Lateral Transfibular Approach Research Articles

Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n=41). The mean age was 59 (range=39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range=14-46) to 80 (range=60-100) (p < .01) and VAS from 7.8 (range=6.1-9.7) to 1.3 (range=0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

Lateral Trans-Fibular Total Ankle Replacement Capability in Correcting Ankle Osteoarthritis Deformities and Improving Clinical Outcomes

Category: Ankle; Ankle Arthritis; Hindfoot; Other Introduction/Purpose: Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion in patients with Ankle osteoarthritis (AO). Standard anterior approach TAR capability in correcting deformities is already established by several studies. However, there is a paucity of literature evaluating patient outcomes as well as the potential to correct alignment using a lateral approach TAR. Therefore, the primary objective of this study was to assess the capability of lateral trans-fibular approach TAR in correcting coronal and sagittal plane deformity and secondarily to report the ability to improve patient-reported outcomes (PROs) following lateral TAR. Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans- fibular approach TAR for end-stage AO. Average age and BMI were 63.9 years (range 43-83) and 32.7 kg/m2 (SD 7.5). All patients had received pre- and post-operative weight-bearing CT imaging on the affected foot and ankle. Foot and Ankle Offset (FAO), Talar Tilt Angle (TTA), Hindfoot Moment Arm (HMA), and Lateral Talar Station (LTS) were performed. PROs were collected pre- and post-operatively at the latest clinical follow-up including: PROMIS Global Physical Health score, the Tampa Scale of Kinesiophobia (TSK), the European Foot and Ankle Society (EFAS) score, the Pain Catastrophizing Scale (PCS) and the Foot and Ankle Ability Measure (FAAM) Daily Living Score. One-way ANOVA and Wilcoxon tests were used for comparison at each interval time period. A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results: Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months (range 11 to 24), all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA (10.93mm - 5.10mm, p=0.037), TTA (7.9o - 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROs demonstrated significant improvement postoperatively: TSK (42.7-34.5, p=0.012), PROMIS Global Physical Health (46.1- 54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7, p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of 0.98). Improvements in TSK were associated with changes in the HMA (p=0.0074), R2 of 0.66. Improvements in FAAM correlated (p=0.048) with improvements in FAO (p=0.023) and TTA (p=0.029), and an R2 of 0.78. Conclusion: In this retrospective comparative cohort study, the results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct and strong correlations between deformity correction measurements and the significantly improved PROs were found. The obtained data might help surgeons when planning treatment and may serve as the basis for future comparative prospective studies.

90-Day Reoperation and Wound Complication Rates in Lateral Approach to Total Ankle Replacement for Post-Traumatic Arthritis

Category: Ankle Arthritis; Ankle; Diabetes Introduction/Purpose: Total ankle replacement (TAR) has achieved relatively successful outcomes with respect to postoperative complications; however, mixed evidence exists regarding early complication rates, reoperation, and infection1-5. The largest study of TAR to date indicates a statistically significant risk of postoperative infection in tobacco users and diabetic patients6. Unlike currently established anterior approaches to arthroplasty, the lateral transfibular approach potentially avoids disruption of perfusion to the skin, possibly decreasing postoperative complications7. The lateral ankle allows surgeons to correct malunion of the fibula in post-traumatic arthritis deformity cases and achieve appropriate coronal and sagittal implant alignment to achieve similar physiological joint orientation8,9. The purpose of this study was to report 90-day reoperation and wound complication rates in lateral approach to total ankle replacement for post-traumatic arthritis (PTA). Methods: A retrospective chart review of lateral TAR cases from 2016-2022 was conducted at a single institution. Only patients undergoing TAR for post-traumatic arthritis were included in this review. A total of 49 patients (22 females and 27 males) underwent total ankle replacement with the Zimmer Biomet Trabecular MetalTM Total Ankle by a single surgeon. Patient demographics, operative data, complications, and adverse events requiring corrective surgery were recorded within 90 days of arthroplasty. Results: The patient sample included 6 active smokers, 11 diabetics, and 32 patients with hypertension with an average age of 60.7 and average BMI of 34.3 (Table 1). Three of the 49 (6.1%) patients required secondary surgery within 3 months of surgery (Table 2). Revision surgery indications included: 1 (2.0%) for removing painful hardware, 2 (4.1%) due to infection, and 1 (2.0%) for tarsal tunnel syndrome after surgery. There were 0 nonunions of the fibula at 90 days and through 1 year follow up. Of the patients requiring secondary surgery for infection, 1 was a smoker and 1 had a history of ankle fusion nonunion and avascular necrosis which was converted to a TAR (Table 4). Conclusion: This retrospective study demonstrates a comparable rate of secondary surgeries following TAR via lateral approach in the early postoperative period (6.1%) while having a slightly higher rate of infection than those previously reported (4.1%)7,8. Notwithstanding, we observed a 100% healing rate of fibula osteotomies; however, we failed to demonstrate a lower incidence of wound complications than previously reported. Surgeons should counsel patients of these risks in those with PTA undergoing lateral TAR, especially in smokers and diabetics.

