Adjacent Joint Arthritis Research Articles

TO STUDY THE FUNCTIONAL AND RADIOLOGICAL OUTCOMES OF ANKLE ARTHRODESIS WITH CORTICOCANCELLOUS SCREW FIXATION VS INTRAMEDULLARY NAILING

Objective: We aimed to evaluate the functional and radiological outcomes of ankle arthrodesis using corticocancellous screw fixation vs intramedullary nailing. Methods: In our study, 22 cases underwent the procedure. This evaluation was performed based on preoperative radiologic data and at postoperative clinical visits at 2 months, 6 months, and 12 mo required postoperatively. Radiologic outcomes were measured by: (1) Rate of union, (2) Rate of adjacent joint arthritis, and (3) Alignment of the ankle joint. Functional outcomes were measured by using the AOFAS score (American Orthopedic Foot and Ankle Society score). The patients' Subjective assessments were done using the Cumberland Ankle Instability Tool (CAIT). Results: The angle between the tibia's long axis and a line parallel to the talus's long axis is determined in the AP projection. The mean angle was 89.6 degrees (85-100 degrees) in the intramedullary nailing group (IMN group) and 91.4 degrees in the corticocancellous screw group (CC screw). The angle between the tibia's long axis and a line that is perpendicular to the talus’s long axis. The mean angle was 40.5 degrees (30-45 degrees) in the IMN group and 41.6 degrees in the CC screw group. The mean AOFAS score (American Orthopedic Foot and Ankle Society score) was 83.25 in the IMN group and 80.5 in the other group. The mean Cumberland Ankle Instability Tool (CAIT) score was 28 in the IMN group and 27.5 in the other group. All the cases showed bony union except one case, the average time taken for the union was 18.5 w in the IMN group and 20.5 w in the CC screw group. Conclusion: According to our study, all of the patients with normal angles between the tibia's long axis and a line perpendicular to the talus's long axis were obtained in the AP projection, and the angle between the tibia's long axis and a line that is perpendicular to the talus’s long axis. These patients also showed better Cumberland Ankle Instability Tool (CAIT) and AOFAS (American Orthopedic Foot and Ankle Society) scores in both comparison groups.

Influence of Isolated Talonavicular and Subtalar Joint Arthrodesis on Hindfoot Kinematics and Range of Motion During Cadaveric Gait Simulation.

Isolated subtalar and talonavicular joint arthrodeses have been associated with adjacent joint arthritis and altered hindfoot kinematics during simplified loading scenarios. However, the effect on kinematics during dynamic activity is unknown. This study assessed changes in subtalar and talonavicular kinematics after isolated talonavicular (TNiso) and subtalar (STiso) arthrodesis, respectively, during stance simulations. Fourteen midtibia specimens received either a TNiso or STiso arthrodesis, with 7 randomized to each group. A 6-degree-of-freedom robot sequentially simulated the stance phase for the intact and arthrodesis conditions. Bootstrapped bias-corrected 95% CIs of the talonavicular and subtalar joint kinematics were calculated and compared between conditions. The TNiso decreased subtalar inversion, adduction, and plantarflexion in late stance (P < .05). The subtalar range of motion in the sagittal and coronal planes decreased by 40% (P = .009) and 46% (P = .002), respectively. No significant changes in talonavicular joint kinematics were observed after isolated subtalar arthrodesis; however, the range of motion was reduced by 61% (P = .007) and 50% (P = .003) in the coronal and axial planes, respectively. In this model for arthrodesis, changes in subtalar kinematics and motion restriction were observed after isolated talonavicular arthrodesis, and motion restriction was observed after isolated subtalar arthrodesis. Surprisingly, talonavicular kinematics did not appear to change after isolated subtalar arthrodesis. Both joint fusions substantially decrease the motion of the reciprocal adjacent joint. Surgeons should be aware that the collateral costs with talonavicular fusion appear higher, and it has a significant effect on subtalar kinematics during the toe-off phase of gait.

Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study.

Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT. A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant. The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023. Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT. Level III, retrospective cohort comparative study.

