End-stage Ankle Arthritis Research Articles

Tibial Stress Fracture Following Ankle Arthrodesis.

End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. Level IV, retrospective case series.

Utility of Dehydrated Human Amniotic Membrane (DHAM) in Total Ankle Arthroplasty.

Wound complications after total ankle arthroplasty (TAA) are a common postoperative complication occurring in 14% to 66% of all surgeries. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and implant, and adhesions of the extensor tendons of the foot. Recent publications have advocated for the implantation of dehydrated human amniotic membrane (DHAM) allograft during closure of anterior ankle incisions during TAA. The goal of this study was to determine whether implantation of DHAM allograft in TAAs decreased overall postoperative wound complications. One hundred seventy patients with end-stage ankle arthritis refractory to conservative management underwent TAA with a standard anterior approach by 1 of 3 board-certified foot and ankle orthopedic surgeons. Ninety-one patients underwent closure of the anterior incision with addition of DHAM, whereas 79 patients served as the control (no addition of DHAM). The primary endpoints considered were postoperative complications and reoperation. Included in the postoperative complications was return to the operating room, postoperative plastic surgery intervention, wound communication with the implant, removal of the implant, neurolysis, tendon debridement, and extensor hallucis longus contracture/adhesions. In the analysis of our demographically homogenous cohorts, there was no statistically significant difference in any postoperative complications between patients closed with DHAM and controls. Return to the operating room occurred in 8.9% of controls and 15.4% of the DHAM group (P = .291). Similarly, there was no statistically significant difference in postoperative plastic surgery, wound communication with the implant, implant removal, neurolysis, and tendon debridement between the control and DHAM groups. The application of DHAM theoretically acts to decrease overall wound complications in TAA. The use of DHAM preceding wound closure in TAA did not show a statistically significant reduction in overall wound complications in our retrospective analysis. Further study, including prospective randomized studies, is needed to further investigate the effectiveness of DHAM in reducing wound complications in TAAs. Level III, retrospective cohort study.

Arthroscopic ankle arthrodesis: the technique to do

Background End-stage ankle arthritis severely affects patients’ health-related quality of life. When nonoperative treatments fail, ankle arthrodesis surgery or total ankle arthroplasty can improve pain, function, and health-related quality of life. For patients with isolated end-stage ankle arthritis and minimal deformity outside the ankle requiring osteotomies or fusions, ankle arthrodesis remains the mainstay of operative treatment. Open ankle arthrodesis has been the standard operative treatment for advanced osteoarthritis ankle not responsive to any nonoperative measures, but arthroscopic technique gained high popularity owing to high rate of fusion with a low incidence of complications. Aim This study aims to evaluate the role and results of arthroscopic assisted ankle arthrodesis in advanced ankle osteoarthritis (AOS). Patients and methods A total of 40 patients with post-traumatic arthritis, primary osteoarthritis, and rheumatoid arthritis were treated by ankle arthroscopic arthrodesis between January 2011 and January 2016 in Suez Canal University Hospital. The ankle was fixed with two cannulated percutaneous screws. The wound healing, complications, postoperative radiographs, and AOS score were evaluated. Both the pain and disability components were used to calculate the total score. Results All the cases united, with the average time for union being 12.8±1.19 weeks. The average duration of the surgery was 85.55±17.31 min (67–134). The mean hospital stay postoperatively was 1.2±0.52 days. The mean follow-up period was 36.4±4.38 weeks. The early results showed major decrease in AOS from 116±8.6 preoperatively to 19.4±2.3 postoperatively. This shows that the arthroscopic fusion was able to decrease the score by an average of 97.7±10.2 points. No incidences of deep infections, deep venous thrombosis, or revision surgery were observed. Screws’ length had been changed in four patients because of prominence. Conclusion Arthroscopic ankle arthrodesis could be considered as an alternative method for traditional open techniques for the management of severe ankle arthritis.

Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty

Many studies have reported the relevance of depression on clinical outcomes after knee or hip arthroplasty. However, no study has investigated this relationship in total ankle arthroplasty (TAA). This study aimed to study the relationship between depressive symptoms and clinical outcomes after TAA. This retrospective comparative study investigated 40 patients who underwent TAA for end-stage ankle arthritis. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale and Patient Health Questionnaire-9. Preoperative and postoperative clinical outcomes were compared using the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores by classifying the subjects into depressive and nondepressive groups. The mean follow-up duration was 24.3 ± 7.3 (range 14 to 37) months. There were 13 and 27 subjects in the depressive and nondepressive groups, respectively. There were no significant differences in the baseline characteristics and preoperative VAS and AOFAS scores between them. The postoperative VAS score was significantly higher in the depressive group (3.1 ± 2.4) than in the nondepressive group (1.4 ± 2.3; p < .001). The postoperative AOFAS scores in the depressive and nondepressive groups were 89.3 ± 13.4 and 95.0 ± 8.1, respectively, showing a significantly superior result in the latter group (p < .001). The clinical outcomes after TAA were poorer in the patients with depressive symptoms than in those without. Depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA. Therefore, clinical considerations of these symptoms are essential before TAA.