Agreement between semiautomatic and manual measurement of selected parameters on weight-bearing computed tomography images in total ankle replacement: a retrospective study

Objective: To assess the agreement between semiautomatic 3D measurements and manual measurements derived from WBCT images in patients with end-stage ankle osteoarthritis (AO) who underwent total ankle replacement (TAR). Methods: In this retrospective, IRB-approved study (ID #201904825), we evaluated patients who underwent TAR via the lateral trans-fibular approach for end-stage ankle OA. The study included 14 ankles from 14 patients. Raw multiplanar data were analyzed using CubeVue® software. Lateral talar station (LTS) was obtained in the sagittal plane, while hindfoot moment arm (HMA) and talar tilt angle (TTA) were calculated in the coronal view. Semiautomatic 3D measurements were performed using Disior® software. Intra-rater reliabilities were analyzed using the intraclass correlation coefficient (ICC). Agreement between methods was tested with Bland-Altman plots. Each measurement was assessed using the Wilcoxon signed-rank test. Alpha risk was set to 5% (α=0.05). P-values of ≤0.05 were considered significant. Results: ICC-measured reliabilities ranged from moderate to almost perfect for manual and semiautomatic WBCT measurements in the preoperative and postoperative groups for HMA and LTS. There was high correlation between parameters calculated from manual and semiautomatic measurements, and strong agreement between the readers and software in both groups. Conclusions: Manual (M) and semiautomatic (SA) 3D measurements expressed excellent agreement for pre- and postoperative groups, indicating a high correlation between the parameters calculated and strong agreement between the readers and the software in both groups. Level of Evidence III; Therapeutic Studies; Comparative Retrospective Study.

Mid-Term Results after Lateral Transfibular Approach Total Ankle Arthroplasty

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Continued improvements in total ankle arthroplasty (TAA) implant design have led to promising clinical outcomes. The lateral transfibular approach TAA allows for excellent visualization of the center of rotation of the ankle and allows for correction of rotational and sagittal deformity by shortening or lengthening of the fibula. Furthermore, the curved implant design allows for minimal bony resection. The purpose of this study is to report the medium-term clinical and radiographic results for consecutive patients who underwent the lateral approach TAA.Methods:IRB approval was obtained for this study. Consecutive patients who underwent lateral approach TAA for tibiotalar arthritis by a single surgeon were enrolled on a prospective basis from January 2013 to June 2015. This time period represented the initial case series of TAA performed by the surgeon. Patient reported outcomes (PROs) were collected including the Ankle Osteoarthritis Scale (AOS), 12-item short-form survey (SF-12), and Visual Analogue Pain Scale (VAS). The need for subsequent procedures was recorded. Radiographs were evaluated for preoperative and postoperative alignment using the lateral distal tibial angle (LDTA), tibiotalar surface angle (TTS), anterior distal tibia angle (ADTA), and the lateral talar station (LTS). Radiographs were also evaluated for the development of peri-implant lucency and subsidence. Data was tested for normality. T-tests were used to determine differences between preoperative data and postoperative data. A p<0.05 was considered significant.Results:53 patients who underwent 59 TAA procedures were included. Average follow-up was 5.7 +/- 0.9 years. Average age was 53 +/- 7.0. Comorbidities included smoking (11/53), diabetes (6/53), and prior procedures (33/53). Sixteen ankles (27%) underwent one or more subsequent procedures including gutter debridement (7/59), debridement for periprosthetic infection (3/59), and removal of hardware (7/59). All fibular osteotomies healed. Four ankles had asymptomatic peri-implant lucency or cysts (4/59). No patients had subsidence or required revision of the tibial or talar components. Coronal and sagittal alignment were significantly improved for all measures (p<0.05). VAS scores improved from a mean of 7.5 preoperatively to 1 at final follow- up (p<0.0001). SF-12 physical component scores improved from 34 to 41.5 (p=0.0227). AOS scores improved from 54.8 to 19.1 (p<0.0001).Conclusion:At medium term follow-up, patient reported outcomes remain significantly improved in patients after lateral approach TAA. There were very few radiographic findings of lucency and cyst formation, and all of these were asymptomatic. No revision of metal implants was required. Excellent deformity correction was achieved. The rate of subsequent procedures was high, although the rate of actual component revision was 0%. Lateral approach TAA appears to have overall good outcomes at medium term follow-up.