Adjacent Joint Arthritis Incidence Rate Following Fusion of the First Tarsometatarsal Joint as Treatment for a Forefoot Deformity

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Nontraumatic forefoot deformities such as hallux valgus (HV) are common causes for patients seeking reconstructive surgery. Known as a “bunion,” HV is characterized by 1-2 intermetatarsal angle widening and first metatarsal head medial drift, resulting in the great toe pointing laterally. Surgery is indicated for patients who fail to find relief with conservative management. However, there is no consensus among orthopedic surgeons on whether osteotomy or first tarsometatarsal (TMT) arthrodesis is the better surgical treatment method. Additionally, no known studies have explored the development of adjacent joint arthritis in patients who have received a first TMT fusion. This study aims to investigate the rate of arthritis development in the adjacent joints following arthrodesis of the first TMT joint. Methods: A retrospective chart review at a tertiary foot and ankle clinic was performed on subjects who received a first TMT fusion between January 2004 and December 2017. This included subjects who received concomitant gastrocnemius recession, tendo-achilles lengthening, 1-2 intermetatarsal arthrodesis, 1-2 intercuneiform arthrodesis, hammertoe corrections, and other soft tissue releases deemed by the senior authors to be inconsequential in the case of adjacent joint arthritis development. Pre- operative, operative, and post-operative indications will be evaluated throughout this thorough chart review, and charts will be continually reviewed for inclusion and exclusion criteria. Patient information gathered includes age, sex, height, weight, BMI, activity level, smoking history, medications, time spent with hardware retained, the method of arthritis diagnosis (x-ray alone, CT, MRI, bone scan), relevant additional diagnoses, and operative data. Pre- and post-operative pain levels and satisfaction scores will follow the AOFAS Score Criteria. Results: Preliminary Results: 899 subjects (148 males, 751 females) are included in this study. The age range was 67 years (18 - 85), with an average age of 56.6 at surgery. Patient BMI varied from 12.7 to 53.1. Concurrent operative soft tissue procedures: gastrocnemius recession (749), tendo-Achilles lengthening (13), and a combination of the two (1). Concomitant fusions: isolated 1- 2 intermetatarsal arthrodesis (799) and combined with 1-2 intercuneiform arthrodesis (695). Clinical follow-up ranged from three to 186 months, averaging 34 (2 years, ten months). Presently, radiographic assessment has been performed for 154 of the 899 patients included in this study. Of these, 11 had developed adjacent joint arthritis at last radiographic follow-up (7.1%); two with naviculocuneiform arthritis, eight with talonavicular arthritis, and one with both. Conclusion: Based on preliminary data, a successful fusion of the first TMT joint, as treatment of a forefoot deformity such as HV, does not appear to accelerate the development of arthritis in the adjacent joints.

Effects of Ankle Arthrodesis vs Total Ankle Arthroplasty on Patient’s Shoe-Wear: What Fits Better?

Category: Ankle Arthritis; Ankle Introduction/Purpose: Currently there are two major surgical options for the treatment of end-stage ankle arthritis (ESAA), namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA). Many patients inquire about what shoes they can expect to wear after surgery. Shoes should fit to the patient’s feet, help shielding pathological joints, be comfortable, but also fashionable, as they are part of personal style and fashion. The impact ESAA surgery has on choice of shoes and consecutively on quality of life, has not been studied. Potentially maintenance of ankle range of motion and improved gait mechanics with TAA could also improve the ability to comfortably wear different styles of shoes. The purpose of this study is to evaluate the effects of either AA and TAA on shoe-wear. Methods: This study is a retrospective analysis of a cohort of ESAA patients surgically treated with AA or TAA from the COFAS (Canadian Orthopaedic Foot and Ankle Society) database. Patient’s shoe wear comfort was obtained from the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaire, completed pre-operatively and post-operatively two and five years following surgery. The relationship between ankle-related quality of life and shoe-wear comfort, adjusting for patient factors was evaluated. A linear regression model adjusted for age, gender, BMI, smoking status, presence of inflammatory arthritis and baseline score was calculated. Additionally, differences within each pre-operative COFAS grades were analyzed. Results: 104 patients after AA and 106 following TAR have been included. The mean pre-operative baseline score did not differ between the cohorts (39.36 for AA and 38.94 for TAA, respectively; p= 0.74). Comparing AA patients with TAA patient scores over a 5-year period, there was no difference in shoe-wear comfort after 2 years, but after 5 years scores significantly improved for TAA patients (p= 0.02). Subgroup analysis showed that COFAS 4 patients improved the most with significant changes already after 2 years (mean difference 5.4, p=0.05), which further improved after 5 years of follow-up (mean difference 10.7, p=0.001). Conclusion: This study is the first study to elucidate patient experience after ankle arthrodesis and total ankle arthroplasty with regards to their shoe-wear. Patients undergoing TAR have better shoe-wear scores by five years post-operatively than those undergoing AA. Especially patients with a COFAS 4 grade, which represents a patient population with adjacent joint arthritis, show significant improvement already 2 years after surgery. This data is useful when counselling patients preoperatively, and further provides support for TAA over AA after appropriate patient selection.