A Novel Technique for Creating an Articulating Cement Spacer for Ankle Prosthetic Joint Infections

Total ankle arthroplasty has been increasing as a treatment for end-stage ankle arthritis. With this increase, the incidence of total ankle prosthetic infections will also increase. Treatment of these infections depends on the duration of symptoms and whether the infection is acute or chronic in presentation. The treatment of choice for chronic infections is a 2-stage procedure, the removal of implants and placement of a static cement spacer. We describe a technique for creating an articulating antibiotic cement spacer through an anterior approach in a patient with an infected total ankle arthroplasty. The articulating antibiotic cement spacer allows high doses of local antibiotics, decreases soft tissue contractures, and allows continued motion of the joint.

Anteroposterior Translational Malalignment of Ankle Arthrodesis Alters Foot Biomechanics in Cadaveric Gait Simulation.

Tibiotalar arthrodesis is a common surgical treatment for end-stage ankle arthritis. Proper ankle alignment is important as malalignment can lead to complications that may require revision surgery. This study aimed to determine how anteroposterior (AP) translational malalignment of ankle arthrodesis affects distal foot joint kinematics and plantar pressure. Ankle arthrodesis was performed on 10 cadaveric foot specimens using a custom fixture that could fuse the ankle neutrally and induce discrete malalignments (3, 6, and 9 mm) anteriorly and posteriorly. Gait was simulated under each alignment with a robotic gait simulator, and foot bone motion and plantar pressure were quantified. AP translational malalignment did not substantially affect plantar pressure or joint range of motion, but there were several significant differences in joint position throughout stance phase. Differences were seen in five joints (talocalcaneal, talonavicular, calcaneocuboid, fifth tarsometatarsal, and first metatarsophalangeal) and in the position of the first metatarsal relative to the talus. The most extreme effects occurred when the talus was displaced 6 mm or more posteriorly. In vivo, this may lead to aberrant joint loading, which could negatively impact patient outcomes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:450-458, 2020.

Total Ankle Arthroplasty: Is Ankle Plantarflexion Strength Important?

Category:Ankle ArthritisIntroduction/Purpose:Ankle push off power, which requires gastroc-soleus muscle strength, is a critical aspect of healthy gait and increases as gait speed increases. It is therefore surprising that one-to-two-year outcomes following total ankle arthroplasty (TAA) include improved gait speed but deficient ankle power. One possible explanation for low ankle power following TAA is ankle plantarflexion weakness. Information on plantarflexion strength is extremely limited in people before or after TAA. Evaluating plantarflexion strength may inform postoperative expectations and guide rehabilitation programs. The purpose of this study was to evaluate the change in ankle plantarflexion strength, ankle power during gait, and gait speed before and after TAA in people with end-stage ankle arthritis, and in comparison to a healthy matched control group.Methods:Twenty-five participants were included in this prospective case-control study. TAA group participants (n = 13) [mean (SD): Age 60.9 (15.3) years; BMI 30.53 (5.5) Kg/m2; 85% male] with end-stage ankle arthritis who received a TAA were evaluated preoperatively and six months postoperatively. Performance of adjunct soft tissue procedures were patient specific (5/13 participants received tendo-achilles lengthening). All patients received formal physical therapy. Healthy control participants (n=12) were matched to the TAA group on age, gender and BMI. Ankle peak isokinetic plantarflexion strength (torque at 60 and 120 degrees/second; Nm/kg) was measured with an instrumented dynamometer. Peak ankle power (joint torque x segmental velocity; W/kg) was calculated via three-dimensional multi-segment foot motion analysis while participants walked barefoot over a force plate at controlled speeds. Gait speed (m/s) was measured with the Six-Minute Walk Test. Appropriate nonparametric comparisons were made to evaluate differences across time, between limbs, and between groups.Results:Compared to preoperative values, involved limb ankle strength was preserved at 60 and 120 degrees/second following TAA (both p > 0.59). Postoperative involved limb ankle strength at both speeds were 37-56% lower than the non-involved limb and control group (all p < 0.05) (Figure 1). Similarly, involved limb ankle power was preserved following TAA (p = 0.43), but remained at least 38% lower than the non-involved limb or control group (both p < .01). A subset analysis revealed that TAA participants with tendo-achilles lengthening had 25-33% less involved limb postoperative ankle power and strength than TAA participants without tendo-achilles lengthening. Interestingly, gait speed increased following TAA (p = 0.01) and was similar to control group speeds [TAA 1.5 vs. Control 1.6 m/s; p = 0.59].Conclusion:Robust improvements in gait speed were observed following TAA. These values approached normative gait speed in spite of diminished ankle strength and power. Ankle plantarflexion weakness reduces the capacity to generate ankle power during gait, regardless of possible contributing factors (i.e. preexisting atrophy/weakness, tendo-achilles lengthening). Accordingly, improvements in gait speed were likely linked to proximal joint compensations (i.e. hip, knee). The long term consequences of plantarflexion weakness may negatively affect implant loading. Study findings provide new information and point to the importance of targeting strength during postoperative TAA rehabilitation, potentially adjusting strategies for patients receiving soft tissue lengthening procedures.