Outcomes Following Intramedullary Nail vs Plate Fixation for Tibiotalocalcaneal Arthrodesis: A Systematic Review

Category:Ankle Arthritis; Hindfoot; TraumaIntroduction/Purpose:Tibiotalocalcaneal arthrodesis (TTCA) is indicated to treat pain and dysfunction that may result from a variety of ankle and hindfoot pathologies by achieving fusion of the tibiotalar and subtalar joints. Two common fixation methods exist to achieve TTCA: retrograde intramedullary nail (IMN) fixation and plate fixation using a lateral trans-fibular or posterior Achilles-tendon splinting approach. The purpose of this study is to review the literature and compare the outcomes of TTCA using IMN fixation with those of plate fixation using a lateral trans-fibular approach.Methods:A comprehensive search of the PubMed, Cochrane, and EMBASE databases was performed on 01 February 2021 for studies of all levels of evidence pertaining to TTCA using IMN and plate fixation. Reasons for exclusion included: no formal joint preparation, non-English language, concomitant methods of fixation (e.g., IMN with additional plate fixation) and follow-up less than 12 months.Results:Fourteen studies (11 level III and 3 level IV) met criteria and were included. A total of 386 fusions were documented in 356 patients [259 (67%) IMN and 127 (33%) plate fixation]. In the IMN group, union rates at the tibiotalar joint (TTJ) were 84% (219/259) and subtalar joint (STJ) were 90% (229/259) with an overall complication rate of 20% (53/259). Average initial AOFAS scores were 34.3+-7.9, increasing to 72.4+-9 postoperatively. In the plate fixation group, union rates at the TTJ were 82% (103/127) and STJ were 86% (108/127) with an overall complication rate of 30% (39/127). Average initial AOFAS scores were 37.0+-6.9, increasing to 74.4+-12.5 postoperatively. No statistical differences were noted between the TTCA IMN and plate cohorts when comparing rates of TTJ or STJ union (p= 0.6, and p=0.2, respectively) and postoperative AOFAS scores (p=0.59). However, the plating group had a statistically higher overall complication rate (p=0.02).Conclusion:A systematic review of the available literature suggests that there is no statistical difference in union rates or functional outcomes between TTCA using intramedullary nail or lateral trans-fibular plate fixation. However, the lateral trans- fibular plate has a statistically higher complication rate when compared to intramedullary nails. Further comparative prospective cohort studies and randomized controlled trials are needed to further elicit differences between these groups and confirm the findings of this systematic review.

Clinical outcome of tibiotalocalcaneal fusion using cannulated screw and humeral proximal locking plate inverted fixation through a lateral transfibular approach