Hindfoot Arthrodeses and the Order of Joint Fixation Influence Tibiotalar Kinematics During Simulated Stance.

Although hindfoot arthrodeses relieve pain and correct deformity, they have been associated with progressive tibiotalar degeneration. The objective was to quantify changes in tibiotalar kinematics after hindfoot arthrodeses, both isolated subtalar and talonavicular, as well as double arthrodesis, and to determine if the order of joint fixation affects tibiotalar kinematics. Hindfoot arthrodeses were performed in 14 cadaveric mid-tibia specimens. Specimens randomly received isolated fixation of the subtalar or talonavicular joint first, followed by fixation of the remaining joint for the double arthrodesis. A 6-degree-of-freedom robot sequentially simulated the stance phase of level walking for intact, isolated, and double arthrodesis conditions. Tibiotalar kinematic changes were compared for the intact and arthrodesis conditions. A subsequent analysis assessed the effect of the joint fixation order on tibiotalar kinematics. Isolated and double hindfoot arthrodeses increased tibiotalar plantarflexion, inversion, and internal rotation during late stance. Tibiotalar kinematics changes occurring after isolated arthrodesis remained consistent after the double arthrodesis for both the subtalar- and talonavicular-first conditions. The order of joint fixation influenced tibiotalar kinematics through some portions of stance, where the talonavicular-first double arthrodesis increased tibiotalar plantarflexion, eversion, and internal rotation compared to the subtalar-first double. Tibiotalar kinematics were modestly altered for all conditions, both isolated and double hindfoot arthrodeses. Changes in tibiotalar kinematics were consistent from the isolated to the double arthrodesis conditions and varied depending on which isolated hindfoot arthrodesis was performed first. Further research is needed to assess the clinical implications of the observed changes in tibiotalar kinematics, particularly as it pertains to the development of adjacent joint arthritis. These findings may correlate with clinical research that has cited hindfoot arthrodesis as a risk factor for adjacent tibiotalar arthritis. Once either the subtalar or talonavicular joint is fused, avoiding the arthrodesis of the second joint may not necessarily protect the tibiotalar joint.

ANKLE DISTRACTION IN YOUNG ADULTS WITH SEVERE ARTHRITIS: A VIABLE TREATMENT OPTION?

Management of ankle arthritis in young patients is challenging. Although ankle arthrodesis gives consistent pain relief, it leads to loss of function and adjacent joint arthritis. Ankle joint distraction (AJD) has been shown to give good outcomes in adults with osteoarthritis or post-traumatic arthritis. The efficacy in children or young adults and those with juvenile idiopathic arthritis is less well evidenced.Clinical notes and radiographs of all patients (n=6) managed with AJD in one tertiary referral centre were retrospectively reviewed. Radiographs were taken pre-surgery, intra-operatively, 1 month following frame removal and at the last follow up, tibiotalar joint space was assessed using ImageJ software. Measurements were taken at the medial, middle and lateral talar dome using frame components as reference. Radiographic data for patients with a good clinical outcome was compared with those who did not.At time of surgery mean age was 16.1 years (12 – 25 years). Mean follow up was 3.4 years (1.5 – 5.9 years). Indications were juvenile idiopathic arthritis (4) post-traumatic (1) and post-infective arthritis (1). Three patients at last follow up had a good clinical outcome. Two patients required revision to arthrodesis (1.3 and 2.4 years following distraction). One patient had spontaneous fusion. One patient required oral antibiotics for pin site infection.Inter-observer reliability was 95%. Mean joint space was 1.17mm (SD = 0.87mm) pre-operatively which increased to 6.72mm (SD = 2.23mm) at the time of distraction and 2.09mm (SD = 1.14mm) at the time of removal. At one-year follow up, mean joint space was 1.96mm (SD = 1.97mm).Outcomes following AJD in this population are variable although significant benefits were demonstrated for 50% of the patients in this series. Radiographic joint space preoperatively did not appear to be associated with need for arthrodesis. Further research in larger groups of young patients is required.