Arthroscopic Debridement and Micronized Adipose Tissue Injection for End-Stage Ankle Arthritis

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Joint arthritis is one of the leading musculoskeletal disorders in the adult population. The surgical treatment for end-stage ankle arthritis generally includes arthrodesis, distraction arthroplasty and total replacement. Recently, new therapeutic approaches, including the use of biologics, have been developed. Among the many sources, the adipose tissue is considered a greater chondrogenic potential and thus a lot of attention is being placed on it in the treatment of arthritis. Although several studies reported good clinical outcomes of adipose-based therapies for knee arthritis, there is a paucity of studies reporting the effects of adipose-based therapies for ankle arthritis. The purpose of this study is to evaluate the effect of intra- articular injection of autologous micronized adipose tissue in patients with end-stage ankle arthritis.Methods:A retrospective cohort study investigating consecutive patients treated with arthroscopic debridement and micronized adipose tissue injection for end-stage ankle arthritis was performed. Micronized adipose tissue was obtained from abdomen using a minimal manipulation technique in a closed system (Lipogems) without the addition of enzymes or any other additives. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS), Short-Form 12 (SF-12), and visual analog scale (VAS) scores preoperatively and at final follow-up.Results:Total of 12 patients were included. The mean age was 57.5 years and mean follow-up time was 13.1 months. Mean symptoms, pain, daily activities and quality of life scores in FAOS significantly improved from 44.5, 41.3, 58.9, and 20.6 preoperatively to 76.2, 70.1, 80.9, and 60.7 postoperatively, respectively at final follow-up (p<0.001). The mean SF-12 and VAS score significantly improved (33.8 to 63.4, 7.2 to 2.9, respectively, p<0.001). One patient did not receive any benefits. In 4 patients, although they had symptomatic relief in early stage, FAOS and VAS scores deteriorated to baseline by 6 months after procedure. Total 4 patients were not satisfied with the procedures. No adverse events or relevant complications were reported.Conclusion:The current study demonstrates that arthroscopic debridement and micronized adipose tissue injection is a safe and beneficial procedure in the treatment of end-stage ankle arthritis. However, in 4 of 12 patients in this small cohort, the deterioration of clinical outcomes to the baseline was observed by 6 months after procedures. All of these patients had mechanical malalignment of hindfoot, suggesting that mechanical alignment may be one of the prognostic factors of this procedure. Further studies investigating longer-term effects in larger cohort should be warranted to confirm the benefit of micronized adipose tissue injection for end-stage ankle arthritis.

Minimum 5 Year Follow-Up Evaluation of a Third Generation Fixed Bearing Total Ankle Arthroplasty with an Intramedullary Tibial Component and a Central Suclus Talus

Category:Ankle ArthritisIntroduction/Purpose:Total ankle arthroplasty (TAA) has been shown to be a viable option in the treatment of end stage ankle arthritis (ESAA). Early reports demonstrated good results with intramedullary fixation implants. Third generation implants of this kind added a central sulcus to the talar component. This is a report of clinical follow up data from a prospectively collected database at a single US institution using a third generation fixed bearing total ankle arthroplasty implant with a stemmed tibial component and a talar component with a central sulcus. To our knowledge, this is the first report of 5 year follow up data for this implant.Methods:Patients undergoing primary TAA at a single institution by one of four fellowship trained orthopedic foot and ankle surgeons with a third generation fixed bearing implant consisting of an intramedullary stemmed tibial component and a sulcus talus that were at least 5 years postoperative were reviewed from a prospectively collected database. These patients were followed at regular intervals with history, physical examination and radiographs; multiple patient reported outcomes (PRO) measures were obtained. Primary outcomes included implant survivability and PRO scores. Secondary outcomes included coronal plane radiographic alignment (Medial distal tibial articular angle (MDTA) and talar tilt angle (TTA)), evaluation for osteolysis, and failure mode when applicable. All reoperation events were recorded using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperations Coding System (CROCS).Results:121 TAA with this implant were performed in 119 patients between 2010 and 2013; 64 met inclusion criteria. The mean age at surgery was 61.3 ± 10.0 years (range 38.7-84.3). The mean duration of follow up for living patients that retained both initial components at final follow-up was 6.1 ± 0.9 years (range 4.7 – 8.1 years). 26.6% of ankles had a preoperative MDTA and/or TTA greater than 10 degrees. There were 6 (9.4%) failures that occurred at a mean 2.0 ± 1.4 years postoperative. Two failures were due to deep infection. Only one failure was related to tibial component subsidence. One patient is currently scheduled for revision due to talar component subsidence.Conclusion:This cohort of TAA patients with minimum 5 year follow up using a third generation fixed bearing implant demonstrates acceptable implant survival, improved patient reported outcomes scores and maintenance of coronal plane alignment. These data also suggest tolerance of a larger preoperative deformity with improved implant design. To our knowledge, this is the first report with 5 year data on this implant. Continued follow up and reporting is needed to ensure that these favorable outcomes are maintained. Additionally, further investigation on acceptable coronal plane alignment correction with TAA is needed to determine the possible limitations of this procedure.