To evaluate the clinical outcome of tibiotalocalcaneal fusion using cannulated screw and humeral proximal locking plate inverted fixation through a lateral transfibular approach. From June 2015 to December 2018, 15 patients underwent a tibiotalocalcaneal fusion operation using cannulated screw and inverted proximal humerus locking plate through a transfibular approach. There were 10 males and 5 females with the age ranging from 45 to 72 (58.9±6.1) years, and the course of disease ranged from 2 to 35 (11.9±7.9)years. Preoperative diagnosis included 8 cases of post traumatic arthritis, 2 cases of Charcot arthritis, 2 cases of Charcot-Marie -Tooth (CMT), 1 case of ankle tuberculosis, 1 case of talar necrosis, and 1 case of pigmented villonnodular synovitis. Among them, 8 patients were combined with simple varus deformity, 4 patients with simple valgus deformity, 2 patients with equinovarus deformity, 1 patient with equinovarus deformity, 2 patients with adduction and internal rotation of middle and forefoot. American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and the visual analogue scale (VAS) score were used to evaluate the clinical outcome at the last follow up. One lost follow up and remaining fourteen patients were followed up. The follow up time ranged from 10 to 25(16.6±4.3) months. All the 15 patients had primary healing. Fusion time ranged from 15 to 24 (16.8 ± 2.4) weeks after operation. One patient with diabetes experienced delayed union and was successfully treated with secondary bone grafting combined with Platelet-Rich Plasma (PRP) injection. The AOFAS score increased from 38.7±3.3 to 84.5±2.6 (P<0.05), and the VAS score decreased from 7.5±1.6 to 1.9±0.3(P<0.05). Tibiotalocalcaneal fusion used cannulated screw and humeral proximal locking plate inverted fixation through a lateral transfibular approach has the advantages of relatively simple technique, high fusion rate, especially for patients with posterior foot deformity, which has satisfactory short term effects.

Clinical-radiological outcomes and complications after total ankle replacement through a lateral transfibular approach: a retrospective evaluation at a mid-term follow-up.

Degenerative ankle arthropathy is a debilitating and increasingly widespread condition with worsening of quality of life. In last years, total ankle replacement has increased indications, thanks to advances in surgical technique, materials and design that provided new solutions for surgeons. The purpose of this study is to evaluate the effectiveness of total ankle replacement (TAR), implanted using a trans-fibular lateral approach in patients with high-grade degenerative arthropathy, in terms of clinical, functional and radiological outcomes and possible complications. This retrospective study included 73 patients, aged between 47 and 79years (mean age 61.7 ± 14.2years), who underwent trans-fibular total ankle arthroplasty. All patients were followed up for at least two years post-operatively with mean follow-up 31.2 ± 8.1months and have been evaluated clinically and radiographically both pre-operatively and post-operatively. Patients demonstrated a significant improvement in average AOFAS score, SF-36 score and VAS scale. Average plantarflexion improved from 9.9° ± 4.2 to 18.4° ± 6.3 and dorsiflexion from pre-operative mean value of 6.8° ± 5.8 to 17.2° ± 3.1 post-operative. Complications recorded in our series were 16 (21.9%), specifically 2 major complications and 14 minor complications. This study found that trans-fibular total ankle replacement is a safe and effective option for patients with ankle osteoarthritis, resulting in improvement of patient-reported outcomes, range of motion, and radiographic parameters. However, further studies are required to determine long-term performance of these implants.

A Novel and Safe Fibular Osteotomy for Total Ankle Replacement through Lateral Transfibular Approach

Category:Ankle ArthritisIntroduction/Purpose:The lateral transfibular total ankle arthroplasty (TAA) has been reported on with good short term outcomes. One key downside to the lateral TAA is the rate of symptomatic hardware and wound issues requiring hardware removal seen with the short oblique fibular osteotomy. Therefore, we report on a comparative cohort study of lateral TAA using the traditional short oblique fibular osteotomy to a long oblique fibular osteotomy, termed Foot and Ankle Reconstruction Group Osteotomy (FARG).Methods:Retrospective identification of primary lateral transfibular TAA performed by a single surgeon from May 2013 to October 2016 with minimum 2 years follow-up. Clinical assessment included patient demographics, wound complications, need for hardware removal, visual analogue scale, American Orthopaedic Foot & Ankle Society score, Short Form-12 Mental Composite Score, and Short Form-12 Physical Composite Score. Radiographic assessment included weight bearing x-rays to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing.Results:A total of 159 primary lateral TAA were identified. The short oblique fibular osteotomy was used in 50 cases and the FARG osteotomy in 109 cases. Implant survival was 100% and there were no fibular osteotomy nonunions in both groups. There was improvement in all clinical parameters in both groups with no significant difference between groups in any of these parameters. The radiographic measures showed excellent alignment at all time points in both groups with no significant difference between groups. There was a significant difference between groups in the rate of wound dehiscence and rate of hardware removal for any reason with the FARG osteotomy having a lower rate of both compared to the short oblique fibular osteotomy.Conclusion:Modification of the traditional fibular osteotomy to the long oblique Foot & Ankle Reconstruction Group fibular osteotomy has excellent 2-year survival with good clinical and radiographic outcomes yet provides decreased rates of wound complications and decreased rates of symptomatic fibular hardware compared to the traditional short oblique fibular osteotomy.