Outcomes After Chevron Osteotomy with and Without Additional Akin Osteotomy: A Retrospective Comparative Study

BackgroundChevron osteotomy is one of the most common approaches to hallux valgus corrective surgery. This procedure is often combined with Akin osteotomy of the proximal phalanx of the hallux. There are no definitive guidelines specifying the indications for a given osteotomy technique nor data on postoperative loss of correction or the effect of the type of first-ray surgery on the development of adjacent-joint arthritis. The aim of this study was to assess radiographic treatment outcomes via chevron osteotomy with and without Akin osteotomy.MethodsThe study evaluated 117 patients treated in the period 2016–2019. Ninety-nine of those patients underwent distal chevron osteotomy alone, and 18 patients underwent a combined chevron–Akin double osteotomy. The analyzed radiograms had been obtained preoperatively, at 6 weeks after surgery, and after a long-term follow-up. The following parameters were assessed: the intermetatarsal angle (IMA), hallux valgus angle (HVA), interphalangeal angle (IPA), postoperative recurrence of valgus deformity, adjacent-joint arthritis, and complications.ResultsChevron-Akin osteotomy helped maintain lower HVA and IPA values in long-term follow-up in comparison with those in the patients who underwent chevron osteotomy alone. The chevron osteotomy group showed a significant increase in the mean HVA from 18.37° at the first follow-up visit to 20.81° at the last follow-up visit. There were no differences between the groups in terms of the remaining assessed radiographic parameters. Hallux valgus surgery does not increase adjacent-joint arthritis.ConclusionThe use of combined chevron-Akin osteotomy does not affect HVA or IMA correction. The combination of chevron and Akin osteotomies reduces the risk of increased HVA and IPA in long-term follow-up. The additional Akin osteotomy does not increase the risk of adjacent-joint arthritis. Combining chevron osteotomy with Akin osteotomy is recommended in hallux valgus deformity correction.

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n=32) or chevron (n=181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

Radiographic Assessment of Tibiofibular Syndesmosis Injury with Different Durations and Types of Fixation.

There is no consensus among orthopedic surgeons on the number of cortical layers (tricortical or quadricortical fixation) involved or the duration of syndesmotic fixation after a tibiofibular syndesmosis (TFSD)-injury treatment. The purpose of this study was to assess radiographic parameters following the treatment of TFSD injuries, with various time-windows of syndesmotic screw removal and numbers of cortical layers involved. Fifty-five patients, aged from 25 to 75 years, were included in the study. The follow-up period ranged from 2 years to 4 years and 2 months. The patients were subdivided into groups based on the duration of the syndesmotic fixation (8-15 weeks-19 patients or 16-22 weeks-36 patients) and the number of cortices involved (tricortical-17 patients or quadricortical fixation-38 patients). The quadricortical fixation group showed a significant development of ankle joint arthritis and subtalar joint arthritis at the final follow-up. The mean medial clear space was 2.84 mm in the tricortical fixation group and 3.5 mm in the quadricortical fixation group (p = 0.005). Both groups, with different screw removal times showed significant development of posttraumatic arthritis. A comparison of the two groups (with different time-windows of the screw removal) revealed a significant difference only in terms of the postoperative tibiofibular (TF) overlap and the observed rates of talonavicular arthritis at the final follow-up. We found that the duration of the screw fixation had no effect on most of the evaluated radiographic parameters. Only the postoperative TF overlap was lower in the 8-15-week fixation group, and the proportion of patients with talonavicular joint arthritis at the final follow-up was higher in the 16-22-week fixation group. In addition, the number of cortices involved in the screw fixation had no effect on the radiographic outcomes in our patients, apart from the differences in one parameter-the medial clear space-at the final follow-up. We achieved similar radiographic results irrespective of the duration of the screw fixation and the number of cortices involved. All study subgroups showed the development of adjacent-joint arthritis following treatment. Considering the results of our study, the economic and medical aspects of treatment, and the possibility of a faster recovery, the most optimal solution seems to be the use of a tricortical fixation, with the screws being removed after 8-15 weeks.