Tibial Stress Fracture After Ankle Arthrodesis: Case Series with Different Treatment Modalities

Category:Ankle, Ankle Arthritis, TraumaIntroduction/Purpose:End-stage ankle arthritis is frequently treated with tibiotalar or tibio-talar-calcaneal (TTC) arthrodesis, whose sequelae include adjacent joint arthritis presumptively due to the increased stress inherent to the loss of a motion segment. The loss of ankle motion may also stress the distal tibia, and individual case reports exist describing tibial stress fracture after ankle arthrodesis. These case reports do not describe operative treatment however. The purpose of this study is to report a case series of patients who presented with a stress fracture of the tibia after ankle arthrodesis, a subsegment of whom failed nonoperative management, highlighting related risk factors and treatment strategies.Methods:The medical records at two large academic medical centers were reviewed retrospectively, from 1990 to 2017 at the first center and from 2013 to 2017 at the second center, to identify patients who had undergone ankle arthrodesis. Any patient who subsequently developed a stress fracture of the tibia, confirmed clinically and/or radiographically, was included in the subsequent analysis. Patients with a history of stress fracture prior to arthrodesis or with non-tibia stress fractures were excluded. Patient demographics were collected alongside surgical technique, duration of postoperative non-weight bearing status, presence of medical co-morbidities including osteoporosis and tobacco use, location of tibial stress fracture, and treatment strategy.Results:Twelve patients out of 988 (1.2%) developed tibial stress fracture. Seven patients underwent isolated ankle arthrodesis, four underwent ankle arthrodesis subsequent to subtalar fusion with a resultant ankle nonunion in two requiring revision TTC nailing, and one underwent primary TTC arthrodesis. Four patients had fibular osteotomy, and four had the lateral malleolus resected. The stress fracture was at the level of fibular osteotomy in two patients, and at the proximal end of existing or removed implant in six patients. All patients were treated initially with immobilization and activity modification except for one who had fracture displacement and underwent immediate plate fixation, and three who failed to improve with nonoperative treatment required fixation (two intramedullary nails, one plate).Conclusion:Tibial stress fractures can occur after an isolated ankle arthrodesis but is likely potentiated in the setting of previously or concomitantly fused subtalar joint. Transition points are especially at risk, either at the proximal end of an implant or at the proximal extent of a fibular osteotomy. Critically, stress fractures may present many years after ankle arthrodesis, with an average of four years in this series. In our series one third of patients necessitated surgical management, underscoring the importance of accurate diagnosis. Ultimately patients appear to do well with surgical repair even if they fail initial nonoperative treatment.

