE=0.5) and mean improvement in SF-36 PCS was 10.2 (SE = 3.4). No significant association was found between comorbidities or perioperative variables and postoperative complications or improved outcomes.

Conclusion:

No specific comorbidities or perioperative variables were identified that increase the risk for unsuccessful surgical correction of hammertoe deformities. While comorbidities in the geriatric population have traditionally been thought to increase complication rates and lead to poor outcomes, further research in this area is warranted. Comorbidities should not necessarily be a deterrent for geriatric patients pursuing operative hammertoe correction.

Foot Width Changes Following Hallux Valgus Surgery

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Every clinician is familiar with the patients’ concerns regarding the postoperative foot appearance and footwear anticipations. Surprisingly, although patients are concerned with postoperative foot width, there are only scarce reports on this issue. This study was undertaken to evaluate the impact of hallux valgus surgical treatment on foot width.

Methods:

Study included 71 consecutive cases with moderate to severe hallux valgus treated with Scarf osteotomy, distal soft tissue release and Akin osteotomy as needed. Patients were included only if pre- and postoperative weightbearing X-rays at minimum 6 months followup were available. The average age was 55.7 years (range, 20 to 76), with average follow-up of 20.7 months (range, 6 to 96). Patients’ medical records were reviewed for clinical data, surgical technique and radiographic measurements. The radiographic measurements included hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and foot width. Foot width was assessed by measuring both the bony width (BW: maximal distance between the medial cortex of 1st metatarsal head and lateral cortex of the 5th metatarsal head) and the soft tissue width (STW: maximal distance between most medial soft tissue outline and the most lateral soft tissue outline at the level of metatarsal heads).

Results:

Preoperative HV deformity (mean HVA 35.8, IMA 14.1 and DMAA 15.2) was successfully corrected (postoperative mean HVA 13.7, IMA 6.9 and DMAA 7.7). Overall bony foot width was reduced by 5% and soft tissue foot width by 2% postoperatively. Further analysis showed there were 13 feet (18.3%) with increased (>5%) bone width, 26 feet (36.6%) with no change (±5%) and 32 feet (45.1%) for which width decreased in more than 5% postoperatively. Patients with the widest foot before surgery, had a decrease in foot width following surgery whereas, patients with the narrowest foot width, had an increase in foot width. Magnitude of preoperative deformity (as assessed by HVA, IMA and DMMA measurements) or amount of correction had low correlation (<0.2) with postoperative foot width.

Conclusion:

While the ability of surgery to correct HV deformity is well established and reported in the literature, its effect on foot width is less understood or predictable. Overall, the postoperative reduction of foot with was modest. Furthermore, while postoperative foot width (both bony and soft tissue) decreases or does not change in 4 out of 5 patients, there are cases in which foot width actually increases.

Radiographic predictors for improved outcomes after hammertoe correction surgery

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect daily activities. When patients seek surgical management, x-rays are utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite the frequent use of radiographs pre- and post-operatively, radiographic results are not necessarily indicative of clinical presentation or surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of improved pain and function after surgical correction of hammertoe deformity.

Methods:

Prospectively collected data was reviewed on 51 consecutive patients who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and post-surgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with a minimum of six-month follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability and arthritis. Data was examined using a multivariable analysis.

Results:

Preoperatively, 15.7% (8/51) of patients had a deformity classified radiographically as mild, 37.3% (19/51) as moderate, and 47.1% (24/51) as severe. Additionally, 60.8% (31/51) had joint instability, 17.7% (9/51) had joint dislocation, and 7.8% (4/51) had joint arthritis. Postoperatively, 74.5% had PIP joint fusion, 35.3% (18/51) had joint arthritis, and 9.8% (5/51) had joint instability. A significant association was found between PIP joint fusion and improved SF-36 PCS scores (p=.004). Preoperative anticoagulant therapy was associated with reduced rates of PIP joint fusion (p=0.02). There was no association found between the other demographic or radiographic parameters, and no parameters were associated with improvement in VAS scores.

Conclusion:

After undergoing surgical correction of hammertoe deformity, postoperative PIP joint fusion was the only variable determined to be indicative of improved physical function. However, pre- and postoperative metatarsophalangeal joint arthritis nor instability was predictive of outcomes. This work informs foot & ankle specialists that healing of the PIP joint is critical to successful hammertoe surgery.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients

BACKGROUND

Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities.