Development and Validation of a Patient Decision Aid for the Treatment of Ankle Arthritis

Category: Ankle Arthritis; Ankle Introduction/Purpose: Choosing a treatment course can be challenging for patients with ankle osteoarthritis given the multiple operative and nonoperative options. We developed and validated the Ankle Arthritis Patient Decision Aid as a tool to improve shared decision-making for such patients. Methods: Eighty patients of 2 surgeons at a US academic foot and ankle practice were recruited from October 2020 to June 2021 using an electronic medical record messaging system. Participants reviewed the tool and answered survey questions evaluating its quality and factors affecting treatment choice in a hypothetical patient scenario. We evaluated the tool using decisional conflict scores (maximum, 40 points, with higher scores indicating greater uncertainty), pre- and post-knowledge test scores (maximum, 8 points), and helpfulness scores (maximum, 7 points). We compared pre- and post-test knowledge scores using paired Student t- tests. Alpha=.05. Results: Mean (+- standard deviation) knowledge scores improved from 4.8 +- 1.2 (pre-test) to 6.7 +- 1.3 (post-test), for a mean improvement of 1.9 +- 1.4 (p&lt;.001). The mean decisional conflict score was 4.1 +- 5.7, reflecting minimal uncertainty. Factors greatly affecting participants' treatment choices were desire to maintain a high level of physical activity (n=58), risk of complications (n=35), recovery time (n=33), and risk of increased rate of arthritis in adjacent joints (n=32). The mean reported helpfulness score was 5.9 +- 1.2, reflecting substantial benefit. Conclusion: The Ankle Arthritis Patient Decision Aid is a comprehensible tool that significantly improves patient knowledge regarding treatment options for ankle arthritis.

Conversion of hindfoot intramedullary nail arthrodesis to total ankle arthroplasty: A case study

Ankle arthrodesis has long been the gold standard for ankle arthritis but issues such as adjacent joint arthritis, non-union, and malunion are common complications. Total ankle arthroplasty (TAA) has gained popularity with recent encouraging long-term results and conversion of ankle arthrodesis to arthroplasty is now being offered. This case study reports a total ankle arthroplasty conversion from a retrograde hindfoot intramedullary nail in a 25 year old female with a history of trauma and several operations. This case describes a rare instance for this particular procedure due to the arthrodesis performed by an intramedullary hindfoot nail complicated by malunion.

The Fall and Rise of Total Ankle Arthroplasty: A Database Analysis of Procedural Incidence Between 2009 and 2019

Category: Ankle; Ankle Arthritis; Hindfoot; Trauma Introduction/Purpose: Ankle osteoarthritis accounts for one of the most common ankle joint pathologies. Although total ankle arthrodesis has been the mainstay treatment for degenerative end-stage ankle arthritis, the popularity of total ankle arthroplasty has been on the rise due improved implant design, technologies, and postoperative outcomes. Yet, there remains a paucity of epidemiologic data in recent years on the incidence of total ankle arthroplasty in the United States. We hypothesize that stratified incidences of patients undergoing this procedure in the last decade has risen. Methods: The Truven MarketScan database was queried to identify patients who underwent total ankle arthroplasty from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of total ankle arthroplasty. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 41,060 total ankle arthroplasty procedures were identified in the database from 2009 to 2019. Annual volumes have increased significantly by 136.1%, from 2,180 to 5,147 total procedures nationwide. Procedural incidence reported per 1,000,000 people significantly increased by 120.8%, at 15.9 in 2019. Significant growth in incidence was demonstrated in males and females below the age of 65 years with the highest annual incidence found in people under the age of 54. Incidence stratified by region rose in all regions of the United States with the South and West seeing the most notable increases. Conclusion: The epidemiology of TAA has yet to be clarified in recent years. We found that annual volumes and incidence of TAA has increased in the past decade. Growth in incidence was demonstrated in both sexes &gt; 54 years as well as in all regions of the US. While ankle arthroplasty succeeds in mitigating certain complications associated with arthrodesis such as impaired ankle motion, gait changes and adjacent joint arthritis, orthopedic surgeons must remain mindful of the significant consequences associated with revision ankle arthroplasty. Describing epidemiology with stratified procedural incidence can help orthopedists adapt to the ever-evolving changes in the field.