Hindfoot Alignment after Total Ankle Replacement

Category:Ankle, Ankle ArthritisIntroduction/Purpose:End-stage ankle arthritis can involve misalignment of the ankle in both the coronal and sagittal planes as up to reported 33% to 44% of patients who present for total ankle replacement have greater than 10° of coronal plane deformity. Normalization of the sagittal and coronal alignment is key in improving survivorship and functional outcomes in TAR. In the present study, we analyzed how both the ankle and hindfoot alignment for both a fixed-bearing and mobile bearing TAR system changes over time. Specifically, we measured coronal and sagittal alignment of both the ankle and hindfoot complex. We hypothesize that both significant differences would be seen between all time points and pre-operative radiographs, and that these differences would not change over time.Methods:A retrospective study performed by a single orthopaedic surgeon was performed on two independent groups of patients undergoing two different systems for total ankle replacement: Zimmer TAR (lateral-approach, fixed-bearing, n=89) and Hintegra (anterior approach, mobile-bearing, n=81). We noted specific demographic data and radiographic data were measured including: Hindfoot alignment view angle (HAV), Hindfoot alignment distance (HAVD), tibiotalar ratio, a angle and ß angle. These were measured pre-operatively, and 6 months, 12 months, and 24 months post-operatively. Within-group comparisons were performed using one-way repeated-measures ANOVA (1-w rANOVA), analyzing temporal course of clinical data (comparisons between different time points, e.g. T0vsT6vsT12vsT24) within the Hintegra and Zimmer groups. To compare the time course of clinical measures between the two groups, 2-w rANOVAs were performed for SA, SD, TT ratio, a and ß angle. Specifically, time*group interaction was tested.Results:At the ankle joint itself, as measured by the a and ß angles (p>.05), the position of the components remains relatively similar in both the fixed and mobile bearing TAR over the course of 24 months. The sagittal alignment, as measured by the TT ratio, demonstrated a posterior shifting of the talus in the mobile bearing group (p=.036). Though the fixed and mobile-bearing TARhad both significant hindfoot alignment improvement between the pre-op radiographs and twenty-four months, over time, the fixed-bearing ankle had a significant increase in both the HAV and HAVD (p<.001), suggesting a dynamism of the hindfoot in the fixed-bearing ankle.Conclusion:Correcting coronal and sagittal alignment is important for the long-term survivorship of a TAR. The fixed and mobile-bearing implants had maintained coronal and sagittal alignment in the short term, the temporal course of the fixed-bearing ankle showed an increased in the valgus positioning of the hindfoot. The mobile-bearing implant maintained its hindfoot alignment over the course of the study. More studies are needed to explore the clinical implications of this new data.

Adverse Events in Total Ankle Arthroplasty, Analysis of the FDA Medical and User Facility Device Experience Database

Category:Ankle ArthritisIntroduction/Purpose:Total ankle replacement has become a popular treatment option for end stage ankle arthritis. Most of the reports of adverse events following total ankle replacement have been from high volume institutions and are subject to either observational or selection bias as well as potential under-reporting as they do not include the experience of community and lower volume centers and surgeons. The FDA’s Medical and User Facility Device Experience (MAUDE) Database provides a more complete scope of adverse events due to the mandatory reporting requirements by the FDA of implant manufactures. We reviewed the database to identify the common modes of failure and complications of total ankle implantsMethods:We retrospectively reviewed reports of the MAUDE database from November 2011 to September 2018 regarding all total ankle implants. Each device in the MAUDE database is classified with a 3-letter code, we identified the 2 codes assigned to total ankle arthroplasty devices, and manually searched the FDA’s published Device Classification list for adverse events. All events were reviewed and classified. Data related to patient age or sex, surgeon, medical center location are not available in the databaseResults:We identified 1000 adverse reports in the period between November 2011 and September 2018. After exclusion of duplicate reports for single events or reports irrelevant to total ankle arthroplasty, a total of 697 adverse event reports were noted. The most common mode of failure was aseptic loosening (21%), followed by infection (16%), alignment and mechanical issues (instability, malalignment, malposition, stiffness, impingement) (15%), implantation issues (pin, screw or drill breakage, alignment guide problems) (9%), polyethylene related problems (wear, displaced or fractured implants) (7%), bony and soft tissue overgrowth (6%), and peri-prosthetic fractures (5%).Conclusion:Our analysis reveals that the most reported mode of failure was aseptic loosening followed by infection. However, it is notable that there are a significant number of issues with implant alignment and mechanics, complications during implantation and polyethylene component failure that are under-reported in the literature. Knowledge of these adverse events may help surgeons avoid similar complications as well as lead to improvement in component implantation and design

Outcomes of Revision Total Ankle Replacement: A Minimum of 2 Year Follow-up

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up.Methods:All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up.Results:32 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 30 patients were included in the study. 5 patients declined participation for completing questionnaires. We received 21 (66%) completed questionnaires. The mean MOX-FQ average domain score for pain was 58.8, walking/standing 65.8 and social function was 48.2. The mean FAOS scores were 50.7 for pain, 50.6 for symptoms, 54.9 for ADL and 28.2 for quality of life. The mean overall health score today for EQ-5D was 67.8/100. 45% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 48% were satisfied with the improved in daily activities. 52% were overall satisfied with the results from surgery.Conclusion:Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery.