Does Retention of Fibula in Transfibular Approach Leads to Complication?

Category:Ankle, Ankle Arthritis, HindfootIntroduction/Purpose:A variety of operative approaches and fixation techniques have been described for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis. In the past two decades, authors have begun to more robustly examine outcomes of the transfibular approach for TT arthrodesis and expanded its indication to include TTC fusion. The transfibular technique is broadly divided into two categories: 1) Complete excision of fibula 2) Soft tissue preservation techniques with retention of fibula. The purpose of this study was to retrospectively assess the surgery outcomes in transfibular approach and compare the fibula excision versus fibula retention techniques and examine the factors that play into the risk.Methods:Following institutional review board approval, a retrospective review was performed on all patients who underwent TT and TTC arthrodesis through a lateral transfibular approach with minimum 1 year clinical and radiologic follow up. All other operative approach and fixation combinations for arthrodesis were excluded. Primary outcomes examined were union rate, revisions, and complications related to fibula excision versus retention group. Sixteen patients underwent TT and TTC arthrodesis with fibular retention and twelve with fibular excision techniques.Results:The overall union rate was 89%, 87% (14 of 16 ankles) for the fibula retention group, and 91% (11 of 12) for fibula excision group (P = .72). Symptomatic nonunion requiring revision arthrodesis occurred in 6% (1 of 16) of the retention group versus 8% (1 of 12) in the excision group (P = .83). There were no significant differences in individual tibiotalar or subtalar union, reoperation, superficial wound problems, infection and symptomatic hardware rates. Elective hardware removal was performed in 12%(2of 16) in fibular retention group versus 25%(3 of 12) in fibula excision group (P = .39), none of the hardware removal was related to the fibula fixation. Each group had three episodes of reoperation due to non-union, osteomyelitis and painful hardware.Conclusion:Union, reoperation rates were similar in fibula resection versus retention groups. The frequency of infection and wound complication was not significantly different in both groups, despite the wide variety of patient population and preoperative indications.

A Modification of the Fibular Osteotomy for Total Ankle Replacement Through the Lateral Transfibular Approach.

One disadvantage of lateral transfibular total ankle arthroplasty is the rate of symptoms related to the implant and wound issues requiring implant removal in association with the traditional fibular osteotomy. In the present study, lateral total ankle arthroplasty involving the traditional short oblique fibular osteotomy was compared with arthroplasty involving a long oblique osteotomy (the Foot & Ankle Reconstruction Group osteotomy). We retrospectively reviewed all primary lateral total ankle arthroplasties that had been performed by a single surgeon from May 2013 to October 2016 and had a minimum of 2 years of follow-up. Clinical assessment included patient demographics, wound complications, the need for implant removal, the pain score on a visual analog scale, the American Orthopaedic Foot & Ankle Society score, and the Short Form-12 Mental and Physical Component Summary scores. Weight-bearing radiographs were used to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing. One hundred and fifty-nine total ankle arthroplasties were identified. The traditional short fibular osteotomy was used in 50 ankles, and the long oblique osteotomy was used in 109. The rate of survival of the tibial and talar components of the ankle replacements was 100%, and there were no osteotomy nonunions. There was improvement in all clinical parameters, with no significant difference between the 2 groups. Radiographs showed excellent arthroplasty alignment at all time points, with no significant difference between the groups. There was a significant difference in the rates of wound dehiscence (p = 0.011) and fibular implant removal (p < 0.0001), with the long oblique osteotomy having lower rates of both (2.8% and 2.8%, respectively) compared with the short oblique osteotomy (14% and 28%, respectively). In total ankle arthroplasty, modification of the traditional short oblique fibular osteotomy to a long oblique configuration provided excellent 2-year survival rates with good clinical and radiographic outcomes and decreased rates of wound complications and symptoms related to the fibular implant. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibiotalocalcaneal arthrodesis via lateral transfibular approach to treat tibiotalar and subtalar arthropathy