METHODS

Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort.

RESULTS

Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively.

CONCLUSIONS

Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients.

LEVEL OF EVIDENCE

Level, III comparative series.

Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 50 Years and Older

Category:

Ankle, Trauma

Introduction/Purpose:

Frailty, a multifaceted syndrome resulting from a decrease in physiologic reserves, has been previously shown to play a significant role in elderly morbidity and mortality. The literature on frailty within orthopaedic surgery is limited currently. No study to date has assessed frailty as a predictor of postoperative outcomes in elderly patients with ankle fractures. We hypothesized that increasing frailty would be associated with increased 30-day reoperation rates and increased postoperative complications.

Methods:

The National Surgical Quality Improvement Project (NSQIP) was queried using the appropriate CPT codes to identify inpatients from 2005-2014 who were aged 50 years and older that sustained an ankle fracture and underwent operative fixation. Frailty was assessed using a modified frailty index (MFI), abbreviated with 11 variables from the Canadian Study of Health and Aging Frailty Index. The primary outcome was 30-day reoperation rate and secondary outcomes were postoperative surgical and medical complications, readmission rates, and length of stay. Bivariate and multivariate analysis was used to determine association between outcomes and MFI.

Results:

6,749 patients were identified, and the mean age of these patients was 64.4 years. Patients with increased MFI scores had significantly higher rates of postoperative complications. In addition, increased MFI scores was also associated with increased 30 day readmissions and reoperations. Multivariate analysis also demonstrated that MFI was a stronger predictor of 30 day reoperation rates (odds ratio of 17.7, P < 0.001) than age, wound class, and ASA class.

Conclusion:

Frailty has the potential to be an important predictive variable of postoperative outcomes in patients aged 50 years and older who sustain ankle fractures. The modified frailty index can be a valuable preoperative risk assessment tool for the orthopaedic surgeon. Further study is necessary to examine the effect of the MFI in a larger prospective setting.

External Fixation versus Primary Open Reduction and Internal Fixation (ORIF) of Intra-articular Calcaneus Fractures

Category:

Hindfoot, Trauma

Introduction/Purpose:

Calcaneus fractures are common injuries of the foot and account for approximately sixty percent of all tarsal bone fractures. Anatomic reduction of the articular surface is associated with good long-term outcomes. Unfortunately, there is a high rate of complications following surgical fixation due to the fragile soft tissue envelope surrounding these injuries. External fixation of joint depression calcaneus fractures allows for restoration of morphology and preservation of soft tissues. The purpose of this work is to determine if acute external fixation in the management of joint depression calcaneus fractures leads to decreased postoperative complications and better outcomes.

Methods:

Patients were identified using the appropriate procedure codes over a ten year span at a level one trauma center. Those under the age of eighteen and underwent nonoperative treatment were excluded. Electronic medical records were reviewed to obtain, basic demographic data, comorbidities, and injury specifics. Calcaneus fractures were classified as open or closed and using the Essex-Lopresti classification system. Operative reports were reviewed to determine which patients initially underwent external fixation versus open reduction internal fixation (ORIF), furthermore any staged operative interventions were also noted. Electronic records were also reviewed to determine the length of follow up and incidence of postoperative complications. Bivariate analysis was used to identify an association between collected variables and postoperative complications (wound dehiscence, hardware failure, infection, nonunion). Multivariate logistic regression analysis was used to determine if patients treated with acute external fixation were associated with lower postoperative complication rates.

Results:

152 calcaneus fractures were identified and included for analysis. The average age was thirty-eight and the majority of patients were male (111/152 = 73%). Average follow up was approximately five months. Seventeen percent (26/152) were open fractures. Twenty-six (17%) were treated initially with external fixation and eleven of these were a staged ORIF. The overall complication rate was 11% (17/152) with the most common complication being wound dehiscence. Only one complication occurred in the group initially managed with external fixation. Statistical analysis revealed that open fractures were associated with increased postoperative complication rates in a bivariate and multivariate model.

