Total Ankle Replacement Research Articles

Radiographic Changes in Tibiotalar Motion Following Achilles Tendon Lengthening and Gastrocnemius Recession in Total Ankle Arthroplasty: A Comparative Cohort Study

Category: Ankle; Hindfoot Introduction/Purpose: End-stage ankle osteoarthritis is a debilitating condition that often results in limited tibiotalar range of motion. Total ankle replacement (TAR) preserves ankle range of motion and improves the patient's functionality. Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are concomitant procedures often performed with TAR to improve tibiotalar dorsiflexion. The purpose of this study is to determine the effect of a TAL and GR during TAR on radiographic range of motion compared to a control group without a lengthening procedure. Methods: A retrospective review of a prospectively maintained TAR database was conducted from November 2015 - June 2020 at a single academic institution. All surgeries were performed by fellowship-trained foot and ankle surgeons. Inclusion criteria included greater than18 years of age and a minimum of one-year radiographic follow-up with both preoperative and postoperative weight-bearing, range of motion radiographs. Exclusion criteria included concomitant 1) calcaneal osteotomies, 2) hindfoot or midfoot arthrodesis, 3) prior ankle arthrodesis, or 4) revision total ankle arthroplasty. A total of seventy-five patients (TAL, n = 40; GR, n = 35) were included with a control group of seventy-five consecutive patients who underwent TAR without a lengthening procedure. Demographic and clinical data were extracted from the TAR database. Preoperative and postoperative radiographic assessment included a measurement of dorsiflexion and plantarflexion. All measurements were performed by two members of the research team. Results: A total of 150 patients were included in this study: TAL: n = 35, GR: n = 40, Control: n = 75. Dorsiflexion significantly improved by 3.4° (p=0.0053) and by 6.7° (p < 0.0001) in the TAL and GR cohorts respectively with no significant difference in the control group (+1.3°, p=0.0857). Plantarflexion was significantly decreased by 3.6° (p=0.0378) and by 6.6° (p=0.0002) in the TAL and GR cohorts respectively with no significant difference in the control group (+0.3°, p=0.7863). The total arc of motion did not change significantly for any of the three groups postoperative (control 1.63°, GR 0.05°, TAL -0.20°; all p>0.05). There were no significant between-group differences in the change in overall arc of motion between the groups (p=0.3913). Compared to TAL group, GR resulted in a greater increase in dorsiflexion (6.7° versus 3.4°; p=0.0459) with a reciprocal, albeit non-significant, greater decrease in plantarflexion (6.8° versus 3.6°; p=0.1598). Conclusion: Both TAL and GR significantly increased postoperative dorsiflexion; however, this was accompanied by a reciprocal significant loss in plantarflexion. GR resulted in double the improvement in dorsiflexion and loss in plantarflexion compared to TAL. The total arc of motion did not significantly change for the control, GR, or TAL cohorts. Patients should be counselled that their preoperative range of motion (ROM) will dictate their postoperative ROM, and that concomitant procedures performed to achieve an increase in dorsiflexion will do so at the expense of plantarflexion.

Home and Outpatient Physical Therapy Utilization Following Total Ankle Replacement.

Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations. TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization. Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits).Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239). Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined. Level III, retrospective cohort study.

Emergency Department Visits Within 90 Days of Total Ankle Replacement.

Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration. This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits. Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) (P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem. Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs. Level III, retrospective cohort study.

Clinical and Radiographic Outcomes after Total Ankle Arthroplasty and Suture Tape Augmentation for Ankle Arthritis Combined with Ankle Instability