The Outcomes of Bone Grafting of Peri-Prosthetic Total Ankle Osteolytic Lesions: A Meta-Analysis

Category:AnkleIntroduction/Purpose:Total ankle replacement (TAR) has become an increasingly popular alternative to ankle arthrodesis as a treatment option for end-stage ankle arthritis. However, total ankle implants are not without short and long-term complications and one of the most common is peri-prosthetic osteolysis, Many studies have been done on the incidence of peri-prosthetic bone cysts as well as the etiology, but there have been limited reports on the optimal management of these lesions. The most widely accepted method of treatment is curettage and grafting of the lesion with or without polyethylene exchange. Our aim was to perform a systematic review of the literature on the outcome of bone grafting in the management of periprosthetic osteolytic following TAR.Methods:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, Medline, PubMed, Scopus, and Google Scholar databases were searched in November and December 2018 for all observational or experimental studies that evaluated bone grafting of peri-prosthethic total ankle osteolytic cysts. The primary outcome was the rate of major revision to either component replacement or ankle arthrodesis and the secondary outcome was the rate of radiological cyst progression after grafting. Descriptive, quantitative, and qualitative data were extracted.Results:Of the 70 articles identified, 6 studies were eligible for the meta-analysis for a total of 120 patients with 123 total ankle replacements. Average age of subjects was 58.5 years. 4 papers included details of patient gender revealing 50 males and 26 females in those studies. The most common type of total ankle replacement was the Ankle Evolutive System(AES) followed by the Scandinavian total ankle replacement (STAR). With an average follow up 5.1 years (1.4-15.4), the rate of conversion to major revision after curettage and bone grafting was 15% (7.6%- 22.4%). Despite that apparent success, there was a 40.4% (5.4%-75.4%) rate of radiological cyst progression after graftingConclusion:Our systematic review shows that curettage and bone grafting of the osteolytic lesions around TAR is safe procedure which can increase the survivorship of the implant and delay the need for further major surgeries. Providing better bone stock for later revision may also be of benefit. However, the high rate of cyst progression is worrisome for future complications. This highlights the need to further research the etiology of the cyst and to explore treatments aimed at eliminating the cause of cysts to prevent the need for repeat procedures and the potential for implant failure.

Role of Total Ankle Arthroplasty in Stiff Ankles – Long Term Follow-Up

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The theoretical benefit of TAA is the ability to preserve range of motion (ROM) at the tibiotalar joint.Previous studies have questioned whether it is justified to perform TAA over AA in stiff, arthritic ankles. However, a recent study showed that patients who underwent TAA with stiff ankles preoperatively experienced significant clinical improvement in range of motion and gait function compared to more flexible groups at 1-year follow-up. We retrospectively assessed these same gait and functional parameters to see if these improvements held up in long-term follow-up.Methods:A retrospective study of long-term, prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 years postoperatively (range 4.8-13.3) used a multivariate regression model to determine the effect of ankle stiffness on the long- term, objective outcomes of TAA. Data was analyzed by quartiles (Q1, Q2+Q3, Q4) of preoperative sagittal ROM using one-way analysis of variance (ANOVA) to compare both preop and postop gait parameters. The two middle quartiles were combined to conform to distribution of the data. The multivariate analysis determined the independent effect of age, gender, BMI, years post- surgery, and preop ROM on every preop and postop parameter of gait.Results:Statistically significant differences were found in all three gait parameter categories, including temporal-spatial (step length and walking speed), kinematic (total sagittal ROM and maximum plantarflexion), and kinetic (peak ankle power). The stiffest ankles preoperatively (Q1) had the greatest absolute increase in total sagittal ROM postoperatively, +5.3o, compared to -1.3o (p<0.0174) in Q4 (most flexible). However, Q1 had the lowest absolute total postoperative sagittal ROM of 13.1 o, compared to 19.7 o (p<0.0108) in Q4. Q1 also had the lowest preoperative step length, walking speed, maximal plantarflexion, and peak ankle power when compared to the other subgroups. There was no difference in any of these same parameters postoperatively. BMI and years post-surgery had no effect on outcomes, while age and gender had a minimal effect.Conclusion:Preoperative range of motion was once again predictive of overall postoperative gait function in long-term follow-up at an average of 7.2 years. A greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion in long-term follow-up. Patients with the stiffest ankles preoperatively once again had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This shows that the clinically meaningful improvement in gait function after total ankle arthroplasty holds up in long-term follow-up, even in the setting of limited preoperative sagittal range of motion.