Objective To observe operative results of tibiotalocalcaneal arthrodesis (TTC) via lateral transfibular ap-proach in the treatment of severe ankle and subtalar diseases. Methods Eighteen patients treated with TTC via lateral transfibu-lar approach from January 2015 to December 2017 were retrospectively analyzed. There were 11 males and 7 females from 39 to 76 years old, with an average age of 53.4 years. Preoperative diagnoses included traumatic arthritis (3 cases), osteoarthritis (10 cas-es), talar necrosis (3 cases), failure of ankle fusion (1 case) and Charcot-Marie-Tooth disease (1 case). Ankle and hindfoot deformi-ty included varus (10 cases), valgus (6 cases), equinus (1 case) and equinovarus (1 case). All cases were classified into stage-3 ar-thritis according to Morrey-Wiedeman classification. All patients sustained pain and stiffness in the ankle and hindfoot as well as walking dysfunction. Preoperative and 1 year postoperative visual analogue scale (VAS) and American Orthopaedic Foot and An-kle Society (AOFAS) ankle-hindfoot scale were collected. Postoperative joint fusion and complications were observed. Results Follow-up ranged from 12-47 months, averaging 25.4 months. Preoperative VAS scores were 6-9, averaging 7.1±1.0, while postop-erative VAS scores at 1 year follow-up were 0-2, averaging 0.9±0.8, which decreased significantly. Preoperative AOFAS scores were 24-59, averaging 40.6±11.5, while postoperative AOFAS scores at 1 year follow-up were 68-84, averaging 75.3±5.8, which increased significantly. 8 cases were good and 10 cases were fair according to AOFAS scores at 1 year follow-up. The excellent and good rate was 44.4% (8/18). All joints were fused successfully without implants loosening or breakage. All patients satisfied with operative results at 1 year follow-up. Lateral distal wound dehiscence happened in 1 case of traumatic arthritis and the wound was finally healed after debridement and vacuum assisted closure (VAC). Two cases of osteoarthritis presented with dorsal lateral foot numbness and became asymptomatic after neurotrophic medication. One case of osteoarthritis complained of discomfort in the lateral heel caused by implants prominence and implants were removed at 1 year after surgery. Postoperative complication rate was 22.2% (4/18) . Conclusion TTC via lateral transfibular approach with cannulated screws and locking plate system is safe and ef-fective. Joint fusion rate is high and complication rate is low. During operation, attention should be paid to restoring hindfoot align-ment, soft tissue balance, proper bone graft and joint compression. Key words: Subtalar joint; Arthrodesis; Arthritis

Early Clinical and Radiographic Outcomes of Trabecular Metal Total Ankle Replacement Using a Transfibular Approach.

In the last 2 decades, total ankle replacement has gained greater acceptance as a treatment option in patients with end-stage ankle osteoarthritis. However, there is a lack of literature on total ankle replacement using a lateral transfibular approach. Therefore, we sought to report early clinical and radiographic results for a patient cohort treated with total ankle replacement using a lateral transfibular approach, performed by a single surgeon. From October 2012 to December 2014, 55 primary total ankle arthroplasties using the Zimmer Trabecular Metal Total Ankle implant were performed in 54 patients (29 male and 25 female; mean age, 67.0 years). Clinical assessment, including pain evaluation and measurement of ankle range of motion, was conducted preoperatively and at the latest follow-up. Weight-bearing radiographs were used to determine angular alignment of the tibial and talar components and to analyze the bone-implant interface. Intraoperative and postoperative complications, revision surgeries, and survivorship were evaluated. Implant survival was 93% at 24 months of follow-up. There were 3 revisions of a tibial component due to aseptic loosening. In 10 of the 55 cases, a secondary procedure was performed during follow-up. The mean follow-up duration was 26.6 ± 4.2 months. No delayed union or nonunion was observed for fibular healing. The average visual analog scale (VAS) pain score decreased significantly, from 7.9 ± 1.3 to 0.8 ± 1.2. The average total range of motion increased significantly, from 22.9° ± 12.7° to 40.2° ± 11.8°. Early results of total ankle replacement using the Zimmer trabecular metal implant and the lateral transfibular approach demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of 2 years. In the 55 consecutive cases, the fibular osteotomy required for access to the ankle healed without complications. Painful early loosening due to lack of osseous ingrowth required revision in 3 of 55 cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach.