Category: Ankle Arthritis; Ankle; Sports Introduction/Purpose: End-stage ankle arthritis is commonly seen in combination with various forms of ligamentous instability. Correction of the ankle arthritis and meticulous ligament balancing is key to a successful outcome after a total ankle replacement. In particular, with varus or multidirectional instability, ligament repair or reconstruction can be performed with a combination of suture and/or suture anchors if there is adequate biologic tissue remaining for repair. To date there has been no study to report on the isolated use of suture tape to correct residual intraoperative lateral ankle instability and talar tilt after total ankle replacement. The purpose of this study is to evaluate the clinical and radiographic outcomes after this combined surgical procedure. Methods: This was a single institution, retrospective study involving 36 patients that underwent a primary total ankle arthroplasty surgery in combination with a lateral ankle ligament reconstruction using a suture tape construct (InternalBraceTM, Arthrex, Naples, FL). Retrospective review of prospectively collected information from patient charts of three foot and ankle fellowship trained surgeons were evaluated at preoperative, 6-months, 1-year and 2-years postoperative for various demographics as well as VAS pain and FAAM scores. Postoperative complications including revision surgery, hardware failure, or persistent instability were also recorded. In addition, preoperative radiographs were compared to 1-year and final follow up (mean, 26 months; range, 13-90 months) radiographs for correction of the coronal deformity. Analysis involved a 1-way repeated Friedman test with post hoc Wilcoxon signed-rank tests. P values are adjusted using the Bonferroni multiple testing correction method. Assumptions for normality were checked through normal quantile-quantile (QQ) plots. Results: At two years postoperative, VAS pain (p&lt;0.001) and FAAM functional scores (p&lt;0.001) were significantly improved from preoperative. Additionally, both VAS pain (p=0.026, p-0.043) and FAAM scores (p=0.00142, p&lt;0.001) significantly improved at each time point (6-months, 1-year) compared to preoperative. On weight bearing mortise view radiographs, the mean preoperative talar tilt angle was 11.9 (range, 1.4-25.7) degrees of varus. At 1-year and 2-years postoperative the mean talar tilt angles were significantly improved from preoperative at 1.1 and 0.7 degrees, respectively (p&lt;0.001, p&lt;0.001)). The correction was significantly improved and maintained at final follow up of at least 2 years. There were no significant differences between 1-year and 2-year talar tilt measurements (p=1.00). There were three complications requiring revision surgery. Two were for component loosening and the third was for a deep infection. Conclusion: Combined ankle arthritis and instability can be a challenging problem for foot and ankle surgeons. This study demonstrated that the use of suture tape to reconstruct the lateral ankle ligament complex after total ankle replacement provides and maintains adequate correction of any residual coronal deformity at a final follow up of at least two years.

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.

Impact of Pre-Operative PROMIS Depression Scores on Total Ankle Replacement Outcomes

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle replacement (TAR) is an effective procedure to help patients with end-stage osteoarthritis regain mobility and function. While previous studies have suggested that pre-operative factors such as stress or depression may influence the success of TAR, there is limited literature investigating this relationship. The goal of this study is to evaluate differences in functional and pain outcomes following TAR from patients with high and average PROMIS depression scores. Methods: Patients enrolled in the Orthopaedic Foot and Ankle Outcomes Research (OFAR) platform who underwent total ankle replacement were retrospectively analyzed. Patients were included if they had PROMIS outcomes collected both pre- and 12- months post-operatively. Patients were grouped as 'no/low depression' if they scored below 60 on the PROMIS depression scale, and 'high depression' if they scored greater than or equal to 60 (one standard deviation from the population mean). Statistical differences were evaluated non-parametrically using Wilcoxon rank tests and Mann-Whitney U tests. Results: 36 patients who underwent TAR met inclusion criteria for analysis. Based on pre-operative PROMIS depression scores, 28 patients were categorized 'no/low depression' (ND), and 8 were categorized as 'high depression' (HD). Both groups showed significant improvement in PROMIS physical function and PROMIS pain interference at 12-months. While the HD group had a significantly higher baseline PROMIS pain interference (65.8) compared to the ND group (58.4, p &lt; 0.05), there was no significant difference between the two groups at 12-months (50.5 vs. 47.6, respectively). Similarly, while there was a significant difference in PROMIS depression score pre-operatively between HD and ND (62.5 vs. 48.3, p &lt; 0.05), there was no significant difference 12- months post-operatively (52.5 vs. 45.8). Conclusion: Our data suggests that patients with high pre-operative PROMIS depression scores may have worse baseline physical function and pain interference compared to other patients but see greater overall improvement after total ankle arthroplasty. Patients in the 'high depression' group also showed a significant improvement in PROMIS depression score 12- months post-operatively. Additional investigation of large, non-commercial outcomes databases, such as OFAR, may also help determine which surgical interventions impact mental health outcomes.

Do COFAS Scores Effect the Outcomes of a 4th Generation Total Ankle Prosthesis? A 2-Year Follow- Up

Category: Ankle Arthritis; Ankle Introduction/Purpose: Fourth generation ankle replacements benefit from improved surgical technique, respect for bony preservation, and increased surgeon awareness of operative indications. In order to better compare and stratify pre-operative ankle arthritis patients, the Canadian Orthopaedic Foot and Ankle (COFAS) pre-operative classification for end-stage ankle arthritis score was developed. The purpose of this study is report on how the COFAS scores effects prospectively collected patient reported outcome measures(PROMs) in a multi-institutional study of a fourth-generation total ankle replacement. Methods: Patients presenting for a total ankle replacement at 9 institutions were prospectively enrolled and implanted in both academic and private settings. Each patient received an INFINITY ankle prosthesis (Stryker, Memphis, TN, USA). Patients had their COFAS pre-operative classification for end-stage ankle arthritis scores, and PROMs recorded pre-operatively and at 6 months,12 months, and 24-month intervals. The following PROMs were collected: Ankle Osteoarthritis Score (AOS), PROMIS Global Physical Health, and Foot and Ankle Outcome Score (FAOS). The preoperative and latest follow-up scores for patients with two years of follow-up were analyzed. Results: A total of 147 patients were prospectively enrolled. for study participation. COFAS types; were delineated as Type 1 (42.6%, isolated ankle arthritis), Type 2 (27.0%, ankle arthritis with varus or valgus deformity, tight Achilles, ankle instability), Type 3(4.7%, ankle arthritis with hindfoot deformity, tibial malunion), and Type 4 (25.8%, Types 1-3, plus hindfoot arthritis). Eighty-eight (88) patients had at least 24 months of follow-up. COFAS Types 1, 2, 3, and 4 patients had significant improvements in all domains of the AOS, PROMIS, and FAOS Scores (p&lt;0001). The type and severity of deformity or amount of hindfoot arthritis, hindfoot deformity, or ankle instability significantly effected the PROMs in those patients with at least 2-year follow-up. Implant revision rates were not affected by COFAS type, and there were three revisions (One Type 4 and two Type 2). Conclusion: At two-year follow-up, all study participants had significant improvements in PROMs, regardless of COFAS Type. These results suggest that COFAS type has little impact on patient outcomes using current generation total ankle replacements. Longer term follow-up may serve to further confirm these promising early results.