Understanding “Recovery” Following Ankle Reconstruction: A Qualitative Study

Category:Ankle, Ankle Arthritis, Outcomes researchIntroduction/Purpose:Patients’ perception of a good outcome (‘feeling recovered’) is not fully understood. A clear understanding of the benefits and harm of a surgery is necessary for clinical decision-making. Qualitative work exploring the nature of patient recovery would improve our ability to understand and measure these outcomes. The purpose of the study is to examine patients’ perceptions of post-surgical outcome following ankle reconstruction for treatment of end-stage ankle arthritis.Methods:Twenty-five English-speaking individuals were asked to participate following a routine clinic visit. They were recruited from an existing cohort of persons who had undergone total ankle replacement or ankle fusion at least one year prior. A qualitative researcher conducted semi-structured, face-to-face interviews with participants in a private hospital room.Results:Twenty-five adults (12 women, 13 men) ages 25–82 years were interviewed for 1-2 hours. Participants varied in their socioeconomic status and education levels. Patients did not view their recovery simply as physiological change. Most participants reported ongoing challenges or difficulties, yet considered themselves better. Participants described a broader concept of recovery with multiple contributing factors, including appraisal of the importance of ongoing issues and coping efforts. When participants experienced ongoing difficulty with valued activities, they gained a sense of recovery using coping efforts. Many ‘readjusted’ behaviorally to continue with their valued goals and activity preferences. Others cognitively redefined their goals or preferences to accommodate their ongoing issues. Participants who could not cope with their difficulties or disliked their coping effort perceived their recovery negatively.Conclusion:Perception of recovery and experience of outcome rarely involved resolution of all symptoms and functional limitations. The manner in which patients described their recovery was typically more nuanced than a simple change in magnitude of symptoms or functional limitations. This research expands our understanding of the experience of ankle reconstruction and draws attention to different meanings of recovery that has implications for outcome evaluation and measurement. Improved measures for evaluating the recovery outcome states will enable clinicians to identify facilitators and barriers to recovery.

Total Ankle Arthroplasty and Ankle Arthrodesis Utilization: An American Board of Orthopaedic Surgery (ABOS) Part II Database Study

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Total ankle arthroplasty (TAA) utilization has increased over the last 20 years, while ankle arthrodesis (AAD) utilization has remained constant. However, annual hospital procedure volume for TAA and AAD remains low, with 50% of hospitals performing a median of =5 cases per year. Practicing in a low-volume setting may have implications for technical performance and patient outcomes, especially amongst early-career surgeons. The purpose of this study was to examine trends in utilization of TAA and AAD in ABOS part-II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis.Methods:The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates who performed =1 TAA or AAD from exam years 2009-2018. Candidates were categorized by exam year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in utilization of TAA and AAD were examined using log-modified regression analyses.Results:From 2009-2018, there was no significant change in the utilization of TAA or AAD amongst all candidates (p=0.92, p=0.20) (Table 1). Candidates reporting a foot and ankle (FA) fellowship trended towards increased utilization of TAA relative to AAD versus non-FA fellowship candidates, but this failed to reach statistical significance (p=0.06). The utilization of arthroscopic AAD increased over time (p<0.01) amongst all candidates. There was no difference in the rates of utilization of open versus arthroscopic AAD amongst FA trained candidates. High-volume (=5 TAA) candidates represented 10.5% of all candidates performing TAA, and accounted for 34.2% of all TAAs performed over the study period.Conclusion:Utilization of TAA and AAD did not change over the study period, and the number of these procedures performed by early-career surgeons remains low. The majority of both procedures are performed by FA trained surgeons with relatively low practice volumes. There was a trend toward increased TAA utilization relative to AAD utilization in FA trained surgeons, but this did not reach statistical significance. The findings in this study may have implications for technical performance impacting patient outcomes and may guide potential changes in training curricula.

Experiences of Living with Bilateral Total Ankle Replacement and Ankle Arthrodesis: A Qualitative Study from a Patient Perspective

Category:Ankle ArthritisIntroduction/Purpose:Total ankle replacement (TAR) and ankle arthrodesis are both effective treatments for end-stage ankle arthritis, however differences in treatment outcomes may be better understood using a qualitative inquiry among individuals who have undergone both procedures. The purpose of this study was to investigate patients’ experiences and impressions of living with bilateral TAR and ankle arthrodesis.Methods:The sample consisted of 10 patients, selected purposively from a larger cohort, who could speak English and had a TAR on one side and ankle arthrodesis on the contralateral side. All procedures were completed by a single experienced surgeon.Semi-structured interviews were conducted at least one year after completion of the most recent procedure (TAR or arthrodesis). Qualitative data analysis was performed in accordance with a descriptive phenomenological theoretical approach, from which codes and themes were derived.Results:Interviews revealed advantages and disadvantages associated with both TAR and ankle arthrodesis from the patients’ perspective. Two overarching domains in which differences between their TARs and ankle fusions emerged: psychological and musculoskeletal. Within these domains, concepts of vigilance (as previously described by Pinsker) and strategizing the use of one ankle over the other emerged as themes that unified nearly all patients. Specific differences between the two procedures with respect to stability versus flexibility were commonly identified. Overall, patients preferred their TAR.Conclusion:This study provides insight into the lived experiences of a unique group of patients who have both an ankle arthrodesis and TAR. Patients evaluated the impact of TAR and ankle arthrodesis on their lives and overwhelmingly favoured TAR. The findings of this study can help clinicians to better counsel patients on expectations after TAR and ankle arthrodesis, and may aid researchers improve patient-report measurement instruments to better capture the outcomes that are important to patients.