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

Superficial and Deep Infections Rate in Primary Total Ankle Replacement through Anterior Approach versus Lateral Transfibular Approach

Category: Ankle, Ankle Arthritis, Periprosthetic Infections Introduction/Purpose: Periprosthetic joint infections represent a relatively infrequent complication following total ankle replacement (TAR), with reported incidence ranging from 2% to 8,6%. Early treatment of any wound infection is the key to prevent disastrous outcomes. One of the most recent TARs (Zimmer Trabecular Metal Total Ankle, Zimmer Biomet, Warsaw, IN) requires implantation through a lateral transfibular approach. Potential advantages of this approach include the supposed decreased risk of wound complications, thanks to a preservation of the distal leg angiosomes. The purpose of this study is to retrospectively compare the rate of superficial and deep infections between TARs performed through an anterior approach and TARs performed through a lateral transfibular approach at 12-months follow-up. Methods: This study included 150 consecutive primary TARs performed between May 2011 and July 2015 with at least 1-year follow up. The 3-component uncemented Hintegra implant (Newdeal SA, Lyon, France) was used in 81 TARs (54.0%) through an anterior approach (group A). The 2-component uncemented Zimmer Trabecular Metal Total Ankle prosthesis, was implanted in 69 TARs (46.0%) through a lateral transfibular approach (Group B). Operative time, tourniquet time and superficial and deep infections were recorded up to 1-year follow-up. All patients were clinically and radiologically evaluated postoperatively at two, six and twelve months. Superficial wound infections were classified as dehiscence, eschar, or wound drainage according to criteria of the Centers for Disease Control and Prevention for surgical wound infection. Deep infections were classified according to Fitzgerald’s classification: acute postoperative, deep late infections, late hematogenous infections. We compared the incidence of superficial and deep infections as well as the operative time. Results: In group A there were 4 (4.9%) superficial infections. Two of these patients developed a deep infection. Overall, there were 3 (3.7%) deep infections in group A that required: intravenous antibiotics and vacuum assisted closure; replacement of the tibial component and polyethylene liner; polyethylene exchange and VAC treatment. In group B, there were 2 (2.9%) superficial infections. One of these patients developed the only deep infection (1.4%) that was treated with antibiotic-impregnated cement spacer. There was no statistically significant difference in terms of superficial (P= 0.687) and deep infections (P= 0.625). The mean operative time in group A was 115.2 minutes (65-150) and 179.5 minutes (105-333) in group B. Operative time was statistically different between group A and group B (P &lt;0.001). Conclusion: This study demonstrates a lower superficial and deep infection rate in the lateral transfibular approach group compared to the anterior approach group. Nonetheless, this difference was not statistically significant. The significantly longer operative time in the lateral approach group did not seem to affect the infection rates. In conclusion, TARs performed through a lateral approach appear to be as safe as TARs done through an anterior approach in terms of the infection rate within the first postoperative year. Further studies on larger cohorts and longer follow-up are essential to validate the findings from this study.

Early Clinical and Radiographic Outcomes of Trabecular Metal Total Ankle Using Transfibular Approach

Category: Ankle, Ankle Arthritis Introduction/Purpose: In the last two decades, total ankle replacement (TAR) has gained more acceptance as a treatment option in patients with end-stage ankle osteoarthritis. However, there is a lack of literature on TAR using a lateral transfibular approach. Therefore, we sought to report early clinical and radiographic results of a patient cohort treated with TAR using a lateral transfibular approach by a single surgeon. Methods: Fifty-five primary total ankle arthroplasties using the Zimmer trabecular metal implant were performed in 54 patients (29 men and 25 women; mean age, 67.0 years) from October 2012 to December 2014. Clinical assessment including pain evaluation and measurement of ankle range of motion was done preoperatively and at the latest follow-up. Weight-bearing radiographs were used to determine the angular alignment of the tibial and talar components and to analyze the bone-implant interface. Intraoperative and postoperative complications, revision surgeries, and failures were evaluated. Results: Implant survival was 93% at 36 months follow-up. There were 3 revisions of a tibial component due to aseptic loosening. In 10 of 55 procedures, a secondary procedure was performed during follow-up. Mean follow-up duration was 26.6 ± 4.2 months. No delayed union or non-union was observed for fibula healing. The average VAS pain score decreased significantly from 7.9 ± 1.3 to 0.8 ± 1.2. The average total range of motion increased significantly from 22.9° ± 11.8° to 40.2° ± 11.8°. Conclusion: Early results of Zimmer trabecular metal total ankle replacement demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of one year. In the first 55 consecutive cases, the fibular osteotomy required for access to the ankle healed without complications. Painful early loosening requiring revision due to lack of bony ingrowth was seen in 3 of 55 cases.