Does Severe Ankle Deformity Affect the Outcomes of a 4th Generation Total Ankle Prosthesis? A 2- Year Follow-Up

Category: Ankle Arthritis Introduction/Purpose: Fourth generation ankle replacements benefit from improved surgical technique, respect for bony preservation, and increased surgeon awareness of operative indications. In some studies, pre-operative degree of deformity has been reported to influence survivorship, pain, and functional outcomes. The purpose of this multi-institutional study was to evaluate whether pre- operative deformity affects prospectively collected patient reported outcome measures (PROMs) of a fourth-generation total ankle replacement. Methods: Patients presenting for a total ankle replacement at 9 institutions were prospectively enrolled and implanted in a variety of academic and private settings. Each patient received an INFINITY ankle prosthesis. (Styker, Memphis, TN, USA). The degree of deformity was radiographically classified pre-operatively as severe if ankle varus or valgus was greater than 10° in the coronal plane. PROMs were recorded pre-operatively and at 6 months, 12 months, and 24-month intervals. The following PROMs were collected: Ankle Osteoarthritis Score (AOS), PROMIS Global Physical Health, and Foot and Ankle Outcome Score (FAOS). The preoperative and latest follow-up scores for patients with two years of follow-up were analyzed. Results: A total of 147 patients were enrolled in the study. Fifty-two patients exhibited a pre-operative ankle deformity of greater than 10° varus or valgus. Eighty-eight patients had 24 months of follow-up. All patients with severe deformity had significant improvements in all domains of the AOS, PROMIS, and FAOS Scores (p&lt;0001). The degree of deformity, ankle instability, or hindfoot arthritis did not impact the PROMs (AOA p=.2661, PROMIS p=.543, FAOS p=.684) in those with 2-year follow-up.There were three revisions with varying degrees of deformity. Two patients had revisions for aseptic loosening (6o valgus and 10o varus). One patient had a revision for tibial subsidence (11o varus). Conclusion: Severe pre-operative deformity did not impact PROMs in patients undergoing implantation with a 4th generation total ankle replacement. In carefully selected patients, greater deformity did not necessarily correlate with an increased need for revision surgery.

Reconstruction of Severe Osteolytic Malleoli using Femoral Head Allograft in a Revision Total Ankle Replacement: A Case Report

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Case: A 38-year-old male patient presented with severe pain in the left ankle who underwent a total ankle replacement (TAR) and syndesmotic fusion for end-stage ankle osteoarthritis (OA) 13 years ago. Radiographic evaluation showed implant loosening and extensive osteolytic lesion of both malleoli. Revision was performed using a three-component TAR system and reconstruction of the malleoli with femoral head allograft. Methods: N/A Results: N/A Conclusion: Reconstruction of severe osteolytic lesions of the malleoli with femoral head allograft in the setting of revision TAR allowed to create a stable bone stock, implant anchorage, desirable stability and therefore maintaining joint function.

Short-Term Outcomes of a Two-Component Total Ankle Replacement in Revision Arthroplasty