2022 Roger A. Mann Award Winner: Total Ankle Replacement vs Arthrodesis (TARVA) Randomized Controlled Trial: 2 Year Results

Category: Ankle Arthritis; Ankle; Hindfoot; Other Introduction/Purpose: End-stage ankle osteoarthritis (EOA) causes severe pain and chronic disability. Once non operative measures have been exhausted the two main surgical treatments include total ankle replacement (TAR) and ankle fusion (AF). Systematic reviews have confirmed that both procedures are effective but there has never been a robust randomised multicentre level I study comparing the two treatments. Our objective was to investigate and compare the clinical and cost effectiveness of TAR against AF in the treatment of end-stage ankle osteoarthritis in patients aged 50-85 years. Methods: TARVA is a multi-centre, parallel-group, open label randomised trial. Patients with EOA, aged 50-85, suitable for either procedure were recruited at 17 UK hospitals. Randomisation was carried out using a secure on-line service and was stratified by surgeon and the presence or absence of adjacent joint OA (based on an independently reviewed preoperative MRI scan). Participants were randomised 1:1 to either TAR or ankle arthrodesis. The primary outcome was the change in the Manchester Oxford Foot &amp; Ankle Questionnaire (MOXFQ) walking/standing domain scores between pre-operation and 52 weeks post- operation. Secondary outcomes measures included FAAM; FAAM (ADL); and Sport subscale scores. Quality of life was measured using the EQ-5D-5L. Total range of tibia to floor motion was measured using a validated method. Health economic analysis used mean incremental cost per quality-adjusted life years (QALY) gained. Analysis was by intention to treat. The trial registration is ISRCTN60672307. Results: Of 933 eligible patients 303 were randomised. 282 underwent surgery. Mean age 68 (71% male). Aetiology was post- trauma in 55.3%, and inflammatory in 7.1%. Groups were well balanced at baseline on all parameters. 54% TARs were fixed bearing. 61% of fusions were performed arthroscopically. At 2 years the adjusted mean difference in the change in MOXFQ W/S between TAR &amp; AF was -4.4(95% CI -11.38 to 2.68, p=0∙23). Post hoc analysis of the commonest implant type (fixed bearing TAR) did show a statistically significant improvement over AF (p=0∙04, -8.9, 95% CI -17.2 to -0.6). Secondary outcomes, EQ5D-VAS and FAAM were significant. Complications included wound healing issues (13.8% vs 5.5%); nerve injuries (4.3% vs 0.7%). 11.8% of AF patients had plain radiographic evidence of non-union but only 6.9% had symptoms. Reoperation rate was 7.2% for TAR vs 5.2% for AF; and revision rate was 0.7% for TAR vs 2.8% for AF. Conclusion: Patients improved in all outcomes in both arms. We did not show a significant difference in our primary outcome measure between TAR and AF overall(p=0.23), but did show significance when fixed bearing TAR alone was compared against AF(p=0.04). Secondary outcomes did show significance. Adjacent joint arthritis increases the size of effect noted between arms. There were more wound healing issues and nerve injuries in TAR group. The symptomatic non-union rate for AF is 6.9%. TAR is likely to be cost-effective compared to AF at the NICE cost-effectiveness threshold of £20,000 per Quality Adjusted Life Year gained over the patients' lifetime.

Cadaveric Gait Simulation of the Effect of Subtalar Arthrodesis on Total Ankle Replacement Kinematics.

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR. Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-STfuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-STfuse. There were significant differences in kinematics and range of motion between TAR and TAR-STfuse groups. At the ankle joint, TAR-STfuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003). In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint. These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.

Individual Surgical Treatment of Stage IV Müller-Weiss Disease According to CT/MRI Examination: A Retrospective Study of 12 Cases.

BackgroundThis study reported the individual surgical treatment of 12 cases with stage IV Müller-Weiss disease (MWD) according to CT/MRI examination.MethodsIn total, 12 cases diagnosed with stage IV MWD in our hospital from 2015 to 2019 were included in the retrospective study. Relevant clinical outcomes were evaluated preoperatively and postoperatively.ResultsThe follow-up results showed satisfactory outcomes in all cases. All the cases were presented with tenderness and chronic pain on the midfoot dorsum, and three cases were also presented with tenderness and pain on the lateral side of the midfoot, in which calcaneal cuboid arthritis was revealed by CT/MRI. The American Orthopedic Foot and Ankle Society (AOFAS) scores elevated from 62.5 ± 6.8 (range: 53–74) preoperatively to 95.3 ± 7.2 (range: 73–100) postoperatively (P < 0.005). The Visual Analog Scale (VAS) scores declined from 4.2 ± 0.9 (range: 3–5.5) preoperatively to 0.5 ± 0.3 (range: 0–2) postoperatively (P < 0.001). On the weight-bearing lateral view of the foot, the Tomeno-Méary angle (TM lat) changed from −11.2 ± 4.2 (range: −17.2 to −2.8) degrees preoperatively to −2.4 ± 3.9 (range: −10.2 to 5.2) degrees postoperatively (P < 0.001).ConclusionsThe fusion of the talus-navicular joint and the adjacent affected joint provide good clinical outcomes. The CT/MRI scans are helpful to identify the adjacent joint arthritis and provide indications for individual treatment for Stage IV MWD.