Posterior Achilles Tendon-Splitting Approach and Intramedullary Nailing versus Lateral Trans-Fibular Approach with Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis

Category: Ankle, Ankle Arthritis, Hindfoot Introduction/Purpose: A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. As a durable, load-sharing device with favorable biomechanical properties, the intramedullary (IM) nail is commonly used. Lateral, fixed-angle plating continues to be popular as well, due to ease of use and lack of significant clinical inferiority. A lateral approach with distal fibula resection allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PAS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either PAS approach and IM nailing or lateral, trans-fibular (LTF) approach with lateral, fixed- angle plating. Methods: Following institutional review board approval, all patients who underwent simultaneous tibiotalar and subtalar arthrodesis were identified with minimum one year clinical and radiographic follow up. A retrospective review of all clinic notes, operative details, and radiographs was performed by a fellowship-trained orthopaedic foot and ankle surgeon not associated with the procedures. Patients were excluded if they underwent TTC arthrodesis through an approach other than PAS or LTF, and received fixation without an IM nail or lateral, fixed-angle plate. Primary outcomes examined were union rate and complications. Statistical analysis was performed with student’s t-test for continuous data and Chi-square test for categorical variables. P-values less than 0.05 were considered significant. Results: 38 patients underwent TTC arthrodesis with a PAS approach and IM nailing, and 28 with a LTF approach and lateral plating. The overall union rate for the PAS/IM nail group was 76.3% (29 of 38), and 64.3% (18 of 28) for LTF/lateral plating group (p=0.41). 15.8% (6 of 38) in the PAS/IM nail group underwent revision arthrodesis versus 7.1% (2 of 28) in the LTF/lateral plating group (p=0.45). Nonunion at the subtalar joint occurred in 25.0% (7 of 28) in the LTF/lateral plating group and 5.3% (2 of 38) in the PAS/IM nail group (p=0.03), but there was not a significant difference in tibiotalar union. Patients were allowed to bear weight 3 weeks earlier in the PAS/IM nail group (11.2 vs 14.4 weeks, p=0.01). Conclusion: Despite similar overall union rates, nonunion of the subtalar joint was significantly increased in the LTF/lateral plating group. This could be due to disruption of blood supply during exposure, insufficient stability, or inadequate compression of the arthrodesis site. However, revision arthrodesis rates were similar between groups because some nonunions were not symptomatic enough to warrant correction. Patients were allowed to fully weight bear significantly earlier in the PAS/IM nail group. PAS approach and IM nailing for TTC arthrodesis may allow for quicker recovery and increased likelihood of radiographic union at the subtalar joint.

Incidence of infections in primary TAR: Anterior versus lateral transfibular approach

Incidence of infections in primary TAR: Anterior versus lateral transfibular approach

Infections in primary total ankle replacement: Anterior approach versus lateral transfibular approach

BackgroundTotal ankle replacement (TAR) represents an alternative to fusion for the treatment of end-stage ankle osteoarthritis. The aim of the present study was to retrospectively assess the frequency of infections between TARs with anterior and lateral transfibular approach at 12-months follow-up. Methods81 TARs through an anterior approach and 69 TARs through a lateral approach were performed between May 2011 and July 2015. We compared surgical time and tourniquet time, as well as superficial and deep infections frequency during the first 12 postoperative months. ResultsIn the anterior approach group, there were 3 (3.7%) deep infections and 4 (4.9%) superficial wound infections. In the lateral approach group, there were 1 (1.4%) deep infection and 2 superficial wound infections (2.9%). There were not statistically significant differences between the groups. There was a significant difference between anterior approach (115minutes) and lateral approach group (179minutes) in terms of surgical time (P<0.001). ConclusionsThe frequency of superficial and deep periprosthetic infections during the first postoperative year was not significantly different in the lateral approach group compared to the anterior approach group, despite the significantly longer surgical time in the lateral transfibular approach group.