Conclusion:

External fixation of joint depression calcaneus fractures restores height and preserves the soft tissue envelope. Although there was only one complication in the external fixation group, the difference in complication rates was not statistically significant based on initial treatment. The low number of patients treated with external fixation initially and the short follow up are limitations of this study. Further work is needed with a larger patient cohort in a prospective setting. Acute external fixation may prove to be a useful tool to help prevent postoperative complications following joint depression calcaneus fractures.

Tibiotalocalcaneal Arthodesis via a Nitinol Containing Intramedullary Nail

Category:

Ankle, Ankle Arthritis, Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is a common procedure used in the management of foot and ankle pathologies. TTC fusions are frequently performed in patients with limited bone stock and poor vascular status. Adequate compression at the arthrodesis site is vital to successful fusion as even small amounts of bone resorption greatly increase nonunion risk. A recently designed hindfoot nail contains a built in nickel titanium alloy (nitinol) that has psuedoelastic properties which maintains compression across joint surfaces in the setting of bone resorption. The authors present a case series of patients who were managed with this nitinol containing intramedullary hindfoot nail system.

Methods:

Patients treated by one board certified orthopaedic foot and ankle surgeon who were managed with the nitinol containing hindfoot nailing system were retrospectively reviewed over a two year span. Electronic medical records were reviewed to collect demographic information and details regarding the patient’s procedure. Operative specifics collected included the data of the procedure and the preoperative diagnosis. Records were reviewed postoperatively as well to document the incidence of postoperative complications and functional outcomes. Proximal migration of the distal interlocking screw on lateral radiographs were measured in a standardized fashion at two, six, and twelve weeks to objectively assess additional compression obtained through the nitinol nailing system.

Results:

Eight patients were included in the case series with an average follow up time of 7 months postoperative (minimum of 4 months for one patient). The most common preoperative diagnosis was posttraumatic arthritis (n = 4). One patient suffered from wound dehiscence postoperatively that required operative intervention within the first three months – this patient’s wound healed by six months with no further complications. All patients were cleared for full weight bearing and activities as tolerated by six months, except only had four months of follow up available. The compression obtained through this nailing system increased at each follow up for all patients. The average compression obtained was 2.9 mm at two weeks, 3.8 mm at six weeks, and 4.4 mm at twelve weeks.

Conclusion:

Tibiotalocalcaneal arthrodesis can be an excellent procedure that provides significant pain relief and restores function. The patients in this case series all had excellent results with only one postoperative complication that ultimately did not result in any functional deficits. Furthermore, patients all demonstrated increased compression at each follow up radiographs which demonstrates the sustained compression obtained at the arthrodesis site through this hindfoot nail system. Further prospective work with a larger patient cohort is warranted to determine if this nailing system is superior to other TTC hindfoot nails.

Complication rates and short-term outcomes similar after hammertoe correction in older patients

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are common lesser toe deformities and multiple methods exist for surgical treatment. The population continues to age and to date, no studies have looked specifically at outcomes in the geriatric cohort, who are often at greater risk of complications or functional compromise due to increased co-morbidities. This study examines differences in short-term outcomes of pain, improvement of SF-36 scores, and complication rates in younger compared to older patients who underwent surgical correction of hammertoe deformities.

Methods:

47 patients undergoing surgical correction of hammertoe deformities were prospectively followed. All surgical procedures were performed by a single surgeon and the specific surgical technique was tailored to each patient’s deformity. All patients were treated with early mobilization and progressive weight-bearing as tolerated. Subjective assessment of function was obtained using pre-operative and post-operative Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of six-month follow-up. 38 patients met inclusion criteria for length of follow-up (5 males, 33 females). Patients were divided into two groups based on age at the time of surgery (those younger than sixty years old, and those older than sixty years old). The improvements in mean (+/- SEM) VAS and SF-36 scores for patients younger than sixty years were compared to outcomes of patients older than sixty years of age, and results were assessed for statistical significance using a student’s t-test.

Results:

The mean age was 46.4 +/- 4.1 years in the younger patients and 68.0 +/- 1.2 years in the older cohort. The mean improvement in VAS score from pre-op to six months post-op was 2.8 +/- 0.8 and 2.8 +/- 0.6 (p = 0.95) in the younger and older cohorts, respectively (Table 1). The mean improvement in SF-36 Physical Component Score from pre-op to six months post-op was 8.6 +/- 6.7 and 6.7 +/- 4.4 (p= 0.81) in the younger and older cohorts, respectively. The mean improvement in SF-36 Mental Component Score was 1.5 +/- 3.7 and 1.4 +/- 4.2 (p=0.99) in the younger and older cohorts, respectively. One complication occurred in the younger cohort (0.11%) and no complications were reported in the older cohort.