Total Talus Replacement with Subtalar Arthrodesis for End-Stage Talar Osteonecrosis and Adjacent Joint Arthritis

Category:Ankle; Hindfoot; Trauma; OtherIntroduction/Purpose:Late stage talar avascular necrosis (AVN) results in devascularization of the talus with osteonecrosis, subchondral collapse, talus fracturing, loss of talar height and declination, and adjacent joint arthritis. This results in significant disability for patients with limited treatment options. Tibiotalocalcaneal arthrodesis with structural allograft has been the historic treatment option for this challenging clinical scenario, however, the outcomes are fair with reported nonunion rate up to 40%. Total talus replacement (TTR) is an emerging treatment option for patients with talar AVN. TTR with subtalar arthrodesis may be utilized for end-stage talar AVN with adjacent joint arthritis. The purpose of this study is to evaluate the short-term outcomes for TTR with subtalar arthrodesis including pain, ankle range of motion, union rates, and complications.Methods:Consecutive patients who underwent TTR with a subtalar arthrodesis from 2016-2020 were retrospectively reviewed. All surgeries were performed by one of two fellowship-trained foot and ankle orthopaedic surgeons at a single academic institution. All talus implants were custom 3D printed total tali (Additive Orthopaedics, Little Silver, NJ), composed of a cobalt chrome alloy. The implants were sized based on computed tomography scans of the contralateral talus. The plantar surface of the tali were prepared with an ingrowth surface and drill holes to accept screws and facilitate subtalar arthrodesis. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, range of motion, union rates, and complications. Data analysis was performed with paired t-tests and a significance level of p<0.05.Results:A total of 19 patients were included with an average of 11.4 months follow-up. There were 11 (57.9%) men, and the average age was 52.3 (range, 18-75) years-old. About half (n=9, 47.4%) of the cohort had a previous talus fracture, and 17 (89.5%) patients had previous ipsilateral ankle surgery. There were 5 (26.3%) patients who underwent concomitant talonavicular arthrodesis at the time of TTR and subtalar arthrodesis. Significant postoperative improvements were observed in VAS scores (2.4 vs. 8.6; p<0.0001), ankle dorsiflexion (10.7° vs. 1.8°; p=0.0131), and ankle plantarflexion (32.9° vs. 21.3°; p<0.0068). All patients achieved a successful union of their subtalar arthrodesis (n=19/19, 100%) and talonavicular arthrodesis (n=5/5, 100%). There were 2 (10.5%) complications including 1 (5.3%) delayed wound healing successfully treated nonoperatively and 1 (5.3%) reoperation in a patient with persistent varus ankle deformity requiring distal tibia and fibula osteotomies. There were no postoperative infections, explants, or amputations required.Conclusion:TTR with subtalar arthrodesis should be considered as a treatment option for patients with end-stage talar AVN and adjacent joint arthritis. Patients experienced significant improvement in pain and ankle range of motion. The complication rate was 10.5% with only 1 patient requiring a reoperation. A union rate of 100% was observed with no postoperative infections, explants, or amputations. This technique perves ankle motion while eliminating hindfoot pain in patients with loss of talar bony integrity and adjacent joint arthritis. Further studies are required including longer-term follow-up and prospective cohorts to ensure continued safety and efficacy.