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Given the growing number of primary total ankle replacements (TAR), an increase in the numbers of failed ankles and consecutive revisions might be expected. Achieving a stable and balanced ankle based on stable components while preserving the remaining bone stock as much as possible, are crucial for success in revision TAR. Most reported techniques rely on bulky implants with extended fixation features. Since 2018, we have used a novel 3-component ankle for revision surgery that is converted in situ to a fixed-bearing 2-component ankle once the components have found their position given by the individual anatomy. The purpose of this study was to determine the short-term results of this novel concept in revision TAR. Methods: This single-center retrospective cohort study included 57 patients (57 ankles, mean age 63+-13 years) treated for failed TAR with the semi-constrained HINTERMANN Series H2© (H2) implant between February 2018 and February 2020. Survival analysis was performed and potential risk factors using Cox regression, were assessed. Clinical and radiological outcomes were assessed preoperatively and at the last follow-up. Clinical outcomes included pain on a visual analog scale (VAS), the American Orthopaedic Foot &amp; Ankle Society (AOFAS) ankle hindfoot score and patient satisfaction. Radiological outcomes were tibial articular surface angle (TAS), tibiotalar surface angle (TTS), talar tilt angle (TT) in the coronal plane and anteroposterior offset (AP-Offset) ratio in the sagittal plane, as well as signs of radiolucency and/or loosening on plane weightbearing radiographs. Results: The median follow-up was 2 (2.0 to 4.0) years. The cumulative incidence for secondary revision after 1 and 2 years was 5.1% (95%CI 0-11) and 7.4% (0-14) respectively. Four patients needed a secondary revision (three for pain/arthrofibrosis and one for aseptic loosening). While the AOFAS hindfoot score increased from median 54 (range 9-94) to 75 (19-98) (p=0.00001), satisfaction increased from moderate to good (p=0.0017). Radiographically, all components were stable without signs of increased shear-forces in terms of loosening or radiolucency. Conclusion: Obtained results with the novel customized semi-constrained total ankle implant design at short-term are encouraging, with a satisfactory survival rate and acceptable revision rate. The fixation concept without extended fixation features was shown to last against increased shear forces.

CT Analysis of the Posteromedial Neurovascular Bundle in Patients with End Stage Ankle Arthritis for Planning of Total Ankle Replacement Surgery

Category: Ankle Arthritis; Ankle Introduction/Purpose: Aim of this study is to identify reliable anatomical landmarks of the posterior tibial neurovascular bundle during Total Ankle Replacement (TAR) to minimise the risk of iatrogenic injury. Secondary aim is to identify if there is associated translation of the bundle when anterior translation of the talus is present. Methods: A radiological landmark protocol was devised to create a consistent method for measuring the relations of the bundle to the tibia, talus and medial gutter line when measured at levels mimicking those of resection undertaken in TAR. Analysis between patients with and without anterior subluxation was undertaken. Results: Total of 42 ankles were reviewed with 38% patient having anterior translation of the talus. At the tibiotalar joint, the bundle lies less than 5mm lateral to the medial gutter line and less than 8mm posterior to the posterior tibia. The same measurements at 10mm superior to the tibiotalar joint are less than 8mm and less than 6.5mm respectively. At 5mm distal to the dome of the talus, the bundle is less than 4mm lateral to the medial gutter line and between 8.4-16.0mm posterior to the posterior talus. The bundle to posterior tibia distance does not increase in the sagittal plane for patients with anterior subluxation of the talus. Conclusion: This study provides relevant guidance for surgeons to use intraoperatively when undertaking tibial and talus resections in TAR to identify their relations to the vulnerable neurovascular structures. The measurements of this study indicate for the first time that there is not an increased risk of iatrogenic injury during bone resection at the tibia in patients with anterior subluxation of the talus.

A Prospective Evaluation of a 4th Generation Total Ankle Prosthesis with 2-Year Follow-Up

Category: Ankle Arthritis; Ankle Introduction/Purpose: The availability of fourth-generation ankle replacements has burgeoned over the past several years. These ankle replacements benefit from improved surgical technique, respect for bony preservation, and increased surgeon awareness of operative indications. Documentation of implant survivability and comparison studies of the latest generation implants are limited. The purpose of this study is report on prospectively collected patient reported outcome measures (PROMs) in a multi-institutional study of a fourth-generation total ankle. Methods: Patients presenting for a total ankle replacement at 9 institutions were prospectively enrolled and implanted in both academic and private settings. Each patient received an INFINITY ankle prothesis (Stryker, Memphis, TN, USA) Patients had demographics and PROMs recorded pre-operatively and at 6 month, 12 months, and 24- month intervals. The following PROMs were collected: Ankle Osteoarthritis Score (AOS), PROMIS Global Physical Health, Foot and Ankle Outcome Score (FAOS), and satisfaction scores. The preoperative and latest follow-up scores for patients with two years of follow-up were analyzed. Results: A total of 147 patients were enrolled :(54.7% male) average age of 64.2 +- 9.4 years old, average BMI of 31.0 +- 5.2. pre- operative diagnosis for arthritis type was degenerative arthritis (48.7%), rheumatoid arthritis (2.7), post-traumatic arthritis (47.9%), and other (0.70%). Thirty-seven percent of patients had previously undergone surgery at the index joint. Eighty-eight patients had at least two years of follow-up. There were 3 (1.3%) clinical failures:(2 with aseptic tibial component loosening: at months 17 and 21, and 1 tibial subsidence at month 14). The patients improved in all PROMs domains at two years including: Mean Total AOS (17.2 +- 18.3, p&lt;.0001); PROMIS Global Physical Health (47.6 +- 7.4, p&lt;.0001); Total FAOS (76.3 +- 18.7, p&lt;.0001). 97.5% of patients were satisfied with their surgery. Conclusion: At two-year post-implantation follow-up, the INFINITY total ankle replacement had a low revision rate and proved to be safe and effective compared to historical ankle replacement outcomes. Patients were overwhelmingly satisfied and had statistically significant clinical improvements in each domain of their PROMs.