Conclusion:

Outcomes of surgical correction of hammertoe deformities in older patients were similar to outcomes in younger patients at short-term follow-up. The study had sufficient power to detect differences in means as small as 5-8% depending on the specific outcome parameter. This study establishes a cohort of patients who will be followed to determine the effect of age on long-term outcomes of pain, SF-36 scores, and complication rates of surgical correction of hammertoe deformities. Future studies will also compare radiologic outcomes of hammertoe deformities preoperatively and postoperatively.

Assessment of Recovery From Geriatric Ankle Fracture Using The Life Space Mobility Assessment (LSA)

Category:

Trauma

Introduction/Purpose:

Ankle fractures are the third most common type of fracture seen in the elderly population and recent work has suggested that operative intervention may provide improved outcomes. Current outcome measures do not accurately assess true mobility in the geriatric population. In this study, we utilize the Life Space Assessment (LSA), a novel medical assessment survey which focuses specifically on how a patient functions within his/her environment following a medical event. This tool has not been previously utilized in orthopedic patients. We postulated that the LSA would provide improved assessment of these patients and help identify key differences in operative and non-operatively treated patients when compared to current outcome measures.

Methods:

This study was designed as a prospective observational study in which all geriatric patients age 65 and older with an ankle fracture were followed for one year from the time they presented for treatment. Treatment options of either non- operative or operative were determined by the attending physician on a patient specific basis. The patient was invited to participate in the study at the initial injury visit. The LSA was administered at the initial visit and 6 weeks, 3 months, 6 months and 12 months post injury/surgery. The SF-36 and Visual Analogue Pain Scale surveys were administered at 6 months and 12 months as a comparison. Survey scores were tallied and standard means were determined for each time point. Statistical analyses were performed to determine significance.

Results:

26 patients met inclusion criteria and 20 were enrolled. 11 underwent surgery while 9 were treated non-operatively. The surgical LSA group scored 91.4 pre-injury and improved to 87.6 after 1 year which was near baseline (Graph #1). The non-op group recorded 80.88 pre-injury and only improved to 59.5 at 1 year. For the VAS, surgical patients reported pain of 2.2 and 1.75 at 6 and 12 months. Non-op patients recorded pain of 2.25 and 2.4 at 6 and 12 months. For SF-36 physical score, surgical patients recorded 57.6 and 75.8 at 6 and 12 months while non-op patients scored 53.3 and 59.43. SF-36 mental scores for the surgical group was 60.63 and 74.83 while non-op patients recorded 76.88 and 86.5 at 6 and 12 months.

Conclusion:

Operative patients returned to their baseline LSA while non-operative patients continued to have lower mobility at one year. All patients’ mobility was significantly limited for first three months. Surgical patients had less pain at 12 months compared to non-op. Surgical patients showed significant improvement in SF-36 physical scores from 6 months to 1 year while non-op patients had minimal improvement echoing our findings from LSA. The operative group had improved outcomes compared to non-op and this is reflected in both their LSA and SF- 36 scores. Further investigations are needed to determine optimal treatment paradigm for geriatric ankle fracture patients.

Functional and clinical outcomes of total ankle arthroplasty in elderly compared to younger patients

BACKGROUND

Total ankle arthroplasty (TAA) is becoming an increasingly utilized procedure for the management of end-stage ankle arthritis. Elderly patients are the fastest growing segment of the population in the western world, creating a unique challenge to the health economics of our era. Determining if elderly patients with end-stage ankle arthritis demonstrate the same improvements in clinical outcomes and functional measures of gait following TAA would be valuable. This can aid to evaluate the utilization of TAA in this enlarging cohort of our population.