Return to Physical Activity after Isolated Subtalar Arthrodesis

Category:HindfootIntroduction/Purpose:Subtalar arthrodesis has been shown to provide reliable pain relief and deformity correction for a variety diagnoses including include primary arthritis, posttraumatic arthritis, inflammatory arthritis, talocalcaneal coalitions, and hindfoot deformity. However, the level of functional activity achievable following this procedure is unknown. The aim of this study was to assess physical activity and functional outcomes in patients following isolated, primary subtalar arthrodesis.Methods:A retrospective review of isolated primary subtalar fusions was performed. Inclusion criteria were: age between 18 and 65, isolated primary subtalar fusion that achieved bony union, minimum 4 month radiographic follow up (XR or CT), and 1 year minimum questionnaire follow up. Patients who had neuromuscular diagnoses, adjacent joint arthritis, inflammatory arthritis, contralateral ankle or hindfoot pathology, significant medical comorbidities, or were treated under worker's compensation were excluded. The primary outcome measure was the Foot and Ankle Ability Measure. Additional patient reported outcomes included a novel functional assessment questionnaire, Coughlin Satisfaction Score, and a contralateral hindfoot comparison score.Results:Patient reported outcome measures were collected from 15 (10 F, 5 M) patients at a median of 78 (49, 106) months following surgery. The median FAAM ADL subscore was 83.3 (71.4, 98.8) and the sports subscore was 59.4 (40.6, 87.5). The majority (58%) of patients maintained the same level of physical activity before and after surgery. Fewer patients were able to golf, rollerskate/ice skate, run, weightlift, or take aerobics/yoga after surgery. More patients were able to dance, hike, play tennis/pickleball, or walk for exercise. More patients were able to wear shoes without limitations and fewer patients required a brace or orthotics. Good and excellent outcomes were reported by 73% of the cohort. The median contralateral comparison score for the cohort was 90 (50, 100).Conclusion:Isolated subtalar arthrodesis can provide reliable pain relief and allow reasonable functional outcomes as demonstrated in this patient cohort. In general, most patients maintain their level of function and have fewer limitations with shoe wear. Select, higher impact activities may be more challenging for patients with a fused subtalar joint. These findings may be used to help surgeons appropriately counsel patients about expected postoperative physical activity following an isolated subtalar arthrodesis.

2021 Roger A. Mann Award Winner: Long-Term Revision Rates and Functional Outcomes of Total Ankle Arthroplasty and Ankle Arthrodesis

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Recent studies have shown acceptable long-term survival rates with TAA however there remains a general paucity of information directly comparing ankle arthroplasty to arthrodesis over long-term follow-up. This study compares revision rates and functional outcomes for a large cohort of patients undergoing ankle arthrodesis or arthroplasty. All surgeries were performed by a single surgeon from 1999 to 2013. Ankle arthrodesis was performed using a standardized 3-screw technique with anterior plate supplementation. Arthroplasty was performed utilizing the Scandinavian Total Ankle Replacement (STAR) prosthesis.Methods:A retrospective chart review was performed for 335 consecutive cases in 326 patients (198 ankles in the arthrodesis group and 137 in the arthroplasty group). Patient demographics including age, sex, body mass index (BMI), and preoperative diagnoses were collected. Foot Function Index (FFI) scores were obtained and recorded at final outpatient follow-up. Primary outcomes included the rate of revision surgery and functional outcome scores. Secondary outcomes included perioperative complications such as polyethylene fracture and patients who went on to undergo postoperative subtalar fusion for symptomatic adjacent joint arthritis.Results:Ten (6%) ankles in the arthrodesis group and twenty-one (15%) in the arthroplasty group required revision surgery at a mean of 8.9 +- 6.5 and 61.1 +- 52.9 months, respectively [P=.039]. One hundred four of the 335 cases were available to complete functional outcome surveys at final follow-up at a mean of 11.2 +- 4.1 years from time of surgery (minimum 6-year follow-up).Mean FFI scores were significantly better in the arthroplasty group (40.3 +- 36.9) than in the arthrodesis group (61.5 +- 45.1) [P=.011]. Thirteen polyethylene components in 12 TAAs (8.7%) required replacement for fracture at an average of 9.6 +- 4.2 years postoperatively. Seven (3.5%) cases in the arthrodesis group and three (2.2%) in the arthroplasty group went on to undergo subtalar fusion at an average of 4.9 +- 3.9 years post-operation [P=.536].Conclusion:Long-term functional outcome scores were better in TAA patients; however, the revision rate for major complications was found to be greater over time. While the ankle arthroplasty group did show a slightly lower frequency of adjacent joint arthritis progression leading to subsequent subtalar fusion, this difference was not statistically significant. To our knowledge, this is the largest and longest-term follow-up comparing the STAR prosthesis to ankle arthrodesis published in the United States to date.