Long-Term Survival of Hintegra Revision Ankle Arthroplasty in 116 Patients

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: Total ankle replacement (TAR) became a popularly utilized surgical solution for end-stage ankle osteoarthritis (OA). Consequent to the increased number of primary implantations, failed ankles are evermore challenge for foot and ankle surgeons. Historically, if the ankle failed, salvage was preferably fusion. Nowadays however, maintenance of the ankle and hindfoot functionality is first and foremost for the expanded patient group. Despite revision arthroplasty has been described as a viable option, the available literature on long-term outcomes is scarce. The aim of this study was to investigate the long-term survival of revision ankle arthroplasty in a uniquely large cohort using the mobile-bearing HINTEGRA prosthesis. Methods: We conducted a single-center retrospective cohort study included 116 patients (117) ankles following revision ankle arthroplasty for failed primary TAR from July 2000 to March 2010. Survival analysis was performed. Clinical outcomes including pain on visual analog scale (VAS), American Foot and Ankle Ankle-Hindfoot Score (AOFAS), ankle range of motion (ROM), and patient`s satisfaction were assessed preoperatively and at the last follow-up. Results: The mean follow-up time from initial revision arthroplasty to the latest follow-up was 15.0+-3.0 years (range 11.2 - 20.5). The cumulative survival of the revised ankles at 5, 10 and 15 years was 81+-4%, 74+-4%, and 70+-4%, respectively. Clinical outcomes including pain on VAS declined from median 6 (0 - 10) to 2 (0 - 10) (p&lt;.0001)), and the AOFAS ankle-hindfoot score improved from 43+-17 to 70+-20 (p&lt;.0001)) from preoperatively to the last follow-up. Conclusion: Despite difficult surgical challenge, revision ankle arthroplasty yields an acceptable survival rate and results on long- term, however lower than primary TAR. Careful preoperative planning is crucial to achieve the desired results. Fusion is may not anymore the state-of-the-art solution for failed ankles. The study provides unique information for foot and ankle surgeons improving patient-care and possibly influence decision-making process.

Stress Shielding and Aseptic Loosening in Fully Porous-Coated vs Smooth Stemmed Tibial Implants in Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of implants has gained increased popularity in total ankle replacement surgery. With the integration of porous coating into the newer generation of implants, this theoretically increases the chances of osseous ingrowth and survivorship in total ankle replacements. Alternatively, literature in hip replacement surgery has shown increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects this may have on longevity or aseptic loosening secondary to a stress shielding effect. Methods: Our study identified 9 patients who underwent total ankle arthroplasty via a smooth-stemmed tibial prosthesis and matched these patients based on implant age with patients who received fully porous-coated tibial implants. We reviewed radiographs and compared postoperative rates of backside loosening and cystic formation secondary to stress shielding between the two groups. We also compared rates of heterotopic ossification between the two groups. A homoscedastic t-test was used to identify any statistical significance, which was defined as P &lt; 0.05. Results: While the smooth-stem group showed no rates of backside cystic formation or stress shielding, the follow-up matched porous-coated group showed a rate of 55% of cystic formation and potential loosening secondary to stress shielding observed on final radiographic follow up (P &lt; 0.01). There was no statistical difference between the two groups in their rates of heterotopic bone formation (P = 0.37). Conclusion: Despite having a relatively small sample size, this data shows that there is some consistency with the hip arthroplasty literature suggesting an increased risk for stress shielding in fully porous-coated stemmed tibial implants compared to smooth- stemmed tibial implants in total ankle arthroplasty.

Foot and Ankle Offset (FAO) Does Not Reflect the Actual Hindfoot Alignment in Cases Involving Ankle and/or Sagittal Foot and Ankle Deformities

Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: The foot and ankle offset (FAO) was developed as a 3D biometric tool to measure hindfoot alignment on weightbearing CT (WBCT) scans. It corresponds to the offset between the hindfoot-to-forefoot midline and the talus and is reported as a percentage of foot-length. (1) Recently, with increased availability of WBCT in both research and clinical practice, the FAO has been widely used for hindfoot alignment assessment. (2) However, after extensive review of WBCT scans the authors of this study have noticed that FAO has a high false negative rate. This study aimed to demonstrate why FAO is inadequate in assessing 3D hindfoot alignment using both case examples and mathematical algorithms. Methods: This was a retrospective study including a cohort of 31 cases with various clinical diagnoses selected from a data base of WBCT in 260 patients. The deformities included valgus or varus ankle deformities, hindfoot deformities combined with sagittal plane deformities of the foot and ankle, rocker bottom foot deformity, ankle equinus, metatarsus primus elevatus, and first metatarsal plantarflexion. All of the latter deformities caused one or more parts of the triangular base for FAO evaluation (the 1st metatarsal, the 5th metatarsal and the calcaneus) to remain off the floor. The medical charts and WBCT scans of each patient were reviewed to evaluate the deformities in more detail. The FAO was measured by two fellowship trained foot and ankle surgeons separately. The clinical and radiographic diagnoses were compared with the FAO value to determine the accuracy and utility of the latter measurement. Limitations of FAO as a semi 3D tool using the tripod theory in assessing the hindfoot alignment were also demonstrated mathematically. Results: For each of these 31 cases examined, the hindfoot alignment information reflected by the FAO value was vastly different from the clinical and imaging study findings. (Table 1). Using the reference value for FAO (Normal 2.3% ± 2.9%, Varus −11.6%± 6.9%, and Valgus 11.4% ± 5.7%), 24 out of 31 cases in the cohort had a normal FAO value, however, among them there were 7 with a valgus ankle or distal tibia plus a normal or cavovarus hindfoot, 2 varus ankles with a normal hindfoot, 1 varus ankle with a valgus hindfoot, 3 cavovarus feet, 1 clubfoot, 1 equinus ankle with cavovarus foot, 2 equinus ankle with severe valgus hindfoot, 4 severe valgus hindfoot and 1 varus hindfoot with sagittal plane deformities, 2 Muller Weiss Disease; 5 out of 31 cases had a varus FAO value, but they all had a valgus ankle with either a varus hindfoot or sagittal plane deformities; 2 out of 31 cases had a valgus FAO value, however both cases had a valgus ankle with a varus hindfoot. Thorough algorithm and geometric evidence were provided. Conclusion: FAO has a very limited capacity to reflect hindfoot deformities, understandable when analyzing how the FAO is designed and measured mathematically. It is not a 3D tool. It does not include the level of the ankle nor the tibia, therefore it is not appropriate nor capable to be used as a hindfoot alignment evaluation tool. The tripod and talus projection theories cannot reflect sagittal plane deformities or coronal plane rotation, and false results are inevitably generated. Reference: 1. Lintz F, Barton T, Millet M, Harries WJ, Hepple S, Winson IG. Ground reaction force calcaneal offset: a new measurement of hindfoot alignment. Foot Ankle Surg. 2012;18(1):9-14. 2. de Cesar Netto C, Day J, Godoy-Santos AL, Roney A, Barbachan Mansur NS, Lintz F, Ellis SJ, Demetracopoulos CA. The use of three-dimensional biometric Foot and Ankle Offset to predict additional realignment procedures in total ankle replacement. Foot Ankle Surg. 2022 Feb 16:S1268-7731(22)00036-4.

The Effects of Anxiety and Depression in Outcomes of Patients with Total Ankle Replacement

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Pain control is important following TAA. Prior studies have reported that anxiety and depression are associated with worse outcomes after orthopaedic surgery. However, the association between anxiety and depression on patient reported outcomes following TAA is not well-defined. Therefore, the purpose of this study was to investigate the effects of anxiety and depression on postoperative reported pain control following TAA. Methods: Following institutional review board approval, a retrospective chart review was conducted for all patients that underwent TAA from 2018-2021 at our institution. Patients were separated into two groups. Group A consisted of patients with a documented pre-operative history of anxiety and depression and Group B consisted of patients without documented anxiety or depression. Electronic records were reviewed at 2- and 6-weeks following surgery. Statistical analysis was then run to determine the relative risk of poorly controlled pain postoperatively in patients with and anxiety and depression. Results: At our institution, from 2018-2021, 56 patients underwent TAA. The mean age of our cohort was 60.9 (Range, 56-83). In our cohort, 31 patients were male, 25 were female, the mean patient BMI was 33.8 (Range, 21-56.2), 8 patients reported poor pain control (14.3%) and 24 patients had anxiety or depression (42.9%). Of the patients with anxiety or depression, 4 reported poor pain control. There was no statistically significant increased risk of poor pain control in patients with a history of anxiety or depression (RR: 1.5; 95% CI: 0.4145 to 5.4279). Conclusion: Despite the increased risk of poor outcomes reported in patients with a history of anxiety and depression, the results from our cohort indicate that a history of anxiety or depression is not associated with going on to have poor pain control following TAA. Albeit, our sample size was small, warranting further investigation.

Prophylaxis for the Prevention of PJI after TAA: Is It Economically Justifiable?