Comparison of Tibial and Talar Bone Density as a Function of Resection Level in Patients Undergoing Total Ankle Replacement vs Demographic-Matched Controls

Category:Ankle ArthritisIntroduction/Purpose:Initial implant fixation is critical for long-term success of total ankle replacement (TAR). One important factor which contributes to implant stability is the quality of the surrounding bone. Previous studies characterized a decrease in bone density with increasing distance from the level of the joint in the tibia and talus in non-arthritic ankles. However, ankle arthritis affects bone density remains unclear. The objective of this study is to compare the bone density in patients with and without ankle arthritis as a function of resection level from the joint. We hypothesized that there would be no difference in bone densities at each resection level between groups and bone density would decrease with greater distance from articular surface in both groups.Methods:We retrospectively reviewed 93 end-stage ankle arthritis patients with available preoperative non-weight bearing ankle computed tomography scans (CT)(Group A) and identified another cohort of 83 patients with non-arthritic ankles as a demographic-matched control group(Group B). Patients with retained ankle hardware, history of osteomyelitis, osteoporosis, and cysts greater than 1 cm in diameter at the ankle were excluded. There was no difference in term of gender, age and body mass index (BMI) between the groups(Table 1). The ROI tool in Sectra IDS7 picture archiving and communication system (PACS) was used to calculate Hounsfield Unit (HU) values in the cancellous region of the tibia and talus around the ankle joint. Measurements were obtained on axial CTs from 6 mm to 12 mm above the distal tibial plafond, and from 1 mm to 4 mm below the talar dome. The HU measurements and percentage decrease of HU values at each level were compared between groups.Results:Patients with ankle arthritis demonstrated significantly greater bone density than the control group between 6 mm and 10 mm from the joint in the tibia. There was no significant difference in bone density between 10 mm and 12 mm from the joint on the tibia, and at all levels in the talus between groups (Table 1). In both groups, bone density decreased significantly at each successive level from the joint for the tibia and talus. In addition, the percentage decrease of HU values at each relative level was the same in both groups.Conclusion:Patients with ankle arthritis demonstrated greater bone density at 6 mm to 10 mm from the joint in the tibia compared to demographic-matched controls. The increased bone density close to the joint may stem from bone eburnation that occurs as part of the arthritic process. In TAR, a tibial bone resection between 6 mm and 10 mm may provide improved initial stability of the implant. Contrary to traditional thinking, fixation into the talus may be of less concern.

Assessing the Ankle Joint Line Level Before and After Total Ankle Arthroplasty With the "Joint Line Height Ratio".

Background:Restoring the joint line is an important principle in total knee arthroplasty. However, the effect of joint line level on patient outcomes after total ankle arthroplasty (TAA) remains unclear, as there is no established method for measuring ankle joint level in TAA. The objective of this study was to develop a reliable radiographic ankle joint line measurement method and to compare ankle joint line level measured pre-TAA, post-TAA, and in nonarthritic ankles.Methods:A total of 112 radiographic sets were analyzed. Each set included weightbearing anteroposterior radiographs of the operative ankle taken preoperatively, 1-year postoperatively, and of the contralateral ankle. Measurements of vertical intermalleolar distance (VIMD) and vertical joint line distance (VJLD) at pre-TAA, post-TAA, and of the contralateral ankle were recorded by 2 authors on 2 separate occasions. The ratio of VJLD to VIMD was defined as the joint line height ratio (JLHR). Reliability of measurements and correlation between VIMD and VJLD were assessed. Pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHR were compared and considered significantly different if P <.05.Results:The inter- and intrarater reliability of radiographic measurements was excellent (r > 0.9). There were strong positive correlations of VIMD and VJLD, r = 0.809 (pre-TAA)/0.756 (post-TAA), P < .001. Mean (SD) pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHRs were 1.54 (0.31), 1.39 (0.26), and 1.62 (0.49), respectively. Pre- and post-TAA JLHRs were significantly higher compared to the nonarthritic contralateral ankle (P < .05). JHLR was not significantly different between pre- and post-TAA (P = .15).Conclusion:The JLHR was reliable and could be a clinically applicable method for assessing ankle joint line level in patients undergoing TAA. End-stage ankle arthritis demonstrated elevated joint line level compared with nonarthritic ankles, and the joint line level post-TAA remained elevated compared with nonarthritic ankles. Further studies are needed to understand the effect of joint line elevation on clinical outcomes after TAA.Level of Evidence:Level III, retrospective comparative study.