METHODS

Consecutive series of twenty-one patients over the age of 70, who underwent TAA for end-stage ankle arthritis, was prospectively compared to a series of twenty-one patients aged 50-60, who underwent the same procedure by single surgeon during same time period. Clinical outcomes were measured with outcome scores including VAS pain score, AOFAS Ankle and Hindfoot Score, and the SF-36. Three-dimensional gait analysis was performed preoperatively and at a minimum of one year postoperatively, to measure temporal-spatial, kinematic, and kinetic parameters of gait. Mixed model multivariate statistical analysis was used to evaluate and compare the independent contributions to outcomes of the surgical intervention over time; of patient age; and of time-plus-age interaction, as these influenced both the clinical outcomes and the functional gait outcomes.

RESULTS

Statistically significant improvements in VAS pain scores, AOFAS ankle/hindfoot scores, and SF-36 scores were demonstrated in both age groups. Following surgery, there were improvements in all parameters of gait, including temporal-spatial parameters as step length and walking velocity; kinematic parameters, including, increase in total range of motion to a total of 17-19°; and kinetic parameters, including increase in ankle power and moment. The improvements both in clinical and gait outcomes were equivalent in the two age groups.

CONCLUSIONS

In this comparative study, it is shown that both elderly patients over the age of 70 and younger patients aged 50-60 demonstrated equivalent improvements clinical and gait outcomes following ankle arthroplasty. This may be important data both for clinical decision-making and the health economics for our ageing population.

Gait abnormalities in patients with chronic ankle instability can improve following a non-invasive biomechanical therapy: a retrospective analysis

[Purpose] The purpose of this study was to evaluate the changes in gait patterns and clinical outcomes of patients with chronic ankle instability (CAI) following treatment with a home-based non-invasive biomechanical device. [Subjects and Methods] Thirty-three patients with CAI were compared with 43 healthy controls. Patients underwent a spatiotemporal gait assessment before and three months following treatment. Clinical evaluation was recorded with SF-36 Health Survey and the Foot and Ankle Outcome Score (FAOS). [Results] Significant baseline differences were found between groups. Patients with CAI showed a statistically significant improvement in velocity, cadence, symptomatic limb step length and single limb support over time. Significant improvements in SF-36 PCS and FAOS outcome scores were found in patients with CAI. [Conclusion] Patients with CAI have baseline spatiotemporal gait abnormalities as compared with healthy controls. However, clinical and gait metrics improvement can be expected after 12 weeks of perturbation training using a non-invasive biomechanical device.

Posterior Malleolus Fractures

Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.

Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis

Aims

The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis.

Patients and Methods

We prospectively studied 20 patients who underwent three-dimensional gait analysis before and after tibiotalar arthrodesis. Cadence, step length, walking velocity and total support time were assessed. Kinetic parameters, including the moment and power of the ankle in the sagittal plane and hip power were also recorded.

Results

Significant improvement was recorded across numerous parameters compared with pre-operative measurements. Temporal-spatial data demonstrated a significant increase in step length (p = 0.003) and velocity (p = < 0.001). Total support time decreased for the unaffected limb (p = 0.01). Kinematic results demonstrated that in the affected limb, total sagittal range of movement did not change significantly (p = 0.1259). However, the arc of movement had a near congruent shift with mean maximal dorsiflexion increasing from 5° (-17° to 16°) to 12° (5° to 18°) (p < 0.001) and mean maximal plantarflexion decreasing from 6.8° (6° to 21°) to 0.9° (-9° to 8°) (p = 0.003). Mean hip joint range of movement increased by 6° (-7° to 24°; p = 0.003). Kinetic results demonstrated no statistically significant change in ankle power (p = 0.1292). However, there was an increase in ankle moment (p = 0.04) and hip power (p = 0.01) in the surgically treated extremity. Sagittal plane range of movement was not reduced after tibiotalar fusion.

Conclusion

Although following tibiotalar arthrodesis the gait demonstrated never matched the gait shown in unaffected ankles, compared with the pre-operative analysis there was improvement in numerous temporal-spatial, kinematic, and kinetic measures. Cite this article: Bone Joint J 2016;98-B:1369–75.

Management of ankle fractures

Ankle fractures are a common injury across all age groups. Management may be operative or nonoperative, depending on the severity of the injury and the patient's overall health and functional status. Although imaging defines the nature of the fracture, a careful history and physical also helps determine the patient's plan of care. Initial management is focused on adequate alignment and safe immobilization of the injury. Definitive management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues. Rehabilitation after either operative or nonoperative treatment aims at restoring range of motion, strength, proprioception, and function.