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons will use intraoperative vancomycin powder or copiously irrigate the surgical site with Povidone-iodine to prevent this outcome. Additionally, many surgeons will prescribe a short course of postoperative antibiotics. However, the efficacy of such prophylaxis continues to be debated, and little is known about the cost-effectiveness of these agents. Therefore, the purpose of this study was to perform a 'break-even' analysis to determine the number of cases that could be performed while only preventing a single PJI and still breaking even on cost. Methods: The literature was searched to determine the rate of PJI and the mean cost of total ankle replacement. The prices of topical vancomycin powder and Povidone-iodine were obtained from our institution's purchasing records. An online drug database was then used to determine the cost of a 14 day twice daily course of Sulfamethoxazole/Trimethoprim (800/160 mg), Cephalexin (500 mg), and Amoxicillin/Potassium Clavulanate (875/125 mg). A break-even analysis was then performed to determine the absolute risk reduction (ARR) necessary to make a drug cost-effective. Using the ARR, we calculated the number of patients that would need to be treated with these agents to prevent a single PJI (NNT). Results: The price of intraoperative vancomycin powder was found to be $3.06 while povidone-iodine was found to cost $3.64. Sulfamethoxazole/Trimethoprim (800/160 mg), Cephalexin (500 mg), and Amoxicillin/Potassium Clavulanate (875/125 mg) were determined to cost $3.00, $3.64, and $14.51, respectively. At the prices obtained Vancomycin Powder, Povidone-iodine, Sulfamethoxazole/Trimethoprim, and Cephalexin were all cost-effective if the initial rate decreased by ARRs of 0.01%. Likewise, Amoxicillin/Potassium Clavulanate was cost-effective if the initial rate decreased by an ARR of 0.03%. Additional analyses run found that all drugs-maintained cost-effectiveness even if the initial rate of PJI was as low as 0.1%. Conclusion: PJI following TAA is devastating and costly. Despite the ongoing debate regarding the efficacy of prophylactic measures to reduce the risk of PJI in TAA, limited is known about their cost-effectiveness. Our study demonstrates that intraoperative vancomycin powder, povidone-iodine lavage, and multiple commonly prescribed antibiotics are all highly cost- effective to prevent PJI following TAA. We feel that a tailored approach to taking measures to reduce PJI with cost-effectiveness in mind is crucial to providing value-based care.

Early Radiographic and Clinical Outcomes of the Cadence Total Ankle Replacement System

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The Cadence Total Ankle System (Smith and Nephew, Memphis, TN) is a two-component, fixed-bearing fourth generation total ankle arthroplasty (TAA) system that was introduced for clinical use in 2016. Few studies have investigated short-term outcomes of this new TAA system, and no outcomes have yet been reported by independent authors. The purpose of this study was to report non-inventor, non-industry funded survivorship, radiographic and clinical outcomes, and early complications following use of the new fourth generation TAA system at a minimum of 2 years. Methods: This is a single-center retrospective study of patients who underwent TAA by two surgeons with the Cadence between January 2017 and September 2018. There were 50 ankles in 50 patients, and 48 (96%; mean age of 66.1 years) patients were evaluated at a minimum 2-year follow-up. Two patients were lost due to death and refusal to participate in the study. Patients had an average follow-up of 33.6 (range, 24-50) months. Radiographic outcomes included preoperative and postoperative tibiotalar alignment (TTA) on anteroposterior radiographs of the ankle, sagittal tibial alignment (STA) on lateral radiographs of the ankle, and periprosthetic cyst formation (greater than 5mm in size) and cyst location. Data regarding reoperations and revisions were also collected. Patient-reported outcomes were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Subgroup analysis was performed to assess for associations between preoperative deformity, postoperative implant alignment, PROMIS scores, and periprosthetic cyst formation. Results: Survivorship of implant was 93.7%, with 3 revisions, 1 due to infection and 2 due to loosening of the implant (one tibial and one talar component). Three patients had reoperations (6.3%): 2 for irrigation and debridement for cellulitis, and 1 for gutter debridement due to medial gutter impingement. Preoperatively, 9 ankles had varus alignment (mean TTA 77.9 degrees), 20 had neutral alignment (mean TTA 90.2 degrees), and 13 had valgus alignment (mean TTA 102.9 degrees). Postoperatively, TTA and STA significantly improved, and all patients demonstrated neutral coronal alignment (TTA between 85 and 95 degrees). Fifteen patients (35.8%) developed periprosthetic cysts, all on the tibial side. PROMIS scores improved after surgery in all domains except Depression (Table 1). Patients with postoperative periprosthetic cysts had a smaller preoperative STA and a worse postoperative PROMIS Physical function and Pain interference domain than patients without periprosthetic cysts (p&lt;0.05). Conclusion: This study demonstrated excellent minimum 2-year clinical and radiographic outcomes, along with low revision and reoperation rates, of this new fourth generation TAA system. Future studies with longer follow-up, especially on patients with periprosthetic cysts, are necessary to investigate the long-term complications and understand the long-term functional and radiographic outcomes of this implant.

Mid-Term Follow-Up of Patient Reported Outcomes and Reoperation Rates for Minimal-Resection Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) is increasing in treatment of end-stage ankle arthritis. Modern implants show improved survival at 10-year and greater follow-up with patient reported outcomes exceeding those obtained with arthrodesis.1-5 Other benefits include maintaining ankle range of motion and decreased rate of adjacent joint arthrosis. The Infinity (Stryker, Mahwah, NJ), Salto-Talaris (Salto) (Smith &amp; Nephew, Memphis, TN), and Scandanavian Total Ankle Replacement (STAR) (DJO Global, Lewisville, TX) TAA have become highly utilized implants due to minimal bone resection to preserve both tibial and talar bone stock. The purpose of this study is to determine implant survival, reoperation rate, and patient reported outcomes of minimal-resection total ankle implants. Methods: After obtaining IRB approval, a retrospective review was performed of all patients who underwent TAA between January 1, 2007 - December 31, 2018. Inclusion criteria, including minimum 2 year follow-up, and exclusion criteria left ninety- eight (98) patients for review. Primary outcome measures included patient-reported outcome measure information systems (PROMIS) scores preoperatively, 1-year and last follow-up. Secondary outcomes measures included reoperation and need for revision surgery as well as radiographic analysis at 3-months, 1-year, 2-year, 5-years and last follow up to identify loosening and lucency. Demographics including age, gender, race, body mass index (BMI), smoking status and diabetes were tabulated. Student's T-test compared PROMIS outcomes between the Infinity and Other groups. Chi-squared test investigated differences in categorical variables and a repeated-measure analysis of variance (ANOVA) was used to investigate differences between PROMIS scores for the Infinity group. Results: 75 Infinity and 23 STAR or Salto patients were identified, average follow up of 3.4 years (range of 5-months to 10.75- years). PROMIS scores for depression and anxiety were significantly lower at most recent follow-up for the Infinity group (p&lt;0.05). Physical function and pain interference scores were not significantly different between groups (p&gt;0.05). Infinity patients saw favorable improvements in anxiety, depression, physical function and pain interference scores postoperatively (p&lt;0.05). A higher incidence of revision with Salto and STAR was observed when compared to Infinity (1 Infinity, 1 Salto, 4 STAR) (p&lt;0.05). Salto and STAR groups presented more 5-year cysts than the Infinity group (p&lt;0.05). Evidence of loosening was higher in the Infinity group at 5-years compared to Salto and STAR (1 Infinity, 0 Other, p&lt;0.05). Finally, more lucency zones were identified at 3 months in Infinity group compared to Salto and STAR (p&lt;0.05). Conclusion: TAA is a durable treatment for ankle osteoarthritis demonstrating equivalent physical function and pain inference PROMIS scores across all minimal resection implants. Patients who received Infinity had significant improvements in depression and anxiety PROMIS scores when compared to other implants at an average 3.4 year follow-up suggesting significant improvement in quality of life as measured by PROMIS between the preoperative and early/late term follow-up periods. Patients who underwent TAA with Infinity experienced lower rates of revision and a trend toward lower need for reoperation when compared to other minimal resection implants.

Rare Presentation of Flexor Hallucis Longus Tendinopathy, Idiopathic Hallux Saltans

Category: Arthroscopy; Sports Introduction/Purpose: Ankle arthritis can be a significant source of pain and disability showing similar morbidity as arthritis in other joints like hip and knee. Nevertheless, ankle arthritis differs from arthritis in other joints because patients are often younger and have higher expectations and demands. After joint-sparing options fail, patients are usually limited to an ankle fusion or total ankle arthroplasty. However, it is not infrequent that these ablative procedures appear too aggressive to treat the underlying condition. As either fusion or replacement is not without complications, an intermediate option that does not burn any bridge is desirable. Ankle hemiarthroplasty is a one-piece implant system replacing the talar side of the tibiotalar joint. It also offers limited bone resection and more straightforward revision surgery than ablating procedures Methods: Prospective, single-center, non-comparative, non-randomized clinical study. Clinical, radiological, and functional outcomes (FAOS, FAAM, SF-36, SMFA, and VAS pain scores) were obtained at 3, 12 months, and last follow-up (mean 31.9 months). Results: Ten patients met the inclusion criteria; three were converted to total ankle replacement at 14, 16, and 18 months. PROMs comparisons were made between preoperative status and 3, 12 months, and last FU. Pain VAS score improved from 6.8 to 4.8 (P = 0.044). SF-36 Physical Health Component improved from 25.03 to 42.25 (P=0.030). SMFA Dysfunction and Bother indexes improved from 46.36. FAAM sports improved from 12.5 to 34.5 (P = 0.023) Conclusion: Patients undergoing hemiarthroplasty of the ankle joint exhibited significant pain reduction, functional improvements, and better quality of life in the midterm follow-up. This procedure offers an intermediate alternative for cases in which joint ablative procedures appear to be excessive surgery for the underlying condition.